Wound tissue can utilize a polymeric template to synthesize a functional extension of skin

Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment

The safety and effectiveness of Integra Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1-95%). Integra was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra-treated sites was 3.1% (95% confidence interval, 2.0-4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0-15.7%). Mean take rate of Integra was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.

Use of Integra artificial skin is associated with decreased length of stay for severely injured adult burn survivors

Mortality and length of stay (LOS) of survivors was examined retrospectively in 270 adults with acute burns > or =20% of body surface area to determine the effect of Integra Dermal Regeneration Template treatment on outcome. No difference in mortality was found between patients who received Integra (30%; n = 43) and patients who did not (30%; n = 227). Surviving Integra patients (n = 30) stayed longer, but they were more extensively injured than survivors who did not receive Integra (n = 158), and therefore longer hospitalizations were expected. In a subgroup analysis, mean LOS of Integra patients with two or more mortality risk factors (age > 60 years, burn size >40% body surface area, or inhalation injury; n = 15) was 63 days compared with 107 days in patients with two or more risk factors (n = 29) who did not receive Integra ( =.014). Integra use in severely injured burned adults was associated with a marked decrease in LOS.

Cultured autologous fibroblasts augment epidermal repair

BACKGROUND

Autologous dermal fibroblasts may be useful in the treatment of skin wounds and for the enhancement of keratinocyte proliferation. This paper addressed the following questions: (1) can cultured fibroblasts (CF) be transplanted as suspensions to full-thickness skin wounds and do they influence wound healing; (2) will the transplanted CF be integrated into the new dermis; (3) can a transgene that encodes a secretable marker, human epidermal growth factor (hEGF), be expressed in the wound fluid by the transplanted CF; and (4) do CF cotransplanted with cultured keratinocytes (CK) influence the rate of wound healing?

METHODS

Suspensions of CF were transplanted alone or together with CK to full-thickness wounds covered with liquid-containing chambers in an established porcine model.

RESULTS

Transplantation of CF accelerated reepithelialization as determined from wound histologies and sequential measurements of protein efflux over the wound surface. CF transfected with a marker gene, beta-galactosidase, resulted in in vivo gene expression and demonstrated that transplanted CF integrated into the developing dermis. Transplantation of hEGF gene-transfected CF resulted in significant hEGF expression in wound fluid. The hEGF levels peaked at day 1 (2450 pg/ml) and then sharply decreased to low levels on day 6. CF cotransplanted with CK led to greater number of keratinocyte colonies in the wound and accelerated reepithelialization as compared with CK alone.

CONCLUSIONS

Transplanted CF integrated into the dermis, accelerated reepithelialization, and improved the outcome of CK transplantation. CF may also be used for the expression of transgenes in wound and wound fluid.

A new device for measuring the viscoelastic properties of hydrated matrix gels

Determinations of the viscoelastic properties of extracellular matrices (ECMs) are becoming increasingly important for accurate predictive modeling of biological systems. Since the interactions of the cells with the ECM and surrounding fluid (e.g., blood, media) each affect cell behavior; it is advantageous to evaluate the ECM's material properties in the presence of the hydrating fluid. Conventional rheometry methods evaluate the bulk material properties of gel materials while displacing the hydrating liquid film. Such systems are therefore nonideal for testing materials such as ECMs, whose properties change with dehydration. The new patent pending, piezoelectrically actuated linear rheometer is designed to eliminate this problem. It uses a single cantilever to apply an oscillating load to the gel and to sense the gel's deflection. Composed of two thin film piezopolymer layers, the cantilever uses one layer as the actuator, and the second piezopolymer layer to measure the lateral movement of its attached probe. The viscoelastic nature of the ECM adds stiffness and damping to the system, resulting in the attenuation and phase shift of the sensor's output voltage. From these parameters, the ECM's shear storage and loss moduli are then determined. Initial tests on the BioMatrix I and type I collagen ECMs reveal that the first prototype of the piezoelectrically actuated linear rheometer is capable of accurately determining the trend and order of magnitude of an ECM's viscoelastic properties. In this paper, details of the rheometer's design and operating principles are described.

Control of pore structure and size in freeze-dried collagen sponges

Because of many suitable properties, collagen sponges are used as an acellular implant or a biomaterial in the field of tissue engineering. Generally, the inner three-dimensional structure of the sponges influences the behavior of cells. To investigate this influence, it is necessary to develop a process to produce sponges with a defined, adjustable, and homogeneous pore structure. Collagen sponges can be produced by freeze-drying of collagen suspensions. The pore structure of the freeze-dried sponges mirrors the ice-crystal morphology after freezing. In industrial production, the collagen suspensions are solidified under time- and space-dependent freezing conditions, resulting in an inhomogeneous pore structure. In this investigation, unidirectional solidification was applied during the freezing process to produce collagen sponges with a homogeneous pore structure. Using this technique the entire sample can be solidified under thermally constant freezing conditions. The ice-crystal morphology and size can be adjusted by varying the solute concentration in the collagen suspension. Collagen sponges with a very uniform and defined pore structure can be produced. Furthermore, the pore size can be adjusted between 20-40 microm. The thickness of the sponges prepared during this research was 10 mm.

