Utilization of piezoelectric surgery for creation of cantilever cosmetic bone flap

Background and importance Piezoelectric surgery (PS) enables precise osteotomies with minimal bone loss and reduced soft tissue injury. While its neurosurgical applications are established, its use in optimizing cranial flap design for cosmetic and structural outcomes remains underexplored. We describe a novel PS technique to create an asymmetric cantilever cranial flap that maximizes bone-on-bone contact, minimizes hardware requirements, and improves anterior cosmetic results. Clinical presentation A 44-year-old patient presented with a 4-month history of progressive speech difficulty and was found to have a large left frontal enhancing mass with significant surrounding edema. Following symptomatic improvement with antiepileptic and steroid therapy, surgical resection was pursued for tissue diagnosis and mass effect relief. Given the patient's age and anterior craniotomy location, PS was selected to optimize flap geometry and reduce visible hardware. Using a Mectron piezoelectric bone cutter, a 3 × 4 cm left frontal craniotomy was fashioned with three sides beveled internally toward the flap center and the anterior margin beveled externally, creating a cantilever construct. This configuration facilitated atraumatic elevation, precise edge apposition, and fixation confined to regions posterior to the hairline. The procedure was completed without complication, and postoperative imaging confirmed ideal bony alignment. Conclusion PS can be used to engineer an asymmetric cantilever cranial flap that enhances cosmesis, improves mechanical stability, and reduces anterior fixation hardware. This technique may offer a valuable alternative to conventional high-speed drill approaches in patients where cosmetic and bone-preservation goals are paramount.