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

Transplantation of autologous cells and porous gelatin microcarriers to promote wound healing

Definitive treatment to achieve wound healing in major burns frequently include skin transplantation, where split-thickness skin grafts is considered gold standard. This method is associated with several drawbacks. To overcome these hurdles, efforts have been made to develop tissue engineered skin substitutes, often comprised of a combination of cells and biomaterials. In the present study, we aimed to investigate transplantation of autologous keratinocytes and fibroblasts seeded on porous gelatin microcarriers using a porcine wound model. Pre-seeded microcarriers were transplanted to a total of 168 surgical full-thickness wounds (2cm diameter) on eight adult female pigs and covered with occlusive dressings. The experimental groups included wounds transplanted with microcarriers seeded with the combination of keratinocytes and fibroblasts, microcarriers seeded with each cell type individually, microcarriers without cells, each cell type in suspension, and NaCl control. Wounds were allowed to heal for one, two, four or eight weeks before being excised and fixated for subsequent histological and immunohistochemical analysis. In vitro, we confirmed that viable cells populate the surface and the pores of the microcarriers. In vivo, the microcarriers were to a large extent degraded after two weeks. After one week, all treatment groups, with the exception of microcarriers alone, displayed significantly thicker neo-epidermis compared to controls. After two weeks, wounds transplanted with microcarriers seeded with cells displayed significantly thicker neo-epidermis compared to controls. After four weeks there was no difference in the thickness of neo-epidermis. In conclusion, the experiments performed illustrate that autologous cells seeded on porous gelatin microcarriers stimulates the re-epithelialization of wounds. This method could be a promising candidate for skin transplantation. Future studies will focus on additional outcome parameters to evaluate long-term quality of healing following transplantation.

Three-dimensional cryogels for biomedical applications

Cryogels are a subset of hydrogels synthesized under sub-zero temperatures: initially solvents undergo active freezing, which causes crystal formation, which is then followed by active melting to create interconnected supermacropores. Cryogels possess several attributes suited for their use as bioscaffolds, including physical resilience, bio-adaptability, and a macroporous architecture. Furthermore, their structure facilitates cellular migration, tissue-ingrowth, and diffusion of solutes, including nano- and micro-particle trafficking, into its supermacropores. Currently, subsets of cryogels made from both natural biopolymers such as gelatin, collagen, laminin, chitosan, silk fibroin, and agarose and/or synthetic biopolymers such as hydroxyethyl methacrylate, poly-vinyl alcohol, and poly(ethylene glycol) have been employed as 3D bioscaffolds. These cryogels have been used for different applications such as cartilage, bone, muscle, nerve, cardiovascular, and lung regeneration. Cryogels have also been used in wound healing, stem cell therapy, and diabetes cellular therapy. In this review, we summarize the synthesis protocol and properties of cryogels, evaluation techniques as well as current in vitro and in vivo cryogel applications. A discussion of the potential benefit of cryogels for future research and their application are also presented.

Cell therapy for severe burn wound healing

Cell therapy has emerged as an important component of life-saving procedures in treating burns. Over past decades, advances in stem cells and regenerative medicine have offered exciting opportunities of developing cell-based alternatives and demonstrated the potential and feasibility of various stem cells for burn wound healing. However, there are still scientific and technical issues that should be resolved to facilitate the full potential of the cellular devices. More evidence from large, randomly controlled trials is also needed to understand the clinical impact of cell therapy in burns. This article aims to provide an up-to-date review of the research development and clinical applications of cell therapies in burn wound healing and skin regeneration.

