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Coutant K, Magne B, Ferland K, Fuentes-Rodriguez A, Chancy O, Mitchell A, Germain L, Landreville S. Melanocytes in regenerative medicine applications and disease modeling. J Transl Med 2024; 22:336. [PMID: 38589876 PMCID: PMC11003097 DOI: 10.1186/s12967-024-05113-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Melanocytes are dendritic cells localized in skin, eyes, hair follicles, ears, heart and central nervous system. They are characterized by the presence of melanosomes enriched in melanin which are responsible for skin, eye and hair pigmentation. They also have different functions in photoprotection, immunity and sound perception. Melanocyte dysfunction can cause pigmentary disorders, hearing and vision impairments or increased cancer susceptibility. This review focuses on the role of melanocytes in homeostasis and disease, before discussing their potential in regenerative medicine applications, such as for disease modeling, drug testing or therapy development using stem cell technologies, tissue engineering and extracellular vesicles.
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Affiliation(s)
- Kelly Coutant
- Department of Ophthalmology and Otorhinolaryngology-Cervico-Facial Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Université Laval Cancer Research Center, Quebec City, QC, Canada
| | - Brice Magne
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Karel Ferland
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Aurélie Fuentes-Rodriguez
- Department of Ophthalmology and Otorhinolaryngology-Cervico-Facial Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Université Laval Cancer Research Center, Quebec City, QC, Canada
| | - Olivier Chancy
- Department of Ophthalmology and Otorhinolaryngology-Cervico-Facial Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Université Laval Cancer Research Center, Quebec City, QC, Canada
| | - Andrew Mitchell
- Department of Ophthalmology and Otorhinolaryngology-Cervico-Facial Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada
- Université Laval Cancer Research Center, Quebec City, QC, Canada
| | - Lucie Germain
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada.
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada.
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada.
| | - Solange Landreville
- Department of Ophthalmology and Otorhinolaryngology-Cervico-Facial Surgery, Faculty of Medicine, Université Laval, Quebec City, QC, Canada.
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Quebec City, QC, Canada.
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX, Quebec City, QC, Canada.
- Université Laval Cancer Research Center, Quebec City, QC, Canada.
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Liang Y, Wei C, Song Y, Feng Y. Antibacterial functionalization of calfskin bioremediation film. Biotechnol J 2024; 19:e2300150. [PMID: 37750457 DOI: 10.1002/biot.202300150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
Decellularized calfskins are a well-established skin substitute that retains the dermal tissue's spatial structure, facilitating skin regeneration, and is already available in the market. However, their mechanical properties can change with degradation, leading to tearing at the suture. Moreover, decellularized calfskins do not possess inherent antimicrobial abilities, which can lead to wound infection and further injury during the healing process. With the objectives of supporting the clinical use of decellularized calfskins, minimizing the probability of decellularized calfskin fracture and damage during usage, and improving their anti-infective properties, this study utilized a post-loading method to load gentamicin sulfate onto the decellularized calfskin to functionalize it for antimicrobial purposes. In addition, the mechanical and physicochemical properties of the drug-carrying film were investigated to see if they could meet the clinical requirements. The results revealed that vancomycin sulfate could be loaded onto the decellularized calfskin without affecting collagen. The tensile strength of the drug-loaded membrane was determined to be in the range of 5.53-29.25 MPa, meeting the clinical requirements. Thermal analysis and pH analysis experiments demonstrated that the drug-loaded membrane did not undergo thermal denaturation or decomposition during skin repair and remained within the normal pH range of the skin, avoiding significant fluctuations in wound pH.
