Determinants of aesthetic symmetry and complications after pediatric cranioplasty: a retrospective multicenter study

OBJECTIVE: Cranioplasty plays a crucial role in restoring cranial integrity and aesthetics in pediatric patients following decompressive surgery. However, systematic analyses of factors affecting cosmetic outcomes and postoperative complications in children remain limited. This study aimed to evaluate the predictors of aesthetic and clinical outcomes following pediatric cranioplasty, with a focus on cranial defect characteristics, surgical timing, and patient age. METHODS: A multicenter retrospective study was conducted, enrolling pediatric patients (< 18 years of age) who underwent first-time cranioplasty between January 2017 and January 2025. Demographic and perioperative variables were collected. Aesthetic outcomes were assessed using the cranioplasty fitting score and cranial symmetry score. Postoperative complications were categorized as local structural or neurological. Univariate and multivariate logistic regression analyses were performed to identify independent predictors. RESULTS: A total of 96 patients were included, with a mean follow-up of 30 months. The overall complication rate was 43.75%, with local structural complications (33.33%) more common than neurological ones (21.88%). Larger cranial defect size was an independent risk factor for poor aesthetic outcomes and increased complications. Preschool-aged children were more likely to experience structural complications, while older children had a higher incidence of neurological events such as postoperative seizures. The use of polyetheretherketone implants and intraoperative drainage were significantly associated with better cosmetic outcomes and reduced complication rates. CONCLUSIONS: Cranial defect size and age at repair are key determinants of postoperative outcomes in pediatric cranioplasty. Individualized surgical planning, including appropriate material selection and drainage strategies, can improve implant conformity and reduce the risk of complications. These findings provide practical guidance for optimizing aesthetic and clinical results in children undergoing cranioplasty.