\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"2538",leadTitle:null,fullTitle:"Glucocorticoids - New Recognition of Our Familiar Friend",title:"Glucocorticoids",subtitle:"New Recognition of Our Familiar Friend",reviewType:"peer-reviewed",abstract:'As one class of the most important steroid hormones, glucocorticoids have long been recognised and their therapeutic benefits have been widely used in clinical treatment, especially in anti-inflammation cases. Glucocorticoids regulate various processes in the body including the mobilization of energy stores, immune functions, gene expression, and maintenance of the homeostasis as well as the stress response, this is not surprising that the concept of "glucocorticoids" is mentioned in almost all medical text books that focus on specific organs or systems such as the cardiovascular system, the immune system, and the neuroendocrine system. The book of Glucocorticoids - New Recognition of Our Familiar Friend aims to introduce the latest findings relating to glucocorticoids, either freshly from the laboratory or from clinical case studies, and to open up a new angle of looking at the issue of balancing the therapeutic benefits and side effects brought up by glucocorticoids.',isbn:null,printIsbn:"978-953-51-0872-6",pdfIsbn:"978-953-51-7046-4",doi:"10.5772/2915",price:159,priceEur:175,priceUsd:205,slug:"glucocorticoids-new-recognition-of-our-familiar-friend",numberOfPages:660,isOpenForSubmission:!1,isInWos:1,hash:"317d6ea020414596baedc9e33fc75c1d",bookSignature:"Xiaoxiao Qian",publishedDate:"November 28th 2012",coverURL:"https://cdn.intechopen.com/books/images_new/2538.jpg",numberOfDownloads:57623,numberOfWosCitations:69,numberOfCrossrefCitations:37,numberOfDimensionsCitations:93,hasAltmetrics:1,numberOfTotalCitations:199,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"December 1st 2011",dateEndSecondStepPublish:"December 22nd 2011",dateEndThirdStepPublish:"March 27th 2012",dateEndFourthStepPublish:"June 25th 2012",dateEndFifthStepPublish:"July 25th 2012",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,editors:[{id:"143871",title:"Dr.",name:"Xiaoxiao",middleName:null,surname:"Qian",slug:"xiaoxiao-qian",fullName:"Xiaoxiao Qian",profilePictureURL:"https://mts.intechopen.com/storage/users/143871/images/3424_n.jpg",biography:"Dr. Xiaoxiao Qian, a neuroscientist/neurobiologist working in the field of stress and depression. After earned her BSc’s degree in Pharmacology and Pharmacy from Peking University (Beijing, China) in 2003, she went to the University of Bristol (Bristol, United Kingdom) to pursue her MSc study in Molecular Neuroendocrinology. After that she went to the University of Oxford (Oxfordshire, United Kingdom) to investigate the brain circuits involved in the pathology of schizophrenia and was rewarded with a D. Phil (PhD) in Neuropharmacology in 2007. Being fascinated by the unknown questions remained in mental diseases, she went back to the University of Bristol and has been investigating the relationship between stress and depression, especially the relationship between hypothalamus-pituitary-adrenal axis and stress response-induced glucocorticoid changes in the body.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Bristol",institutionURL:null,country:{name:"United Kingdom"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1012",title:"Neuroendocrinology",slug:"medicine-endocrinology-neuroendocrinology"}],chapters:[{id:"41176",title:"Mechanisms of Glucocorticoid Receptor (GR) Mediated Corticotropin Releasing Hormone Gene Expression",doi:"10.5772/54844",slug:"mechanisms-of-glucocorticoid-receptor-gr-mediated-corticotropin-releasing-hormone-gene-expression",totalDownloads:1813,totalCrossrefCites:0,totalDimensionsCites:1,signatures:"Rosalie M. 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\r\n\tThis book will discuss the mechanisms by which TTM can mitigate the pathophysiologies responsible for secondary brain injury, as well as the available evidence for use of TTM in multiple neurologic injuries (stated above). In addition, this review will also provide information to help guide this treatment with regard to timing, depth, duration, and management of side-effects. It will also address normothermia and fever prevention in brain injury.
\r\n\tThe book will also discuss the pathophysiology and therapeutic approach to shivering during TTM. It will also provide grounds for future directions in the application of and research with TTM.
Saddle nose is a pathological deformity characterized by loss of nasal dorsal height due to osseocartilaginous collapse.
\nWhile the cause can be congenital, for example, syphilis or intrauterine trauma, most cases are due to trauma of the nasal septum and pyramid, Wegener granulomatosis, relapsing polychondritis, cocaine abuse, and previous rhinoplasty. The removal of an excessive amount of the bone and/or cartilage during a prior operation is the most frequent cause.
\nSaddle nose is one of the most difficult morpho-functional deformities of the nose to correct, as it entails not only masking with a graft but also planned anatomical reconstruction of all the structures involved. Grafts obtained from septal or conchal cartilage, sutured in overlapping layers so as to increase the thickness where necessary, can be sufficient in cases of low to medium severity. The presence of septal remnants can be exploited to combine septal grafts with grafts of auricular concha in order to increase the thickness of the final graft. There is instead less agreement on the choice of material for use in reconstruction in cases of greater severity, where the absence of cartilage is often combined with the absence of the bony support of the nasal pyramid. The ideal graft material must be nontoxic, non-carcinogenic, non-allergenic, nondestructive with respect to adjacent tissues, non-resorbable, readily available, and sterilizable as well as easy to shape and to remove if necessary.
