Advancements in rhinoplasty: Exploring smart artificial cartilage implants for enhanced tissue regeneration and minimized rejection

Abstract

Rhinoplasty often requires cartilage grafts to restore nasal contour and function. Traditional options, such as autologous, allogeneic, and synthetic materials, remain limited by donor-site morbidity, restricted availability, and long-term complications, including resorption and extrusion. Advances in tissue engineering and biomaterial science have led to the development of smart artificial cartilage implants that combine mechanical strength with biologic responsiveness. These materials can adapt to external stimuli, such as mechanical load, temperature, or electrical signals, promoting better integration and durability. Hydrogels, piezoelectric composites, and nanohybrid scaffolds have shown enhanced chondrogenic potential and mechanical compatibility in preclinical studies. Furthermore, three-dimensional bioprinting and stem-cell–based strategies enable the fabrication of patient-specific constructs that reduce intraoperative manipulation and improve anatomical fit. Although early experimental and limited clinical results are promising, current evidence remains heterogeneous and largely confined to small case series. Broader clinical validation, standardized testing protocols, and clear regulatory frameworks are needed to ensure safe and reproducible translation. Smart artificial cartilage implants thus represent a significant step toward next-generation rhinoplasty materials, merging functional durability with biologic adaptability.

Introduction

Rhinoplasty is one of the most common cosmetic surgical procedures worldwide and often requires cartilage grafting for contour and functional restoration^[1,2]. Traditional graft options include autologous cartilage, allografts, and synthetic materials – all of which have pros and cons[1]. Autologous cartilage continues to be the reference standard because of its resistance to immunogenicity and good biological integration, but well-known donor-site morbidity and limited supply frequently prohibit its use in many patients^[3,4]. The evolution of tissue engineering and three-dimensional bioprinting is overcoming the major limitations of classical grafts by enabling the fabrication of cell-engineered cartilage with minimal patient risk^[5,6]. Using differentiated adipose-derived stem cells into chondrocytes, which secrete extracellular matrix, research aims to biomimic the natural environment that allows in vivo formation of cartilage^[7,8].

HIGHLIGHTS

• Smart artificial-cartilage implants represent a new frontier in rhinoplasty, merging biomechanical design with biological functionality.

• Hydrogels and composites: Hyaluronic-acid–based hydrogels, gelatin-methacrylamide composites, and fiber-reinforced bilayer hydrogels support chondro-conducive microenvironments while offering mechanical reinforcement in both in vitro and in vivo models.

• Three-dimensional bioprinting allows the creation of anatomically accurate implants using cells, growth factors, and customized microarchitectures.

• Preclinical data are encouraging regarding chondrogenic potential, and initial clinical reports show favorable short-term outcomes.

The manuscript follows the TITAN Checklist 2025 guidelines for transparent reporting of AI tool usage[9].

Current issues in rhinoplasty

Surgeons must strike an optimal balance between mechanical stability, biocompatibility, material availability, and esthetic outcomes when choosing graft substrates for rhinoplasty. Autologous cartilage grafts, commonly harvested from septal, auricular, or costal sources, remain the gold standard given their superior biological integration^[4,10]. However, their use is limited by donor-site morbidity, limited volume available for harvest, and the overall additional operative burden on the patient[11]. In contrast, allografts and synthetic implants avoid donor-site complications but are often associated with resorption, infection, extrusion, immune-mediated reactions, and progressive biomechanical degradation over time^[12,13]. Intraoperative precision for accurate graft contouring introduces considerable technical variability, depending on the surgeon’s expertise and manual dexterity. Traditional implant materials may also predispose patients to long-term postoperative complications, such as cutaneous and soft-tissue thinning, implant visibility, and extrusion, particularly when there are discrepancies in the mechanical properties between the graft and host tissue^[14,15].

Smart artificial cartilage implants: definitions and design principles

They consist of smart biomaterials designed to respond specifically to physical or chemical changes in external factors, such as mechanical load, temperature, light, or electrical fields[16]. In the design of implants for rhinoplasty, several critical objectives must be met: matching the implants’ mechanical properties to the native viscoelastic behavior, controlled porosity for tissue ingrowth, predictable degradation kinetics in resorbable constructs, and surface chemistries for cellular adhesion with minimal immune rejection[17].

Materials and manufacturing processes

Hydrogels and composites

Hyaluronic-acid–based hydrogels, gelatin-methacrylamide composites, and fiber-reinforced bilayer hydrogels support chondro-conducive microenvironments while offering mechanical reinforcement in both in vitro and in vivo models^[18,19].