Use of Clotted Human Plasma and Aprotinin in Skin Tissue Engineering: A Novel Approach to Engineering Composite Skin on a Porous Scaffold

Tissue-engineered composite skin is a promising therapy for the treatment of chronic and acute wounds, including burns. Providing the wound bed with a dermal scaffold populated by autologous dermal and epidermal cellular components can further entice host cell infiltration and vascularization to achieve permanent wound closure in a single stage. However, the high porosity and the lack of a supportive basement membrane in most commercially available dermal scaffolds hinders organized keratinocyte proliferation and stratification in vitro and may delay re-epithelization in vivo. The objective of this study was to develop a method to enable the in vitro production of a human skin equivalent (HSE) that included a porous scaffold and dermal and epidermal cells expanded ex vivo, with the potential to be used for definitive treatment of skin defects in a single procedure. A collagen-glycosaminoglycan dermal scaffold (Integra(®)) was populated with adult fibroblasts. A near-normal skin architecture was achieved by the addition of coagulated human plasma to the fibroblast-populated scaffold before seeding cultured keratinocytes. This resulted in reducing scaffold pore size and improving contact surfaces. Skin architecture and basement membrane formation was further improved by the addition of aprotinin (a serine protease inhibitor) to the culture media to inhibit premature clot digestion. Histological assessment of the novel HSE revealed expression of keratin 14 and keratin 10 similar to native skin, with a multilayered neoepidermis morphologically comparable to human skin. Furthermore, deposition of collagen IV and laminin-511 were detected by immunofluorescence, indicating the formation of a continuous basement membrane at the dermal-epidermal junction. The proposed method was efficient in producing an in vitro near native HSE using the chosen off-the-shelf porous scaffold (Integra). The same principles and promising outcomes should be applicable to other biodegradable porous scaffolds, combined with autologous cells, for use in wound treatment.

Cell proliferation on three-dimensional chitosan-agarose-gelatin cryogel scaffolds for tissue engineering applications

Tissue engineering is a potential approach for the repair of damaged tissues or organs like skin, cartilage, bone etc. Approach utilizes the scaffolds constructed from natural or synthetic polymers fabricated by the available fabrication technologies. This study focuses on the fabrication of the scaffolds using a novel technology called cryogelation, which synthesizes the scaffolds at sub-zero temperature. We have synthesized a novel scaffold from natural polymers like chitosan, agarose and gelatin in optimized ratio using the cryogelation technology. The elasticity of the scaffold was confirmed by rheological studies which supports the utility of the scaffolds for skin and cardiac tissue engineering. Proliferation of different cell types like fibroblast and cardiac cells was analysed by scanning electron microscopy (SEM) and fluorescent microscopy. Biocompatibility of the scaffolds was tested by MTT assay with specific cell type, which showed higher proliferation of the cells on the scaffolds when compared to the two dimensional culture system. Cell proliferation of C(2)C(12) and Cos 7 cells on these scaffolds was further analysed biochemically by alamar blue test and Hoechst test. Biochemical and microscopic analysis of the different cell types on these scaffolds gives an initial insight of these scaffolds towards their utility in skin and cardiac tissue engineering.

A phage-targeting strategy for the design of spatiotemporal drug delivery from grafted matrices

Background

The natural response to injury is dynamic and normally consists of complex temporal and spatial cellular changes in gene expression, which, when acting in synchrony, result in patent tissue repair and, in some instances, regeneration. However, current therapeutic regiments are static and most rely on matrices, gels and engineered skin tissue. Accordingly, there is a need to design next-generation grafting materials to enable biotherapeutic spatiotemporal targeting from clinically approved matrices. To this end, rather then focus on developing completely new grafting materials, we investigated whether phage display could be deployed onto clinically approved synthetic grafts to identify peptide motifs capable of linking pharmaceutical drugs with differential affinities and eventually, control drug delivery from matrices over both space and time.

Methods

To test this hypothesis, we biopanned combinatorial peptide libraries onto different formulations of a wound-healing matrix (Integra^®) and eluted the bound peptides with 1) high salt, 2) collagen and glycosaminoglycan or 3) low pH. After three to six rounds of biopanning, phage recovery and phage amplification of the bound particles, any phage that had acquired a capacity to bind the matrix was sequenced.

Results

In this first report, we identify distinct classes of matrix-binding peptides which elute differently from the screened matrix and demonstrate that they can be applied in a spatially relevant manner.

