Composite autologous-allogeneic skin replacement: development and clinical application

The use of banked skin in the Burns Centre of Verona

BACKGROUND

The use of glycerol and subsequent research enabling the conservation of tissues over time have led to the establishment and development of tissue banks, first in the USA and then in Europe. The Verona Tissue Bank was instituted in 2003 as the Regional Centre for the storage of skin and bone, adding to the already existing Italian banks at Turin, Milan, Cesena and Siena. This retrospective study analyses the use of banked skin (autologous and allogeneic grafts) from April 2003 (date of starting activity) to December 2007, in 171 patients with burns and four with necrotising fasciitis at the Burns Centre of Verona.

MATERIALS AND METHODS

Homologous skin was used for superficial and deep skin burns to protect the residual structures, thus facilitating healing by spontaneous re-epithelialisation, and for deep burns after eschar removal to clean and prepare the base of the lesion for the definitive autologous graft. The placement of a homologous graft alone led to spontaneous healing of lesions in 65 patients (36 aged >15 years and 29 aged <15 years) with superficial skin burns, while the remaining 106 patients (84 aged >15 years and 22 aged <15 years) with deeper burns underwent surgery.

CONCLUSIONS

The results obtained confirm the essential role of banked skin in covering superficial burns in order to protect important underlying structures and in deep burns by guaranteeing a good preparation of the base of the lesion for the subsequent definitive autologous graft.

Cultured epithelial autografts for coverage of large burn wounds in eighty-eight patients: the Indiana University experience

Since 1990, the authors have used a new technique for coverage of large burns, which begins with early tangential excision and coverage with cadaver allograft (A), followed by placement of cultured epithelial autograft (CEA) onto an allodermis base (CEA/A). They present their 18-year experience (1990-present) using CEA in 88 patients (20 children and 68 adults) with age range of 6 months to 73 years. A review of prospectively collected data was conducted on adult and pediatric patients grafted with CEA at the Indiana University Medical Center for definitive wound coverage (TBSA 28-98%). These patients were followed up for 3 to 90 months. Complications, take rates, and outpatient follow-ups were noted. The mean final take rate of CEA/A was 72.7%, and the overall patient survival rate was 91% (80 of 88 patients). Complications were classified as early and late, they included: (early) blistering and shearing (31%), pruritus and itching (4.7%), (late) CEA loss (2 patients, 2.3%), and wound contractures (66%). Contracture releases were performed on 32 patients (36%); of which, 18 were children (56%). Cultured keratinocytes provide an excellent alternative or adjunct to conventional split-thickness skin grafting in treating large burn wounds. A dedicated team of physicians, nurses, and therapists well rehearsed in CEA care are vital for success in keratinocyte grafting. The final graft take of 72.7% with a 91% overall survival rate gives much optimism for continuing to use CEA in critically burned patients.

Viability and Efficacy of Coverage of Cryopreserved Human Skin Allografts in Mice

Human skin allografts are considered one of the best temporary biological coverages for severe burn patients. Human skin allografts can be either viable or nonviable depending on their preservation modalities. However, there is a debate about the use of viable versus nonviable skin for severe burn patients because there is no established correlation between viability and efficacy of coverage. The authors tried to correlate the viability of cryopreserved human skin allografts as assessed by the MTT assay, with efficacy of coverage, intensity of rejection at day 8, and delay of wound healing in a xenograft model using human fresh skin (FS) and cryopreserved skin (CPS) on murine recipients (n = 49). Cryopreserved grafts were less rejectable than fresh grafts, with statistically significant different delays ( P = .0008). Mice that had received grafts healed with delays; the delays, whether associated with fresh grafts or cryopreserved grafts, were not statistically significant. On day 8 after the graft, the overall damage score for the tissue’s histological architectural integrity was higher for FS. Furthermore, flow cytometry analysis showed a significant increase in the number of CD4 and CD8 T-cells ( P = .001) in the spleens of FS-grafted mice. These results confirm that the use of viable CPS does not change the potential for healing.

Closure of the excised burn wound: autografts, semipermanent skin substitutes, and permanent skin substitutes

Although definitive closure of the excised burn wound using split- or full-thickness autografts is the gold standard, permanent closure of larger defects may not be immediately feasible, especially if the presence of large burns limits the availability of donor sites. Newer temporary and permanent membranes can serve as adjuncts in some cases. Someday, burn surgeons may be in a position to close virtually any wound they generate using an immediately available, permanent, synthetic or laboratory-derived autologous composite.

In Vivo Culturing of a Bilayered Dermal Substitute with Adipo-Stromal Cells

BACKGROUND

Skin grafting is an important procedure to cover skin defects. Recently, cultured epidermal sheets and bilayered cultured skin have been used clinically, but they lack subcutaneous tissue. The objective of this study was to produce a bilayered dermal substitute with adipose tissue simultaneously in vivo.

MATERIALS AND METHODS

We disseminated adipo-stromal cells on one side of a collagen sponge at a density of 1,0 x 10(5)cells/cm(2) and incubated overnight. Then, we turned over the sponge and disseminated dermal fibroblasts and keratinocytes at a density of 1,0 x 10(6)cells/cm(2) on the other side of the sponge. Finally, we cultured this for 1 wk and implanted it on the backs of severe combined immunodeficiency mice with or without basic FGF.

RESULTS

Six weeks after implantation, specimens were harvested. Macroscopically, the formed tissue in the bFGF-administered group was thick, and the epidermal component, the dermal component, and adipose tissue were formed in the cross section. The thickness of newly formed tissue in bFGF-administered group was significantly greater than that in the group without bFGF administration. The area of the newly formed capillaries in the bFGF-administered group was significantly larger than that in the group without bFGF administration.

CONCLUSIONS

We could produce a thick composite tissue in vivo, combining three kinds of human cells, collagen scaffold, and bFGF. This composite graft was thicker than the bilayered dermal substitute and could be a substitute for a skin flap.

