Cranioplasty restores cranial integrity after trauma or decompressive craniectomy but presents unique challenges in pediatric patients due to ongoing cranial growth and wound healing dynamics. While autogenous bone grafts are biologically ideal, they are not always feasible. Titanium mesh serves as an alternative for large defects but carries risks like implant exposure and infection. Flap necrosis secondary to lack of vascularity, infection or complex procedures further complicates recovery, necessitating advanced reconstructive techniques. This report highlights the use of a temporo-parieto-occipital flap to address titanium mesh exposure in a pediatric patient.

A 6-year-old male with a post-traumatic calvarial defect underwent cranioplasty using titanium mesh six months after decompressive craniectomy. Despite initial uneventful recovery, ischemia developed in the intermediate flap within one week, progressing to necrosis and implant exposure, the NCCT revealed post-cranioplasty status with no abnormality in brain and implant seemed inert. A secondary intervention involved debridement of necrotic tissue and reconstruction with a contralateral temporo-parieto-occipital flap. The robust vascular supply ensured full implant coverage, and meticulous closure was performed. Postoperative recovery was uneventful, with the flap integrating successfully and resolving the complication.

Implant exposure and flap necrosis are critical complications in pediatric cranioplasty. The temporo-parieto-occipital flap, with its robust vascularity, offers reliable coverage for exposed implants, reducing infection risks and ensuring long-term stability. This case underscores the importance of individualized surgical planning and advanced flap techniques in managing complex cranial reconstruction challenges in pediatric patients. The approach demonstrates significant potential for improving functional and aesthetic outcomes in cranioplasty.