TABLE 2.

Examples of applications of BC implants in reconstructive surgery.

Reconstructive surgery field	Application description	BC type and modification	Stage of research	Benefits of using BC	Literature
Cardiovascular surgery	BC conduit as small-caliber vascular prosthesis	• wet and dry tubes • smoothness of inner surface improvement • application of antiplatelet therapy	Animals • rabbits, carotid artery • sheep, carotid artery	• excellent anticoagulant properties and cells compatibility	(Weber et al., 2018; Wacker et al., 2020; Bao et al., 2021; Klemm et al., 2021)
				• good tensile strength and suture retention
				• reduced thrombogenic
				potential for smoother BC surface
				• improved patency rates for BC tubes receiving antiplatelet therapy
				• modification of BC with hyaluronic acid triggered the inflammatory reaction
	BC patch for blood vessel reconstruction	• BC patch • BC composite with hyaluronic acid	Animals • pigs, walls of jugular vein and jugular artery		(Kołaczkowska et al., 2019; Osorio et al., 2019; Klemm et al., 2021)
Neurosurgery	BC nerve conduit (tube), regeneration of peripheral nerves	• wet tubes • native and mercerized tubes	Animals • rats, facial nerve and femoral nerve	• BC easily shaped into a hollow tube guided nerve axons, resulting in better nerve regeneration after transection	(Kowalska-Ludwicka et al., 2013; Binnetoglu et al., 2020)
				• reduction of inflammatory reaction and neuroma formation
	BC membrane as dura mater substitute	• native BC • electrospun BC	Animals • rats, rabbits; dural defects	• retaining the properties of local tissues and providing adequate mechanical properties, without the need for sutures	(Lima et al., 2017a; Jing et al., 2020)
				• no induced immune reaction, nor chronic inflammatory response, absence of neurotoxicity signals
				• electrospun BC implantation showed more collagen fibers evenly distributed on the outer side of implants, fewer brain tissue adhesions and epidural scars were found
	BC-based intervertebral disc	• 3D micropatterned BC	Animals • rats, total disk implantation in caudal spine 3/4	• excellent structural (shape maintenance, hydration, tissue integration) and functional (mechanical support and flexibility) performance	Yang et al. (2018)
				• controlled cellular alignment
General surgery	BC based surgical mesh, abdominal muscle aponeurotic defect, hernia repair, soft tissues reinforcement, antiadhesive material	• BC composite with chitosan and/or polypropylene mesh • compact and perforated BC membrane • single-layer dry BNC patches, multi-layered BNC meshes in combination of BNC with standard polypropylene meshes	Animals • rats: implantation into the pocket of panniculus carnosus muscles along the dorsal midline; muscle aponeurotic defect reconstruction; intraperitoneal implantations • rabbits, implantations onto the abdominal wall between the peritoneum and the visceral organs	• reduced immune response	(Coelho Junior et al., 2015; Silveira et al., 2016b; Piasecka-Zelga et al., 2018; Anton-Sales et al., 2021)
				• induced tissue remodelling
				• no connective tissue proliferation in nearby muscle structures
				• superior to common polypropylene and ePTFE meshes biological integration with surrounding tissues
				• reduced peritoneal adhesions as compared to standard synthetic meshes
				• BC laminates with 2 or 3 films were resistant enough to reach the minimal acceptance criteria for abdominal wall reinforcement applications
				• BC exhibited favourable surgical features in terms of saturability, manageability and accommodation to the implantation site
	BC mesh for pelvic floor reconstruction following implantation in the vagina	• native BC membrane	Animals • sheep, implantation in the submucosa of the posterior vagina wall	• biomechanical characteristics and tissue remodelling of the BC mesh met the basic requirements of pelvic floor reconstruction	Ai et al. (2020)
				• negative effect: BC induced greater inflammatory response than standard Gynemesh™ implant
	BC membrane as a protective barrier to prevent urethral damage after implantation of artificial devices	• native BC membrane	Animals • rats, strip of the BC applied around the urethra below the bladder neck	• integration with the surrounding tissue, contributing to its architecture remodelling and strengthening	Lima et al. (2017b)
				• the obtained level of collagen deposition parameters, vascularization and structural increase in urethral wall thickness may represent new perspective for longer survival of artificial implants
	BC membrane to reinforce urethrovesical anastomosis	• perforated native BC membrane	Animals • rabbits, urethrovesical anastomosis with BC reinforcement	• absence of extrusion, stenosis or urinary fistula	Maia et al. (2018)
				• good biocompatibility and biointegration with tendency to the urothelial wall thickening
	BC gel to revert the loss of anal resting pressure after anorectum sphincter injury (fecal incontinence)	• hydrated BC gel	Animals • rats, sphincter injury followed by BC gel injection	• BC presented the ideal characteristics as bulking agent	Cavalcante et al. (2018)
				• increased anorectal resting pressures were observed
				• BC promoted neovascularization, the implant area was colonized by multinucleated giant cells, fibroblasts and dense conjunctive tissue associated to collagen fibres
	BC film for reparation of bile duct injury	• native BC film	Animals • pigs, reconstruction of common bile duct defect	• BC proved to be a biocompatible material that produced a complete healing process and biliary flow continuity	de Abreu et al. (2020)
				• a compact nonporous BC structure prevented leakage of bile
Laryngology	BC graft in closure of tympanic membrane perforation (myringoplasty)	• dried BC membrane	Human • BC put over the perforation and lateral to the tympanic membrane remnant	• 100% healing in patients with BC graft	(Silveira et al., 2016a; Mandour et al., 2019)
				• BC graft myringoplasty was a good, simple, rapid and safe surgery that could be done under local anesthesia in outpatient clinic with shorter time of surgery than fat graft myringoplasty and temporalis fascia graft myringoplasty, with better hearing and healing
				• BC graft functions as an inducer of tissue remodelling and as a promoter of the healing process, by enabling an intensive process of revascularization and epithelialization, which might explain the regeneration of the eardrum remains and also the closure of tympanic membrane
	BC membrane for pharyngocutaneous fistula closure after laryngectomy	• native BC membrane	Animals • rats, pharyngoesophagotomy closed with BC or sutures and BC	• fistula closure was significantly better in BC with primary sutures group	Demir et al. (2018)
				• BC promoted fibroblasts proliferation, which was significantly higher in the group treated with both BC and primary sutures
	BC graft material in correcting and preventing dorsal nasal disorder in rhinoplasty	• native BC membrane	Animals • rats, shredded cartilage wrapped in BC and placed in a subcutaneous area at the back	• good cartilage health and integrity	Aydinli et al. (2017)
				• negative effect: significantly lower degree of vascularization and fibrosis and greater degree of chronic inflammation for BC implants
Other	BC membrane for trapping tumor cells in glioblastoma treatment, implantation after surgical resection	• native BC discs	Animals • rats, implantation in brain parenchyma	• BC was a biocompatible scaffold that could trap tumor cells	Autier et al. (2019)
				• high flexibility made it easy to introduce into the tumor bed after resection and its visibility on MRI may facilitate stereotactic radiosurgery
				• BC could be easily loaded with chemoattractants