Hyalomatrix: a temporary epidermal barrier, hyaluronan delivery, and neodermis induction system for keratinocyte stem cell therapy

Keratinocyte stem cell technology provides at least an adjuvant therapy to clinically close large cutaneous wounds (e.g., burn wounds). Here, the performance of keratinocyte cultures depends primarily on the quality of the bed to which they are applied. Clinical take rates for cultured keratinocyte grafts are optimal when applied to a vascularized dermal bed with minimal bacterial colonization. In the absence of autologous dermis, staged reconstruction with a dermal equivalent or dermal regeneration template is required. A novel product, Hyalomatrix, is a bilayer of an esterified hyaluronan scaffold beneath a silicone membrane. The scaffold delivers hyaluronan to the wound bed, and the silicone membrane acts as a temporary epidermal barrier. The product has been investigated in a controlled, porcine, acute full-thickness excisional wound model. Cultured autologous keratinocytes (CAKs) were delivered on Laserskin to acute full-thickness wounds treated with Hyalomatrix within chambers, and graft take rates were assessed longitudinally using image analysis. In the absence of chambers, wound contraction was assessed. Clinical CAK take rates fall sequentially with delay in application post-Hyalomatrix pre-treatment, but repeated pre-treatment removed this, with maximal take of 57.2% at 5 weeks post-wounding. In the absence of chambers, more-complete wound closure resulted from edge re-epithelialization and contraction, by a factor of 5 at 1 month, and was achieved at least 2 weeks sooner in the gold standard controls of split-thickness autograft to an acute or pre-treated wound bed. Wound contraction and late neodermal morphology (1 year) were similar in pre-treated CAKs and split-thickness autograft wounds. In this model, the Hyalomatrix wound bed pre-treatment increase in CAK take appeared to be dose dependent. The product appeared to act as a hyaluronan delivery system rather than a dermal regeneration template. The silicone membrane may limit wound bed colonization, and the combination of this temporary barrier with hyaluronan delivery and neodermis induction has been termed a barrier-delivery-induction system. The development of similar systems for serial application offers an alternative to a dermal regeneration template when CAKs are engrafted in the hostile, colonized environment of large burn wounds.

Hyaluronic acid: the scientific and clinical evidence

Hyaluronic acid is a naturally occurring biopolymer whose molecular structure is highly conserved between mammalian species. First described in 1934, it has since been used across a wide variety of medical fields as diverse as neurosurgery and cutaneous wound healing. Presently it has reached prominence in cosmetic practice where it is now the injectable dermal filler of choice for most surgeons. We used our experience of this technology with searches in the English language literature for the purpose of a systematic review. We present an overview, including the scientific evidence for its use in wound healing and, briefly, in other fields. We summarise the evidence for and against hyaluronic acid and provide a resumé of the current technologies available in fields such as skin regeneration and wound healing, in addition to cosmetic surgery. This overview is not intended to teach the reader about the various formulations currently on the market or how to use these materials clinically - rather to provide a solid scientific background enabling the reader to understand the attributes (and otherwise) of the material. We hope to allow clinicians to assess the evidence for a material now in common use in order that they may be fully aware of its properties.

Cultured epithelial autograft (CEA) in burn treatment: three decades later

Methods for handling burn wounds have changed in recent decades and increasingly aggressive surgical approach with early tangential excision and wound closure is being applied. Split-thickness skin (STSG) autografts are the "gold standard" for burn wound closure and remain the mainstay of treatment to provide permanent wound coverage and achieve healing. In some massively burned patients, however, the burns are so extensive that donor site availability is limited. Fortunately, considerable progress has been made in the culture of human keratinocytes and it is now possible to obtain large amounts of cultured epithelium from a small skin biopsy within 3-4 weeks. Questions related to optimal cell type for culture, culture techniques, transplantation of confluent sheets or non-confluent cells, immediate and late final take, carrier and transfer modality, as well as final outcome, ability to generate an epithelium after transplantation, and scar quality are still not fully answered. Progress accomplished since Reinwald and Green first described their keratinocyte culture technique is reviewed.

Wound closure with EDC cross-linked cultured skin substitutes grafted to athymic mice

Collagen-glycosaminoglycan (C-GAG) sponges are commonly utilized as a substitute for the extracellular matrix of dermal tissue. Cultured skin substitutes (CSS) were assessed, after fabrication using sponges cross-linked with 1-ethyl-3-3-dimethylaminopropylcarbodiimide hydrochloride (EDC) at 0, 1, 5, or 50 mm, for development of viable, stratified skin tissue anatomy in vitro, and for wound contraction and cell viability in vivo. Cross-linking the C-GAG sponges with EDC reduced in vitro contraction of the CSS from a 39% reduction in area in the 0 mm CSS to 0% in the 50 mm group. Conversely, the wounds closed with 0, 1 and 5 mm EDC groups exhibited significantly less wound contraction than the 50 mm group. Engraftment of human cells occurred in 86%, 83%, and 83% of the wounds treated with CSS fabricated using 0, 1, and 5 mm EDC cross-linked sponges, respectively, which were significantly higher engraftment rates than the 50 mm group (17%). These data suggest that low concentrations of EDC can be used to improve the biochemical stability of the C-GAG component of CSS in vitro, and promote stable wound closure.

Thermolysin in human cultured keratinocyte isolation

BACKGROUND: When treating extensively burned patients using cultured epidermal sheets, the main problem is the time required for its production. Conventional keratinocyte isolation is usually done using Trypsin. We used a modification of the conventional isolation method in order to improve this process and increase the number of colonies from the isolated epidermal cell population. PURPOSE: To compare the action of trypsin and thermolysin in the keratinocyte isolation using newborn foreskin. METHODS: This method used thermolysin as it selectively digests the dermo-epidermal junction. After dermis separation, the epidermis was digested by trypsin in order to obtain a cell suspension. RESULTS: Compared to the conventional procedure, these experiments demonstrated that in the thermolysin group, the epidermis was easily detached from the dermis, there was no fibroblast contamination and there were a larger number of keratinocyte colonies which had a significant statistical difference. CONCLUSION: The number of colonies in the thermolysin group was significantly greater than in the trypsin group.

