Restoring the failed cranioplasty: nonanatomical titanium mesh with perforator flap.

The calvaria is covered by a thin, well-vascularized soft-tissue envelope, providing a rich environment for a variety of local and regional flaps.1 Composite cranial vault restoration aims to protect the brain and restore cranial form. Primary reconstructions result in good outcomes, provided there is adequate quality and quantity of soft tissue. The complexity also increases with the size and thickness of the defect, and the predictability and durability decrease with attenuating factors. Local and systemic factors such as malnutrition, extensive zone of injury from radiation therapy, and multiple surgical explorations play a pivotal role and potentially complicate routine options. Thus, composite calvarial defects within a field of multiple surgical interventions or radiation therapy result in less predictable outcomes. Secondary cranioplasty in the setting of an attenuated soft-tissue envelope presents a unique challenge. The purpose of this article is to present a novel alternative for managing the failed cranioplasty with associated soft-tissue deficit that includes distant tissue transfer in the form of perforator-based flaps in addition to a nonanatomical titanium mesh cranioplasty, ensuring rigid brain protection and durable tissue coverage.