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Affiliation(s)
- Yi Liang
- School of Mechanical Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
- Shandong Institute of Mechanical Design and Research, Jinan, China
| | - Chao Wei
- School of Intelligent Manufacturing, Shandong University of Engineering and Vocational Technology, Jinan, China
| | - Yuying Song
- School of Mechanical Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
- Shandong Institute of Mechanical Design and Research, Jinan, China
| | - Yihua Feng
- School of Mechanical Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
- Shandong Institute of Mechanical Design and Research, Jinan, China
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Sierra-Sánchez Á, Magne B, Savard E, Martel C, Ferland K, Barbier MA, Demers A, Larouche D, Arias-Santiago S, Germain L. In vitro comparison of human plasma-based and self-assembled tissue-engineered skin substitutes: two different manufacturing processes for the treatment of deep and difficult to heal injuries. BURNS & TRAUMA 2023; 11:tkad043. [PMID: 37908563 PMCID: PMC10615253 DOI: 10.1093/burnst/tkad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/13/2023] [Accepted: 07/21/2023] [Indexed: 11/02/2023]
Abstract
Background The aim of this in vitro study was to compare side-by-side two models of human bilayered tissue-engineered skin substitutes (hbTESSs) designed for the treatment of severely burned patients. These are the scaffold-free self-assembled skin substitute (SASS) and the human plasma-based skin substitute (HPSS). Methods Fibroblasts and keratinocytes from three humans were extracted from skin biopsies (N = 3) and cells from the same donor were used to produce both hbTESS models. For SASS manufacture, keratinocytes were seeded over three self-assembled dermal sheets comprising fibroblasts and the extracellular matrix they produced (n = 12), while for HPSS production, keratinocytes were cultured over hydrogels composed of fibroblasts embedded in either plasma as unique biomaterial (Fibrin), plasma combined with hyaluronic acid (Fibrin-HA) or plasma combined with collagen (Fibrin-Col) (n/biomaterial = 9). The production time was 46-55 days for SASSs and 32-39 days for HPSSs. Substitutes were characterized by histology, mechanical testing, PrestoBlue™-assay, immunofluorescence (Ki67, Keratin (K) 10, K15, K19, Loricrin, type IV collagen) and Western blot (type I and IV collagens). Results The SASSs were more resistant to tensile forces (p-value < 0.01) but less elastic (p-value < 0.001) compared to HPSSs. A higher number of proliferative Ki67+ cells were found in SASSs although their metabolic activity was lower. After epidermal differentiation, no significant difference was observed in the expression of K10, K15, K19 and Loricrin. Overall, the production of type I and type IV collagens and the adhesive strength of the dermal-epidermal junction was higher in SASSs. Conclusions This study demonstrates, for the first time, that both hbTESS models present similar in vitro biological characteristics. However, mechanical properties differ and future in vivo experiments will aim to compare their wound healing potential.
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Affiliation(s)
- Álvaro Sierra-Sánchez
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- Unidad de Producción Celular e Ingeniería Tisular (UPCIT), Virgen de las Nieves University Hospital, ibs. GRANADA, Andalusian Network for the design and translation of Advanced Therapies, Av. de las Fuerzas Armadas, Nº2, 4ª Planta Ed. de Gobierno, 18014, Granada, Spain
| | - Brice Magne
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Etienne Savard
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Christian Martel
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Karel Ferland
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Martin A Barbier
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Anabelle Demers
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Danielle Larouche
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
| | - Salvador Arias-Santiago
- Unidad de Producción Celular e Ingeniería Tisular (UPCIT), Virgen de las Nieves University Hospital, ibs. GRANADA, Andalusian Network for the design and translation of Advanced Therapies, Av. de las Fuerzas Armadas, Nº2, 4ª Planta Ed. de Gobierno, 18014, Granada, Spain
- Department of Dermatology, Virgen de las Nieves University Hospital, Av. Madrid, Nº11–15, 18012, Granada, Spain
- Department of Dermatology, Faculty of Medicine, University of Granada, Av. de la Investigación, Nº11, 18016, Granada, Spain
| | - Lucie Germain
- LOEX Tissue Engineering Laboratory and Department of Surgery, Faculty of Medicine, Université Laval, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
- CHU de Québec – Université Laval Research Center, Division of Regenerative Medicine, 1401 18e rue, Québec (Québec) G1J 1Z4, Canada
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Zielinska D, Fisch P, Moehrlen U, Finkielsztein S, Linder T, Zenobi-Wong M, Biedermann T, Klar AS. Combining bioengineered human skin with bioprinted cartilage for ear reconstruction. SCIENCE ADVANCES 2023; 9:eadh1890. [PMID: 37792948 PMCID: PMC10550230 DOI: 10.1126/sciadv.adh1890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 09/01/2023] [Indexed: 10/06/2023]
Abstract
Microtia is a congenital disorder that manifests as a malformation of the external ear leading to psychosocial problems in affected children. Here, we present a tissue-engineered treatment approach based on a bioprinted autologous auricular cartilage construct (EarCartilage) combined with a bioengineered human pigmented and prevascularized dermo-epidermal skin substitute (EarSkin) tested in immunocompromised rats. We confirmed that human-engineered blood capillaries of EarSkin connected to the recipient's vasculature within 1 week, enabling rapid blood perfusion and epidermal maturation. Bioengineered EarSkin displayed a stratified epidermis containing mature keratinocytes and melanocytes. The latter resided within the basal layer of the epidermis and efficiently restored the skin color. Further, in vivo tests demonstrated favorable mechanical stability of EarCartilage along with enhanced extracellular matrix deposition. In conclusion, EarCartilage combined with EarSkin represents a novel approach for the treatment of microtia with the potential to circumvent existing limitations and improve the aesthetic outcome of microtia reconstruction.