Gene-modified tissue-engineered skin: the next generation of skin substitutes

Tissue engineering combines the principles of cell biology, engineering and materials science to develop three-dimensional tissues to replace or restore tissue function. Tissue engineered skin is one of most advanced tissue constructs, yet it lacks several important functions including those provided by hair follicles, sebaceous glands, sweat glands and dendritic cells. Although the complexity of skin may be difficult to recapitulate entirely, new or improved functions can be provided by genetic modification of the cells that make up the tissues. Gene therapy can also be used in wound healing to promote tissue regeneration or prevent healing abnormalities such as formation of scars and keloids. Finally, gene-enhanced skin substitutes have great potential as cell-based devices to deliver therapeutics locally or systemically. Although significant progress has been made in the development of gene transfer technologies, several challenges have to be met before clinical application of genetically modified skin tissue. Engineering challenges include methods for improved efficiency and targeted gene delivery; efficient gene transfer to the stem cells that constantly regenerate the dynamic epidermal tissue; and development of novel biomaterials for controlled gene delivery. In addition, advances in regulatable vectors to achieve spatially and temporally controlled gene expression by physiological or exogenous signals may facilitate pharmacological administration of therapeutics through genetically engineered skin. Gene modified skin substitutes are also employed as biological models to understand tissue development or disease progression in a realistic three-dimensional context. In summary, gene therapy has the potential to generate the next generation of skin substitutes with enhanced capacity for treatment of burns, chronic wounds and even systemic diseases.

High yields of autologous living dermal equivalents using porcine gelatin microbeads as microcarriers for autologous fibroblasts

Permanent skin replacement requires a dermal component to ensure adequate long-term graft stability and to prevent wound contraction. This study was to construct a bioreactor microcarrier cell culture system (Bio-MCCS) to produce autologous living dermal equivalents on a large scale. Autologous fibroblasts were isolated from split-thickness skin biopsy from a leg ulcer patient, inoculated onto macroporous porcine gelatin microbeads, and incubated in a bioreactor (Cellspin) in serum-free fibroblast growth medium or in DMEM medium containing 10% fetal calf serum (FCS). Fibroblasts rapidly adhered to and actively proliferated on the microbeads in the bioreactor in both serum-free and serum-containing medium. MTT assay showed the number of fibroblasts on the microbeads reached up to 5.3- or 4.0-fold the cells seeded in DMEM medium containing 10% FCS or serum-free medium, respectively. When removed from Bio-MCCS and cultured under static conditions, fibroblasts were able to leave the microbeads and proliferate to confluence on the bottom of tissue culture flasks. When stored at room temperature in DMEM containing 10% FBS, fibroblast cultured on the microbeads retained highest viabilities for at least 3 weeks, up to 82% of originals. This Bio-MCCS using porcine gelatin microbeads as carriers for fibroblasts offers a new option of mass production of autologous living dermal equivalents.

EDC cross-linking improves skin substitute strength and stability

Collagen-based scaffolds are extensively utilized as an analog for the extracellular matrix in cultured skin substitutes (CSS). To improve the mechanical properties and degradation rates of collagen scaffolds, chemical cross-linking is commonly employed. In this study, freeze-dried collagen-GAG sponges were crosslinked with increasing concentrations of 1-ethyl-3-3-dimethylaminopropylcarbodiimide hydrochloride (EDC; 0, 1, 5, 10, 50mm). Cross-linking with EDC at concentrations >1mm was shown to greatly decrease degradation by collagenase up to 21 days. Ultimate tensile strength (UTS) of acellular collagen sponges scaled positively with EDC concentration up to 10mm. At 50mm EDC, the UTS decreased dramatically likely due to the brittle nature of the highly crosslinked material. Co-culture of human fibroblasts (HF) and keratinocytes (HK) on these substrates reveals an apparent cytotoxicty of the EDC at high concentrations with reduced cell viability and poor cellular organization in CSS fabricated with scaffolds crosslinked with 10 or 50mm EDC. From the data gathered in this study, intermediate concentrations of EDC, specifically 5mm, increase collagen sponge stability and strength while providing an environment in which HF and HK can attach, proliferate and organize in a manner conducive to dermal and epidermal regeneration.

Human Skin Preserved Long-Term in Anhydric Pulverized Sodium Chloride Retains Cell Molecular Structure and Resumes Function After Transplantation

BACKGROUND

Human skin is needed to cover large areas of the body lost through burns, trauma, and extensive maxillofacial surgery. Contemporary methods of skin storage are limited by the period of preservation to a few days. Our previous findings showed that fixation and storage of human skin in anhydric sodium chloride at room temperature for weeks or months preserves its morphological and molecular structure. In this study, we examined whether skin grafts preserved in sodium chloride may be successfully transplanted.

METHODS

Skin was harvested from lower limbs of patients during elective surgery, placed in containers with anhydric salt powder, and kept at 22 degrees C for 3 to 12 weeks. Desalination and rehydration took place before transplantation. Desalinated fragments were transplanted onto the dorsum of scid mice.

RESULTS

All grafts were accepted by recipients. Three weeks after transplantation, keratinocytes synthesized keratins 10, 16, and 17 and expressed antigens specific for stem (p63) and transient (CD29) cells. Moreover, they proliferated vigorously, their basal layer cells incorporated bromdeoxyuridine and expressed proliferative cell nuclear antigen. Isolated from transplants and cultured in vitro, they remained viable and produced enzymes. Dermis retained its structure and expressed fibroblast-specific antigen. All graft cells remained human leukocyte antigen I.

CONCLUSION

Human skin preserved in anhydric sodium chloride at room temperature for months can be successfully transplanted to scid mice. We propose the concept of "spore-like" keratinocyte stem cells to explain the long-term ex vivo survival of keratinocytes. The mechanism of survival of fibroblasts remains to be determined.

