Cited by 927Immune cells in cancerTissue Engineering and Regenerative MedicineWound Healing and Treatments

The DOI matches its Crossref record; 161 of the 166 references it cites were found in a registry or an index; none of the 198 sources its claims cite is checked for support yet.

Macrophage polarization: An opportunity for improved outcomes in biomaterials and regenerative medicine

Open access

Abstract

The host response to biomaterials has been studied for decades. Largely, the interaction of host immune cells, macrophages in particular, with implanted materials has been considered to be a precursor to granulation tissue formation, the classic foreign body reaction, and eventual encapsulation with associated negative impacts upon device functionality. However, more recently, it has been shown that macrophages, depending upon context dependent polarization profiles, are capable of affecting both detrimental and beneficial outcomes in a number of disease processes and in tissue remodeling following injury. Herein, the diverse roles played by macrophages in these processes are discussed in addition to the potential manipulation of macrophage effector mechanisms as a strategy for promoting site-appropriate and constructive tissue remodeling as opposed to deleterious persistent inflammation and scar tissue formation.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This review argues that macrophages are not simply drivers of the foreign body reaction; their context-dependent M1/M2 polarization can determine whether injury or implanted biomaterials lead to scarring or constructive tissue remodeling. It proposes that biomaterial properties and regenerative strategies could be designed to steer macrophage phenotype toward M2-like, pro-repair states.

Key findings

  • Macrophages are plastic and exist along an M1/M2 continuum rather than as fixed subsets. M1, or classically activated, macrophages are induced by IFNγ alone or with LPS/TNFα and are pro-inflammatory; M2, or alternatively activated, macrophages are induced by IL-4, IL-13, IL-10, immune complexes, glucocorticoids, or vitamin D3 and are associated with Th2-like, pro-repair responses. A timely M1-to-M2 switch appears necessary for functional remodeling, while failure to resolve polarization is linked to cancer, atherosclerosis, obesity/insulin resistance, periodontal disease, and fibrosis.
  • In tissue remodeling, the default mammalian response to injury often ends in scar tissue. Skin wound healing showed early upregulation of a mixed M1/M2 gene cluster (11 M1 genes and 7 M2 genes) and later upregulation of a predominantly M2 cluster (1 M1 gene and 9 M2 genes). Skeletal muscle repair requires an M1-to-M2 transition; blocking M2-associated gene expression in a mouse necrotic muscle injury model produced highly fibrotic tissue and decreased myofiber size, whereas wild-type mice recovered. In spinal cord injury, a predominantly M1 response persisted, and M2-conditioned media improved neuronal survival and neurite extension compared with M1-conditioned media.
  • Following biomaterial implantation, macrophage phenotype is associated with outcome. Retrieved periprosthetic tissues from loose total joint replacements with osteolysis showed predominantly M1 macrophages, while synovium from osteoarthritic joints treated by primary joint replacement showed more M2 macrophages. Porous synthetic implants with 30–40 mm pores healed with less fibrosis, greater vascularity, and higher M2/M1 ratios than non-porous controls. Extracellular matrix scaffolds promoted a switch from predominantly M1 cells immediately after implantation to an M2-enriched population by 7–14 days; crosslinking that delayed degradation inhibited the M2 response and led to scar tissue.
  • Adipose tissue macrophages illustrate disease-associated polarization shifts: they can make up as much as 10% of cells in lean tissue and as much as 40% in obese tissue, with M2-like cells in lean states and strongly M1-like cells in obesity.

Methods

  • Narrative review, not a primary study; no new experiments, systematic search, or meta-analysis are described.
  • The paper synthesizes literature on macrophage biology, disease pathogenesis, tissue remodeling after injury, and host responses to biomaterials, using selected examples from animal models, human tissue retrieval studies, and in vitro work.
  • Main analysis is conceptual and thematic, organizing evidence around M1/M2 polarization, plasticity, and the potential for biomaterials to modulate macrophage phenotype.

Limitations

  • Stated: the exact factors and mechanisms controlling macrophage differentiation and polarization switching are not fully identified; few studies have specifically evaluated macrophage polarization after biomaterial implantation; further studies are needed to define M1/M2 involvement in conditions such as periodontal disease and to develop strategies for controlling phenotype.
  • Evident: as a narrative review, the selection of examples is not systematic and no quantitative synthesis is provided; many cited findings come from animal models or in vitro systems, which limits direct clinical generalizability.

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Integrity signals

Registry

Crossref · 10.1016/j.biomaterials.2012.02.034

Cites

161 of 161 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

0 of 198 cited sources checked · 0 supported · 0 flagged

Show all 76 claims

  • Probably not a substantial claim. 11
  • It may state two separate claims as one. 48
  • The quote only partly states this claim. 1
57 of 57
  • The paper relies on this without support.

    The ultimate functional success or failure of implantable materials is a function of the host tissue response and associated remodeling at each anatomical site.

    “However, the ultimate functional success or failure of such materials is invariably a function of the host tissue response to the presence of the materials and the associated remodeling process at each anatomical site.”
  • The paper relies on this without support.

    Surface structure, both topographical and chemical, are critically important determinants of downstream events at the material-tissue interface.

    “Therefore, surface structure, both topographical and chemical, are critically important determinants of downstream events.”
  • The paper relies on this without support.

    The specific factors and exact mechanisms controlling macrophage differentiation upon entering tissues have not been fully identified.

    “However, the specific factors and exact mechanisms which control macrophage differentiation upon entering tissues have not yet been fully identified.”
  • The paper relies on this without support.