\nThe variety of autogenous (bony and cartilaginous), homologous (irradiated cartilage), and alloplastic grafts put forward in the literature attests to the nonexistence of one “ideal” material. Alloplastic grafts have a tendency toward extrusion and infection, and homologous grafts are characterized by the highest rate of resorption. The bone is difficult to shape, requires solid stabilization, and can be reabsorbed. In the end, despite its tendency toward distortion, costal cartilage remains at present the material of choice for the correction of severe cases of saddle nose.
\nIt should also be pointed out, on the basis of the majority of cases presented in the literature, that cartilaginous grafts give rise to the fewest problems as regards shaping, attachment, and infection. The only negative data regarding resorption is, however, limited in the case of autologous cartilage and generally ceases in the first few months after the operation.
\nThe bone is the material most commonly employed to remedy saddle nose over the last century. The first to use the autologous bone for nasal reconstruction was Ollier in 1861, who inserted a piece of the frontal bone in an Indian flap. The material is mostly taken from the cranium and the iliac crest [1, 2]. The bone cannot be regarded as a material of choice, however, because it tends to be reabsorbed when inserted into the nasal dorsum. Complications at the donor site and the fact that grafts of this nature create a dorsum of excessive rigidity are further reasons why the use of autologous bone in cases of saddle nose has been practically abandoned today [3].
\nCurrently regarded as the graft material closest to the ideal, autologous cartilage presents the following characteristics: (1) it causes little reaction in the tissues of the recipient site; (2) it possesses the combination of rigidity, elasticity, and flexibility required to reconstruct the contours of the nose; (3) it can resist the traction forces of wound healing; (4) it can survive without functional use (unlike the bone); (5) it is available in large amounts; and (6) it is easy to reshape and survives over time without the perichondrium. Tardy reports no cases of infection or rejection in 6000 cartilaginous grafts. It has also been shown that resorption is short-lived and limited to the initial postoperative period [2, 4].
\nIn cases of low or moderate severity, cartilage from the nasal septum or auricular concha can be used. In more severe cases, a graft of costal cartilage constitutes the preferred therapeutic option. This cartilage is hyaline and proves to be rigid and fragile (Figure 1). Always available in large amounts and thicknesses, it is sufficiently rigid for use in cases where it is necessary to counter the retraction of thick, inelastic, cicatricial tissues. While the material is usually harvested from the ninth and tenth ribs, the sixth, seventh, and eighth are preferable in the case of female patients, as the incision is thus made in the inframammary fold and the postoperative scar is not visible. Gunter et al. [5] suggest that a CT scan of the sternal-costal region should be carried out in the case of adult patients to ascertain the degree of calcification of the cartilaginous portion of the ribs.
\nCostal cartilage used to reconstruct the “L-structure” of the septum.
The incision (about 5 cm) must be performed horizontally in the medial (cartilaginous) portion of the rib. In harvesting material from the sixth, seventh, and eighth ribs, it must be borne in mind that their medial portion is covered by the rectus abdominis muscle of the abdomen (Figure 2). The fascia of this muscle must be cut and the fibers opened out in the same direction as the fascicle. The ninth and tenth ribs are instead located at the side of the rectus abdominis muscle. Once the outer surface of the rib has been exposed, it must be separated from the intercostal muscles, which can be facilitated on the inner side by the use of a specific curved rib elevator (Figure 3).
\nPreoperative drawing of the second to sixth rib of a patient.
Harvesting of the cartilaginous segment of the sixth rib.
The perichondrium can be separated from the rib for subsequent use to cover any residual irregularities of the nasal dorsum.
\nParticular care must be taken in detaching the inferior portion of the rib, as this is where the anterior intercostal branches of the internal thoracic (or mammary) artery, the venae comitantes, and the intercostal nerves are all situated. It is important to identify the joint of the bony and cartilaginous portions so as to harvest the largest possible amount of cartilage. Once the portion of the rib required has been exposed and detached, it can be removed by excision, using a scalpel with sturdy blade; after which it is necessary to make sure that the pleura below is undamaged. The cavity thus left is filled with a saline solution, and the anesthetist is asked to increase the pressure in the airways, making sure that no bubbles appear in the cavity.
\nA considerable amount of cartilage can be obtained from the rib, and more than one can be harvested with no postoperative functional deficit (Figure 4).
\nIntraoperative view of the costal harvesting.
It is very important to suture the remaining perichondrium tightly so as to seal off the empty space left after harvesting the rib.
\nThe major problem of costal cartilage is its tendency to become distorted [6]. Various methods have been put forward for the prevention of this complication. Gibson and Davis [7] demonstrated that “balanced cross-sectional carving” (removal of the perichondrium and a strip of cartilage from the outer and inner sides with respect to the thorax and the use of the cartilage in the middle) reduced the tendency toward distortion considerably. Gibson then stated, however, in a later publication that distortion of the cartilage could only be prevented by not harvesting it. Some authors investigated the molecular basis of the tendency toward distortion of the cartilage and showed that certain protein-polysaccharide complexes inhibits the intracartilaginous stress causing distortion, an interesting discovery that has, however, had no clinical application [8]. Gunter et al. [9] have demonstrated that distortion of the harvested costal cartilage is significantly reduced by the insertion of a Kirschner thread. While the different authors all agree that the distortion peaks 15–30 minutes after harvesting, some claim that it exists only in the first half of an hour and others claim that it can take place even months after the operation. The most superficial and deepest layers of the costal cartilage harvested are those that undergo the greatest distortion according to the rule of cross-sectional carving. Common experience suggests that this is accelerated if the cartilage is immersed in a saline solution immediately after removal.