Conclusions

We suggest that further applications of these combinatorial techniques to wound-healing matrices may offer a new way to improve the performance of clinically approved matrices so as to introduce temporal and spatial control over drug delivery.

The effectiveness of basic fibroblast growth factor in fibrin-based cultured skin substitute in vivo

Cultured skin substitute (CSS), comprised keratinocytes and fibroblasts in a biopolymer matrix, is useful for adjunctive burn therapy. However, the vascularization of CSS is much slower than split-thickness autografts, because it lacks a vascular plexus. This study evaluated the influence of basic fibroblast growth factor (bFGF) on fibrin-based CSS grafting in vivo. Fibrin-based CSS treated with 0, 0.26, 1.3, 6.5, 13, or 130 microg/cm bFGF was transplanted into athymic mice, and macroscopic and histologic examinations of the graft were performed on day 21 posttransplantation. Engrafted CSS of the 0.26 to 6.5 microg/cm bFGF treatment groups were similar to the untreated control. However, the engrafted area was significantly suppressed in the 13 microg/cm bFGF treatment group, and the 130 microg/cm bFGF treatment group was not engrafted. Neovascularization of CSS was significantly increased in the 1.3 microg/cm bFGF treatment group compared with the control (P < .05). The number of human fibroblastic cells in CSS that were positive for vimentin increased significantly in the 0.26 and 1.3 microg/cm bFGF treatment groups (P < .01). CSS treated with 0.26 to 6.5 microg/cm bFGF showed normal epidermis with keratinizing stratified squamous epithelium, whereas the thickness of the epidermis and proliferation of keratinocytes in the basal layer was decreased. These results demonstrated that bFGF treatment (1.3 microg/cm) in fibrin-based CSS may enhance angiogenesis and fibroblast proliferation after transplantation.

[Cultured keratinocyte cells from foreskin and future application for burns in children]

PURPOSE OF THE STUDY

We tested in vitro the keratinocytes capacity for division and differentiation. The donor site was the human foreskin.

PATIENTS AND METHODS

For 12 months, we harvested 18 foreskins after circumcision. The middle age of the operated children was four years. The keratinocytes were isolated after double enzymatic digestion (thermolysin and trypsin, respectively). After filtration and centrifugation we put the keratinocytes in culture. In parallel, the keratinocytes were cultivated on the surface of collagen lattices. The keratinocytes were cultured in submerged condition for two days and then in an air-liquid interface condition for further differentiation. After nine days of culture, a histological examination and immunostain were used. An immunohistologic analysis made it possible to highlight the markers characteristic of epidermal skin differentiation.

RESULTS

We obtained an average of 8.8 10(6) cells per foreskin. After seven days of culture, we obtained on average 23.7 10(6) cells by culture. In contact with the collagen lattices, we obtained an epidermal skin and we highlighted the markers of keratinocytes differentiation as well as the markers of the dermoepidermic junction.

CONCLUSION

The keratinocytes resulting from foreskin have a high capacity of division. These cells can divide a long time before differentiation. The observations enable us to propose with our patients the keratinocytes from foreskin for wound healing especially for burns in children.

Wound healing on athymic mice with engineered skin substitutes fabricated with keratinocytes harvested from an automated bioreactor

The Kerator is a computer controlled bioreactor for the automated culture and harvest of keratinocytes that can reduce labor and materials involved in the fabrication of engineered skin substitutes (ESS). Previous studies have shown that the Kerator is comparable to tissue culture flasks by keratinocyte confluence during culture, clonogenic potential of harvested keratinocytes and microanatomy, cell viability, and surface hydration of ESS fabricated with the harvested keratinocytes. In this study, the Kerator and tissue culture flasks were further compared by keratinocyte proliferation in vitro and wound healing after transplantation of ESS to athymic mice. The number of bromodeoxyuridine-positive keratinocytes in ESS fabricated with keratinocytes harvested from Kerator after 2 wk of in vitro maturation was 34 +/- 3 per high power field (hpf) (mean +/- SEM), which was not significantly different from that fabricated with keratinocytes harvested from flasks (34 +/- 1.5 per hpf). Percentage original wound area 6 wk after surgery of ESS fabricated with keratinocytes from the Kerator was 36% +/- 3.3%, which was not significantly different from that of ESS fabricated with keratinocytes from flasks (30% +/- 4.3%). In both cases, 78% (7 of 9) mice transplanted were positive for engraftment of human keratinocytes by direct immunofluorescence for HLA-ABC antigens. These results further confirm that the ESS fabricated with keratinocytes harvested from Kerator and flasks are equivalent in vitro and in vivo. Therefore, use of Kerator for large scale production of ESS can lead to increased availability at reduced cost while maintaining ESS quality for grafting.