    The M1/M2 paradigm provides a useful simplified framework for deciphering macrophage roles in disease and tissue remodeling.

    “However, the M1/M2 paradigm provides a simplified framework from which to begin deciphering the complex and context dependent roles of macrophages in disease and tissue remodeling.”
  • The paper relies on this without support.

    Manipulating macrophage effector mechanisms can promote site-appropriate constructive tissue remodeling rather than persistent inflammation and scar formation.

    “Herein, the diverse roles played by macrophages in these processes are discussed in addition to the potential manipulation of macrophage effector mechanisms as a strategy for promoting site-appropriate and constructive tissue remodeling as opposed to deleterious persistent inflammation and scar tissue formation.”
  • The paper relies on this without support.

    Few studies have assessed the role of specific macrophage sub-populations in dermal wound healing remodeling.

    “However, despite the understanding that macrophages play an important and potentially determinant role in dermal wound healing, few studies to date have assessed the role of specific macrophage sub-populations in the remodeling process.”
  • The paper relies on this without support.

    Every material used in implantable medical devices, tissue engineered constructs, or scaffold-based approaches will evoke a host response beginning immediately upon implantation.

    “Every material used in implantable medical devices, tissue engineered constructs, or scaffold-based approaches to regenerative medicine will evoke a host response which begins immediately upon implantation.”
  • The paper relies on this without support.

    Few studies have evaluated macrophage polarization specifically with respect to biomaterials implantation.

    “However, few studies have evaluated macrophage polarization specifically with respect to biomaterials implantation.”
  • The paper relies on this without support.

    In periprosthetic tissues from loose, revised implants with osteolysis, M1 macrophages predominate, whereas M2 macrophages are more prevalent in synovium from osteoarthritic joints treated by primary total joint replacement.

    “In the former tissues, an M1 macrophage phenotype predominated, whereas M2 macrophages were more prevalent in the latter tissues, indicating that macrophage phenotype may play an important role in outcomes following TJR.”
  • The paper relies on this without support.

    Exact strategies for eliciting an M2 response and the ability of such strategies to prevent osteolysis have yet to be explored.

    “However, exact strategies for eliciting this type of response and the ability of such strategies to prevent osteolysis have yet to be explored.”
  • The paper relies on this without support.

    Studies examining specific effects of macrophage polarization following implantation of synthetic or naturally derived biomaterials in regenerative medicine have been few.

    “To date, studies examining the specific effects of macrophage polarization following implantation of synthetic or naturally derived biomaterials in regenerative medicine have been few.”
  • The paper relies on this without support.

    Exact mechanisms underlying the observed responses of porous biomaterials remain largely unknown.

    “Although the exact mechanisms which underlie the observed responses still remain largely unknown, such biomaterials mediated control of macrophage phenotype has significant implications for improving outcomes in regenerative medicine.”
  • The paper relies on this without support.

    Mechanisms by which ECM-based scaffold materials promote M1 to M2 transition remain unknown.

    “The mechanisms by which ECM based scaffold materials promote the M1 to M2 transition remain unknown.”
  • The paper relies on this without support.

    Exact surface ligands responsible for macrophage-surface interactions have yet to be identified.

    “While the exact surface ligands responsible have yet to be identified, a better understanding of macrophage-surface ligand interaction has significant potential to inform future biomaterial design and applications.”
  • The paper relies on this without support.

    Exact contributions of specific M1 and M2 populations in fibrosis are not well defined.

    “The exact contributions of specific M1 and M2 populations in fibrosis are not well defined.”
15 of 15

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  • TLR-4 obesity claim conflicts with a cited reference

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    The text says TLR-4 deficiency does not protect against diet-induced obesity, but the title of cited reference 76 says a TLR-4 loss-of-function mutation prevents it.

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Metadata

Authors
Brown, B. N., Ratner, B. D., Goodman, S. B., Amar, S., & Badylak, S. F.
Affiliations
  • University of Pittsburgh (US)
  • University of Washington (US)
  • Stanford Medicine (US)
  • Boston University (US)
Corresponding author
Badylak, Stephen F.
Venue
Biomaterials
Publisher
Elsevier BV
Published
2012-05
Volume
33
Issue
15
Pages
3792-3802
ISSN
0142-9612 (ISSN-L)
OpenAlex
W2055901626
Cited by
926
References
166
Citations by year
2026: 53 · 2025: 53 · 2024: 69 · 2023: 63 · 2022: 77 · 2021: 98 · 2020: 84 · 2019: 64 · 2018: 68 · 2017: 82 · 2016: 65 · 2015: 52 · 2014: 54 · 2013: 33 · 2012: 9
FWCI
4.36
Type
journal article
Language
en
Open access
Locations
  • Biomaterials (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Touro Scholar (Touro College) (submittedVersion)
Funders
National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01AR063717, R01AR055650)
Topics
  • Life Sciences › Immunology and Microbiology › Immunology › Immune cells in cancer
  • Health Sciences › Medicine › Surgery › Tissue Engineering and Regenerative Medicine
  • Health Sciences › Medicine › Surgery › Wound Healing and Treatments
Keywords
macrophage polarization, foreign body reaction, granulation tissue, tissue remodeling, scar formation, chronic inflammation, regenerative medicine, biomaterial implantation
MeSH terms
Animals, Biocompatible Materials, Humans, Macrophages, Cell Polarity, Treatment Outcome, Prostheses and Implants, Regenerative Medicine

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