Decompressive craniectomy (DC) is a procedure commonly employed to relieve medically-refractory intracranial hypertension by removing a portion of the skull, thereby allowing for cerebral expansion and reducing the risk of internal herniation and secondary brain injury. This intervention is indicated in patients with severe traumatic brain injury, malignant middle cerebral artery infarction, or other pathologies resulting in elevated intracranial pressure. Although the procedure can be life-saving, it carries risks including hemorrhage, infection, and postoperative hydrocephalus. This review provides a detailed overview of the surgical techniques, intraoperative considerations, and complications associated with DC, with an emphasis on strategies to optimize outcomes and minimize morbidity. Although herein we review the unilateral frontotemporoparietal craniectomy, several of the principles are applicable to the bicoronal approach as well.