The role of hyaluronic acid in wound healing: assessment of clinical evidence

Hyaluronic acid (hyaluronan), a naturally occurring polymer within the skin, has been extensively studied since its discovery in 1934. It has been used in a wide range of medical fields as diverse as orthopedics and cosmetic surgery, but it is in tissue engineering that it has been primarily advanced for treatment. The breakdown products of this large macromolecule have a range of properties that lend it specifically to this setting and also to the field of wound healing. It is non-antigenic and may be manufactured in a number of forms, ranging from gels to sheets of solid material through to lightly woven meshes. Epidermal engraftment is superior to most of the available biotechnologies and, as such, the material shows great promise in both animal and clinical studies of tissue engineering. Ongoing work centers around the ability of the molecule to enhance angiogenesis and the conversion of chronic wounds into acute wounds.

Construction of Chitosan— Gelatin—Hyaluronic Acid Artificial Skin In Vitro

To further enhance the properties of chitosan (Cs)-gelatin (Gel) scaffolds for skin tissue engineering, hyaluronic acid (HA) is introduced to the Cs—gel complex. Porous scaffolds composed of Cs, Gel, and HA are prepared using the freeze-drying method. The scaffold has an interconnected pore structure with two different pore size layers. The water uptake ability, flexibility, and biocompatibility of the scaffold are greatly increased with the incorporation of HA. To construct an artificial skin in vitro, fibroblasts and keratinocytes are co-cultured in Cs—Gel—HA scaffolds at an air—liquid interface. After 2 weeks of co-culture, the epithelial layer becomes progressively stratiform, including cubic perpendicularly oriented cells and a superficial layer of flattened cells. Immunohistochemical analyses confirmed the presence of laminin and type IV collagen, typical molecules of the basement membrane. The results of this study suggest that it is possible to construct a functional artificial skin in vitro and the Cs—Gel—HA scaffold is a promising matrix for skin tissue engineering.

Other uses of homologous skin grafts and skin bank bioproducts

The main use of homologous skin grafts or grafts of related bioproducts is in the treatment of severe burns. However, various new clinical and experimental sectors, in which this type of skin substitute can be useful, have recently emerged. The main new clinical indications for skin allografts include: skin loss, surgical wounds and bullous diseases. In these fields donor skin can be used for different purposes: as a physiological biological dressing to control pain and protect deep structures such as tendons, bones, cartilage and nerves, and to promote reepithelization with a significant reduction in healing time, and as skin substitute with dermal tissue to guide repair and make it as physiological as possible. In particular, skin bank bioproducts are currently used in the treatment of several conditions such venous and arterial leg ulcers, pressure ulcers, diabetic foot ulcers, pyoderma gangrenosum, post traumatic lesions, Mohs surgery, reconstructive surgery, wound cover in critical areas, aesthetic surgery, congenital epidermolysis bullosa and Lyell's syndrome. Skin bank bioproducts have also been used for experimental indications, to study in vitro toxicology and in vitro skin biology. Recently the demonstration that de-epidermized dermis (DED) has all the characteristics of an excellent dermal substitute into which various types of cells can be introduced and made to develop, opens exciting new possibilities of research in the field of wound healing and tissue engineering. Our preliminary observations seems to indicate that CD 34+ stem cells from umbilical cord blood can survive in DED and in a few weeks populate collagen bundles. The observation of tubular structures without lumina close to collagen bundles as well as clusters of epithelioid or fibroblast-shaped cells may represent aspects of differentiation of CD 34+ stem cells. More detailed and sophisticated studies are clearly needed to answer all the questions that these initial observations pose. Anyway the 3-dimensional model proposed seems to be suitable for the study of the behaviour of peripheral CD 34+ and perhaps also other types of stem cells in 3-dimensional dermal matrix.

Allogenic skin in the treatment of burns

Allogenic skin has had a major role in acute burns care for over 100 years. The principle source of allogenic skin is from cadavers. Allogenic skin provides the gold standard for temporary skin substitutes. The main drawbacks to its wider use are availability and disease transmission. The major obstacle to prolonged use is its immunogenicity. As more effective means are developed to ensure the supply and safety of allogenic skin and novel ways of circumventing the immunologic problems are developed, it is possible that allogenic skin may find a new role as a permanent skin replacement in future burns care.

Skin bank organization

Skin allografts were first used at the end of the last century by Girdner [Girdner JH. Skin grafting with graft taken from the dead subject. Med Rec (NY) 1881;20:119-20]; however, routine storage of human tissue developed only in the 1930s to 1940s [Webster JP. Refrigerated skin grafts. Ann Surg 1944;120:431-49] when reliable preservation methods became available. The first proper skin bank was the US Navy Skin Bank, set up in 1949 [McCauley RL. The skin Bank. In: Herndon DN, editor. Total burn care. 1st ed. Philadelphia: Saunders; 1996. p. 159-63]. Several skin banks were subsequently established in the United States and Europe, and in most cases they were organized as multitissue banks. Nowadays, it is estimated that 30 to 50 tissue banks are active in the United States, working according to the American Association of Tissue Banking (AATB) standards (AATB. Standards for tissue banking; 1984) and federal regulations (Real E S and regulations. Fed Regist. 1993).

Immunology of skin transplantation

Untreated viable allogeneic skin is highly immunogenic. Epidermal Langerhans migrate after transplantation out of the donor skin into the lymph node of the recipient where they can activate T cells capable to mediate rejection. Allogeneic skin is used as a temporary coverage of burn wounds, often in combination with autologous skin grafts. Several methods to pretreat the allogeneic skin have been used to delay the rejection process. Processing of allogeneic skin in 85% glycerol results in a non-viable skin with a well-preserved structure. Experiments in a full thickness porcine wound model showed that rejection of glycerol treated allogeneic skin grafts was up to six days delayed. Viable, untreated allogeneic skin grafts were rejected predominantly by CD8 positive T cells whereas in the glycerol treated grafts the influx of host cells was lower and the majority of the cells were macrophages. The outgrowth of the autologous skin grafts underneath glycerol treated allogeneic skin was three days earlier completed when compared to grafts in combination with untreated allogeneic skin. Thus, by processing the allogeneic skin into 85% glycerol, the direct route to induce graft rejection is blocked since the Langerhans cells are non-viable. The glycerol-preserved skin grafts are finally rejected via an indirect route mediated by macrophages; this process is less disturbing for the outgrowth of autologous cells.

