Background <p>In the neurosurgical practice, decompressive hemicraniectomy (DHC) is a life-saving procedure for refractory intracranial hypertension. The necessary subsequent cranioplasty can be performed using variable techniques including autologous bone flaps preserved in the abdominal wall or synthetic materials such as Polymethyl Methacrylate (PMMA) cement. This study compares the safety, efficacy, and outcomes of these two particular approaches.</p> Methods <p>A retrospective comparative cohort study was conducted from January 2021 to August 2023 across three major hospitals in Iraq. Forty-seven patients underwent autologous cranioplasty with bone flaps preserved in the anterior abdominal wall (prospective group), while 45 patients received hand-formed PMMA cranioplasty (retrospective control group). Primary outcomes included surgical site infection (SSI) rates, revision surgery rates, intracranial hematoma formation, and technical success. Statistical analysis was performed using chi-square tests and Fisher’s exact test where appropriate.</p> Results <p>The autologous group demonstrated lower infection rates (12.7% vs. 20%, <i>p</i> = 0.362), fewer occasions of revision surgeries (8.5% vs. 11%, <i>p</i> = 0.704), reduced intracranial hematoma formation (6.3% vs. 15.6%, <i>p</i> = 0.172), and higher technical success rates (93.7% vs. 83%, <i>p</i> = 0.134). Although between-group differences did not achieve statistical significance (likely due to limited sample size), the autologous group demonstrated numerically lower rates across all measured outcomes.</p> Conclusion <p>Based on the data from the three Iraqi centers we found that abdominal wall-preserved autologous bone flap cranioplasty showed comparable safety to PMMA cranioplasty with numerical trends toward lower overall complication rates. These findings suggest that this technique may represent a viable, cost-effective alternative, potentially offering biological advantages, particularly in resource-limited settings such as Iraq.</p>