Injectable Biomaterials in Plastic and Reconstructive Surgery: A Review of the Current Status

Collagen-Based Medical Devices for Regenerative Medicine and Tissue Engineering

Assisted reproductive technologies are key to solving the problems of aging and organ defects. Collagen is compatible with living tissues and has many different chemical properties; it has great potential for use in reproductive medicine and the engineering of reproductive tissues. It is a natural substance that has been used a lot in science and medicine. Collagen is a substance that can be obtained from many different animals. It can be made naturally or created using scientific methods. Using pure collagen has some drawbacks regarding its physical and chemical characteristics. Because of this, when collagen is processed in various ways, it can better meet the specific needs as a material for repairing tissues. In simpler terms, collagen can be used to help regenerate bones, cartilage, and skin. It can also be used in cardiovascular repair and other areas. There are different ways to process collagen, such as cross-linking it, making it more structured, adding minerals to it, or using it as a carrier for other substances. All of these methods help advance the field of tissue engineering. This review summarizes and discusses the current progress of collagen-based materials for reproductive medicine.

An Update on the Clinical Efficacy and Safety of Collagen Injectables for Aesthetic and Regenerative Medicine Applications

Soft tissues diseases significantly affect patients quality of life and usually require targeted, costly and sometimes constant interventions. With the average lifetime increase, a proportional increase of age-related soft tissues diseases has been witnessed. Due to this, the last two decades have seen a tremendous demand for minimally invasive one-step resolutive procedures. Intensive scientific and industrial research has led to the recognition of injectable formulations as a new advantageous approach in the management of complex diseases that are challenging to treat with conventional strategies. Among them, collagen-based products are revealed to be one of the most promising among bioactive biomaterials-based formulations. Collagen is the most abundant structural protein of vertebrate connective tissues and, because of its structural and non-structural role, is one of the most widely used multifunctional biomaterials in the health-related sectors, including medical care and cosmetics. Indeed, collagen-based formulations are historically considered as the "gold standard" and from 1981 have been paving the way for the development of a new generation of fillers. A huge number of collagen-based injectable products have been approved worldwide for clinical use and have routinely been introduced in many clinical settings for both aesthetic and regenerative surgery. In this context, this review article aims to be an update on the clinical outcomes of approved collagen-based injectables for both aesthetic and regenerative medicine of the last 20 years with an in-depth focus on their safety and effectiveness for the treatment of diseases of the integumental, gastrointestinal, musculoskeletal, and urogenital apparatus.

Chitosan-based biomaterials for the treatment of bone disorders

Bone is an alive and dynamic organ that is well-differentiated and originated from mesenchymal tissues. Bone undergoes continuous remodeling during the lifetime of an individual. Although knowledge regarding bones and their disorders has been constantly growing, much attention has been devoted to effective treatments that can be used, both from materials and medical performance points of view. Polymers derived from natural sources, for example polysaccharides, are generally biocompatible and are therefore considered excellent candidates for various biomedical applications. This review outlines the development of chitosan-based biomaterials for the treatment of bone disorders including bone fracture, osteoporosis, osteoarthritis, arthritis rheumatoid, and osteosarcoma. Different examples of chitosan-based formulations in the form of gels, micro/nanoparticles, and films are discussed herein. The work also reviews recent patents and important developments related to the use of chitosan in the treatment of bone disorders. Although most of the cited research was accomplished before reaching the clinical application level, this manuscript summarizes the latest achievements within chitosan-based biomaterials used for the treatment of bone disorders and provides perspectives for future scientific activities.

Adipose Collagen Fragment: A Novel Adipose-Derived Extracellular Matrix Concentrate for Skin Filling

BACKGROUND

Skin filler is an option for treating skin aging and wrinkles; however, currently used fillers are limited by poor biocompatibility, rapid degradation, and possible hypersensitivity reactions. Autologous adipose tissue-derived products have been recognized as promising options for skin rejuvenation.