In vitro reconstruction of an endothelialized skin substitute provided with a microcapillary network using biopolymer scaffolds

Successful in vitro reconstruction of skin requires the inclusion of several cell types that give rise in coculture to the specific elements present in native skin, and the appropriate scaffolding structure to house and support these cells. In addition to the two main structural components, epidermis and dermis, one critical apparatus of the skin is a capillary network that guarantees adequate perfusion of nutrients and oxygen. The aim of the present study was to develop an in vitro coculture system that assumed the human dermal-epidermal architecture and included a microcapillary network in a three-dimensional biomaterial that guaranteed ease of handling in a clinical setting. Endothelialized skin (ES) was prepared by coculturing three human cell types: keratinocytes, fibroblasts, and endothelial cells, obtained from human full-thickness skin samples, in scaffolds produced from modified hyaluronic acid. Results were evaluated by histological and immunohistochemical analyses at different time points. In vitro, engineered skin obtained with this composite culture developed into a well-differentiated upper layer of stratified keratinocytes lining a dermal-like structure, in which fibroblasts, extracellular matrix and a microvascular network were present. Furthermore, the biodegradable fabric produced from hyaluronic acid and used as the scaffolding support for this in vitro constructed skin graft greatly facilitated handling in the perioperative period.

Survival of Apligraf in acute human wounds

Apligraf consists of bovine collagen dermis seeded with allogeneic male fibroblasts and keratinocytes. It is been shown to promote healing, but the length of persistence and pathological features have not been characterized previously in acute wounds. Forty-eight deep dermal wounds were created and Apligraf, a split-skin graft (SSG), or a dressing was applied. Biopsies of wounds were taken for immunohistochemical analysis and polymerase chain reaction was performed to detect the Y chromosome from Apligraf cells in 14 female wounds. Male allogeneic DNA was detected in wounds for the first 4 weeks. All subsequent time points were negative apart from one biopsy at 6 weeks. The wounds took 4-9 weeks to heal, with the Apligraf exhibiting no features of engraftment. This was in contrast to the rapid healing seen in the SSG control group. Histology revealed a more intense cellular infiltrate, but less vascularization below Apligraf compared with controls. Evidence of an epidermal-mesenchymal interaction was observed. This is the first article to elucidate the survival of Apligraf allogeneic cells in acute wounds in immunocompetent human subjects for up to 6 weeks and demonstrates that in the management of acute surgical wounds, Apligraf has a role only as a temporary biological dressing.

Synthetic scaffold morphology controls human dermal connective tissue formation

Engineering tissues in bioreactors is often hampered by disproportionate tissue formation at the surface of scaffolds. This hinders nutrient flow and retards cell proliferation and tissue formation inside the scaffold. The objective of this study was to optimize scaffold morphology to prevent this from happening and to determine the optimal scaffold geometric values for connective tissue engineering. After comparing lyophilized crosslinked collagen, compression molded/salt leached PEGT/PBT copolymer and collagen-PEGT/PBT hybrid scaffolds, the PEGT/PBT scaffold was selected for optimization. Geometric parameters were determined using SEM, microcomputed tomography, and flow permeability measurements. Fibroblast were seeded and cultured under dynamic flow conditions for 2 weeks. Cell numbers were determined using CyQuant DNA assay, and tissue distribution was visualized in H&E- and Sirius Red-stained sections. Scaffolds 0.5 and 1.5 mm thick showed bridged connected tissue from top-to-bottom, whereas 4-mm-thick scaffolds only revealed tissue ingrowth until a maximum depth of 0.6-0.8 mm. Rapid prototyped scaffold were used to assess the maximal void space (pore size) that still could be filled with tissue. Tissue bridging between fibers was only found at fiber distances < or =401 +/- 60 microm, whereas filling of void spaces in 3D-deposited scaffolds only occurred at distances < or =273 +/- 55 microm. PEGT/PBT scaffolds having similar optimal porosities, but different average interconnected pore sizes of 142 +/- 50, 160 +/- 56 to 191 +/- 69 microm showed comparable seeding efficiencies at day 1, but after 2 weeks the total cell numbers were significantly higher in the scaffolds with intermediate and high interconnectivity. However, only scaffolds with an intermediate interconnectivity revealed homogenous tissue formation throughout the scaffold with complete filling of all pores. In conclusion, significant amount of connective tissue was formed within 14 days using a dynamic culture process that filled all void spaces of a PEGT/PBT scaffolds with the following geometric parameters: thickness 1.5-1.6 mm, pore size range 90-360 microm, and average interconnecting pore size of 160 +/- 56 microm.

Combined use of a collagen-based dermal substitute and a fibrin-based cultured epithelium: a step toward a total skin replacement for acute wounds

Integra, a dermal replacement, is used as an immediate and temporary coverage for acute wounds, after which, autograft is used to reconstitute permanently the epidermal coverage. The fibrin sheet-cultured epithelium autograft (FS-CEA) could provide an effective alternative to the surgical procedure. To evaluate this hypothesis, we compared the association of Integra/FS-CE to Integra/control-cultured epithelium (control-CE). Their respective abilities: (1) to produce dermal-epidermal construct in vitro; (2) to generate skin replacement when grafted onto athymic mice were studied. We have shown that: (1) 83% of the FS-CE attached to the artificial dermis in vitro compared to only 33% for control-CE; (2) retraction of the grafted area was significantly lower 2 weeks after grafted with FS-CE than with the control-CE (P < 0.05); (3) 83% of the mice grafted with FS-CE showed the presence of a differentiated human epidermis 21 days after grafting, while such an epidermis was absent in all the animals of the control-CE group. We found that the use of FS-CE greatly improved adhesion, development of the epithelium and graft take onto the artificial dermis. We believe this technology should significantly improve the performance of dermal-epidermal skin replacement for acute wounds.