\nComplications in the area of the donor site are very infrequent. They can include pneumothorax, localized postoperative atelectasis, and unsightly scarring. Postoperative pain is instead common and can be prevented or reduced by injecting local anesthetic into the subperichondrial space before the final suturing [10, 11].
\nWhile alloplastic grafts present a high risk of infection and extrusion, many surgeons make use of them at first because they are readily available and, above all, avoid any complications at the donor site. Prostheses of silicone (Silastic) are still widely used by many authors to reconstruct the dorsum in cases of saddle nose, probably because they prove to be easy to handle and to remove in the event of infection [12, 13, 14, 15]. Milward reports extrusion rates of up to 55%, however, and Deva et al. complications in 9.7% of cases [12, 13]. Other materials used include polytetrafluoroethylene and hydroxyapatite. Complications have been reported in 2.6–5% of cases for Gore-Tex and 5% for hydroxyapatite [16, 17].
\nAnother synthetic material frequently used at present with an apparently lower percentage of complications is porous high-density polyethylene (PHDPE: MEDPOR surgical implants, Porex Surgical), which has been employed in cranio-maxillofacial surgery for 20 years now and is of proven tolerability. This porous alloplastic material (pores of about 150 microns in diameter) is not degradable in vivo and permits the fibrointegration of soft tissues. Once this has taken place, it proves to be stable, and the risk of extrusion and infection diminishes over the years. Romo et al. suggest covering the MEDPOR graft with a homologous graft of purified acellular human derma in order to taper the edges and make the dorsum less rigid and more natural in appearance. Even though this is one of the alloplastic materials most frequently used at present, Romo reports complications in 3–4% of cases [17].
\nTardy’s classification of saddle nose has three increasing degrees of severity: minimum, moderate, and major [2]. The first degree involves slight accentuation of the depression of the supratip, 1–2 millimeters above the ideal. The presence can be observed in such cases of a dorsal “pseudo-hump” in the upper third of the nasal pyramid caused by collapse of the other two thirds. If saddle nose deformity is due to the absence of the caudal septum, there will also be a certain degree of columellar retraction. Saddle nose of moderate and major severity presents greater depression of the dorsum due to the loss of osseocartilaginous support.
\nThe classification of Daniel and Brenner [18] instead distinguishes six types of saddle nose:
\n(1) Type 0 (pseudo-saddle nose) comprises patients who present depression of the cartilaginous dorsum due to prior rhinoplasty. (2) Type I (minor) includes cases with excessive depression of the supratip and columellar retraction caused by weakening of the cartilaginous septum. (3) Type II (moderate) is characterized by collapse of the cartilaginous ridge, columellar retraction, and loss of support for the tip. (4) Type III (major) comprises more severe cases with the total absence of support for the cartilaginous ridge, the columella, and the nasal tip. (5) Type IV (severe) involves the total absence of osseocartilaginous support, often combined with septal perforation, depression of the osseocartilaginous dorsum, columellar retraction, and the loss of tip projection. (6) Type V (catastrophic) comprises cases that require local or free flaps for reconstruction and are often combined with deformity of other neighboring regions of the face. The authors correlate each of the different types with a therapeutic approach, increasing in complexity in relation to the tissue deficit involved, and a specific etiology.
\nIt is, however, often difficult in practical terms to identify a particular case of saddle nose as belonging to one category or another of an overly specific classification characterized by common etiologies, clinical characteristics, and therapeutic approaches. As Murakami says, “variability exists to large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities.”
\nOn the other hand, the practical need is felt for quick classification of saddle nose as a prerequisite for deciding how to correct it.
\nThe original classification put forward here as a more practical tool involves three degrees of severity and takes the presence or absence of the nasal septum as the primary factor in determining the surgical treatment required.
\nDegree I (slight): depression <2 mm with respect to the ideal height of the dorsum: septum present (Figure 5a).
\n(a) Preoperative view of a patient affected by saddle nose deformity degree I (slight). (b) Postoperative profile view of the same patient of (a).
Degree II (moderate): depression of 2–5 mm with respect to the ideal height of the dorsum:
\n(a) cartilaginous septum present or partially present (Figure 6a) and
\n(a) Preoperative view of a patient affected by saddle nose deformity degree IIa (moderate with cartilaginous septum present). (b) Postoperative profile view of the same patient of (a).
(b) septum absent (Figure 7a)
\n(a) Preoperative view of a patient affected by saddle nose deformity degree IIb (moderate with cartilaginous septum absent). (b). Postoperative profile view of the same patient of (a).
Degree III (severe): depression >5 mm with respect to the ideal height of the dorsum: septum absent (Figure 8a).
\n(a) Preoperative view of a patient affected by saddle nose deformity degree III (severe). (b). Postoperative profile view of the same patient of (a).
The resulting therapeutic algorithm is as follows:
\nI: Onlay grafts from the nasal septum (Figure 5b).
\nIIa: Onlay grafts from the nasal septum and/or auricular concha (Figure 6b).
\nIIb: Reconstruction of the septum and dorsum with auricular concha (Figure 7b).