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Affiliation(s)
- Dominika Zielinska
- Tissue Biology Research Unit, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Philipp Fisch
- Tissue Engineering and Biofabrication Laboratory, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Ueli Moehrlen
- Tissue Biology Research Unit, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | | | - Thomas Linder
- Klinik für Hals-, Nasen-, Ohren- und Gesichtschirurgie, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marcy Zenobi-Wong
- Tissue Engineering and Biofabrication Laboratory, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Agnes S. Klar
- Tissue Biology Research Unit, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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Doucet EJ, Cortez Ghio S, Barbier MA, Savard É, Magne B, Safoine M, Larouche D, Fradette J, Germain L. Production of Tissue-Engineered Skin Substitutes for Clinical Applications: Elimination of Serum. Int J Mol Sci 2023; 24:12537. [PMID: 37628718 PMCID: PMC10454817 DOI: 10.3390/ijms241612537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/25/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Tissue-engineered skin substitutes (TESs) are used as a treatment for severe burn injuries. Their production requires culturing both keratinocytes and fibroblasts. The methods to grow these cells have evolved over the years, but bovine serum is still commonly used in the culture medium. Because of the drawbacks associated with the use of serum, it would be advantageous to use serum-free media for the production of TESs. In a previous study, we developed a serum-free medium (Surge SFM) for the culture of keratinocytes. Herein, we tested the use of this medium, together with a commercially available serum-free medium for fibroblasts (Prime XV), to produce serum-free TESs. Our results show that serum-free TESs are macroscopically and histologically similar to skin substitutes produced with conventional serum-containing media. TESs produced with either culture media expressed keratin 14, Ki-67, transglutaminase 1, filaggrin, type I and IV collagen, and fibronectin comparably. Mechanical properties, such as contraction and tensile strength, were comparable between TESs cultured with and without serum. Serum-free TESs were also successfully grafted onto athymic mice for a six-month period. In conclusion, Surge SFM and Prime XV serum-free media could be used to produce high quality clinical-grade skin substitutes.
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Affiliation(s)
- Emilie J. Doucet
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Sergio Cortez Ghio
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Martin A. Barbier
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Étienne Savard
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Brice Magne
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Meryem Safoine
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Danielle Larouche
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Julie Fradette
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
| | - Lucie Germain
- The Tissue Engineering Laboratory (LOEX), Université Laval’s Research Center, Québec, QC G1V 0A6, Canada; (E.J.D.); (S.C.G.); (M.A.B.); (É.S.); (B.M.); (M.S.); (D.L.); (J.F.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Regenerative Medicine Division, CHU de Québec-Université Laval Research Centre, Québec, QC G1V 0A6, Canada
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Magne B, Demers A, Savard É, Lemire-Rondeau M, Veillette N, Pruneau V, Guignard R, Morissette A, Larouche D, Auger FA, Germain L. Speeding up the Production of Clinical-Grade Skin Substitutes Using Off-the-shelf Decellularized Self-Assembled Dermal Matrices. Acta Biomater 2023:S1742-7061(23)00318-5. [PMID: 37285897 DOI: 10.1016/j.actbio.2023.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023]
Abstract
Patients with deep and extensive wounds need urgent skin coverage to re-establish the cutaneous barrier that prevents life-threatening infections and dehydration. However, the current clinically-available skin substitutes intended for permanent coverage are limited in number, and a trade-off between production time and quality must be made. Here, we report the use of decellularized self-assembled dermal matrices to reduce by half the manufacturing process time of clinical-grade skin substitutes. These decellularized matrices can be stored for over 18 months and recellularized with patients' cells in order to generate skin substitutes that show outstanding histological and mechanical properties in vitro. Once grafted in mice, these substitutes persist over weeks with high graft take, few contraction events, and high stem cell content. These next-generation skin substitutes constitute a substantial advancement in the treatment of major burn patients, combining, for the first time, high functionality, rapid manufacturability and easy handling for surgeons and healthcare practitioners. Future clinical trials will be conducted to assess the advantages of these substitutes over existing treatments. STATEMENT OF SIGNIFICANCE: The number of patients in need for organ transplantation is ever-growing and there is a shortage in tissue and organ donors. In this study, we show for the first time that we can preserve decellularized self-assembled tissues and keep them in storage. Then, in only three weeks we can use them to produce bilayered skin substitutes that have properties very close to those of the native human skin. These findings therefore represent a major step forward in the field of tissue engineering and organ transplantation, paving the way toward a universal off-the-shelf biomaterial for tissue reconstruction and surgery that will be beneficial for many clinicians and patients.