Modulation of scar tissue formation using different dermal regeneration templates in the treatment of experimental full-thickness wounds

The recovery of skin function is the goal of each burn surgeon. Split-skin graft treatment of full-thickness skin defects leads to scar formation, which is often vulnerable and instable. Therefore, the aim of this study was to analyze wound healing and scar tissue formation in acute full-thickness wounds treated with clinically available biopolymer dermal regeneration templates. Full-thickness wounds (3 x 3 cm) on both flanks of Gottingen mini pigs (n= 3) were treated with split-thickness skin graft alone or in combination with a 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide (EDC) cross-linked-collagen scaffold, Integra, or a polyethyleneglycol terephthalate-polybutylene terephthalate (PEGT/PBT) scaffold. The wounds (n= 12 per group) were examined weekly for six weeks to evaluate graft take, contraction (planimetry), and cosmetic appearance. Histologic samples taken after one and six weeks were used to assess scaffold angiogenesis, biocompatibility, and scar tissue quality. In all wounds, one week postwounding graft take was between 93 and 100 percent. The control wound, treated with split-skin graft, showed little granulation tissue formation, whereas the EDC-collagen treated wounds showed two to three times more granulation tissue formation. The collagen scaffold was completely degraded within one week. The Integra and PEGT/PBT scaffolds showed angiogenesis only through two-thirds of the scaffold, which resulted in loss of integrity of the epidermis. Only basal cells survived, proliferated, and regenerated a fully differentiated epidermis within three weeks. Granulation thickness was comparable to collagen scaffold-treated wounds. After six weeks, control wounds showed a wound contraction of 27.2 +/- 6.1 percent, Integra-treated wounds 34.6 +/- 6.4 percent, collagen scaffold-treated wounds 38.1 +/- 5.0 percent, and PEGT/PBT scaffold-treated wounds 54.5 +/- 3.9 percent. The latter wounds had significantly more contraction than wounds of other treatment groups. Microscopically, the control and collagen scaffold-treated wounds showed an immature scar tissue that was two times thicker in the EDC-collagen treated wounds. The Integra-treated wounds showed nondegraded collagen scaffold fibers with partly de novo dermal tissue formation and partly areas with giant cells and other inflammatory cells. The PEGT/PBT scaffold was almost completely degraded. Scaffold particles were phagocytosized and degraded intracellularly by clusters of macrophages. The scar tissue was in the early phase of ECM remodeling. In conclusion, this study showed that the rate of dermal tissue formation and scarring is influenced by the rate of scaffold angiogenesis, degradation, and host response induced by the scaffold materials.

A review of keratinocyte delivery to the wound bed

Over the last 20 years, confluent sheets of cultured epithelial autograft have been used for patients with major burns. Problems with the lack of "take" and long-term durability, as well as the time delay to produce such grafts, have led to the development of delivery systems to transfer keratinocytes to the wound bed. This review article describes the problems of using cultured epithelial autograft and the advantages of using preconfluent keratinocytes. Despite the numerous delivery systems that have been reported, most studies are limited to animal wound bed models. There are a few small clinical studies that have demonstrated enhanced healing using mainly subjective methods. There is a need for controlled, randomized clinical trials to prove the efficacy of keratinocyte delivery systems. Proposals for the use of this technology are made.

Composite cell support membranes based on collagen and polycaprolactone for tissue engineering of skin

The preparation and characterisation of collagen:PCL composites for manufacture of tissue engineered skin substitutes and models are reported. Films having collagen:PCL (w/w) ratios of 1:4, 1:8 and 1:20 were prepared by impregnation of lyophilised collagen mats by PCL solutions followed by solvent evaporation. In vitro assays of collagen release and residual collagen content revealed an expected inverse relationship between the collagen release rate and the content of synthetic polymer in the composite that may be exploited for controlled presentation and release of biopharmaceuticals such as growth factors. DSC analysis revealed the characteristic melting point of PCL at around 60 degrees C and a tendency for the collagen component, at high loading, to impede crystallinity development within the PCL phase. The preparation of fibroblast/composite constructs was investigated using cell culture as a first stage in mimicking the dermal/epidermal structure of skin. Fibroblasts were found to attach and proliferate on all the composites investigated reaching a maximum of 2 x 10(5)/cm(2) on 1:20 collagen:PCL materials at day 8 with cell numbers declining thereafter. Keratinocyte growth rates were similar on all types of collagen:PCL materials investigated reaching a maximum of 6.6 x 10(4)/cm(2) at day 6. The results revealed that composite films of collagen and PCL are favourable substrates for growth of fibroblasts and keratinocytes and may find utility for skin repair.

Stimulation of Skin Repair Is Dependent on Fibroblast Source and Presence of Extracellular Matrix

In this study in vitro and in vivo functions were compared between cultured dermal equivalents produced with human fibroblasts isolated either from papillary dermis or adipose tissue of the same donors. Papillary dermal fibroblasts had a normal spindle cell shape; in contrast, adipose tissue fibroblasts had a stellate cell shape, actin stress fibers containing alpha-smooth muscle actin, multiple narrow extensions at their edges, and longer focal adhesion plaques. After dynamic culture for 14 days in PEGT/PBT carrier scaffolds, cell numbers between the two cell sources were comparable, but tissue morphology was different between the cultured groups. In addition, papillary fibroblasts had deposited significantly more glycosaminoglycans (214 +/- 15 versus 159 +/- 21 microg, p < 0.001) and a lower amount of collagen (49 +/- 14 versus 111 +/- 25 microg of hydroxyproline, p < 0.001) than had adipose fibroblasts. Moreover, the latter constructs were significantly more contracted than the papillary fibroblast-cultured constructs (78 +/- 6 versus 96 +/- 3%, p < 0.001). In comparison with the influence of cultured dermal equivalents on wound healing, the transplantation of five groups (control acellular carrier, papillary fibroblast-seeded construct, adipose fibroblast-seeded construct, papillary fibroblast-cultured construct, and adipose fibroblast-cultured construct) to full-thickness wounds on the backs of athymic mice showed clear differences in angiogenesis and tissue ingrowth after 10 days, and in reepithelialization after 21 days. After 10 days, the level of vascular ingrowth in the carrier (von Willebrand staining) for the five groups was as follows: adipose fibroblast-cultured > papillary fibroblast-cultured = adipose fibroblast-seeded > papillary fibroblast-seeded > acellular carrier. After 21 days, only the acellular carriers were not vascularized and the papillary fibroblast-seeded constructs were not completely vascularized. Complete wound reepithelialization (92 +/- 12%) was observed only in the group treated with adipose cultured constructs. Wound contraction was not observed. Staining for HLA-ABC and alpha-smooth muscle actin showed that human fibroblasts had survived and that adipose fibroblasts continued to express the actin isoform. These results showed not only stimulation of skin repair when fibroblasts were present in the carrier, but also significant positive effects of the deposited extracellular matrix (ECM) in the carrier. In addition, the adipose fibroblast-seeded construct, and especially the adipose fibroblast-cultured construct, significantly stimulated angiogenesis and reepithelialization when compared with their corresponding papillary fibroblast constructs. Apparently, tissue source or fibroblast phenotype and the presence of ECM play a crucial role in the stimulation of (impaired) healing and engineering of dermal equivalents.