\nIII: Reconstruction of the septum and dorsum with costal cartilage (Figure 8b).
\nThe ideal height of the dorsum differs for men and women, coinciding in the first case with the line from the nasion to the tip-defining points (with suitable projection of the tip) and positioned about 2 mm caudally from the same in the second.
\nThe presence or absence of the nasal septum, as ascertained clinically not only by palpation and anterior rhinoscopy but also by radiological means like RMN for greater accuracy, is of crucial importance in deciding how to correct the deformity (Figure 9).
\nClinical sign of absent septal support.
The primary objective must be to restore support for the nose and then to obtain the desired appearance. The reconstruction can be thus described as composite with a bottom layer of support and an upper layer of esthetic importance. In cases I and IIa, where the septum is present and support exists, onlay grafts can be used to correct the deformity. The material can be taken from the present or residual septum and from the cartilage of the auricular concha if this proves insufficient.
\nThe onlay graft must be carefully shaped to make sure that it is not perceptible to sight or touch after the operation. To this end, incisions can be made halfway through the thickness of the cartilage in order to obtain a more or less curved shape as required. The cartilage can be given as inverted V, inverted U, or A shape by means of greenwood fractures.
\nIt must also be oval, wider in the middle, and narrower at the top and bottom, in order to follow the natural shape of the dorsum.
\nAn inverted V graft offers superior adaptation and stability than a flat one. As it consists of a single layer, it can only be used for patients requiring a minimal increase in the dorsum. If more is needed, a pillar of cartilage can be sutured beneath the inverted V so as to create a solid A-shaped structure. This stabilizing pillar can be secured closer to or farther from the top of the inverted V in order to vary the degree of gap between the arms of the V and increase or decrease the height of the graft. Both the inverted V and the A shape present, however, a very acute angle at the top, which can make the dorsum look too narrow in patients with very thin skin. In such cases, it proves useful to make further incisions halfway through the thickness on either side of the median incision so as to obtain an inverted U shape, which is closer to the natural curvature of the nasal dorsum and proves more stable on insertion into the same. Even in cases when only a localized dorsal defect is present, it is usually preferable, where possible, to use a graft covering the area from the nasion to the septal angle in order to reduce the irregularities, obtain the best esthetic result, and reduce the possibility of the graft being moved out of position. In order to secure the onlay graft, a very precise pouch must be created cephalically so as to prevent movement out of position. Caudally, it is instead possible to secure the graft to the septum or the alar cartilages, suturing in this case being obviously facilitated by the open approach. In order to obtain greater stability, a median incision of about 5 mm can be made in the caudal edge of the graft so as to obtain two small strips of cartilage for suturing to the lateral crura.
\nSome authors advise securing the graft also cephalically by means of transcutaneous sutures to be removed after 7–10 days. One further tip when using onlay grafts is to taper the edges carefully in order to prevent the creation of “steps” perceptible to sight or touch after the operation.
\nDegree IIb involves moderate depression of the nasal dorsum and the absence of septal support. In such cases, while costal cartilage is a possibility, reconstruction of the L-shaped structure of caudal dorsal support with auricular cartilage is unquestionably preferable given the almost total absence of undesirable esthetic-functional consequences. It is in any case generally preferable, whenever possible, to harvest material from the auricular concha rather than the rib, not least in terms of acceptability to the patient. Even though its elasticity and natural curvature do not make conchal cartilage an ideal material for reconstruction of the nasal septum, it is possible to obtain a straight and solid L-shaped supporting structure (Figure 10).
\nNeoseptum totally reconstructed by conchal cartilage.
The esthetic and functional results can be excellent, and damage at the donor site is normally minimal [19].
\nThe auricular concha is instead insufficient, even when harvested bilaterally, for the correction of type III saddle nose, where marked dorsal depression and the absence of septal support are often combined with the lack of support from the nasal bones. All this is almost invariably accompanied by contraction of the skin and mucus membrane of a cicatricial nature or as a result of cocaine abuse or previous rhinoplasty.
\nThe therapeutic approach to type III saddle nose is therefore aimed at the reconstruction of a sturdy L-shaped supporting structure capable of adequately withstanding the wound healing traction of the skin and mucus. The material of choice for the graft is unquestionably costal cartilage, shaped primarily with a view to reconstructing the caudal and dorsal support of the septum. To this end, it is possible to connect two pieces of a single rib (or two ribs), one to serve as the dorsal pillar with a socket to secure the other serving as the caudal pillar (Figure 11a and b).
\n(a) and (b) Antero-caudal septal structure reconstructed by costal cartilage.
It is not easy to secure the graft in place, above all in the cephalic portion. While some authors suggest that the creation of a pouch large enough for insertion of the graft is sufficient, others maintain that greater stability is required. According to Gunter et al., Kirschner thread can be used both to prevent distortion of the costal cartilage and to secure the graft cephalically [9]. Meyer suggests securing the graft with wire to the glabellar region after drilling a hole in the bone by means of open access [20]. Other authors maintain that it is sufficient to suture the graft to the skin above transcutaneously for 7–10 days. In the caudal portion, the graft should be secured with non-resorbable thread to the inferior nasal spine or its periosteum.
\nThe saddle nose deformity is a big challenge for the surgeon. Its correction should be structural because the camouflage does not permit to correct the functional problems related to this pathology. In this chapter, we reviewed the different aspects of the saddle nose including its etiology, classification, and surgical treatment. The classification is very important because it can guide the surgical approach we should use for the correction. A fundamental diagnostic finding is the presence of the nasal septum which represents the gold material for the reconstruction. If this is missing, our reconstruction choice should be focused on auricular cartilage or costal cartilage in more severe cases.