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Affiliation(s)
- Brice Magne
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Anabelle Demers
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Étienne Savard
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Marika Lemire-Rondeau
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Noémie Veillette
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Virgile Pruneau
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Rina Guignard
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Amélie Morissette
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Danielle Larouche
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - François A Auger
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center
| | - Lucie Germain
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, Canada.; Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX; CHU de Québec - Université Laval Research Center.
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Hsiung T, James L, Chang SH, Geraci TC, Angel LF, Chan JCY. Advances in lung bioengineering: Where we are, where we need to go, and how to get there. FRONTIERS IN TRANSPLANTATION 2023; 2:1147595. [PMID: 38993882 PMCID: PMC11235378 DOI: 10.3389/frtra.2023.1147595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 07/13/2024]
Abstract
Lung transplantation is the only potentially curative treatment for end-stage lung failure and successfully improves both long-term survival and quality of life. However, lung transplantation is limited by the shortage of suitable donor lungs. This discrepancy in organ supply and demand has prompted researchers to seek alternative therapies for end-stage lung failure. Tissue engineering (bioengineering) organs has become an attractive and promising avenue of research, allowing for the customized production of organs on demand, with potentially perfect biocompatibility. While breakthroughs in tissue engineering have shown feasibility in practice, they have also uncovered challenges in solid organ applications due to the need not only for structural support, but also vascular membrane integrity and gas exchange. This requires a complex engineered interaction of multiple cell types in precise anatomical locations. In this article, we discuss the process of creating bioengineered lungs and the challenges inherent therein. We summarize the relevant literature for selecting appropriate lung scaffolds, creating decellularization protocols, and using bioreactors. The development of completely artificial lung substitutes will also be reviewed. Lastly, we describe the state of current research, as well as future studies required for bioengineered lungs to become a realistic therapeutic modality for end-stage lung disease. Applications of bioengineering may allow for earlier intervention in end-stage lung disease and have the potential to not only halt organ failure, but also significantly reverse disease progression.
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Affiliation(s)
- Tiffany Hsiung
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
| | - Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
- Department of Cardiothoracic Surgery, NYU Transplant Institute, NYU Langone Health, New York, NY, United States
| | - Travis C Geraci
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
- Department of Cardiothoracic Surgery, NYU Transplant Institute, NYU Langone Health, New York, NY, United States
| | - Luis F Angel
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
- Department of Cardiothoracic Surgery, NYU Transplant Institute, NYU Langone Health, New York, NY, United States
| | - Justin C Y Chan
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, United States
- Department of Cardiothoracic Surgery, NYU Transplant Institute, NYU Langone Health, New York, NY, United States
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8
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Chan JCY, Chaban R, Chang SH, Angel LF, Montgomery RA, Pierson RN. Future of Lung Transplantation: Xenotransplantation and Bioengineering Lungs. Clin Chest Med 2023; 44:201-214. [PMID: 36774165 PMCID: PMC11078107 DOI: 10.1016/j.ccm.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Xenotransplantation promises to alleviate the issue of donor organ shortages and to decrease waiting times for transplantation. Recent advances in genetic engineering have allowed for the creation of pigs with up to 16 genetic modifications. Several combinations of genetic modifications have been associated with extended graft survival and life-supporting function in experimental heart and kidney xenotransplants. Lung xenotransplantation carries specific challenges related to the large surface area of the lung vascular bed, its innate immune system's intrinsic hyperreactivity to perceived 'danger', and its anatomic vulnerability to airway flooding after even localized loss of alveolocapillary barrier function. This article discusses the current status of lung xenotransplantation, and challenges related to immunology, physiology, anatomy, and infection. Tissue engineering as a feasible alternative to develop a viable lung replacement solution is discussed.
