A place for plastics: systematic review and quantitative analysis of multidisciplinary cranial reconstruction

Abstract Background Cranioplasty following decompressive craniectomy remains a complex procedure with significant risks of infection, resorption, and implant failure. Increasingly, multidisciplinary surgical teams (MST) composed of neurosurgeons and plastic/reconstructive surgeons have been employed to optimize outcomes. This systematic review and quantitative analysis evaluates MST outcomes, focusing on complication, mortality, and revision rates across materials, flap types, and surgical indications. Methods A systematic review was conducted following guidelines suggested by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Article selection was conducted in the Scopus database. Inclusion criteria were (1) a multidisciplinary approach between neurosurgery and plastic/reconstructive surgery, (2) cranial reconstruction, (3) a definitive flap type, and (4) reported outcomes. Exclusion criteria included any studies without relevant focus, multidisciplinary approach, or reported outcomes. Data extracted included demographics, indication, implant material, flap type, and postoperative outcomes. Complication, mortality, and revision rates were pooled. Subgroup analysis compared outcomes by indication, material, and flap type using chi-square and relative risk calculations. Results A Scopus search identified 88 studies, of which 54 met inclusion criteria. Among 2,692 patients, the overall complication rate was 18.69%, mortality 2.64%, and revision 10.81%. Free flaps were associated with higher complication, revision, and mortality rates compared to local flaps. Tumor cases showed higher mortality (8.8%) compared with trauma (1.1%) and congenital (0.3%) (χ² p < 0.001). Titanium implants carried greater mortality (5%) and complication risk (Relative risk ~ 2.6 vs. autologous). Autologous bone demonstrated the lowest mortality (0.43%) but moderate complication rates. These results are complicated by various surgical indications, showing a use of titanium implants and free flaps in more complex cases. Conclusions MST cranioplasty achieves optimized complication and revision rates in high acuity operations, though tumor indications and titanium implants confer elevated risk. Material choice and surgical indication appear to drive outcomes more than flap type. Prospective, multicenter analyses are warranted to validate MST advantages over single-surgeon practice. Level of Evidence: Not gradable.