OBJECTIVES

This study aimed to develop a novel adipose-derived product for skin filling.

METHODS

Adipose collagen fragment (ACF) was prepared through pulverization, filtration, and centrifugation. The macrography, structure, types of collagen, and cell viability of ACF were evaluated by immunostaining, western blotting, and cell culture assays. ACF, nanofat, and phosphate-buffered saline (9 spots/side, 0.01 mL/spot) were intradermally injected in the dorsal skin of 36 female BALB/c nude mice; the skin filling capacity and the collagen remodeling process were then investigated. Twenty-one female patients with fine rhytides in the infraorbital areas were enrolled and received clinical applications of ACF treatment. Therapeutic effects and patients' satisfaction scores were recorded.

RESULTS

The mean [standard deviation] yield of ACF from 50 mL of Coleman fat was 4.91 [0.25] mL. ACF contained nonviable cells and high levels of collagen I, collagen IV, and laminin. Fibroblasts and procollagen significantly increased in ACF and ACF-treated dermis (P < 0.05). Overall, 85.7% of patients were satisfied with the therapy results, and no infections, injection site nodules, or other unwanted side effects were observed.

CONCLUSIONS

ACF significantly improved dermal thickness and collagen synthesis and may serve as a potential autologous skin filler.

Human decellularized adipose tissue hydrogels as a culture platform for human adipose-derived stem cell delivery

Adipose-derived stem cells (ADSCs) have been widely researched and used as a drug therapy in many fields like disease treatment and tissue engineering. However, ADSCs are susceptible to the surrounding environment. The emergence of acellular extracellular matrix provides a solution, which can serve as biomaterial scaffold as well as original ecological niche for the stem cells. Therefore, we propose the hypothesis that human decellularized adipose tissues (hDAT) are processed into injectable hydrogels and then mixed evenly with ADSCs. So that the ADSCs embedded-hydrogels could directly carry the stem cells to the appropriate sites. The hDAT hydrogel could provide microenvironmental protection for ADSCs. In this study, we successfully made human decellularized adipose tissue hydrogel (hDAT-gel), which was temperature-sensitive, liquid at 4°C and semi-solid at 37°C. When the ADSCs were embedded in hDAT-gel, they survived well and continued to grow well in layers. When the pre-gel containing ADSCs was injected subcutaneously into nude mice, the sample results after 15 min showed gelation occurred in situ. These results suggested that hDAT-gel could provide a culture platform for ADSCs delivery.

Adipose Tissue-derived Stem cells in Plastic and Reconstructive Surgery: A Bibliometric Study

BACKGROUND

Due to the evolving nature of the applications of adipose tissue-derived stem cells (ADSCs) and the rapidly growing body of scientific literature, it is difficult to generate a manual compilation and systematic review of ADSCs in plastic and reconstructive surgery.

METHODS

Bibliographic records were retrieved from the Web of Science Core Collection and analyzed with CiteSpace.

RESULTS

We retrieved 691 publications and their references. We identified 52 research categories. Interdisciplinary studies were common. The journals clustered into 13 subnetworks. The top institutions were Stanford University; University of Pittsburgh; University of Tokyo; University of California, Los Angeles; University of California, Davis; New York University; Tulane University; and University of Michigan. National Institutes of Health and National Natural Science Foundation of China provided the most generous financial support. Studies clustered into 22 topics. Emerging trends may include improvement of fat grafting, and application of ADSCs in wound healing, scleroderma, and facial rejuvenation.