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Affiliation(s)
- Justin C Y Chan
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA.
| | - Ryan Chaban
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Cardiovascular Surgery, University Hospital of Johannes Gutenberg University, Langenbeckstr. 1, Bau 505, 5. OG55131 Mainz, Germany
| | - Stephanie H Chang
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Luis F Angel
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Robert A Montgomery
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Richard N Pierson
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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9
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A Newly Developed Chemically Defined Serum-Free Medium Suitable for Human Primary Keratinocyte Culture and Tissue Engineering Applications. Int J Mol Sci 2023; 24:ijms24031821. [PMID: 36768144 PMCID: PMC9915451 DOI: 10.3390/ijms24031821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/31/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
In our experience, keratinocytes cultured in feeder-free conditions and in commercially available defined and serum-free media cannot be as efficiently massively expanded as their counterparts grown in conventional bovine serum-containing medium, nor can they properly form a stratified epidermis in a skin substitute model. We thus tested a new chemically defined serum-free medium, which we developed for massive human primary keratinocyte expansion and skin substitute production. Our medium, named Surge Serum-Free Medium (Surge SFM), was developed to be used alongside a feeder layer. It supports the growth of keratinocytes freshly isolated from a skin biopsy and cryopreserved primary keratinocytes in cultured monolayers over multiple passages. We also show that keratin-19-positive epithelial stem cells are retained through serial passaging in Surge SFM cultures. Transcriptomic analyses suggest that gene expression is similar between keratinocytes cultured with either Surge SFM or the conventional serum-containing medium. Additionally, Surge SFM can be used to produce bilayered self-assembled skin substitutes histologically similar to those produced using serum-containing medium. Furthermore, these substitutes were grafted onto athymic mice and persisted for up to six months. In conclusion, our new chemically defined serum-free keratinocyte culture medium shows great promise for basic research and clinical applications.
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10
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Dagher J, Arcand C, Auger FA, Germain L, Moulin VJ. The Self-Assembled Skin Substitute History: Successes, Challenges, and Current Treatment Indications. J Burn Care Res 2023; 44:S57-S64. [PMID: 36567476 PMCID: PMC9790893 DOI: 10.1093/jbcr/irac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The self-assembled skin substitute (SASS) is an autologous bilayered skin substitute designed by our academic laboratory, the Laboratoire d'Organogenèse Expérimentale (LOEX) to offer definitive treatment for patients lacking donor sites (unwounded skin) to cover their burn wounds. This product shows skin-like attributes, such as an autologous dermal and epidermal layer, and is easily manipulable by the surgeon. Its development stems from the need for skin replacement in high total body surface area burned survivors presenting few donor sites for standard split-thickness skin grafting. This review aims to present the history, successes, challenges, and current therapeutic indications of this skin substitute. We review the product's development history, before discussing current production techniques, as well as clinical use. The progression observed since the initial SASS production technique described in 1999, up to the most recent technique expresses significant advances made in the technical aspect of our product, such as the reduction of the production time. We then explore the efficacy and benefits of SASS over existing skin substitutes and discuss the outcomes of a recent study focusing on the successful treatment of 14 patients. Moreover, an ongoing cross-Canada study is further assessing the product's safety and efficacy. The limitations and technical challenges of SASS are also discussed.
