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The search for a universal reconstructive material and the application of a routine approach leaves the surgeon limited in cranial reconstruction. Facility with a variety of implant materials and approaches helps optimize surgical management. The variability of surgical defects and challenges in cranial reconstruction highlights the importance of a strategic approach to evaluate both the defect and the clinical circumstance. Among the numerous alloplastic materials available, the utility of titanium mesh, hydroxyapatite cement, and prefabricated custom acrylic implants have remained at the forefront. The onus of responsibility remains on the surgeon to evaluate each clinical scenario and select the optimal course for management.