Keratinocyte growth factor induces hyperproliferation and delays differentiation in a skin equivalent model system

Keratinocyte growth factor (KGF) is a paracrine mediator of epithelial cell growth. To examine the direct effects of KGF on the morphogenesis of the epidermis, we generated skin equivalents in vitro by seeding human keratinocytes on the papillary surface of acellular dermis and raising them up to the air-liquid interface. KGF was either added exogenously or expressed by keratinocytes via a recombinant retrovirus encoding KGF. KGF induced dramatic changes to the 3-dimensional organization of the epidermis including pronounced hyperthickening, crowding, and elongation of the basal cells, flattening of the rete ridges, and a ripple-like pattern in the junction of stratum corneum and granular layers. Quantitative immunostaining for the proliferation antigen, Ki67, revealed that in addition to increasing basal proliferation, KGF extended the proliferative compartment by inducing suprabasal cell proliferation. KGF also induced expression of the integrin alpha 5 beta 1 and delayed expression of keratin 10 and transglutaminase. However, barrier formation of the epidermis was not disrupted. These results demonstrate for the first time that a single growth factor can alter the 3-dimensional organization and proliferative function of an in vitro epidermis. In addition to new strategies for tissue engineering, such a well-defined system will be useful for analyzing growth factor effects on the complex links between cell proliferation, cell movement and differentiation within a stratified tissue.

Films of collagen crosslinked by S-S bonds: preparation and characterization

Collagen (type I from calf-skin) was chemically modified by 4-butyrothiolactone to obtain the mercapto group-bearing collagen (collagenSH), which possessed SH groups in 8-19 M% of a total amino acid residues. The triple helical strands of the collagen was not completely perturbed to exhibit the rotary dispersion [theta]221, which was as much as 70% of an original intensity of the collagen. In the presence of the oxygen dissolved in water, the collagenSH was cross-linked by disulfide bonds to afford the collagenSS. The collagenSS could preserve about 15 and 40% of an original helix structure at 55-70 degrees C and in 2mm sodium dodecyl sulfate, respectively. The film made of the collagenSS exhibited the tensile strength as high as 36 MPa and was insoluble in most organic solvents including water. The collagenSS film was more resistant to degradation by collagenase (type I) than the collagen film. The collagenSS film supported the growth of L929 fibroblast cell in a manner similar to a collagen film.

A honeycomb collagen carrier for cell culture as a tissue engineering scaffold

As a three-dimensional carrier for cell culture, a honeycomb structure cell scaffold was created from atelopeptide collagen Types I, II, and III. The diameter of the honeycomb pores ranged from 100 to 1,000 microm. The depth of the pores was from 10 to 3,000 mm. The scaffold was elastic and hard. Creation of various shapes was easy, and these shapes were easily maintained. Human fibroblasts, CHO-K1, BHK-21, and bovine endothelial cells were cultured with the scaffold. The growth curves of these cells were satisfactory. These results suggest that this carrier is a suitable scaffold for cell culture and will be useful as a three-dimensional tissue engineering scaffold.

A preliminary in vitro study on the fabrication and tissue engineering applications of a novel chitosan bilayer material as a scaffold of human neofetal dermal fibroblasts

The bilayer structure of chitosan film and sponge was designed as a scaffold of skin tissue engineering and a dermis substitute. It was processed successively via the formation of a dense chitosan film by casting method and a porous chitosan sponge by lyophilization. The dry thickness of the film layer was 19.6 microm and that of the sponge layer was controlled at 60-80 microm. Porogens such as sodium chloride, glucose, and sucrose were used to create large pores of the chitosan sponge layer. Human neofetal dermal fibroblasts were seeded in the chitosan sponge layer and cultured for 4 weeks. It was found that the cells could grow and proliferate well in an extended shape on the flat bottom of large pores with 15-100 microm width and in spherical form on the rough pore walls or at the edges of micropores less than 5 microm. Fibroblasts after the culture could bind tightly with the sponge layer via newly formed extracellular matrices to give a living cell-matrix-chitosan composite. The bilayer chitosan material remained stable in shape and size during the cell culture. The results suggested that the bilayer chitosan material would be an alternative of collagen materials which was obviously contracted during cell culture.

