Balancing form and function: A single-center review of autologous vs. synthetic grafts in cranioplasty
Isabel Snee, Ryan Gensler, Ehsan Dowlati, Rajiv P. Parikh, Daniel R. Felbaum
Abstract
BACKGROUND: Cranioplasty is performed to restore cranial integrity following decompressive hemicraniectomy, with both autologous bone grafts (ABGs) and synthetic grafts (SGs) serving as reconstructive options. While previous studies have examined clinical outcomes, there is a lack of robust data comparing aesthetic outcomes and complication rates between ABGs and SGs. This study evaluates these parameters to guide optimal graft selection. METHOD: A single-center retrospective review was conducted on patients who underwent cranioplasty with either ABGs or SGs between January 2017 and November 2023. Patient demographics, perioperative variables, and postoperative complications were collected. Aesthetic outcomes were assessed using axial CT scans to measure frontal and parietal asymmetry. Statistical analyses included univariate and multivariate comparisons, adjusting for potential confounders such as age, cerebrovascular accident (CVA) history, hypertension (HTN), atrial fibrillation (AFib), ventriculoperitoneal (VP) shunt status, and insurance type. RESULTS: Among 200 patients, 82 (41.0%) received ABGs, and 118 (59.0%) received SGs. Frontal and parietal asymmetry scores did not significantly differ between groups (p = 0.321, p = 0.348). Median time to cranioplasty was shorter for ABGs than SGs (106.5 vs. 117 days; p = 0.038). Postoperative complications were significantly higher in the SG group compared to ABGs (30.5% vs. 9.8%; p = 0.001), with infections being more frequent in SGs (p = 0.048). SGs were also associated with a higher rate of revision surgeries. CONCLUSIONS: ABGs and SGs provide comparable aesthetic outcomes, but SGs carry a significantly higher risk of complications and revisions. Given its lower complication rates and cost-effectiveness, ABGs should be prioritized when feasible. However, SGs remain a viable option in cases where autologous bone is unavailable or contraindicated. Future studies should focus on long-term follow-up and patient-reported outcomes to further refine cranioplasty decision-making.