\nThe saddle nose represents one of the most challenging nasal deformities for the surgeon. The patient affected by saddle nose has almost always psychological problems, including concerns related to their own identity. The surgeon should evaluate the patient from different points of view, including diagnostic, therapeutical, and psychological. The choice of the correct surgical approach should be rational and based on the severity of the deformity. Different techniques of surgical correction of the saddle nose have to be present in our armamentarium, because only if we choose the right one, we can obtain optimal results.
\nThe field of wearable technology has experienced evident exponential growth in the past 20 years (fueled by the significant increase in mobile device usage and in the expansion of the Internet of Things). Recent market research on wearables also forecasts further growth in the next 3 years [2]. This growth in wearable technology, exemplified in terms of products entering the market and academic research output [1], has been quoted by numerous articles and been used to justify further research potential in the field. However various statistics indicate that the sector of wearable technology on the market represented by Smart Textiles & Apparel, despite the abundance of research output in this sector, continues to be much smaller than that represented by (hard) accessories and devices (e.g., smartwatches and earbuds), which are by far dominating the wearable landscape. Furthermore, various studies show that even with the dominant sector of wearable accessories and devices, there is a high rate of abandonment by users after a short period of time [22].
\nGiven that “wearable technology” and “Smart Textiles & Apparel” have already gained a great deal of attention and traction in the market and in academic research, there is a tendency for terms to be misused interchangeably or confused; therefore, this review begins by defining and distinguishing terminology used in the scope of Smart Textiles & Apparel. It will then outline the various ways in which Smart Textiles & Apparel have evolved over time by providing examples of innovations in the field. Finally, it will consider some of the practical barriers and challenges in the field.
\nBy mapping out the evolution of Smart Textiles & Apparel as well as its practical barrier and challenges, it will help provide a more realistic sense of the direction the field is headed in the future and subsequently the potential opportunities which need to be addressed in order to propel the field forward—and ultimately toward making a valuable contribution to society.
\nAs the fields of wearable technology and Smart Textiles & Apparel have expanded and matured over the years, their scope has broadened to encompass increasingly more facets and applications. As a result, a great deal of associated terminology has emerged and some of which have the tendency to be interchangeably or confused with another. Therefore, it is relevant to take a moment to provide clarification and distinction on the quintessential terms of the field (as accepted in academia and the industry, as well as within the bounds of this article).
\nAccording to Google Trends (which presents statistics on the amount of interest a search term or topic has garnered online over the years), Web searches on topic of “wearable technology” skyrocketed between 2013 and 2015 by about 500% (see Figure 1), which aligns with the proliferation of commercially available wearables, such as the Apple iWatch (which was released in early 2015). However, Figure 1 also shows that the topic of “wearable technology” had been circulating long (over 20 years) before its surge presence in the last 5 years [3].
\nGraph of Google Trends “Web search interest” on the topic of “wearable technology” over time, with image markers indicating the release dates of the earliest iterations of some “landmark” wearable technology product lines [28, 29, 30, 31, 32].
The term “wearable technology” (often shortened to just “wearables” and sometimes used interchangeably with “wearable devices” or “smart devices”) originated to describe the integration of electronics and computers into clothing or accessories that could be worn comfortably on the body [4], given that the earliest developments, such as the 1999 “Wearable Motherboard,” were motivated and enabled by the successive ubiquity of computers, mobile electronics, World Wide Web usage, and big data [5]. However, there are now many examples of advanced “technology” that are also “wearable,” but which do not necessarily integrate electronic or computing components—these instead belong to the scope of “Smart Textiles & Apparel.” Figure 2 presents a visual to further help distinguish and clarify wearable technology and Smart Textiles & Apparel as well as provide examples of the types of technologies associated with each area. Therefore, as shown in Figure 2, “smart textile” is a category on its own which does not fully overlap with wearable technology, as even though there are wearable technology examples which involve smart textiles (in which case they count as “smart apparel or other wearables inanimate objects”), there are a great deal of smart textiles which are not used toward wearables but toward applications which do not require removal of the textile once applied (such as car interiors or wallpaper). Instead the key distinguishing quality of smart textiles is that they are “soft” materials with flexibility and drapability.
\nDiagram to help distinguish and clarify terms within wearable technology and Smart Textiles & Apparel [37, 38, 40, 41].
Another pair of terms which are often confused are “smart textiles” and “electronic textiles” (“E-textiles”). Essentially, smart textiles describe a novel category of textiles which have the capability to sense or/and react with or/and adapt to external conditions or stimuli [6], while E-textiles are generally defined as textiles with electronic components or conductive fibers integrated within to give it smart or intelligent functions [7, 8]. Therefore smart textiles are the overarching category which includes E-textiles as one type of smart textile; however, it also includes other types of textiles which exhibit smart or intelligent functions without electronic or conductive elements (see Figure 2 for examples of the different types of smart textiles).
