Material type versus defect size in adult cranioplasty: a multi-institutional analysis of 30-day outcomes and risk prediction modeling

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Background The optimal cranioplasty material remains controversial in the context of defect size and patient risk. We analyzed multi-institutional data over 13 years to evaluate the interaction between material type and defect size. Methods We performed a retrospective cohort analysis of adult cranioplasty patients in the ACS-NSQIP (2011–2023), stratifying by material type (autograft vs. alloplastic) and defect size (≤5 cm vs. >5 cm). The primary outcome was any 30-day complication. Multivariable logistic regression adjusting for 21 covariates, interaction analyses, and machine learning models were applied. Results Among 3,894 patients, 88% underwent autograft and 12% alloplastic cranioplasty. The 30-day complication rate was 22%, with no significant difference between material types (p=0.72). On multivariable analysis, material type was not independently associated with complications (p=0.715); defect size >5 cm was an independent predictor (aOR 1.24, p=0.032). For large defects, alloplastic reconstruction reduced operative time by 90 minutes (189 vs. 279 min; p<0.001). Nine independent predictors were identified; ventilator dependence (aOR 8.44) and preoperative transfusion (aOR 4.35) were strongest. Alloplastic use increased five-fold while adjusted complication risk decreased by 4.5% annually. Logistic regression achieved the highest predictive performance (AUC 0.737). Conclusion Material type is not an independent predictor of short-term complications following cranioplasty, regardless of defect size or patient risk profile. Larger defects are associated with increased morbidity, but alloplastic materials offer significant operative efficiency without compromising short-term perioperative safety. Prospective studies with extended follow-up stratified by alloplastic subtype are needed.

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