Paradigm Shift in Rhinoplasty with Virtual 3D Surgery Software and 3D Printing Technology.

Most Asians have a nose with a short columella and a low dorsum; augmentation rhinoplasty using implants is commonly performed in Asian countries to achieve a taller and more well-defined nasal dorsum. However, the current knowledge is insufficient to fully understand the various subjective desires of patients, reflect on them during surgery, or to objectively analyze the results after surgery. Advances in digital imaging technologies, such as 3D printing and 3D scanning, have transformed the medical system from hospital-centric to patient-centric throughout the medical field. In this study, we applied these techniques to rhinoplasty. First, we used virtual 3D plastic surgery software to enable surgical planning through objectified numerical calculations based on the visualized data of the patient's medical images rather than simple virtual plastic surgery. Second, the customized nasal implant was manufactured by reflecting the patient's anatomical shape and virtual 3D plastic surgery data. Taken together, we describe the surgical results of applying these rhinoplasty solutions in four patients. Our experience indicates that high fidelity and patient satisfaction can be achieved by applying these techniques.

A multi-channel collagen conduit with aligned Schwann cells and endothelial cells for enhanced neuronal regeneration in spinal cord injury.

Traumatic spinal cord injury (SCI) leads to Wallerian degeneration and the accompanying disruption of vasculature leads to ischemia, which damages motor and sensory function. Therefore, understanding the biological environment during regeneration is essential to promote neuronal regeneration and overcome this phenomenon. The band of Büngner is a structure of an aligned Schwann cell (SC) band that guides axon elongation providing a natural recovery environment. During axon elongation, SCs promote axon elongation while migrating along neovessels (endothelial cells [ECs]). To model this, we used extrusion 3D bioprinting to develop a multi-channel conduit (MCC) using collagen for the matrix region and sacrificial alginate to make the channel. The MCC was fabricated with a structure in which SCs and ECs were longitudinally aligned to mimic the sophisticated recovering SCI conditions. Also, we produced an MCC with different numbers of channels. The aligned SCs and ECs in the 9-channel conduit (9MCC-SE) were more biocompatible and led to more proliferation than the 5-channel conduit (5MCC-SE) in vitro. Also, the 9MCC-SE resulted in a greater healing effect than the 5MCC-SE with respect to neuronal regeneration, remyelination, inflammation, and angiogenesis in vivo. The above tissue recovery results led to motor function repair. Our results show that our 9MCC-SE model represents a new therapeutic strategy for SCI.

In vitro skin irritation assessment using EpiDerm™: applicability for updating toxicity information of oxybenzone and N,N-diethyl-m-toluamide.

A skin irritation test using in vitro reconstructed human epidermis (RhE) models was established for hazard identification of irritant chemicals in accordance with UN Globally Harmonized System of Classification and Labelling of Chemicals (GHS) category. In this study, EpiDerm™ was used to assess skin irritation by oxybenzone and N,N-diethyl-m-toluamide (DEET), which are widely used sunscreen and insect repellent components, respectively. EpiDerm™ was applied with oxybenzone and DEET, combined and sequentially with each single dose. Epidermal morphology and differentiation/proliferation were examined microscopically. Oxybenzone and sequential administration groups were determined as nonirritant with cell viability >50% and the morphology was comparable to the human epidermis. Contrastingly, the DEET and coadministration groups exhibited cell viability <50% and poor epidermal morphology. Interleukin (IL)-1α release from substance-treated EpiDerm™ increased inversely to cell viability, suggesting the pro-inflammatory reaction was initiated by DEET. CK-10, E-cadherin, Ki-67, laminin, and ceramide were identified as relevant markers to assess oxybenzone- or DEET-induced epidermal injury. In conclusion, these results may indicate to be aware of the possible skin irritation by indiscriminate use of oxybenzone and DEET without animal testing.

A potential dermal substitute using decellularized dermis extracellular matrix derived bio-ink.

Upon bioprinting, cells are mixed with a biomaterial to fabricate a living tissue, thus emphasizing the importance of biomaterials. The biomaterial used in this study was a bio-ink prepared using skin decellularized extracellular matrix (dECM). Skin dECM was extracted by treating the dermis with chemicals and enzymes; the basic structural and functional proteins of the ECM, including collagen, glycosaminoglycans (GAGs), bioreactive materials and growth factors, were preserved, whereas the resident cells that might cause immune rejection or inflammatory responses were removed. The bio-ink based on dECM powder, together with human dermal fibroblasts (HDFs), was loaded into the nozzle of the 3D bioprinter to create the 3D construct. This construct underwent gelation with changing temperature while its shape was maintained for 7 days. The cells showed over 90% viability and proliferation. By analysing the gene expression pattern in the cells of the construct, the skin regenerative mechanism of the bio-ink was verified. Microarray results confirmed that the gene expression related to skin morphology and development had been enhanced because the bioreactive molecules and growth factors, in addition to residual ECM in dECM, provided an optimal condition for the HDFs.