Piezoelectric and nanohybrid materials

Piezoelectric nanohybrid materials, which transduce mechanical stimuli into electrical signals, have shown potential for enhancing chondrogenesis using physiological loading to drive extracellular-matrix deposition in preclinical models; however, their actual applications remain limited^[20,21].

Bioprinting and patient-specific constructs

Three-dimensional bioprinting allows the creation of anatomically accurate implants using cells, growth factors, and customized microarchitectures. Adipose-derived stem cells are one of the most common seed cells used because of their easy accessibility and strong chondrogenic potential. This approach minimizes intraoperative graft sculpting and allows preoperative planning for an optimal anatomical fit^[7,22].

Biological augmentation and functionalization

Growth factors and cell-based strategies

Functionalization of scaffolds with chondrogenic cues, such as TGF-β3 and MGF, has increased extracellular-matrix deposition and induced the creation of hyaline-like cartilage in preclinical models^[,23,24]. Silk-fibroin scaffolds and sericin-based hydrogels represent biomimetic matrices that support chondrocyte viability, proliferation, and matrix synthesis^[25,26].

Acellular ECM and MSC strategies

Decellularized extracellular-matrix constructs and mesenchymal-stromal-cell-based approaches facilitate host-tissue integration with reduced immunogenic responses. Preclinical studies have confirmed that when MSC therapies are combined with mECM scaffolds, they enhance graft–host-interface integration with increased acceleration of matrix maturation^[27,28].

Clinical evidence and long-term outcomes

There are few clinical data on smart cartilage implants in rhinoplasty, and they remain heterogeneous. Most reports represent small case series or device-specific studies with short- to mid-term follow-up. A prospective series of an adjustable titanium-based nasal implant reported extrusion in 3 out of 39 patients at mid-term follow-ups, illustrating device-specific risks and emphasizing the need for long-term evaluation using standardized outcome measures^[29,30].

The mechanical compatibility of polycaprolactone-based scaffolds and other hybrid constructs with native cartilage appears promising, and short-term tolerance has been satisfactory in small clinical series. However, incompletely characterized features – such as long-term durability, host-tissue integration, and immunologic response – should be validated in larger, controlled cohorts with standardized endpoints^[11,31].

Manufacturing and regulatory considerations

Regulatory pathways for implantable devices depend on intended use, material composition, and risk classification. Authorities such as the FDA require conformance with ISO 10993 standards for biocompatibility evaluation and submission of performance and safety data in 510(k) or premarket-approval filings^[32,33]. Manufacturers of implantable devices must provide complete documentation covering material characterization, biological evaluation, mechanical testing, sterilization validation, and post-market vigilance strategies. Additional manufacturing challenges include batch-to-batch consistency, validation of additive manufacturing for patient-specific implants, sterility, and storage. Customized implants also pose standardization and quality-assurance challenges that require early regulatory consideration[32].

Limitations of current evidence

Existing literature is constrained by small sample sizes, heterogeneous outcome measures, variable follow-up durations, and a predominance of preclinical data. Differences in material composition, scaffold architecture, and biological adjuncts limit cross-study comparability. Moreover, economic feasibility and scalability are rarely reported, hindering the translation of experimental approaches into widespread clinical application[27].

Future directions

To enable responsible clinical translation of smart cartilage implants, future research should focus on: (1) establishing multicenter registries and standardized outcome measures for robust, pooled safety and efficacy assessments; (2) conducting randomized controlled trials comparing smart implants with autologous grafts and common alloplastic materials; (3) developing harmonized preclinical-testing pipelines, including mechanical-fatigue, biocompatibility, and long-term-performance endpoints; (4) early regulatory engagement to delineate evidence requirements for personalized implants; and (5) performing cost-effectiveness analyses to support healthcare-system integration[34].

Conclusion

Smart artificial-cartilage implants represent a new frontier in rhinoplasty, merging biomechanical design with biologic functionality. Preclinical data are encouraging regarding chondrogenic potential, and initial clinical reports show favorable short-term outcomes. However, large-scale translation will require long-term data, standardized preclinical and manufacturing protocols, and clear regulatory pathways to ensure safety, efficacy, and reproducibility before routine clinical adoption.

Ethical approval

This article is a review of the literature and does not involve any new studies with human or animal subjects conducted by any of the authors.

Consent

A review paper does not need consent because it does not involve any new human subjects or data collection – only the analysis of previously published material.

Sources of funding

This research received no external funding.

Author contributions

M.H.A., J.N., N.S., H.K., N.K., A.J., and H.S.: writing and editing – manuscript; M.O.: supervising and final review. All the authors have read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Research registration unique identifying number (UIN)

Registration is not applicable for this type of study.

Guarantor

Mohamad Obeid.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

This study is based on previously published data.