Decompressive Craniectomy (DC) is a neurosurgical procedure that involves removing a portion of the skull, known as a bone flap, to reduce intracranial pressure. This procedure creates additional space for the swollen brain to decompress, which can help alleviate symptoms and prevent further brain damage.1 Indications to perform DC depend on the clinical scenario. It is a critical component in the management of acute traumatic brain injury, where intracranial hypertension has been independently associated with higher risk of death and poor outcomes.2 Moreover, it has been employed in nontrauma settings, such as space-occupying or malignant middle cerebral artery infarction, cerebral venous sinus thrombosis, intractable intracranial hypertension secondary to various causes, among others.3, 4, 5 After DC, a cranioplasty is performed to reestablish the protective function of the skull. Restoration of the bone flap has also been associated with improvements in cerebral metabolism, cerebrospinal fluid, blood flow, and neurological function.6, 7, 8, 9

Alongside the progress of biomedical technology, existing cranioplasty materials have evolved substantially.6, 7, 8, 9, 10, 11, 12 This progress led to the inquiry of which material possesses the best risk profile to improve patients' outcomes. A meta-analysis conducted by Khalid et al. concluded that there is insufficient evidence available to make definitive conclusions regarding the risk profiles (infections, healing problems, and poor cosmesis) associated with different cranioplasty materials like autologous bone, hydroxyapatite, methyl methacrylate, demineralized bone matrix, polyether ether ketone, titanium, or composite materials.6 As a result, the selection of material will depend on multiple factors including patient age, size and location of the cranial defect, the implant's biocompatibility, resistance to infection and resorption, osteoconductivity, and availability.6,8,11

Despite technological and material advances, both craniectomy and cranioplasty carry some risks. Regarding cranioplasty, complications rates range from 25.6% to 33.8%.12, 13, 14, 15, 16, 17 Among the most commonly reported complications are hydrocephalus (3.1%–13.5%),13, 14, 15, 16, 17, 18 epidural hematoma (1.8% - 2.2%),16, 17, 18, 19 subdural hygroma formation (2.2%–5.5%)13,14,16,17 surgical site infection (5% - 11.3%),16,18,20 and bone resorption (7.2%–15.4%).13,16,21 Furthermore, adhesions between the temporalis muscle and the dura can develop after the initial decompressive intervention. During cranioplasty, these adhesions represent an additional challenge, making dissection more difficult. As a result, inadequate dissection of the temporalis muscle may occur, carrying the risk of direct injury to muscle fibers, affection of blood vessels and nerves, in addition to potential dura and brain tissue damage,22,23 all of which have been associated with temporal muscle atrophy.23 Moreover, atrophy and the resulting asymmetry of the temporalis muscle give rise to postoperative cosmetic sequela (1.5%–7.2%),16,19 most notably temporal hollowing, which can cause patient dissatisfaction and a negative self-perception.22, 23, 24

To prevent adhesions, recent approaches have focused on placing an additional layer of non-biologic antiadhesive materials as a subtemporal barrier.12,24, 25, 26, 27, 28, 29 However, very few studies have focused on temporalis muscle preservation, an essential element for postoperative masticatory function and esthetic outcomes.22 We present a modified technique for DC, consisting of bone flap removal followed by duraplasty and a titanium mesh. The mesh is placed between the temporalis muscle and the dura graft, partially covering the most critical areas in the craniectomy area. Finally, with the temporalis muscle is sutured to the mesh. Adding this procedure to the conventional DC can provide several potential benefits: it may prevent the adhesion between the temporalis muscle and the dura layer, prevent muscle atrophy, and protect the temporal lobe and deep brain structures from minor trauma. Moreover, it offers improved functional and aesthetic outcomes, making it a feasible solution to address all these issues.