Initial experience of Integra in the treatment of post-burn anterior cervical neck contracture

Bilaminate bioartificial skin substitutes such as Integra have been described as a temporary substitute for autograft in acute burns. The aim of this study was to assess their role in the treatment of hypertrophic scarring and anterior neck contracture in the reconstructive phase of burns surgery. Five patients underwent Integra grafting over a 12-month period, with one patient having the procedure performed on two separate occasions. One patient had a combination of hypertrophic scarring of the face and neck contracture, and two patients suffered from recurrent folliculitis in hypertrophic scars in the bearded area of the neck. Mean hospital stay was 24 days (range, 19-30 days). Mean follow-up was 48 months (range, 43-54 months). In all cases of neck contracture a superior cosmetic result was achieved. Recurrence of contracture of greater than 50% occurred within the follow-up period in all cases. Ineffective immobilisation of the graft and overgranulation were identified as contributing to contracture recurrence. Based on our initial experience bilaminate artificial skin substitutes offer an improved cosmetic result in cases of neck contracture and hypertrophic scarring, particularly in the bearded area of the neck. Recurrence of neck contracture remains a problem despite improved techniques of immobilisation. Long-term follow-up will be necessary to assess the applications of this technique fully.

Long-term follow-up study of artificial dermis composed of outer silicone layer and inner collagen sponge

In the oriental population including the Japanese, donor-site hypertrophy is more pronounced than in Caucasians. To solve the problem of donor-site morbidity and to ensure graft 'take', we started the second-stage procedure of a thin split thickness skin graft (STSG) onto acellular 'bilayer artificial skin', or 'artificial dermis'. Since reporting the original version of the material (OV), a revised version (RV) and the present version (PV, Pelnac) have been developed in stages to eliminate inconveniences associated with its use and to reduce the primary cost of manufacture. We have now used our materials, consisting of OV, RV and PV, on 52 skin defects in 41 patients. STSG took almost perfectly in all patients. The long-term results of these three materials were investigated in 20 patients who had been followed up for more than 2 years, excluding three patients whose donor sites had been directly closed. The longest and the mean follow-up periods of these patients were 12 years 5 months and 6 years 10 months, respectively. At the grafted sites, wrinkles caused by shrinkage, partial depigmentation and hypertrophy were observed in five (25%), one (5%) and one (5%) of the 20 patients, respectively. At the donor sites, slight unsightliness was observed in five (25%) of the 20 patients. Excellent or good results were obtained in 18 (90%) of the 20 patients in comprehensive evaluation. There were no significant differences in the long-term follow-up evaluations among these materials. In conclusion, the long-term postoperative appearance of the STSG site was good though a very thin (approximately 0.2mm) STSG is used; scarring of the donor site was minimal and it was possible to take repeated skin grafts from the same donor site.

Can we produce a human corneal equivalent by tissue engineering?

Tissue engineering is progressing rapidly. Bioengineered substitutes are already available for experimental applications and some clinical purposes such as skin replacement. This review focuses on the development of reconstructed human cornea in vitro by tissue engineering. Key elements to consider in the corneal reconstruction, such as the source for epithelial cells and keratocytes, are discussed and the various steps of production are presented. Since one application of this human model is to obtain a better understanding of corneal wound healing, the mechanisms of this phenomenon as well as the function played both by membrane-bound integrins and components from the extracellular matrix have also been addressed. The analysis of integrins by immunohistofluorescence labelling of our reconstructed human cornea revealed that beta(1), alpha(3), alpha(5), and alpha(6) integrin subunits were expressed but alpha(4) was not. Laminin, type VII collagen and fibronectin were also detected. Finally, the future challenges of corneal reconstruction by tissue engineering are discussed and the tremendous applications of such tissue produced in vitro for experimental as well as clinical purposes are considered.

Modern aspects of wound healing: An update

Wound healing is an area of cutaneous medicine in which there have been many recent advances. Interest has focused on the development of an in vitro reconstructed skin, although neither the commercially available products nor the products currently described in experimental studies are able to fully substitute for natural living skin. The substitution of the main component of each wound, the connective tissue matrix, is an advance. Once dermis is reconstructed, the covering of the wound surface with both in vitro expanded epidermis and autologous split-skin transplants is significantly easier and has an improved chance of success. Epidermal stem cells may facilitate functionality of the superficial part of such a system. New experimental and clinical trials are currently under way.

Collagen-based biomaterials as 3D scaffold for cell cultures: applications for tissue engineering and gene therapy

Many substances are used in the production of biomaterials: metals (titanium), ceramics (alumina), synthetic polymers (polyurethanes, silicones, polyglycolic acid (PGA), polylactic acid (PLA), copolymers of lactic and glycolic acids (PLGA), polyanhydrides, polyorthoesters) and natural polymers (chitosan, glycosaminoglycans, collagen). With the rapid development in tissue engineering, these different biomaterials have been used as three-dimensional scaffolds and cell transplant devices. The principal biochemical and biological characteristics of the collagen-based biomaterials are presented, including their interactions with cells (fibroblasts), distinct from those of synthetic polymers, and their potential use in gene therapy through the formation of neo-organs or organoids.

