Hydrogels are polymeric materials with chemically, physically or topologically crosslinked networks which have a capacity to absorb and retain water. They have been frequently used for many medical applications because of their useful physical properties such as oxygen permeability and excellent compatibility with living tissue and blood. The long term goal of this research is to develop a hydrogel system for potential use in reconstructive and plastic surgeries such as the closure of cleft palate defects and syndactyly (congenitally fused fingers or toes) repair. The medical requirements for such systems are not only a high degree of swelling, but also slow swelling rate, preferred direction of swelling (anisotropic swelling), appropriate mechanical strength, in addition to being biocompatible. A large degree of swelling would limit the number of surgical procedures required thereby reducing the cost and risk of surgery. A slow swelling rate can avoid tissue necrosis and help tissue growth during the tissue expansion process. Anisotropic swelling is required for specific surgical applications such as cleft palate repairs. Known to be biocompatible hydrogel systems, of a neutral gel system consisting of N-vinyl-2-pyrrolidinone (VP) and 2-hydroxyethyl methacrylate (HEMA) copolymers and an ionizable gel system of VP and acrylic acid (AA) copolymers were prepared using thermal and controlled UV-initiated polymerization. Using these VP/HEMA and VP/AA gel systems, various approaches to control their degree and rate of swelling were studied as a function of key controllable parameters. Their mechanical properties and structural characteristics determining their swelling behavior and mechanical properties also were investigated. Through these studies, how to control the key parameters that affect such swelling behavior was understood in addition to optimizing the gel systems for large degree of swelling, slow swelling rate, and mechanical integrity. Investigations into a number of methods to control the swelling rate were also undertaken for different VP/HEMA based gel systems. Multilayers of alternating gels and elastomer films (polybutadiene (PB) or polydimethylsiloxane (PDMS)) as well as gels encapsulated with the elastomer films were prepared. In addition, gels were prepared with inclusion of either silver nanoparticles or methacrylates with increasing the length of hydrophobic groups for the studies of swelling rate. In this work, two novel methods to control swelling direction (anisotropic swelling) of hydrogels were investigated. One method induces anisotropic swelling through structural gradients within the VP/HEMA gels synthesized by UV polymerization using gradient photomasks. A more promising method used stress induced anisotropic swelling for compressed VP/AA gels. The morphology-gradient VP/HEMA hydrogel system did not show large scale anisotropic swelling. However, the compressed VP/AA gels produced significant anisotropic swelling due to the controlled anisotropy of network morphology. A systematic study as a function of compression temperature, stain and strain rate was performed to derive an understanding of the anisotropic swelling behavior. These compressed gel systems produced not only a large degree of swelling and slow swelling rates but also high anisotropic swelling and proper mechanical stiffness of hydrogels. These materials are believed to be ideal candidates for tissue or skin expansion.

Artificial tissue expansion is required to generate new skin prior to reconstructive surgery, in order to compensate for a deficit of healthy tissue. Hydrogel tissue expanders, which expand anisotropically, show great promise in overcoming clinical limitations in the field, thus allowing the technique to be used in a wider range of surgeries. These devices consist of pellets of dry poly(methyl methacrylate-co-vinylpyrrolidone), compressed into discs through a hot compression moulding process. However, a number of significant problems still exist in these devices, and this thesis aims to address these issues. To date, there has been a lack of investigation of the factors governing the behaviour of anisotropic swelling. For this reason, a range of different compression ratios have been investigated, with particular focus on the relationship between the material flow during compression and the swelling behaviour of the resulting device. It was found that samples of the same initial size expand to the same reference swelling dimensions, regardless of compression ratio. During hot pressing, the material flow was found to be governed by slip-stick behaviour at the interface between the hot press and the device, affecting the properties and swelling behaviour of the devices. Based on these findings, devices were developed which could expand from a disc into a non-prismatic shape (dome or wedge). Such devices could reduce complication rates and allow the growth of new tissue with anisotropic resting tension. The devices were tested in a small in vivo trial, where it was shown that there were no adverse effects on the tissue produced, and that the shape of the expander (dome) was retained. As devices are being produced for medical use, understanding the effect of sterilization by γ-irradiation is essential, but to date this has been overlooked in the literature. It was found that γ-irradiation caused an increase in cross-linking in the P(MMA-co-NVP). Whilst this produced little change in swelling behaviour for isotropic devices, in the case of anisotropic devices it caused a change in the shape of expansion, reducing the area of new skin which could be generated by the device. It was found that by reducing the concentration of impurities (residual molecules from the polymer synthesis) the impact of γ-irradiation could be greatly reduced. Finally, controlling the rate of expansion is essential in order to avoid clinical complications. In order to control the rate of expansion, particularly during the initial period of swelling, semi-permeable PDMS coatings were applied to the compressed devices. Coatings of thickness greater than 0.375mm were found to effectively control the rate of swelling, for both cylindrical and non-prismatic shapes. As the coating thickness increased, the maximum swelling size decreased. However, it has been shown that change in height (the parameter which governs the area of skin produced) is affected less than the change in mass or diameter.

