Primary objective: To assess clinical outcome following restoration of cranial contour in a young male who had suffered a severe traumatic brain injury. Research design: Case report. Methods and procedures: A young male was assessed before and after cranial reconstructive surgery with a custom-made titanium plate. The patient had previously required a bifrontal decompressive craniectomy in order to control intractable intracranial hypertension due to neurotrauma. Following an autologous cranioplasty he made very little neurological recovery and remained wheelchair-bound with severe contractures and was only able to follow single stage commands. Over the following 2 years he developed extensive resorption of his bone flap such that it required augmentation. Main outcomes and results: After surgery he clinically improved such that he was able to communicate more effectively and, although he remained severely disabled and fully dependent, he was able to communicate that he would have provided consent for the initial decompressive procedure even if he had known that the eventual outcome would be survival with severe disability and total dependence. Conclusions: Long-term follow-up is required for patients with severe traumatic brain injury not only to assess outcome and complications, but also to assess how acceptable that outcome is for the patient and their families. © 2013 Informa UK Ltd.