\nTo better understand the current and potential future state of Smart Textiles & Apparel, it is helpful to conduct a critical review of the statistics reflecting the progress in the field. One example of such statistics is shown in Figure 3, which shows the number of “Smart Textiles & Apparel”—related scholarly publications produced over the years, based on a search via the widely used scholarly publications database Scopus using the following search criteria: TITLE-ABS-KEY (smart or intelligent or conductive or electronic or sensor) and TITLE-ABS-KEY (textile or apparel or clothing or fashion or knit or yarn or fiber or wearable). Figure 3 indicates an obvious exponential growth in academic research output in the field of Smart Textiles & Apparel, which appears even more consistent and unwavering than the sporadic surge in Web search topic interest in “wearable technology” from Google Trend statistics (Figure 1). However, to gain a more balanced view beyond just academic research, statistics on market presence should also be considered. One source of information which can help gauge and compare the market presence of different forms of wearable technology is the annual attendance audit from the Consumer Electronics Show (CES), a highly prominent conference for innovative technologies being introduced to the market [9]. In particular, data on the number of exhibit attendees representing the “wearables” category was extracted from the annual CES audit summaries of 2012 to 2018 (a sample of this 2017 data is shown in Figure 4) and compiled into Figure 5. Given that CES is a prominent platform for technologies entering the market, its data compiled in Figures 5 and 6 validates the growing presence of wearable technology in the market. However, according to statistics from Gartner (Figure 7), the share of wearable technology’s growing presence occupied specifically by Smart Apparel is much less significant (less than 5% representation), while (hard) accessories (e.g., smart watches, ear-worn devices) represent the dominant category.
\nNumber of publications on Smart Textiles & Apparel over time (based on Scopus database search results). Source: Scopus.
An example of the CES annual audit summary data on the number of attendees representing the top 20 product categories, from the 2017 CES audit summary.
Numbers of CES exhibit attendees representing the “Wearables” category from 2012 to 2018 (obtained from the annual CES audit summaries).
Photographs taken at the 2011 CES [39].
Global unit shipments of wearable technology by category (2017–2022), alongside image examples. Source: Gartner © Statista 2019 [27, 33, 34, 35, 36].
Statistics such as that shown in Figure 7 suggest that Smart Textiles & Apparel still have room to grow in terms of market presence, despite its exponential growth in academic research output. This contrast between its growth in academia and in the market indicates a clear gap and prompts the question of what factors are deterring Smart Textiles & Apparel from being more prominent in the market. This article will start to address this question in the following sections.
\nUnderstanding how Smart Textiles & Apparel have evolved over the years will help anticipate the direction and opportunities of future growth. Based on an overview of literature, it was deducted that Smart Textiles & Apparel have evolved in three different ways: their degree of integration, their degree of intelligence (or “smartness”), and their degree of self-sufficiency (as summarized in the diagram of Figure 8)—each will be explained in the following sections.
\nFlowchart summarizing the evolution of Smart Textiles & Apparel.
Smart Textiles & Apparel have evolved in terms of their degree of intelligence (or smartness). This concept is based on the characterization of smart textiles as described by Tao and various other authors in the field, which classifies their degree of intelligence (or “smartness”) according to whether they can perform one or more of the following functions: sense, react, and adapt [6, 10, 11].
\nTraditional textiles (e.g., woven cotton fabrics, knitted wools yarns, etc.), while still functional (i.e., providing warmth, softness, etc.), are latent and do not sense, react, or adapt to external stimuli. The minimum requirement for a smart textile is the ability to sense environmental conditions or an external stimulus, which qualifies it as “passive smart.” If it further has the ability to react after sensing, then it qualifies as “active smart.” Some examples of this include Grado Zero Espace’s shape-memory shirt made from Oricalco fabric which reacts by changing shape based on sensing heat [12] and Aurelie Mosse’s intentional use of electro-active light-responsive polymers to create textiles for interiors which sense light and react by changing shape for esthetic effect or for function [13]. Finally, if a smart textile cumulatively has the ability to sense, react, and adapt based on the learned experience from what it sensed and reacted to previously, then it qualifies as “very smart.” A conceptual example of this is exemplified in the “No-Contact Jacket” created by Adam Whiton and Yolita Nugent, which functions to sense heavy force applied to the jacket (e.g., when wearer is hit by an attacker) and reacts by emitting an electrical chart (i.e., to electrocute the attacker) but also could, in the future, have the potential to integrate machine-learning intelligence to record data on cumulative forces sensed and learn to differentiate between amicable forces (e.g., from a hug or tap) and violent forces, depending on position or amount of force or time of day [13].
\nSee Figure 8 which presents a visual overview of these definitions of degree of intelligence (or “smartness”).
\nAnother way Smart Textiles and Apparel have evolved is in terms of their degree of integration. This refers to the extent to which the component/material/substance which performs the “smart” function is embedded into the textile. As Smart Textiles & Apparel have evolved, there has generally been a progression toward a higher degree of embeddedness or integration of the “smart”-functioning component material/substance into the textile. This progression is characterized by Hughes-Riley et al. as three generations: first generation, second generation, and third generation [7]. Although Hughes-Riley describes this progression in the context of E-textiles, it could very well apply to non-electronic smart textiles (e.g., thermochromic inks).