Microfabrication of an analog of the basal lamina: biocompatible membranes with complex topographies

A microfabrication approach was used to produce novel analogs of the basal lamina with complex topographic features. A test pattern of ridges and channels with length scales (40 to 310 micrometer) similar to the invaginations found in a native basal lamina was laser machined into the surface of a polyimide master chip. Negative replicates of the chip were produced using polydimethylsiloxane silicone elastomer and these replicates were used as templates for the production of thin ( approximately 21 micrometer) membranes of collagen or gelatin. The resulting membranes had a complex topography of ridges and channels that recapitulated the features of the master chip. To demonstrate their utility, these complex membranes were laminated to type I collagen sponges and their surfaces were seeded with cultured human epidermal keratinocytes to form a skin equivalent. The keratinocytes formed a differentiated and stratified epidermis that conformed to the features of the microfabricated membrane. The topography of the membrane influenced the differentiation of the keratinocytes because stratification was enhanced in the deeper channels. Membrane topography also controlled the gross surface features of the skin equivalent; infolds of the epidermis increased as channel depth increased. These novel microfabricated analogs of the basal lamina will help to elucidate the influence of topography on epithelial cell proliferation and differentiation and should have applications in the tissue engineering of skin equivalents as well as other basal lamina-containing tissues.

Possibility of wound dressing using poly(L-leucine)/poly(ethylene glycol)/poly(L-leucine) triblock copolymer

ABA-type block copolymers (abbreviated as LEL) composed of poly(L-leucine) (PLL) as the A component and poly(ethylene glycol) (PEG) as the B component were synthesized by ring-opening polymerization of L-leucine N-carboxyanhydride initiated by primary amino group located at both ends of PEG chain. A silver sulfadiazine (AgSD)-impregnated wound dressing of sponge type was prepared by the lyophilization method. Morphological structure of this wound dressing by scanning electron microscopy was observed to be composed of a dense skin layer and a porous inner layer. Equilibrium water content of LEL wound dressing increased with an increase in PEG content in the block copolymer due to the hydrophilicity of PEG. AgSD release from AgSD-impregnated wound dressing in PBS buffer (pH = 7.4) was dependent on PEG content in the block copolymer. Release of AgSD was increased in proportion to the PEG content in the copolymer. Antibacterial capacity of AgSD-impregnated wound dressing was examined in agar plate against Pseudomonas aeruginosa and Staphylococcus aureus. It was found that the suppression of bacterial proliferation in the wound dressing was dependent upon the PEG content. In cytotoxicity test, cell damage did not occur by the release of AgSD from the LEL sponge matrix of AgSD-medicated wound dressing. In in vivo test, granulous tissue formation and wound contraction for the AgSD- and dehydroepiandrosterone-impregnated LEL-2 wound dressing were faster than for any other groups.

Tissue engineered artificial skin composed of dermis and epidermis

We made an artificial skin comprised of a stratified layer of keratinocytes and a dermal matrix with a type I collagen containing fibroblasts. In this work, we showed keratinocyte behavior under primary culture, gel contractions varying with concentration of collagen solution, and cell growth plots in the collagen gel. The optimum behavior of dermal equivalent could be obtained using 3.0 mg/ml collagen solution and attached gel culture. The attached gel culture had a jumping effect of growth factor on cell growth at the lag phase. To develop the artificial skin, 1x10(5) cells/cm2 of keratinocytes were cultured on the dermal equivalent at air-liquid interface. Finally, to overcome the problem that artificial skin of collagen gel was torn easily during suturing of grafting, we prepared histocompatible collagen mesh and attached the mesh to the bottom of the gel. Cultured artificial skins were successfully grafted onto rats.

Fibrin scaffold as an effective vehicle for the delivery of acidic fibroblast growth factor (FGF-1)

The effect of wound healing by fibrin and acidic fibroblast growth factor (FGF-1) in an in vivo model was evaluated in this study. Four full-thickness wounds were made on the dorsum of each rabbit (n = 5). Each of these wounds had different treatment groups: control, topical FGF-1 (100 microg/9 cm2), fibrin (2.0 mL at 60 mg/mL fibrinogen), and FGF-1 (100 microg/9 cm2)/fibrin. The animals were sacrificed at the end of 2 weeks. Histomorphometric analysis and mechanical testing were conducted to assess the healing response. FGF-1/fibrin treatment improved the mechanical properties of the healed tissue. Fibrin scaffold exhibited the desired tissue response, as demonstrated by the lack of inflammation, and was deemed an effective carrier for FGF-1.