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Affiliation(s)
- Jason Dagher
- Centre de Recherche en Organogénèse Expérimentale de l’Université Laval (LOEX), Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de chirurgie, Faculté de Médecine, Université Laval, Québec, Canada
| | - Charles Arcand
- Centre de Recherche en Organogénèse Expérimentale de l’Université Laval (LOEX), Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de chirurgie, Faculté de Médecine, Université Laval, Québec, Canada
| | - François A Auger
- Centre de Recherche en Organogénèse Expérimentale de l’Université Laval (LOEX), Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de chirurgie, Faculté de Médecine, Université Laval, Québec, Canada
| | - Lucie Germain
- Centre de Recherche en Organogénèse Expérimentale de l’Université Laval (LOEX), Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de chirurgie, Faculté de Médecine, Université Laval, Québec, Canada
| | - Véronique J Moulin
- Centre de Recherche en Organogénèse Expérimentale de l’Université Laval (LOEX), Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de chirurgie, Faculté de Médecine, Université Laval, Québec, Canada
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11
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Girardeau-Hubert S, Lynch B, Zuttion F, Label R, Rayee C, Brizion S, Ricois S, Martinez A, Park E, Kim C, Marinho PA, Shim JH, Jin S, Rielland M, Soeur J. Impact of microstructure on cell behavior and tissue mechanics in collagen and dermal decellularized extra-cellular matrices. Acta Biomater 2022; 143:100-114. [PMID: 35235868 DOI: 10.1016/j.actbio.2022.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
Skin models are used for many applications such as research and development or grafting. Unfortunately, most lack a proper microenvironment producing poor mechanical properties and inaccurate extra-cellular matrix composition and organization. In this report we focused on mechanical properties, extra-cellular matrix organization and cell interactions in human skin samples reconstructed with pure collagen or dermal decellularized extra-cellular matrices (S-dECM) and compared them to native human skin. We found that Full-thickness S-dECM samples presented stiffness two times higher than collagen gel and similar to ex vivo human skin, and proved for the first time that keratinocytes also impact dermal mechanical properties. This was correlated with larger fibers in S-dECM matrices compared to collagen samples and with a differential expression of F-actin, vinculin and tenascin C between S-dECM and collagen samples. This is clear proof of the microenvironment's impact on cell behaviors and mechanical properties. STATEMENT OF SIGNIFICANCE: In vitro skin models have been used for a long time for clinical applications or in vitro knowledge and evaluation studies. However, most lack a proper microenvironment producing a poor combination of mechanical properties and appropriate biological outcomes, partly due to inaccurate extra-cellular matrix (ECM) composition and organization. This can lead to limited predictivity and weakness of skin substitutes after grafting. This study shows, for the first time, the importance of a complex and rich microenvironment on cell behaviors, matrix macro- and micro-organization and mechanical properties. The increased composition and organization complexity of dermal skin decellularized extra-cellular matrix populated with differentiated cells produces in vitro skin models closer to native human skin physiology.
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12
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Barbier MA, Piaceski AD, Larouche D, Villeneuve SH, Ghani K, Pope E, Caruso M, Germain L. Efficient Gamma-Retroviral Transduction of Primary Human Skin Cells Using the EF-c Peptide as a Transduction Enhancer. Curr Protoc 2022; 2:e353. [PMID: 35085429 DOI: 10.1002/cpz1.353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Efficient gene transfer into cultured fibroblasts and keratinocytes during retroviral transduction is a critical step toward the treatment of genodermatoses such as epidermolysis bullosa. However, achieving high transduction rates is still a difficult task, particularly for the insertion of large coding sequences for which high viral titers cannot always be obtained. Multiple polycationic molecules, such as polybrene, which has been used in several clinical trials, have the ability to boost ex vivo retroviral gene transfer. However, the use of polybrene has been associated with a reduction of the proliferation and growth potential of human keratinocytes in culture. We developed a method for the efficient retroviral transduction of primary fibroblasts and keratinocytes using EF-c, a polycationic nanofibril-forming peptide. In comparison with polybrene, we found that the retroviral transduction efficiency with EF-c was increased 2.5- to 3.2-fold for fibroblasts, but not for keratinocytes. Moreover, the use of EF-c did not affect fibroblast proliferation and keratinocyte stem cell content, whereas polybrene induced a decrease in both. This method could have a positive impact on the development of ex vivo gene correction of genodermatoses, allowing for more efficient gene transfer into primary skin cells with little to no effect on proliferation and stem cell content. © 2022 Wiley Periodicals LLC. Basic Protocol: Fibroblast and keratinocyte transduction Support Protocol: Assessment of transduction efficiency through flow cytometry analysis.
