Fifty-six-year-old male patient, with a history of ChagasMazza disease, diagnosed in 1996 with anterior skull base meningioma due to headaches without any other accompanying symptoms. He underwent surgery in a different center before reaching our institution in 2016, with a recurrent meningioma with intranasal and right orbit invasion [ and ]. Complete exeresis was performed by double surgical approach: transcranial and endoscopic transnasal [ and ]. Due to the defect of the anterior skull base, an anterolateral thigh (ALT) flap was performed and anastomosed to the temporal vessels with an internal saphenous vein graft. The histopathologic analysis revealed an atypical meningioma [-]. In January 2017, hypofractionated radiosurgery was performed, with a total dose of 25 Gy (5 Gy/day during 5 days), which was well tolerated. In this case, hypofractionated radiosurgery was chosen due to the tumor’s location and short distance from the optic pathways and other critical structures. One year later, the patient presented with anterior skull base tumor recurrence and nasal skin infiltration, as well as pial and brain parenchyma infiltration, associated to right level II cervical lymphadenopathy [-]. The latter was biopsied and confirmed lymphatic metastasis of meningioma, Ki-67 labeling index was 20%. Chest and abdomen contrast tomography was performed to exclude any other metastasis; brain computed tomography showed typical bone erosion []. We decided to perform total resection of the meningioma and subsequent microsurgical reconstruction. The histopathologic analysis confirmed the recurrence of an atypical meningioma [-]. Total lesion resection included superior orbital rim, nasal dorsum, medial orbital wall, nasi proprium bone, upper portion of the medial wall of the maxillary sinus, ethmoidal cells, and vomer bone. Intraoperative frozen sections of margins were negative. CSF loss was reported after resection of part of the tumor attached to the ALT flap from the previous surgery. We performed a primary closure of the defect. Reconstruction was planned with a free anterior rectus abdominis muscle flap. However, due to the lack of adjacent adequate vascular pedicles, this flap was transformed into a deep inferior epigastric artery perforator (DIEP) flap with an 8 × 4 cm skin paddle. In a chimeric fashion, we included a segment of anterior rectus abdominis muscle based on the external branch of the epigastric artery. In this way, the pedicle was extended to 10 cm to reach the neck, where vascular anastomosis with the facial artery and the thyrolinguofacial trunk was performed without resorting to a vein graft [-]. Later, selective resection of the right cervical level II was performed []. The patient spent the first postoperative 48 h in an intensive care unit. The flap was clinically controlled by checking temperature, skin color, and type of bleeding by puncture every 4 h. He did not present postoperative complications and was discharged on the 8th postoperative day. Subsequently, on the 15th postoperative day, it was found that the flap was vital and healing, so we decided to remove the stitches. The reconstruction gave a good cosmetic outcome. 3 months later, the patient returned to the consult with less inflammation and the facial defect was well covered. It persisted with a mild hypopigmentation and the sensory recovery was satisfactory. There were no donor-site morbidities and the imaging controls until this instance did not show recurrence of the tumor. Even though radiant therapy was indicated at this stage, the patient refused it and finally returned to his hometown. He passed away a year later due to pneumonia.