Porosity effect of 3D-printed polycaprolactone membranes on calvarial defect model for guided bone regeneration.

The appropriate porosity and pore size of barrier membranes were associated with the transportation of biomolecules required for new bone formation and angiogenesis. In this study, we fabricated three-dimensional (3D)-printed resorbable polycaprolactone (PCL) membranes with different porosities (30%, 50%, and 70%) to evaluate the effective pore size for guided bone regeneration (GBR) membranes. To analyze mechanical properties and cytocompatibility, PCL membranes prepared using extrusion-based 3D printing technology were compared in dry and wet conditions and tested in vitro. The proliferation rates and pattern of fibroblasts and preosteoblasts on PCL membranes with different porosities were determined using a cell counting kit-8 assay and scanning electron microscopy. PCL membrane porosity did not affect cell proliferation, but osteogenic differentiation and mechanical properties were increased with lower porosity (30%) on day 14 (p < 0.001). Similar results were found in an in vivo calvarial defect model; new bone formation was significantly higher in PCL membranes with lower porosity (p < 0.001). These results indicate that 3D-printed PCL with 30% porosity (130 µm pore size) is an excellent pore size for GBR membranes.

Precise stacking of decellularized extracellular matrix based 3D cell-laden constructs by a 3D cell printing system equipped with heating modules.

Three-dimensional (3D) cell printing systems allow the controlled and precise deposition of multiple cells in 3D constructs. Hydrogel materials have been used extensively as printable bioinks owing to their ability to safely encapsulate living cells. However, hydrogel-based bioinks have drawbacks for cell printing, e.g. inappropriate crosslinking and liquid-like rheological properties, which hinder precise 3D shaping. Therefore, in this study, we investigated the influence of various factors (e.g. bioink concentration, viscosity, and extent of crosslinking) on cell printing and established a new 3D cell printing system equipped with heating modules for the precise stacking of decellularized extracellular matrix (dECM)-based 3D cell-laden constructs. Because the pH-adjusted bioink isolated from native tissue is safely gelled at 37 °C, our heating system facilitated the precise stacking of dECM bioinks by enabling simultaneous gelation during printing. We observed greater printability compared with that of a non-heating system. These results were confirmed by mechanical testing and 3D construct stacking analyses. We also confirmed that our heating system did not elicit negative effects, such as cell death, in the printed cells. Conclusively, these results hold promise for the application of 3D bioprinting to tissue engineering and drug development.

Effects of 3D-Printed Polycaprolactone/ß-Tricalcium Phosphate Membranes on Guided Bone Regeneration.

This study was conducted to compare 3D-printed polycaprolactone (PCL) and polycaprolactone/ß-tricalcium phosphate (PCL/ß-TCP) membranes with a conventional commercial collagen membrane in terms of their abilities to facilitate guided bone regeneration (GBR). Fabricated membranes were tested for dry and wet mechanical properties. Fibroblasts and preosteoblasts were seeded into the membranes and rates and patterns of proliferation were analyzed using a kit-8 assay and by scanning electron microscopy. Osteogenic differentiation was verified by alizarin red S and alkaline phosphatase (ALP) staining. An in vivo experiment was performed using an alveolar bone defect beagle model, in which defects in three dogs were covered with different membranes. CT and histological analyses at eight weeks after surgery revealed that 3D-printed PCL/ß-TCP membranes were more effective than 3D-printed PCL, and substantially better than conventional collagen membranes in terms of biocompatibility and bone regeneration and, thus, at facilitating GBR.

New application of three-dimensional printing biomaterial in nasal reconstruction.