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Affiliation(s)
- Martin A Barbier
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX et Département de chirurgie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada.,Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Angela Dakiw Piaceski
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX et Département de chirurgie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada.,Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Danielle Larouche
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX et Département de chirurgie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada.,Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Sarah H Villeneuve
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX et Département de chirurgie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada.,Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada
| | - Karim Ghani
- Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada.,Centre de recherche sur le cancer de l'Université Laval, Département de biologie moléculaire, de biochimie médicale et de pathologie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada
| | - Elena Pope
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Manuel Caruso
- Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada.,Centre de recherche sur le cancer de l'Université Laval, Département de biologie moléculaire, de biochimie médicale et de pathologie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada
| | - Lucie Germain
- Centre de recherche en organogénèse expérimentale de l'Université Laval/LOEX et Département de chirurgie, Faculté de médecine, Université Laval, Québec City, Quebec, Canada.,Centre de recherche du CHU de Québec-Université Laval, Québec City, Quebec, Canada
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13
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Dearman BL, Boyce ST, Greenwood JE. Advances in Skin Tissue Bioengineering and the Challenges of Clinical Translation. Front Surg 2021; 8:640879. [PMID: 34504864 PMCID: PMC8421760 DOI: 10.3389/fsurg.2021.640879] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 07/31/2021] [Indexed: 01/17/2023] Open
Abstract
Skin tissue bioengineering is an emerging field that brings together interdisciplinary teams to promote successful translation to clinical care. Extensive deep tissue injuries, such as large burns and other major skin loss conditions, are medical indications where bioengineered skin substitutes (that restore both dermal and epidermal tissues) are being studied as alternatives. These may not only reduce mortality but also lessen morbidity to improve quality of life and functional outcome compared with the current standards of care. A common objective of dermal-epidermal therapies is to reduce the time required to accomplish stable closure of wounds with minimal scar in patients with insufficient donor sites for autologous split-thickness skin grafts. However, no commercially-available product has yet fully satisfied this objective. Tissue engineered skin may include cells, biopolymer scaffolds and drugs, and requires regulatory review to demonstrate safety and efficacy. They must be scalable for manufacturing and distribution. The advancement of technology and the introduction of bioreactors and bio-printing for skin tissue engineering may facilitate clinical products' availability. This mini-review elucidates the reasons for the few available commercial skin substitutes. In addition, it provides insights into the challenges faced by surgeons and scientists to develop new therapies and deliver the results of translational research to improve patient care.
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Affiliation(s)
- Bronwyn L. Dearman
- Skin Engineering Laboratory, Adult Burns Centre, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adult Burns Centre, Royal Adelaide Hospital, Adelaide, SA, Australia
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, SA, Australia
| | - Steven T. Boyce
- Department of Surgery, University of Cincinnati, Cincinnati, OH, United States
| | - John E. Greenwood
- Skin Engineering Laboratory, Adult Burns Centre, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adult Burns Centre, Royal Adelaide Hospital, Adelaide, SA, Australia
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14
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Kelly C, Wallace D, Moulin V, Germain L, Zuccaro J, Galdyn I, Fish JS. Surviving an Extensive Burn Injury Using Advanced Skin Replacement Technologies. J Burn Care Res 2021; 42:1288-1291. [PMID: 34343315 DOI: 10.1093/jbcr/irab146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There have been significant improvements in the technology available for treating extensive burns in the past decade. This case presents two unique, skin replacement technologies that were used to treat an 86% surface area flame burn in a pediatric patient. A temporary dermal replacement, known as "Novosorb™ Biodegradable Temporizing Matrix" was first used to stabilize the burn injury and remained in place for approximately three months. Given the large burn size and lack of available donor skin for grafting, a permanent skin replacement product known as "Self-Assembled Skin Substitute (SASS)" was then utilized to cover the burns. SASS is a novel technology that was developed to replace skin as an autologous skin graft and is currently available in Canada through a clinical trial for major burns. Ultimately, the concurrent use of these two technologies allowed for the unprecedented survival of a child following an extensive and life-threatening burn injury.
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Affiliation(s)
- Charis Kelly
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Wallace
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Veronique Moulin
- CHU of Québec-Laval University Research Center and Center of Research in Experimental Organogenesis of Laval University/LOEX, Québec, Canada
| | - Lucie Germain
- CHU of Québec-Laval University Research Center and Center of Research in Experimental Organogenesis of Laval University/LOEX, Québec, Canada
| | - Jennifer Zuccaro
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Izabela Galdyn
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joel S Fish
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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