<p>Breast cancer affects 12.5\% of women over their life time and tissue expansion (TE) is the most common technique for breast reconstruction after mastectomy. However, the rate of complications with TE can be as high as 15\%. Even though the first documented case of TE happened in 1957, there has yet to be a standardized procedure established due to the variations among patients and the TE protocols are currently designed based on surgeon's experience. There are several studies of computational and theoretical framework modeling skin growth in TE but these tools are not used in the clinical setting. This dissertation focuses on bridging the gap between the already existing skin growth modeling efforts and it's potential application in the clinical setting.</p> <p><br></p> <p>We started with calibrating a skin growth model based on porcine skin expansions data. We built a predictive finite element model of tissue expansion. Two types of model were tested, isotropic and anisotropic models. Calibration was done in a probabilistic framework, allowing us to capture the inherent biological uncertainty of living tissue. We hypothesized that the skin growth rate was proportional to stretch. Indeed, the Bayesian calibration process confirmed that this conceptual model best explained the data. </p> <p><br></p> <p>Although the initial model described the macroscale response, it did not consider any activity on the cellular level. To account for the underlying cellular mechanisms at the microscopic scale, we have established a new system of differential equations that describe the dynamics of key mechanosensing pathways that we observed to be activated in the porcine model. We calibrated the parameters of the new model based on porcine skin data. The refined model is still able to reproduce the observed macroscale changes in tissue growth, but now based on mechanistic knowledge of the cell mechanobiology.  </p> <p><br></p> <p>Lastly, we demonstrated how our skin growth model can be used in a clinical setting. We created TE simulations matching the protocol used in human patients and compared the results with clinical data with good agreement. Then we established a personalized model built from 3D scans of a patient unique geometry. We verified our model by comparing the skin growth area with the area of the skin harvested in the procedure, again with good agreement.</p> <p><br></p> <p>Our work shows that skin growth modeling can be a powerful tool to aid surgeons design TE procedures before they are actually performed. The simulations can help with optimizing the protocol to guarantee the correct amount of skin is growth in the shortest time possible without subjecting the skin to deformations that can compromise the procedure.</p>

<div>Excessive deformation and stress of skin following reconstructive surgery plays a crucial role in wound healing, often leading to complications. Yet, despite of this concern, surgeries are still planned and executed based on each surgeon's training and experience rather than quantitative engineering tools. The limitations of current treatment planning and execution stem in part from the difficulty in predicting the mechanical behavior of skin, challenges in directly measuring stress in the operating room, and inability to predict the long term adaptation of skin following reconstructive surgery. Computational modeling of soft tissue mechanics has emerged as an ideal candidate to determine stress contours over sizable skin regions in realistic situations. Virtual surgeries with computational mechanics tools will help surgeons explore different surgeries preoperatively, make prediction of stress contours, and eventually aid the surgeon in planning for optimal wound healing. While there has been significant progress on computational modeling of both reconstructive surgery and skin mechanical and mechanobiological behavior, there remain major gaps preventing computational mechanics to be widely used in the clinical setting. At the preoperative stage, better calibration of skin mechanical properties for individual patients based on minimally invasive mechanical tests is still needed. One of the key challenges in this task is that skin is not stress-free in vivo. In many applications requiring large skin flaps, skin is further grown with the tissue expansion technique. Thus, better understanding of skin growth and the resulting stress-free state is required. The other most significant challenge is dealing with the inherent variability of mechanical properties and biological response of biological systems. Skin properties and adaptation to mechanical cues changes with patient demographic, anatomical location, and from one individual to another. Thus, the precise model parameters can never be known exactly, even if some measurements are available. Therefore, rather than expecting to know the exact model describing a patient, a probabilistic approach is needed. To bridge the gaps, this dissertation aims to advance skin biomechanics and computational mechanics tools in order to make virtual surgery for clinical use a reality in the near future. In this spirit, the dissertation constitutes three parts: skin growth and its incompatibility, acquisition of patient-specific geometry and skin mechanical properties, and uncertainty analysis of virtual surgery scenarios.