\nIn first-generation smart textiles, the lowest degree of integration, the “smart”-functioning component/material/substance was applied or attached to the surface of the textile; this generation of Smart Textiles Apparel is typically more rigid and bulky and lacks drapability. Some examples of first-generation smart textiles include the use of the “LilyPad Arduino” electronic components on garments [14], printing circuits with conductive ink onto the surface of fabrics, or even embroidering conductive yarns onto fabrics to create conductive pathways. In second-generation smart textiles, the “smart”-functioning component/material/substance is integrated into the textile structure, for example, the weaving or knitting of conductive yarns to form a textile pressure sensor [15], Layne and Orth’s work of weaving LEDs, or conductive yarns into the woven textile structure [13]. This generation of Smart Textiles & Apparel is typically more flexible but still tends to be lacking in comfort and versatility. In third-generation smart textiles, the highest degree of integration, the “smart” function is manifested innately as a part of the yarn or fiber and able to exist much more discretely within a textile design without interfering with its esthetic qualities and comfort level. Most examples of this generation of Smart Textiles & Apparel have been made possible by nanotechnology, such as embedding semiconductor systems within fibers for energy harvesting and storage [7] or the Mincor TX TT “lotus effect” coating of nanoparticles on yarns which allow a high level of hydrophobicity to enable a self-cleaning function [16].
\nThe term “fourth generation” used in this article refers to the potential next degree of integration in which Smart Textiles & Apparel are progressing towards but have not yet been fully realized in production and therefore currently exist more as inspiring visionary concepts. One example of a “fourth-generation” concept is the idea of harnessing the innate “smartness” of the nature to create textiles which function “smartly,” which is exemplified in the design research of Carole Collette. In her work titled “Suicide Pouf,” Collette created cushions which would physically change shape with time as the fibers shed in their natural death process, i.e., relying on the biological process of cell death (apoptosis) to create a dynamic textile object. In “bio-lace,” Collette demonstrates an inspiring idea of biologically engineered plants to grow roots which are able to form lace designs on their own [13]. Another visionary concept explored in the work of artists McRae and Tilbury is that of having the human biology or skin to contribute to the creation or modification of what we wear—so not just “smart” functionalities being more integrated into a textile but essentially engineering the human body’s biological functions to form its own textiles [13]. Currently, these are rather conceptual ideas, far from mass-market realization. However, they stretch the imagination on the degree of integration that Smart Textiles & Apparel could possibly be achieved in the future.
\nSee Figure 8 which presents a visual overview of these characterizations of degree of integration.
\nSmart Textiles & Apparel have also evolved in terms of their degree of self-sufficiency. This refers to the extent to which they can self-sufficiently perform their “smart” functionalities and sustain itself throughout its life cycle, without depending on (non-renewable) energy input or producing (non-biodegradable) waste output. The evolution of degree of self-sufficiency is categorized here as past, present, and future.
\nThe “past” stage refers to Smart Textiles & Apparel which have been made from non-renewable or non-biodegradable raw materials and dependent on non-renewable energy resources to manufacture, to function (e.g., batteries), to maintain (e.g., laundry), and to dispose of. However the growing concern of how polluting the apparel and textile industry and the recent buzz of fashion companies committing to achieving carbon neutrality or employing 100% sustainable materials within the next 10 years [17, 18, 19] is motivating a progression toward the “present” stage of the degree of self-sufficiency evolution, which refers to Smart Textiles & Apparel that perform their “smart” (sensing and reacting) functions self-sufficiently (i.e., without requiring a non-renewable energy source input), are self-sustaining (e.g., self-cleaning, self-healing, energy harvesting), and produce limited environmental impact in its manufacture, maintenance, and disposal. The “present” stage factors in sustainability as not only an afterthought but as an intrinsic part of the development and life of Smart Textiles & Apparel. Some examples which fall in this category include the self-cleaning “lotus effect” coating of Mincor TX TT yarn, the use of natural yarns with shape-memory properties which give the textile structure the functionality of becoming more permeable when damp or warm [16], self-healing “green” composites [20], and the light energy absorbing and storing properties of phosphorescent pigments integrated into textiles [13, 21].
\nOne potential “future” direction in the degree of self-sufficiency of Smart Textiles & Apparel could involve an additional element of intelligently adapting (and gradually improving) its self-sufficient smart functions by learning from each experience. So, for example, it could be manifested in the ability of a shape-memory textile to predict when to react without waiting on an external stimulus to trigger it or for a self-healing composite to learn where the weak points in a textile are and produce more self-healing agent in certain areas. These are, once again, only visionary ideas for now; however, with the help of quickly advancing artificial intelligent technologies, its realization could present itself sooner than we think.
\nSee Figure 8 which presents a visual overview of these characterizations of degree of self-sufficiency.
\nDespite burgeoning research into Smart Textiles & Apparel, there remains a great deal of room for improvement in terms of market presence. Furthermore, even with wearable technology (hard) accessories which represent a larger portion of market share, there is the hurdle of low retention and high abandonment rates of such devices less than a year after purchase [22]. Hence below defines some of the challenges contributing to the above disparities and potential opportunities to help tackle those disparities:
Lack of esthetic appeal: a common feedback on the Smart Apparel options in the market is that they are not fashionable and lack esthetic appeal [23, 24]. What becomes quickly apparent when browsing some of the most exciting wearable innovations at the 2019 Consumer Electronics Show [25] is that they still look more like “techy” electronic devices than something we would recognize as wearable. More and more consumers expect flexibility, comfort, and ease in clothing; however, most smart technologies approved for the market are still relatively bulky and difficult to integrate seamlessly and discretely into traditional clothing materials and styling and dressing habits. (Therefore, as Figure 7 shows, the smartwatches and ear-worn devices lead in the wearables category at CES, because they have already been adopted as electronic devices that can be worn without causing disruption to or conflict with an outfit). But also, the lack of visibility and accessibility designers in the industry have to Smart Textiles & Apparel technologies is also a barrier to help breed better design esthetics in the field.