CONCLUSION

The present study provides a panoramic view of ADSCs in plastic and reconstructive surgery. Analysis of journals, institutions, and grants could help researchers in different ways. Researchers may consider the emerging trends when deciding the direction of their study.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

COLLAGEN: STRUCTURE, METABOLISM, PRODUCTION AND INDUSTRIAL APPLICATION

This review presents the current scientific literature data about structure, properties, and functions of collagen, which is known as one of the most abundant human and animal proteins. The building of collagen molecule from the primary structure to submolecular formations, the main stages of its synthesis and biodegradation are briefly described. The information about collagen diversity, its features and metabolic ways in various tissues, including skin, tendons, bones, etc. is presented. The problems of pathologies caused by collagen synthesis and breakdown disorders as well as age-related changes in collagen properties and their causes are discussed. A comparative analysis of the advantages and disadvantages of collagen and its derivatives obtaining from various sources (animals, marine, and recombinant) is given. The most productive methods for collagen extraction from various tissues are shown. The concept of collagen hydrolysis conditions influence on the physicochemical properties and biological activity of the obtained products is described. The applications of collagen and its products in various fields of industrial activity, such as pharmaceutical, cosmetic industry and medicine, are discussed. Further prospective directions of fundamental and applied investigations in this area of research are outlined.

Review of Plastic Surgery Biomaterials and Current Progress in Their 3D Manufacturing Technology

Plastic surgery is a broad field, including maxillofacial surgery, skin flaps and grafts, liposuction and body contouring, breast surgery, and facial cosmetic procedures. Due to the requirements of plastic surgery for the biological safety of materials, biomaterials are widely used because of its superior biocompatibility and biodegradability. Currently, there are many kinds of biomaterials clinically used in plastic surgery and their applications are diverse. Moreover, with the rise of three-dimensional printing technology in recent years, the macroscopically more precise and personalized bio-scaffolding materials with microporous structure have made good progress, which is thought to bring new development to biomaterials. Therefore, in this paper, we reviewed the plastic surgery biomaterials and current progress in their 3D manufacturing technology.

Advances in biomaterials for adipose tissue reconstruction in plastic surgery

Adipose tissue reconstruction is an important technique for soft tissue defects caused by facial plastic surgery and trauma. Adipose tissue reconstruction can be repaired by fat transplantation and biomaterial filling, but there are some problems in fat transplantation, such as second operation and limited resources. The application of advanced artificial biomaterials is a promising strategy. In this paper, injectable biomaterials and three-dimensional (3D) tissue-engineered scaffold materials for adipose tissue reconstruction in plastic surgery are reviewed. Injectable biomaterials include natural biomaterials and artificial biomaterials, which generally have problems such as high absorptivity of fillers, repeated injection, and rejection. In recent years, the technology of new 3D tissue-engineering scaffold materials with adipose-derived stem cells (ADSCs) and porous scaffold as the core has made good progress in fat reconstruction, which is expected to solve the current problem of clinical adipose tissue reconstruction, and various biomaterials preparation technology and transformation research also provide the basis for clinical transformation of fat tissue reconstruction.

Signaling Molecule-Immobilized Porous Particles with a Leaf-Stacked Structure as a Bioactive Filler System

The ultimate purpose of this study was to develop a bioactive filler system that would allow volume restoration (passive property) and continuous release of signaling molecules to recruit soft tissues (bioactive property) and thus effectively correct facial aging. To achieve this, we prepared porous particles with a leaf-stacked structure throughout the entire particle volume (LSS particles) using a simple heating-cooling technique. LSS particles were loaded with insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) separately, by immersing the particles in signaling molecule-containing solutions for target tissue recruitment (adipose by IGF-1 and blood vessels by VEGF). IGF-1 and VEGF were continuously released from LSS particles for 28 and 21 days in vitro, respectively, even without additional chemical/physical modifications, because of the unique morphology of the particles. Signaling molecules preserved their bioactivity in vitro (induction of adipogenic and angiogenic differentiation) and in vivo (recruitment of fat and blood vessels) for a sufficient period. Moreover, it was observed that the LSS particles themselves have stable volume retention characteristics in the body. Thus, we suggest that the signaling molecule-loaded LSS particles can function as a bioactive filler system for volume retention and target tissue regeneration.