OBJECTIVES: Polycaprolactone (PCL) is an U.S. Food and Drug Administration-approved synthetic biodegradable polymer and is easily fabricated into three-dimensional (3D) structures. In this study, the 3D-printed PCL implant for nasal augmentation was further evaluated for its suitability for nasal surgeries such as septoplasty and rhinoplasty. METHODS: Ten New Zealand White rabbits were included and divided into study and sham groups (7 and 3, respectively). A lateral incision was made on the nasal dorsum and a pocket formed in the subperichondrial plane between the upper lateral cartilage and nasal septum. Polycaprolactone was fabricated based on 3D printing technology into a 0.8 × 0.8-cm rectangular shape for use as a nasal implant. The material was inserted as a septal extension graft and sutured with alar cartilage for nasal reshaping. The implants were harvested 4, 8, and 12 weeks after implantation and evaluated by gross morphological assessment and histological examination. RESULTS: The initial shape of the implant was unchanged in all cases, and no definitive postoperative complications were seen over the 3-month period. Gross morphological evaluation confirmed that implants remained in their initial location without migration or extrusion. Histologic evaluations showed that the implant architectures were maintained with excellent fibrovascular ingrowth and minimal inflammatory reactions. CONCLUSION: Polycaprolactone can be used for nasal reconstruction such as nasal augmentation. Polycaprolactone is easy to work with and will avoid the increased operative time and morbidity associated with autograft harvesting. Therefore, PCL implants designed by 3D printing can serve as clinically biocompatible materials in craniofacial reconstruction in the future. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:1036-1043, 2017.

Interaction between platelets and endothelial progenitor cells via LPA-Edg-2 axis is augmented by PPAR-δ activation.

BACKGROUND: Peroxisome proliferator-activated receptor (PPAR)-δ is a nuclear receptor regulating cell metabolism. The role of PPAR-δ in late endothelial progenitor cells (EPCs) has not been fully elucidated. We aim to understand the effects of PPAR-δ activation on late EPC and to reveal the underlying mechanism. METHODS AND RESULTS: Treatment with a highly selective PPAR-δ agonist (GW501516) induced proliferation of late EPCs and enhanced their vasculogenic potential. Search for the target molecule of PPAR-δ activation revealed endothelial differentiation gene (Edg)-2. Chromatin immunoprecipitation and promoter assays demonstrated that Edg-2 gene was specifically induced by PPAR-δ through direct transcriptional activation. Lysophosphatidic acid (LPA), an Edg ligand, mimicked the pro-vasculogenic effects of GW501516 in late EPCs whereas Edg antagonist (Ki16425) blocked these effects. Edg-2 is a membrane receptor for LPA which is a major growth factor from activated platelets. Thus, the interaction between platelets and late EPCs via the LPA-Edg-2 axis was assessed. Platelet supernatant boosted the pro-vasculogenic effects of GW501516, which was reversed by antagonist to PPAR-δ (GSK0660) or Edg (Ki16425). Both of in vivo Matrigel plug model and mouse skin punch-wound model demonstrated that the combination of platelets and PPAR-δ-activated late EPCs synergistically enhanced vascular regeneration. CONCLUSIONS: There exists a synergistic interaction between human platelets and late EPCs leading to vascular regeneration. This interaction consists of LPA from platelets and its receptor Edg-2 on the surface of EPCs and can be potentiated by PPAR-δ activation in EPCs. A PPAR-δ agonist is a good candidate to achieve vasculogenesis for ischemic vascular disease.

AKAP6 inhibition impairs myoblast differentiation and muscle regeneration: Positive loop between AKAP6 and myogenin.

Skeletal muscle regeneration occurs continuously to repair muscle damage incurred during normal activity and in chronic disease or injury. Herein, we report that A-kinase anchoring protein 6 (AKAP6) is important for skeletal myoblast differentiation and muscle regeneration. Compared with unstimulated skeletal myoblasts that underwent proliferation, differentiated cells show significant stimulation of AKAP6 expression. AKAP6 knockdown with siRNA effectively halts the formation of myotubes and decreases the expression of the differentiation markers myogenin and myosin heavy chain. When shAKAP6-lentivirus is delivered to mice with cardiotoxin (CTX)-induced muscle injury, muscle regeneration is impaired compared with that of mice injected with control shMock-lentivirus. The motor functions of mice infected with shAKAP6-lentivirus (CTX+shAK6) are significantly worse than those of mice infected with shMock-lentivirus (CTX+shMock). Mechanistic analysis showed that AKAP6 promotes myogenin expression through myocyte enhancer factor 2A (MEF2A). Notably, myogenin increases AKAP6 expression as well. The results of chromatin immunoprecipitation and luciferase assays showed that myogenin binds to an E-box site on the AKAP6 promoter. Taken together, our findings demonstrate a novel interplay between AKAP6 and myogenin, and we suggest that AKAP6 is an important regulator of myoblast differentiation, myotube formation, and muscle regeneration.