PMMA Cranioplasty Making by Using Open-Source CAD Software, PLA Printers, and Silicone Rubber Molds: Technical Note with Two Illustrative Cases.

We read with great interest Malikov et al's case report/technical note entitled “PMMA cranioplasty making by using open-source CAD software, PLA printers, and silicone rubber molds: technical note with two illustrative cases.”[1] We were the first in the literature to begin an ultra-low-cost patient-specific polymethyl methacrylate (PMMA) cranioplasty implant service in Pakistan, that too in a public sector hospital, and we have already published our technical note and limited case series with 1-year follow-up.[2] Since then, our technique has been adopted by our colleagues at neighboring centers, and we have amassed an experience of over 50 cases, and many of our patients are in long-term follow-up. At the national level, the lowest cost offered by commercial companies for a patient-specific PMMA implant exceeded US$ 1,000 and US$ 10,000 for titanium and polyetheretherketone (PEEK) hemicraniectomy implants, respectively. The vast majority of the Pakistani population are poor and underprivileged, and the trauma cohort who require this operation are actually those who could never meet these costs in their lifetime. Free-hand PMMA cranioplasty was utilized in virtually all cases nationally. After beginning our initial service, the total cost to manufacture an implant in consumables was US$ 40. The printer we used was a locally assembled Chinese Prusa i3 clone. Thus, production cost was exponentially cheaper than commercial rates, and in our experience, our clinical and aesthetic outcomes are the same, if not better. Naturally, when one intends to offer a service for the patient benefit rather than profit, affordability is one of the most important parameters, especially in the impoverished developing world. We would be delighted to know the exact specification of the printer used by Malikov et al, the cost of disposables and printing of each implant, and the context of this cost in their patient's socioeconomic demographic/health care system, and whether commercial options were as extortionate for their general public as it was for ours.