Cryopreservation of keratinocytes in a monolayer

The cryopreservation of cells in tissues is one of the major challenges in current cryobiology, especially with regard to the progressively increasing field of tissue engineering. It is very questionable whether protocols which were developed for the cryopreservation of isolated cells are also applicable for cells in more complex structures, such as tissues. As a starting point toward cryopreservation of these three-dimensional structures, the aim of this study was to find an optimum cryopreservation protocol for keratinocytes in a monolayer (two-dimensional structure). These epidermal cells can be transplanted as a monolayer grown on an appropriate matrix for the treatment of deep-dermal burns and leg ulcers. The successful cryopreservation of such transplants would offer the advantage of long-term storage and immediate availability of the transplant. In our study, the variables investigated were the cryoprotective solution and the cooling rate. In order to find a nontoxic cryoprotective agent (CPA) which could be transplanted without an additional washing step, we included hydroxyethyl starch (HES) as a possible CPA in our experimental protocol with the commonly used CPAs Me(2)SO, glycerol, and ethylene glycol. For the evaluation, the cell survival rate was determined by dye exclusion (trypan blue) and the cell metabolism was investigated by cell activity assay (alamarBlue). In conclusion, the cryopreservation protocol with 10 wt.-% HES resulted not only in the highest survival rate (72%) but also in the highest metabolic activity of the cells after thawing; comparable values for the other CPAs were: Me(2)SO, 48%; glycerol, 8%; and ethylene glycol, 10%.

Creation of an acellular dermal matrix from frozen skin

At present, one of the treatments of choice for closure of full-thickness skin loss is to use a cultured epidermal autograft when skin loss is extensive. In this study, we investigated a simple method of processing frozen surplus skin to produce an acellular, structurally intact, dermal matrix. First, the acellular dermal matrix prepared from normal human skin (ADM) we processed was observed using a transmission electron microscope and a scanning electron microscope. The matrix maintained the basement membrane complex and the extracellular matrix structure of the dermis despite frozen skin being used. Next, using an animal model, we transplanted the ADM and Pelnac, which is used as a contrast in full-thickness wounds onto nude rats. The dermal matrix supported fibroblast infiltration and neovascularization. These results suggest that skin processed by our simple method has the potential to be used as a dermal template together with the cultured epidermis in the closure of full-thickness wounds.

Polyelectroylte complex composed of chitosan and sodium alginate for wound dressing application

Drug-impregnated polyelectrolyte complex (PEC) sponge composed of chitosan and sodium alginate was prepared for wound dressing application. The morphological structure of this wound dressing was observed to be composed of a dense skin outer layer and a porous cross-section layer by scanning electron microscopy (SEM). Equilibrium water content and release of silver sulfadiazine (AgSD) could be controlled by the number of repeated in situ PEC reactions between chitosan and sodium alginate. The release of AgSD from AgSD-impregnated PEC wound dressing in PBS buffer (PH = 7.4) was dependent on the number of repeated in situ complex formations for the wound dressing. The antibacterial capacity of AgSD-impregnated wound dressing was examined in agar plate against Pseudomonas aeruginosa and Staphylococcus aureus. From the behavior of antimicrobial release and the suppression of bacterial proliferation, it is thought that the PEC wound dressing containing antimicrobial agents could protect the wound surfaces from bacterial invasion and effectively suppress bacterial proliferation. In the cytotoxicity test, cellular damage was reduced by the controlled released of AgSD from the sponge matrix of AgSD-medicated wound dressing. In vivo tests showed that granulation tissue formation and wound contraction for the AgSD plus dihydroepiandrosterone (DHEA) impregnated PEC wound dressing were faster than any other groups.

PHA applications: addressing the price performance issue: I. Tissue engineering

This paper describes the development of medical applications for polyhydroxyalkanoates (PHAs), a class of natural polymers with a wide range of thermoplastic properties. Methods are described for preparing PHAs with high purity, modifying these materials to change their surface and degradation properties, and methods for fabricating them into different forms, including tissue engineering scaffolds. Preliminary reports characterizing their in vivo behavior are given, as well as methods for using the natural polymers in tissue engineering applications.

