Biostimulating fillers and induction of inflammatory pathways: A preclinical investigation of macrophage response to calcium hydroxylapatite and poly‐L lactic acid

Abstract Introduction Initial macrophage response to biostimulatory substances is key in determining the subsequent behavior of fibroblasts and the organization of newly synthesized collagen. Though histological studies suggest that calcium hydroxylapatite (CaHA) filler initiates a regenerative healing response with collagen and elastin deposition similar to natural, healthy tissue rather than an inflammatory response with fibrosis, the relative activity of macrophages stimulated by CaHA, as well as how this activity compares to that induced by other biostimulatory fillers, has not been explored. The aim of the study is to characterize the in vitro macrophage response to two biostimulory fillers, CaHA and PLLA (poly‐L lactic acid), and to evaluate their inflammatory potential. Methods Primary human macrophages were incubated with two dilutions (1:50 and 1:100) of commercially available CaHA or PLLA. After 24 h incubation, an inflammation array was used to screen for the expression of 40 cytokines, released by macrophages. ELISA was used to confirm array results. Results Four cytokines were significantly upregulated in M1 macrophages incubated with PLLA compared to both unstimulated controls and CaHA: CCL1 ( p < 0.001), TNFRII ( p < 0.01), MIP‐1α ( p < 0.05), and IL‐8 ( p < 0.001). In M2 macrophages, MIP‐1α ( p < 0.01) and MIP‐1β ( p < 0.01) were significantly upregulated by PLLA compared to CaHA and unstimulated controls. Conclusion Together, these findings indicate that the CaHA mode of action is a non‐inflammatory response while PLLA initiates expression of several cytokines known to play a role in inflammation. Our study supports the concept that these two “biostimulatory” fillers follow distinct pathways and should be considered individually with regard to mechanism of action.