</div><div>Skin growth induced by tissue expansion has been widely used to gain extra skin before reconstructive surgery. Within continuum mechanics, growth can be described with the split of the deformation gradient akin to plasticity. We propose a probabilistic framework to do uncertainty analysis of growth and remodeling of skin in tissue expansion. Our approach relies on surrogate modeling through multi-fidelity Gaussian process regression. This work is being used calibrate the computational model against animal model data. Details of the animal model and the type of data obtained are also covered in the thesis. One important aspect of the growth and remodeling process is that it leads to residual stress. It is understood that this stress arises due to the nonhomogeneous growth deformation. In this dissertation we characterize the geometry of incompatibility of the growth field borrowing concepts originally developed in the study of crystal plasticity. We show that growth produces unique incompatibility fields that increase our understanding of the development of residual stress and the stress-free configuration of tissues. We pay particular attention to the case of skin growth in tissue expansion.</div><div>Patient-specific geometry and material properties are the focus on the second part of the thesis. Minimally invasive mechanical tests based on suction have been developed which can be used in vivo, but these tests offer only limited characterization of an individual's skin mechanics. Current methods have the following limitations: only isotropic behavior can be measured, the calibration problem is done with inverse finite element methods or simple analytical calculations which are inaccurate, the calibration yields a single deterministic set of parameters, and the process ignores any previous information about the mechanical properties that can be expected for a patient. To overcome these limitations, we recast the calibration problem in a Bayesian framework. To sample from the posterior distribution of the parameters for a patient given a suction test, the method relies on an inexpensive Gaussian process surrogate. For the patient-specific geometry, techniques such as magnetic resonance imaging or computer tomography scans can be used. Such approaches, however, require specialized equipment and set up and are not affordable in many scenarios. We propose to use multi-view stereo (MVS) to capture patient-specific geometry.</div><div>The last part of the dissertation focuses on uncertainty analysis of the reconstructive procedure itself. To achieve uncertainty analysis in the clinical setting we propose to create surrogate and reduced order models, especially principal component analysis and Gaussian process regression. We first show the characterization of stress profiles under uncertainty for the three most common flap designs. For these examples we deal with idealized geometries. The probabilistic surrogates enable not only tasks such as fast prediction and uncertainty quantification, but also optimization. Based on a global sensitivity analysis we show that the direction of anisotropy of skin with respect to the flap geometry is the most important parameter controlled by the surgeon, and we show hot to optimize the flap in this idealized setting. We conclude with the application of the probabilistic surrogates to perform uncertainty analysis in patient-specific geometries. In summary, this dissertation focuses on some of the fundamental challenges that needed to be addressed to make virtual surgery models ready for clinical use. We anticipate that our results will continue to shape the way computational models continue to be incorporated in reconstructive surgery plans.</div>