Allogeneic cultured dermal substitute composed of spongy collagen containing fibroblasts: evaluation in animal test

The authors developed a cultured dermal substitute (CDS) composed of a spongy collagen containing cultured fibroblasts. The cultured fibroblasts derived from Sprague Dawley rat skin were seeded on a spongy collagen at a density of 5 x 10(5) cells cm(-2) and cultured for 7 days. This CDS was applied to the debrided wound of full-thickness burn which was inflicted experimentally on the dorsum of Wister rat, and then the wound conditions were observed over a period of 2 weeks. The comparative study was conducted using an acellular spongy collagen as well as a commercially available temporary wound dressing, Biobrane, since a different type of cultured dermal substitute, Dermagraft-TC, is composed of Biobrane, whose inner site is combined with cultured fibroblasts. Each covering material was applied on the debrided wound area and exchanged by new one 1 week later. When the debrided wound was covered with Biobrane, a small portion of necrotic tissue was observed 1 week after application, and the granulation tissue formation was greatly delayed. This wound area showed a poor granulation tissue even 2 weeks later. On the contrary, when covered with an acellular spongy collagen, no necrotic tissue was observed. This wound area showed a more or less irregular granulation tissue at 1 week and then a healthy granulation tissue 2 weeks later. This preliminary comparative study suggests that an acellular spongy collagen is able to function as a more suitable matrix for CDS, compared with Biobrane. The wound area covered with a CDS assumed a moist, shiny, and hyperaemic appearance 1 week after application showing a healthy granulation tissue. The macroscopic evaluations indicate that the CDS is able to prepare a healthy granulation tissue at an earlier stage, compared with the acellular spongy collagen. In addition, the histologic views demonstrate that the CDS is able to prepare a thicker and denser granulation tissue, compared with the acellular spongy collagen. Although the fate of cultured fibroblasts in the CDS on the wound surface within 1 week is not clear, these findings suggest that fibroblasts in CDS are able to provide excellent conditions for wound healing.

A silver-sulfadiazine-impregnated synthetic wound dressing composed of poly-L-leucine spongy matrix: an evaluation of clinical cases

The management of severe burns requires the suppression of bacterial growth, particularly when eschar and damaged tissue are present. For such cases, silver sulfadiazine (AgSD) cream has been traditionally applied. This antibacterial cream, however, cannot be used in conjunction with a temporary wound dressing that is needed to promote healing. The authors developed a synthetic wound dressing with drug delivery capability for clinical use by impregnating a poly-L-leucine spongy matrix with AgSD, which is released in a controlled, sustained fashion. In general, the dressing adhered firmly to the wound in the case of superficial second-degree burns, and during the healing process it separated spontaneously from the re-epithelialized surface. In the management of deep second-degree burns where eschar and damaged tissue were present, the dressing had to be changed at intervals of 3 to 5 days until it adhered firmly to the wound. Once the dressing had firmly attached to the wound, it was left in place until it separated spontaneously from the re-epithelialized surface. Dressing changes were fewer than with other treatments and the pain was effectively reduced. Cleansed wounds were effectively protected from bacterial contamination. Of 52 cases treated with this wound dressing, 93% (14/15) of superficial second-degree burns, 75% (3/4) of deep second-degree burns, 85% (6/7) of superficial and deep second-degree burns, and 75% (12/16) of split-thickness skin donor sites were evaluated as achieving good or excellent results.

The effect of TGF-beta delivered through a collagen scaffold on wound healing

In this preliminary study, the wound healing response of full-thickness skin defects to transforming growth factor beta (TGF-beta) incorporated in a collagen scaffold was evaluated. The objectives of this study were (1) to compare the effects of TGF-beta on the cellular and tissue response and mechanical properties and (2) to determine the effects of a collagen scaffold on wound healing when compared to control. Three 3 x 3 cm, full-thickness defects were created on the dorsi of 15 New Zealand White rabbits. Each rabbit had a control (no treatment), collagen scaffold, and collagen scaffold with TGF-beta (2 microg/cm2). All the wounds were covered with a transparent polyurethane dressing. There were three periods of study (1, 2, and 3 weeks) with five rabbits in each period. The volume fraction of the tissue and cells was histomorphometrically determined for each wound. A greater inflammatory response was found in the collagen scaffold-treated group, but the fastest epithelialization and contraction rates were associated with TGF-beta and collagen. No significant differences in the mechanical strength between the different treatment groups were seen. Overall, TGF-beta delivered through a collagen scaffold enhanced the healing process and showed promise for future clinical applications.

Tissue engineering of skin

The skin plays a crucial role in protecting the integrity of the body's internal milieu. The loss of this largest organ is incompatible with sustained life. In reconstructive surgery or burn management, substitution of the skin is often necessary. In addition to traditional approaches such as split- or full-thickness skin grafts, tissue flaps and free-tissue transfers, skin bioengineering in vitro or in vivo has been developing over the past decades. It applies the principles and methods of both engineering and life sciences toward the development of substitutes to restore and maintain skin structure and function. Currently, these methods are valuable alternatives or complements to other techniques in reconstructive surgery. This review article deals with the evolution and current approaches to the development of in vitro and in vivo epidermis and dermis.