A randomized trial comparing ReCell system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns

BACKGROUND

Our purpose was to directly compare results obtained with the ReCell system and the classic skin grafting for epidermal replacement in deep partial thickness burns.

MATERIALS AND METHODS

We recruited all patients with deep partial thickness burns admitted at the Burn Centre of S. Eugenio Hospital in Rome over 2 years. Enrollment was conducted with a controlled strategy--sampling chart--that allowed homogeneous groups (ReCell and skin grafting) for age, gender, type of burns and total burn surface area (TBSA). We evaluated as primary endpoints of the study the (i) time for complete epithelization (both treated area and biopsy site) and (ii) aesthetic and functional quality of the epithelization (color, joint contractures). Secondary endpoints were the assessment of infections, inflammations or any adverse effects of the ReCell procedure, particular medications assumed, postoperative pain.

RESULTS

Eighty-two patients were analyzed in two homogeneous groups. All of them received adequate epidermal replacement, but skin grafting was faster than ReCell (p<0.05). On the contrary, ReCell biopsy areas and postoperative pain were smaller than classic grafting (p<0.05). The aesthetic and functional outcomes were similar between procedures.

CONCLUSIONS

ReCell is a feasible, simple and safe technique. It gives similar results to skin grafting but, harvesting minor areas, can open possible future applications in the management of large-burns patients.

Microengineered surface topography facilitates cell grafting from a prototype hydrogel wound dressing with antibacterial capability

Skin wounds derive therapeutic benefit from redeployment of dermal tissues, whether as split-thickness allo- and autografts or as biological dressings comprising cultured cells. However, the clinical outcome is strongly influenced by the techniques used for cell/tissue grafting and also the microbiological status of the wound. Here we report that microtopography incorporated into the surface of a novel polymeric material, derivatized with fibronectin to promote attachment and encourage motility, improved the efficiency of cell transfer onto de-epithelialized human skin ex vivo. The microtopography had two functions, first as a conduit for migrating cells to cross between the vehicle and recipient surface and second to shield adherent cells from destruction by mechanical shearing during handling and application. Quantitative analysis showed that topographic projections (columns) rather than recesses (pits) in the hydrogel surface achieved the highest efficiency of cell transfer. In order to address the crucial relevance of microbiological contamination to the success of wound grafting, the effect of iodine on several common bacterial pathogens was examined using an XTT+C(Q10) kinetic cell viability assay. Increasing concentrations of iodine initially stressed and after 0.5% v/v were subsequently bacteriocidal for Gram-negative Pseudomonas aeruginosa and Escherichia coli and Gram-positive Bacillus subtillis and Staphylococcus aureus. Slightly higher doses of iodine (approx 1-1.5% v/v) were required to kill HaCaT cells outright, but for both pro- and eukaryotes the major determinant of cytotoxicity was absolute dose rather than duration of exposure. Iodine delivered by the hydrogel at low concentration was bacteriostatic but not apparently cytotoxic to epithelial cells as measured by MTT end-point cell viability assay. Zone of inhibition studies confirmed that bacteriocidal quantities of neomycin, phenol red, and silver could also be delivered using the same hydrogel. This research suggests that grafting cell-based biological dressings to wounds using a topographically modified hydrogel dressing capable of simultaneous reducing the microbiological threat to a successful outcome may be a realistic clinical proposition.