Adipose tissue is one of the most dynamic tissues in the body and is vital for metabolic homeostasis. In the case of excess nutrient uptake, adipose tissue expands to store excess energy in the form of lipids, and in the case of reduced nutrient intake, adipose tissue can shrink and release this energy. Adipocytes are most functional when the balance between these two processes is intact. To understand the molecular mechanisms that drive insulin resistance or conversely preserve the metabolically healthy state in obese individuals, our laboratory performed a screen for differentially regulated adipocyte genes in insulin resistant versus insulin sensitive subjects who had been matched for BMI. From this screen, we identified the type II transmembrane protein tenomodulin (TNMD), which had been previously implicated in glucose tolerance in gene association studies. TNMD was upregulated in omental fat samples isolated from the insulin resistant patient group compared to insulin sensitive individuals. TNMD was predominantly expressed in primary adipocytes compared to the stromal vascular fraction from this adipose tissue. Furthermore, TNMD expression was greatly increased in human preadipocytes by differentiation, and silencing TNMD blocked adipogenic gene induction and adipogenesis, suggesting its role in adipose tissue expansion. Upon high fat diet feeding, transgenic mice overexpressing Tnmd specifically in adipose tissue developed increased epididymal adipose tissue (eWAT) mass without a difference in mean cell size, consistent with elevated in vitro adipogenesis. Moreover, preadipocytes isolated from transgenic epididymal adipose tissue demonstrated higher BrdU incorporation than control littermates, suggesting elevated preadipocyte proliferation. In TNMD overexpressing mice, lipogenic genes PPARG, FASN, SREBP1c and ACLY were upregulated in eWAT as was UCP-1 in brown fat, while liver triglyceride content was reduced. Transgenic animals displayed improved systemic insulin sensitivity, as demonstrated by decreased inflammation and collagen accumulation and increased Akt phosphorylation in eWAT. Thus, the data we present here suggest that TNMD plays a protective role during visceral adipose tissue expansion by promoting adipogenesis and inhibiting inflammation and tissue fibrosis.

La reconstruction en deux étapes par expanseur et implant est la technique la plus répandue pour la reconstruction mammmaire post mastectomie. La formation d’une capsule périprothétique est une réponse physiologique universelle à tout corps étranger présent dans le corps humain; par contre, la formation d’une capsule pathologique mène souvent à des complications et par conséquent à des résultats esthétiques sous-optimaux. Le microscope électronique à balayage (MEB) est un outil puissant qui permet d’effectuer une évaluation sans pareille de la topographie ultrastructurelle de spécimens. Le premier objectif de cette thèse est de comparer le MEB conventionnel (Hi-Vac) à une technologie plus récente, soit le MEB environnemental (ESEM), afin de déterminer si cette dernière mène à une évaluation supérieure des tissus capsulaires du sein. Le deuxième objectif est d‘appliquer la modalité de MEB supérieure et d’étudier les modifications ultrastructurelles des capsules périprothétiques chez les femmes subissant différents protocoles d’expansion de tissus dans le contexte de reconstruction mammaire prothétique. Deux études prospectives ont été réalisées afin de répondre à nos objectifs de recherche. Dix patientes ont été incluses dans la première, et 48 dans la seconde. La modalité Hi-Vac s’est avérée supérieure pour l’analyse compréhensive de tissus capsulaires mammaires. En employant le mode Hi-Vac dans notre protocole de recherche établi, un relief 3-D plus prononcé à été observé autour des expanseurs BIOCELL® dans le groupe d’approche d’intervention retardée (6 semaines). Des changements significatifs n’ont pas été observés au niveau des capsules SILTEX® dans les groupes d’approche d’intervention précoce (2 semaines) ni retardée. / Two-stage implant-based (expander to implant) breast reconstruction is the most frequently applied technique following total mastectomy. While the periprosthetic capsule is a normal physiologic response to any foreign body, pathological capsule formation often leads complications and suboptimal aesthetic results. The scanning electron microscope (SEM) is a powerful tool that offers unparalleled assessment of capsule ultrastructural topography. The first research aim was to compare conventional high-vacuum (Hi-Vac) SEM with newer environmental scanning electron microscopy (ESEM) technology to determine whether the latter offers superior assessment of breast capsular tissue. The second aim was to apply the most optimal SEM mode to study periprosthetic capsule ultrastructural modifications in women undergoing differing expansion protocols during the first stage of implant-based reconstruction. Ten patients were prospectively included in the first study and 48 prospectively included into the second. Conventional Hi-Vac mode was deemed superior for the comprehensive analysis of breast capsular tissue. Using Hi-Vac mode within the established study protocol, a more pronounced capsular 3-D relief was observed around BIOCELL® expanders when the first postoperative saline inflation took place at 6 weeks following expander insertion (delayed approach). No significant changes were observed with SILTEX® expander capsules in both early (2 weeks) and delayed approach groups.