Long-Term Survival of Human Skin Allografts in Patients with Immunosuppression

Severe burn patients lack adequate skin donor sites to resurface their burn wounds. Patients with severe burn injuries to areas such as an entire face are presently reconstructed with skin grafts that are inferior to normal facial skin. This study was designed in part to determine whether human skin allografts would survive, repopulate, and persist on patients with immunosuppression and after discontinuation of immunosuppression. Small split-thickness skin grafts were synchronously transplanted at the time of renal transplantation from six renal transplant donors to recipients. All six patients were immunosuppressed with the usual doses of renal transplant immunosuppressants (methylprednisolone, cyclosporine, prednisone, and azathioprine). The skin allografts were biopsied when rejection was suspected and at various intervals. Special histologic studies were performed on skin biopsy specimens. Class II DNA tissue typing was performed on transplanted and autogenous skin biopsy specimens of four patients. Fluorescent in situ hybridization was performed successfully on skin biopsies of four patients' transplanted skin and on two of these four patients' autogenous skin. All six human skin allografts sustained a 100 percent take and long-term clinical survival. DNA tissue typing performed on skin allograft biopsy specimens from patients taking immunosuppressants all revealed donor and recipient cells. DNA tissue typing performed on autogenous skin biopsies from the same patients all revealed only recipient cells. Fluorescent in situ hybridization performed on allograft and autogenous specimens from patients taking immunosuppressants revealed transplanted donor cells with rare recipient cells in the allograft and only recipient cells in the autogenous skin. This study of six patients proves that it is possible for human skin allografts to survive indefinitely on patients taking the usual dosages of immunosuppressants used for renal transplantation. There was minimal repopulation of skin allografts by autogenous keratinocytes and fibroblast while patients were taking immunosuppressants. Immunosuppression was discontinued in two patients after renal transplant rejection after 6 weeks and 5 years. When immunosuppression was discontinued after 5 years in one patient, the skin allograft cells were destroyed and replaced with autogenous cells, but the skin graft did not reject acutely and persisted clinically. It is hypothesized that the acellular portion of the skin allograft was not rejected acutely because of relatively low antigenicity and because it acted as a lattice for autogenous cells to migrate into and replace rejected allograft skin cells. No chimerism was seen in autogenous skin in the skin-renal transplant patients in this study.

Autologous cultured keratinocytes on porcine gelatin microbeads effectively heal chronic venous leg ulcers

We have established a specific bioreactor microcarrier cell culture system using porcine gelatin microbeads as carriers to produce autologous keratinocytes on a large scale. Moreover, we have shown that autologous keratinocytes can be cultured on porcine collagen pads, thereby forming a single cell layer. The objective of this study was to compare efficacy and safety of autologous cultured keratinocytes on microbeads and collagen pads in the treatment of chronic wounds. Fifteen patients with recalcitrant venous leg ulcers were assigned to three groups in a single-center, prospective, uncontrolled study: five underwent a single treatment with keratinocyte monolayers on collagen pads (group 1); another five received a single grafting with keratinocyte-microbeads (group 2); and the last five received multiple, consecutive applications of keratinocyte-microbeads 3 days apart (group 3). All patients were followed for up to 12 weeks. By 12 weeks, there was a mean reduction in the initial wound area of 50, 83, and 97 percent in the three groups, respectively. The changes in wound size were statistically significant between the first and third groups (p= 0.0003). Keratinocyte-microbeads proved to be more effective than keratinocyte monolayers on collagen pads when the former were applied every 3 days. Rapid availability within 10-13 days after skin biopsy and easy handling represent particular advantages.

Burn wound assessment and surgical management

Ideally, in a burn-traumatized patient, nonviable skin and tissues should be excised early in the course of treatment and replaced with a graftable material that mimics the properties of normal skin in function,texture, sensation, and appearance. The difficulty in identifying indeterminate-depth dermal injuries requires further studies to establish the line between extending injury and delaying the progressive excision of nonviable tissue. Recent studies have shown that molecularly the process of wound healing is an interaction among multiple macromolecules and therefore requires in-depth studies of growth factor symptoms, the extra-cellular matrix, and the immunologic response to wounds [8788].The survival of patients with major thermal injuries (Fig. 35) has dramatically increased in recent years. Therefore, greater emphasis must be placed on improving the overall treatment process and the quality of the end result for these patients. Surgically directed and laboratory-based investigations into the cellular components of wound repair and the development of alternative methods of final wound closure are continuing to evolve, and bum specialists are,optimistic that new alternatives will become available for their patients.

Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolioum salt assay

Cell viability assessment in allograft skin is an essential step to ensure a supply of good quality allograft skin for clinical repair of wounds. It is widely recognised that 'take' of allografts is strongly influenced grafted by tissue viability. The aim of this study was to set-up storage protocols that maintain high viability of the allograft after harvest, treatment and storage. In this study, the viability of post-mortem allografts (n=350) harvested from 35 different donors, was investigated using the MTT salt assay. The conditions of preparation and storage of the allograft included: 1. Fresh skin samples (about 12, 30, and 60h after harvesting). 2. The same specimens (stored at 4 and 37 degrees C) tested for at least 1 month. 3. Samples after cryopreservation and thawing. 4. Thawed specimens tested daily for at least 6 days. Parallel histomorphological analysis performed, under each of these conditions, showed a correlation between changes in structure and changes in viability as measured by the MTT quantitative assay. The viability index (VI) of skin is expressed as the ratio between the optical density (O.D.) produced in the MTT assay by the skin sample and its weight in grams. The percentage viability index is the ratio of the VI of the fresh sample (considered as 100% viability) and the value of specimens from the same harvest batch after storage or cryopreservation. The results indicated that samples tested within 12-30h from harvesting have an average viability index of about 75 with little variation. Samples tested within 60h have an average viability index of 40, showing a viability decrease of about 50%. A protocol to treat skin within a maximum of 30h was, therefore, set-up. The data suggested that skin stored at 37 degrees C, undergoes a viability increase during the first 2 days after harvesting. However, the viability under these conditions then decreased very quickly. After 6 days of preservation at this temperature the samples were no longer viable (PVI = 0). The tissue structure started to become damaged after 3 days. On the other hand, skin stored at 4 degrees C, showed a very slow viability decrease. After 15 days, viability was still almost 25% of the fresh sample. The tissue architecture showed no signs of damage under these conditions until day 7 from harvesting. MTT analysis was performed on the specimens cryopreserved with DMSO at 10%. These measurements were compared to viability assessment of the same fresh skin samples (considered as 100%) that were analysed within 30h from harvesting. The average PVI of thawed skin was 54% of the fresh sample. This result demonstrates that the viability of cryopreserved skin is comparable to the viability of fresh skin stored at 4 degrees C for 4 days. The PVI of thawed skin samples decreased dramatically within 24h, and had reached 0% within 6 days.

Clinical applications of tissue engineered constructs

The reconstruction of soft tissue defects poses a challenge for plastic surgeons and tissue engineers. The construction of a biologically, functionally, and cosmetically successful replacement part will involve the combination of a composite that contains endoderm, mesoderm, and ectoderm. It will be active in immune surveillance and function. It must be durable to withstand the stress and strain encountered by the skin. Such a composite will involve the use of bone, cartilage, muscle, blood vessels, nerves, connective tissue, dermis, and epidermis. Fortunately, many of these tissues are among the best studied by tissue engineers. The future of this field will likely involve to some degree the co-mingling of current reconstructive modalities, including the techniques of prefabrication and pre-lamination, with more aggressive and successful tissue engineering technology and the rapidly developing science of stem cell biology. Tissues synthesized in vitro with better structure, color, and texture can be pre-laminated to a site that has already been prefabricated. Prefabrication of a bio-absorbable matrix can create a well perfused scaffold onto which larger subunits can be prelaminated. The future of this field of endeavor is exciting, and, with further research, experience, and interdisciplinary collaboration, bioengineered tissue constructs will become a reality.

Experimental model of cultured keratinocytes

The bioengineering research is essential in the development of ideal combination of biomaterials and cultured cells to produce the permanent wound coverage. The experimental model of cultured keratinocytes presents all steps of the culture, since the isolation of the keratinocytes, preparation of the human acellular dermis, preparation of the composite skin graft and their elevation to the air-liquid interface. The research in cultured keratinocytes model advances in two main ways: 1. optimization of the methods in vitro to the skin cells culture and proliferation and 2. developing biomaterials that present similar skin properties.

Permanent restoration of human skin treated with cultured epithelium grafting--wound healing by stem cell based tissue engineering--

The technique of epidermal cell culture developed by Green and colleagues made a breakthrough in the treatment of massive wounds in vivo with grown cells in vitro. In the past two decades, progress of culture methods and clinical practice have been made and now it is possible to treat extensive skin defect with large amounts of cultured epithelium. Since 1985, we have been successfully used cultured epidermis as autografts for the permanent coverage of full-thickness burn wounds or excised burn scars, giant nevi, tattoos and so on. Furthermore, cultured epidermis has been available as allografts to promote the healing of chronic skin ulcers or deep dermal burn. In this paper we describe our clinical experience of cultured epithelium grafting for the treatment of wounds and predict new trial of wound management and regeneration based on tissue engineering concept.

Principles and practices for treatment of cutaneous wounds with cultured skin substitutes

BACKGROUND

Skin substitutes prepared from cultured skin cells and biopolymers may reduce requirements for donor skin autograft, and have been shown to be effective in treatment of excised burns, burn scars, and congenital skin lesions.

DATA SOURCES

Cultured skin substitutes (CSS) generate skin phenotypes (epidermal barrier, basement membrane) in the laboratory, and restore tissue function and systemic homeostasis. Healed skin is smooth, soft and strong, but develops irregular degrees of pigmentation. Quantitative analysis demonstrates that CSS closes 67 times the area of the donor skin, compared to less than 4 times for split-thickness skin autograft.

CONCLUSIONS

CSS reduce requirements for donor skin autograft for closure of excised, full-thickness cutaneous wounds, and demonstrate qualitative outcome that is not different from meshed, split-thickness autograft. These results offer reductions in morbidity and mortality for the treatment of burns and chronic wounds, and for cutaneous reconstruction.

Regeneration of neomucosa using cell-seeded collagen-GAG matrices in athymic mice

Tissue engineering of oral mucosa could allow improved reconstructive options for intraoral tissue defects. Porous collagen-glycosaminoglycan (CG) matrices coated with a silicone elastomer were seeded by centrifugation with cultured human oral mucosal epithelial cells (strain OKG4 gingival keratinocytes) at a density of 250,000 cells per square centimeter. Full-thickness dorsal wounds (1.5 x 1.5 cm) were created surgically on each athymic mouse and were treated with either a seeded matrix or an unseeded matrix, or they were left open as a control. The CG matrices reduced the degree of wound contraction at day 14 compared with open wounds. The epithelial thickness of seeded matrices at day 14 was significantly greater (p = 0.0001) than that of unseeded matrices. Seeded matrices had more rapid degradation at 14 days compared with unseeded matrices. Human oral mucosal cells seeded into CG matrices contribute to form a stratified and differentiated epithelial layer during revascularization, cellular infiltration, and degradation of the CG matrix.