Optimal Condition of Isolation from an Adipose Tissue-Derived Stromal Vascular Fraction for the Development of Automated Systems

BACKGROUND

The stromal vascular fraction (SVF) isolated from adipose tissue, which contains stem cells as well as other cell types, has been applied in various research fields. Although different enzymatic concentrations and treatment durations have been applied to isolate the SVF, optimal conditions have not been established. Thus, we aimed to establish the optimal conditions for isolation of the SVF from adipose tissue by automated systems.

METHODS

The SVF was collected from removed adipose tissues of five donors during surgery. The SVF was treated with 0.1% or 0.2% collagenase type I for 20, 40, or 60 min. Then, colony forming unit (CFU) assays and flow cytometry were performed to characterize the adipose stem cells (ASCs). A cytokine array was used to investigate the correlation between colony-formation ability and the secretion of isolated ASCs.

RESULTS

Treatment with 0.1% collagenase type I for 60 min resulted in a higher SVF yield, whereas treatment with 0.1% collagenase for 40 min resulted in higher CFU values. In addition, expression of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 in the SVF was higher in the high-CFU group than in the low-CFU group.

CONCLUSION

The optimal conditions for isolation of the SVF from adipose tissue were treatment with 0.1% collagenase type I for 40 min. We identified the conditions required for efficient SVF isolation based on high CFU values, and our results will facilitate the development of automated systems.

Engineering 3D degradable, pliable scaffolds toward adipose tissue regeneration; optimized printability, simulations and surface modification

We present a solution to regenerate adipose tissue using degradable, soft, pliable 3D-printed scaffolds made of a medical-grade copolymer coated with polydopamine. The problem today is that while printing, the medical grade copolyesters degrade and the scaffolds become very stiff and brittle, being not optimal for adipose tissue defects. Herein, we have used high molar mass poly(L-lactide-co-trimethylene carbonate) (PLATMC) to engineer scaffolds using a direct extrusion-based 3D printer, the 3D Bioplotter®. Our approach was first focused on how the printing influences the polymer and scaffold's mechanical properties, then on exploring different printing designs and, in the end, on assessing surface functionalization. Finite element analysis revealed that scaffold's mechanical properties vary according to the gradual degradation of the polymer as a consequence of the molar mass decrease during printing. Considering this, we defined optimal printing parameters to minimize material's degradation and printed scaffolds with different designs. We subsequently functionalized one scaffold design with polydopamine coating and conducted in vitro cell studies. Results showed that polydopamine augmented stem cell proliferation and adipogenic differentiation owing to increased surface hydrophilicity. Thus, the present research show that the medical grade PLATMC based scaffolds are a potential candidate towards the development of implantable, resorbable, medical devices for adipose tissue regeneration.

Reconstruction of midface defects using local flaps: An algorithm for appropriate flap choice

BACKGROUND

Local flap surgery is commonly performed to cover defects with appropriate skin color and texture match. The purpose of this study was to present an algorithm for choosing an appropriate flap when reconstructing a midface defect using a local flap.

METHODS

Between February 2013 and February 2019, 38 patients with midface defects underwent local flap surgery. All defects larger than 3 cm in diameter were reconstructed with perforator-based transposition flaps. Defects smaller than 3 cm in diameter were reconstructed differently depending on their location. Defects near the nasolabial fold (NLF) were reconstructed with perforator-based transposition flaps, whereas defects just on the NLF were reconstructed with VY advancement flaps. Defects distant from the NLF were also reconstructed with VY advancement flaps.

RESULTS

Perforator-based transposition flaps were used in 22 cases and VY advancement flaps were used in 16 cases according to our new algorithm. All flaps survived without any complications. The aesthetic results were superior for VY advancement flaps, with higher patient satisfaction scores. The skin color match was similar for both flaps, but the contour was more natural in advancement flaps than in transposition flaps. However, transposition flaps had the benefits of being able to cover relatively large defects and allowing the donor scar to be hidden in a wrinkle line.

CONCLUSION

The most suitable local flap for coverage of a midface defect can be chosen based on the patient's condition. By following our algorithm, appropriate reconstructions can be performed, with satisfactory results.