Novel thermally reversible hydrogel as detachable cell culture substrate

A novel UV crosslinkable co-polymer of 4-(N-cinnamoylcarbamide)methylstyrene (CCMS) and N-isopropylacrylamide (IPAAm) was partially entrapped in traditional tissue-culture-treated polystyrene and crosslinked by UV light irradiation. Dishes modified by this method showed a change in contact angle with respect to temperature as compared to tissue culture polystyrene controls. Surface chemical analysis indicated that the crosslinked hydrogel does not detach from the surface after successive rinsing in ethanol and water, keeping the cells or cell construct free of unwanted soluble polymer after detachment. Cultures of both bovine endothelium and human retinal pigmented epithelium were confirmed to be able to attach and grow on the polymer-modified surfaces morphologically identical to that on control tissue culture polystyrene surfaces. Corresponding to a change in temperature, these cultures would detach and could be transplanted to another culture surface without functional and structural changes. These results show that the new, photo-crosslinkable hydrogel system can utilize the hydrophobic/hydrophilic change of the surface for cell culture detachment while being permanently applicable to any tissue culture geometry.

Organized skin structure is regenerated in vivo from collagen-GAG matrices seeded with autologous keratinocytes

A well-characterized collagen-glycosaminoglycan matrix (CGM) that has been shown to function as a dermal analog was seeded with freshly disaggregated autologous keratinocytes and applied to full-thickness wounds in a porcine model. CGM were impregnated with 50,000 keratinocytes per cm2, a seeding density that produces a confluent epidermis within 19 d post-grafting and affords a 60-fold surface expansion of the donor epidermis. In this study, the temporal sequence of events in epidermal and neodermal formation was analyzed histopathologically and immunohistochemically from 4 to 35 d post-grafting. The epidermis was observed to form from clonal growth of individual keratinocytes into epithelial cords and islands that gradually enlarged, coalesced, differentiated to form large horn cysts, and finally reorganized at the graft surface to form a fully differentiated, normally oriented epidermis with rete ridges. Simultaneously, a neodermis formed from migration of endothelial cells, fibroblasts, and macrophages into the CGM from the underlying wound bed, resulting in formation of blood vessels, the production of abundant extracellular matrix, and the degradation of the CGM fibers, respectively. Gradually, the stromal cellularity of the CGM decreased and collagen deposition and remodeling increased to form a neodermal connective tissue matrix beneath the newly formed epidermis. Complete dissolution of the CGM occurred, partly as a result of degradation by an ongoing foreign-body giant cell reaction that peaked at 8-12 d post-grafting, but neither acute inflammation nor evidence of immune stimulation were observed. Within 1 mo, many structural components of normal skin were reconstituted.

Effect of keratinocyte seeding of collagen-glycosaminoglycan membranes on the regeneration of skin in a porcine model

A collagen-glycosaminoglycan matrix, impregnated with autologous keratinocytes, was applied as island grafts onto full-thickness porcine wounds to determine whether complete epidermal coverage could be achieved in a single grafting procedure. Twenty-four grafts with seeding densities ranging from 0 to 3,000,000 cells/cm2 were used to determine the kinetics of epidermal coverage. The time sequence of epidermal formation was then studied between days 14 and 28 using four additional grafts, each seeded with a density of 500,000 cells/cm2. Autologous keratinocytes proliferated as the collagen-glycosaminoglycan matrix was vascularized to form a confluent epidermis by 2 weeks in matrices seeded with at least 100,000 cells/cm2. The epidermal thickness and the number of keratinocyte cysts observed in the neodermis at 2 weeks increased linearly with the logarithm of the seeding density. Sequential analysis of neoepidermis showed the nascent epidermis to be hyperplastic, parakeratotic, and focally lacking in granular layer differentiation at 2 weeks. After 2 weeks, it underwent normal maturation and differentiation. Irrespective of seeding density at 2 weeks the collagen-glycosaminoglycan matrix was well vascularized, contained a dense cellular infiltrate, and was almost completely degraded. These studies demonstrate that seeded keratinocytes proliferate and differentiate to form a confluent epidermis by 2 weeks in matrices seeded with at least 100,000 cells/cm2.

Design of an artificial skin. IV. Use of island graft to isolate organ regeneration from scar synthesis and other processes leading to skin wound closure

Deep skin wounds in the adult mammal close spontaneously by epithelialization, wound contraction, and scar synthesis. In previous wound healing studies, it has been unsuccessfully attempted to separate from each other the natural processes that close wounds. In this study, we attempted to isolate skin regeneration from spontaneous processes of wound closure using "island" grafts. A porous analog of the extracellular matrix, composed of a graft copolymer of type I collagen and chondroitin 6-sulfate, was seeded with uncultured autologous keratinocytes and served to induce regeneration of the dermis and the epidermis. Grafts of the copolymer, measuring 1 x 2 cm, were placed in the center of 5 x 6-cm wounds in guinea pigs. By day 14, the edges of the island grafts were clearly separated from the host epidermis and dermis by a distinct bed of granulation tissue. Histologic study of island grafts on day 14 showed that the copolymer grafts had largely degraded and that a new epidermis and dermis had been synthesized in its place. The thickness of the new epidermis increased as the density of cells seeded into the graft increased. No synthesis of epidermis or dermis was observed in the granulation tissue outside the perimeter of the island grafts. We conclude that island grafting allows the study of early events in skin regeneration in isolation from epithelialization, contraction, and scar synthesis.