Limited design options: even with wearables that are esthetically well-designed, they tend to come in limited varying options (e.g., in terms of size, colorways, silhouettes, etc.). Currently, the complexity of smart functionalities can limit the design flexibility, so once a successful design is established, it is not easy to vary. This is an issue as today’s consumer demand options and flexibility in what they purchase. Therefore, there is a need for Smart Textiles & Apparel technologies to be more versatile, complement different materials, and able to be used in different textile manufacturing processes.
Lack of assimilation with current supply chain processes/quality standards: the apparel and textile supply chain and quality standards have yet to adapt to the nuances and specific needs of Smart Textiles & Apparel [26]. Because the apparel and textile supply chain is still very much catered to the production of traditional textiles, many suppliers and retailers in the industry might be dissuaded from adopting “smart” technologies due to the time and cost needed to recalibrate processes in the supply chain to manage those “smart” technologies effectively. Furthermore, a great deal of “smart” technologies are not yet developed enough to meet the rigid, long-established quality standards of the textiles and apparel industry or vice versa in that the long-established industry quality standards are not being updated sufficiently to keep up with the incoming “smart” technologies.
Lack of understanding real human and societal needs: an underlying impression of wearable technology is that it is creating a supply for which there is no real demand (i.e., trying to create a demand). Therefore, in order to make wearables more relevant and desired, there is a need to better understand real human and societal needs so that Wearables can improve in ways to meet those needs. For example, in today’s connected world, it is clear that people desire to be connected, but how much so? Where do people draw the line in terms of where they want technology integrated into their everyday lives? When does it become disruptive? These are just some questions that need to be asked to better understand the true needs of humans and society.
Lack of selling performance and consumer feedback: there is a great deal of statistics available on the quantity of wearable technology and Smart Textiles & Apparel entering or available in the market but limited statistics on how well products sold or on feedback from customers after use. Obtaining such information is important to formulating a clear understanding of real consumer needs. Furthermore, as there are evidently successful wearable technology commercial products out on the market, it would be informative to evaluate what differentiates the successful products from the rest.
This review has attempted to provide a brief introductory overview to the now expansive field of wearable technology and Smart Textiles & Apparel, starting by looking at the evident surge in interest in wearable technology in the last 6 years which has been fueled by the release of many “landmark” devices to the commercial market as well as an increasingly mobile-reliant and connected landscape. The exponential growth is also manifested in academic research output in the field, as well as wearable technology products released to the market (which is also forecasted to continue to grow in the future). This chapter also provided clarification on terminology, distinguishing wearable technology and Smart Textiles & Apparel as two separate fields which overlap only in some cases, but also each has their separate unique sub-categories. The chapter then presented the analysis of the progression or evolution of Smart Textiles & Apparel in terms of degree of intelligence, degree of integration, and degree of self-sufficiency. The chapter also takes on a more critical lens to realize the fact that Smart Apparel has a much smaller representation in the wearable technology boom (in comparison with the “hard” wearable accessories and devices such as smartwatches and earbuds which are the dominant categories) as well as the low retention rate of most wearable devices. Given these limitations, the chapter discusses some areas of opportunity for Smart Textiles & Apparel research and product development to enable it to gain more traction and ultimately make a more valuable contribution in the society.
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\\n\\nThe combined printing and delivery times for orders vary from 12-20 business days, depending on the printed quantity and destination. This period does not include any customs clearance difficulties that may arise and that are beyond our control. Once your order has been printed and shipped, you will receive a confirmation email that includes your DHL tracking number. You can then track your order at www.dhl.com.
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\\n\\nIf you do not receive your order within 30 days, please contact us to inquire about the shipping status at orders@intechopen.com.
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\\n\\nTaxes: Residents of European Union countries need to add a Book Value-Added Tax of 5%. Institutions and companies, registered as VAT taxable entities in their own EU member state, will not pay VAT by providing us their VAT registration number. This is made possible by the EU reverse charge method.
\\n\\nCustoms: Shipping costs do not include any duties, taxes or clearing charges levied by the destination country. These charges are the responsibility of the customer and will vary from country to country.
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\n\nThe combined printing and delivery times for orders vary from 12-20 business days, depending on the printed quantity and destination. This period does not include any customs clearance difficulties that may arise and that are beyond our control. Once your order has been printed and shipped, you will receive a confirmation email that includes your DHL tracking number. You can then track your order at www.dhl.com.
\n\nMy order has not arrived, what do I do?
\n\nIf you do not receive your order within 30 days, please contact us to inquire about the shipping status at orders@intechopen.com.
\n\nPOD products are non-returnable and non-refundable, except in the event of poor print quality or an error in quantity. If we delivered the item to you in error or the item is faulty, please contact us. Inspect your order carefully when it arrives. Any problems should be immediately reported to orders@intechopen.com.
\n\nTaxes: Residents of European Union countries need to add a Book Value-Added Tax of 5%. Institutions and companies, registered as VAT taxable entities in their own EU member state, will not pay VAT by providing us their VAT registration number. This is made possible by the EU reverse charge method.
\n\nCustoms: Shipping costs do not include any duties, taxes or clearing charges levied by the destination country. These charges are the responsibility of the customer and will vary from country to country.
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