Morphologies of fibroblast cells cultured on surfaces of PHB films implanted by hydroxyl ions

Polyhydroxybutyrate (PHB) films were implanted with 40 keV hydroxyl ions with fluences ranging from 1 x 10(12) to 1 x 10(15) ions/cm2, respectively. The as-implanted PHB films were characterized by scanning electron microscopy (SEM), electron spectroscopy for chemical analysis (ESCA) and water contact angle measurements. The surface structures and properties of the as-implanted PHB films were closely related with hydroxyl ion fluence. They were further investigated by inoculating 3T6 fibroblasts cells on their surfaces. Morphologies of the 3T6 fibroblast cells cultured on surfaces of the as-implanted PHB films were observed by SEM. Characterization of the cultural 3T6 cells was analyzed qualitatively. The preliminary experimental results reveal that the bioactivity of the PHB films modified by hydroxyl ion implantation was improved at different levels, and the fluence of 1 x 10(13) ions/cm2 is optimal for PHB film.

Cell transplantation inhibits inflammatory reaction and stimulates repair processes in burn wound

We compared the effects of transplantation of fetal fibroblasts and fibroblast-like mesenchymal stem cells of the bone marrow on healing of deep burn wound in rats. It was found that transplantation of fetal fibroblasts and fibroblast-like mesenchymal stem cells on the burn surface reduces cell infiltration, promotes the formation of vessels and granulation tissue, which creates conditions for more rapid healing of the burn wounds.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Analysis of neovascularization of PEGT/PBT-copolymer dermis substitutes in balb/c-mice

INTRODUCTION

A fundamental prerequisite for using degradable synthetic biopolymers as composite skin substitutes is the ability to establish vascular tissue. PEGT/PBT block-copolymer matrices have previously been shown as a favorable dermal substitute. In this study, quantitative data on neovascularization of PEGT/PBT block-copolymer matrices are presented.

MATERIALS AND METHODS

PEGT/PBT-block-copolymer discs of three different pore diameters (1: < 75 microm, 2: 75-212 microm, 3: 250-300 microm) were implanted into dorsal skinfold chambers of balb/c mice. Histological sections were evaluated 7, 14, and 21 days post implantation by light and scanning electron microscopy. Blood vessel analysis was performed by means of digital image analysis (n = 288) of hematoxylin/eosin stained sections within apical (AOF) and basal (BOF) observation fields of the matrices.

RESULTS

Twenty-one days after implantation the density of blood vessels within the BOF of the scaffolds with a pore size of 75-212 and 250-300 microm were 4.6 +/- 0.45 and 5.8 +/- 0.62 (mean +/- S.E.M.; blood vessel profiles (BVF)), respectively. In <75 microm scaffolds, smaller numbers of BVF were found (4.2 +/- 0.39). In contrast, the evaluation within the AOF revealed significantly higher numbers of BVF in 75-212 microm group (3.5 +/- 0.49) and 250-300 microm group (4.5 +/- 0.66) as compared to the < 75 microm group (2.3 +/- 0.48).

CONCLUSION

There is evidence that the three-dimensional structure of PEGT/PBT-block-copolymer (pore size structure) influences neovascularization. The porous structures of copolymer matrices with adequate interconnection of pores (pore sizes of 75-212 and 250-300 microm) are characterized by faster ingrowth of vascular tissue.

New technologies for burn wound closure and healing--review of the literature

Methods for handling burn wounds have changed in recent decades. Increasingly, aggressive surgical approach with early tangential excision and wound closure is being applied leading to improvement in mortality rates of burn victims. Autografts from uninjured skin remain the mainstay of treatment. Autologous skin graft, however, has limited availability and is associated with additional morbidity and scarring. Severe burn patients invariably lack sufficient adequate skin donor sites requiring alternative methods of skin replacement. The present review summarizes available replacement technologies.

A general overview of burn care

The majority of burn victims do not need to be treated in a burn centre. Adequate care can be given by non specialised medical personnel, provided that proper guidelines are followed. The article outlines and reviews these guidelines.