Design of an artificial skin. IV. Use of island graft to isolate organ regeneration from scar synthesis and other processes leading to skin wound closure

Deep skin wounds in the adult mammal close spontaneously by epithelialization, wound contraction, and scar synthesis. In previous wound healing studies, it has been unsuccessfully attempted to separate from each other the natural processes that close wounds. In this study, we attempted to isolate skin regeneration from spontaneous processes of wound closure using "island" grafts. A porous analog of the extracellular matrix, composed of a graft copolymer of type I collagen and chondroitin 6-sulfate, was seeded with uncultured autologous keratinocytes and served to induce regeneration of the dermis and the epidermis. Grafts of the copolymer, measuring 1 x 2 cm, were placed in the center of 5 x 6-cm wounds in guinea pigs. By day 14, the edges of the island grafts were clearly separated from the host epidermis and dermis by a distinct bed of granulation tissue. Histologic study of island grafts on day 14 showed that the copolymer grafts had largely degraded and that a new epidermis and dermis had been synthesized in its place. The thickness of the new epidermis increased as the density of cells seeded into the graft increased. No synthesis of epidermis or dermis was observed in the granulation tissue outside the perimeter of the island grafts. We conclude that island grafting allows the study of early events in skin regeneration in isolation from epithelialization, contraction, and scar synthesis.

Videofetoscopically assisted fetal tissue engineering: skin replacement

BACKGROUND/PURPOSE

Treatment of several congenital anomalies is frequently hindered by lack of enough tissue for surgical reconstruction in the neonatal period. The purposes of this study were (1) introduction of a novel concept in perinatal surgery, involving minimally invasive harvest of fetal tissue, which is then processed through tissue engineering techniques in vitro while pregnancy is allowed to continue, so that, at delivery, the newborn can benefit from having autologous, expanded tissue promptly available for surgical implantation at birth; (2) analysis of the progress of an engineered fetal skin graft with time, after implantation in the neonate; and (3) study of the effects of current tissue engineering techniques on fetal keratinocytes and fetal dermal fibroblasts.

METHODS

Ten 90- to 95-day-gestation fetal lambs underwent surgical creation of two large paramedian excisional skin defects on the posterior body wall. Subsequently, fetal skin specimens no larger than 1.5 x 1.5 cm were videofetoscopically harvested. Fetal keratinocytes and dermal fibroblasts were then separately cultivated and expanded in vitro for 45 to 50 days, resulting in a total of approximately 250 to 300 million cells. Seven to 10 days before fetal delivery, all cells were seeded in two layers on a 16 to 20-cm2, 3-mm thick biodegradable polyglycolic acid polymer matrix. One to 4 days after delivery, the autologous engineered skin was implanted over one of two previously created skin defects. The second skin defect region received an absorbable polymer scaffold without cells as a control. If necessary, the original skin wounds were further amplified before implantation. Each animal provided at least one time-point for histological analysis of both types of repair through excisional biopsies performed at weekly intervals, up to 8 weeks postimplantation. Normal skin specimens were also used as controls.

RESULTS

Fetal and neonatal survival rates were 100%. Based on previous postnatal skin engineering studies, fetal dermal fibroblasts multiplied significantly faster in vitro (approximately fivefold) than expected. Fetal keratinocytes multiplied at expected postnatal rates. The engineered grafts induced faster epithelization of the wound (partial at 1 week and complete between 2 and 3 weeks postoperatively) than did the acellular ones (partial at 3 weeks and complete between 3 and 4 weeks postoperatively). Analysis of skin architecture showed a higher level of epidermal organization and less dermal scarring in the wounds that received the engineered, cell-implanted polymer scaffold.

CONCLUSIONS

(1) Videofetoscopically assisted fetal tissue engineering is a viable method for obtaining expanded autologous tissue for prompt surgical reconstruction at birth. (2) Fetal skin can be expanded and engineered in vitro at faster rates than expected postnatally, with current tissue engineering techniques. (3) Engineered autologous fetal skin induces a faster and more organized healing of neonatal skin defects than that observed with second intention. This concept may prove useful for the treatment of certain human neonatal conditions such as giant neoplasias, ectopia cordis, and other body wall defects.