Evaluation of human skin reconstituted from composite grafts of cultured keratinocytes and human acellular dermis transplanted to athymic mice

Basic Quality Controls Used in Skin Tissue Engineering

Reconstruction of skin defects is often a challenging effort due to the currently limited reconstructive options. In this sense, tissue engineering has emerged as a possible alternative to replace or repair diseased or damaged tissues from the patient's own cells. A substantial number of tissue-engineered skin substitutes (TESSs) have been conceived and evaluated in vitro and in vivo showing promising results in the preclinical stage. However, only a few constructs have been used in the clinic. The lack of standardization in evaluation methods employed may in part be responsible for this discrepancy. This review covers the most well-known and up-to-date methods for evaluating the optimization of new TESSs and orientative guidelines for the evaluation of TESSs are proposed.

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.

Functional Skin Grafts: Where Biomaterials Meet Stem Cells

Skin tissue engineering has attained several clinical milestones making remarkable progress over the past decades. Skin is inhabited by a plethora of cells spatiotemporally arranged in a 3-dimensional (3D) matrix, creating a complex microenvironment of cell-matrix interactions. This complexity makes it difficult to mimic the native skin structure using conventional tissue engineering approaches. With the advent of newer fabrication strategies, the field is evolving rapidly. However, there is still a long way before an artificial skin substitute can fully mimic the functions and anatomical hierarchy of native human skin. The current focus of skin tissue engineers is primarily to develop a 3D construct that maintains the functionality of cultured cells in a guided manner over a period of time. While several natural and synthetic biopolymers have been translated, only partial clinical success is attained so far. Key challenges include the hierarchical complexity of skin anatomy; compositional mismatch in terms of material properties (stiffness, roughness, wettability) and degradation rate; biological complications like varied cell numbers, cell types, matrix gradients in each layer, varied immune responses, and varied methods of fabrication. In addition, with newer biomaterials being adopted for fabricating patient-specific skin substitutes, issues related to escalating processing costs, scalability, and stability of the constructs under in vivo conditions have raised some concerns. This review provides an overview of the field of skin regenerative medicine, existing clinical therapies, and limitations of the current techniques. We have further elaborated on the upcoming tissue engineering strategies that may serve as promising alternatives for generating functional skin substitutes, the pros and cons associated with each technique, and scope of their translational potential in the treatment of chronic skin ailments.

Bioengineered Skin Intended for Skin Disease Modeling

Clinical use of bioengineered skin in reconstructive surgery has been established for more than 30 years. The limitations and ethical considerations regarding the use of animal models have expanded the application of bioengineered skin in the areas of disease modeling and drug screening. These skin models should represent the anatomical and physiological traits of native skin for the efficient replication of normal and pathological skin conditions. In addition, reliability of such models is essential for the conduction of faithful, rapid, and large-scale studies. Therefore, research efforts are focused on automated fabrication methods to replace the traditional manual approaches. This report presents an overview of the skin models applicable to skin disease modeling along with their fabrication methods, and discusses the potential of the currently available options to conform and satisfy the demands for disease modeling and drug screening.

Short-term changes of human acellular dermal matrix (Megaderm) in a mouse model

BACKGROUND

Physicians tend to overcorrect when applying the acellular dermal matrix for reconstructive option because of volume decrement problem after absorption comparing with initial volume. However, there are no studies on the exact volume decrement and absorption rate with commercial products in South Korea. To figure out absorption rate of acellular dermal matrix product in South Korea (Megaderm), authors designed this experiment.

METHODS

Nine mice were used and randomly divided into three groups by the time with sacrificing. The implant (Megaderm) was tailored to fit a cuboid form (1.0 cm× 1.0 cm in length and width and 2.0 mm in thickness). A skin incision was made at anterior chest with blade #15 scalpel with exposing the pectoralis major muscle. As hydrated Megaderm was located upon the pectoralis major muscle, the skin was sutured with Ethilon #5-0. After the surgical procedure, each animal group was sacrificed at 4, 8, and 12 weeks, respectively, for biopsies and histological analysis of the implants. All samples were stained with routine hematoxylin and eosin staining and Masson's trichrome staining and the thickness were measured. A measurements were analyzed using Friedman test. Statistically, the correlation between thicknesses of Megaderm before and after implantation was analyzed.

RESULTS

After sacrificing the animal groups at postoperative 4, 8, 12 weeks, the mean tissue thickness values were 2.10± 1.03 mm, 2.17± 0.21 mm, and 2.40± 0.20 mm (p= 0.368), respectively. The remaining ratios after absorption comparing with after initial hydrated Megaderm were 82.7%, 85.4%, and 94.5%, respectively. In histopathological findings, neovascularization and density of collagenous fiber was increased with time.

CONCLUSION

Author's hypothesis was absorption rate of implant would be increased over time. But in this experiment, there is no statistical significance between mean absorption thickness of implant and the time (p= 0.368). Also it can be affected by graft site, blood supply, and animals that were used in the experiment.

Transient Hyperproliferation of a Transgenic Human Epidermis Expressing Hepatocyte Growth Factor

Hepatocyte growth factor (HGF) is a fibroblast-derived protein that affects the growth, motility, and differentiation of epithelial cells including epidermal keratinocytes. To investigate the role of HGF in cutaneous biology and to explore the possibility of using it in a tissue engineering approach, we used retroviral-mediated gene transfer to introduce the gene encoding human HGF into diploid human keratinocytes. Modified cells synthesized and secreted significant levels of HGF in vitro and the proliferation of keratinocytes expressing HGF was enhanced compared with control unmodified cells. To investigate the effects of HGF in vivo, we grafted modified keratinocytes expressing HGF onto athymic mice using acellular dermis as a substrate. When compared with controls, HGF-expressing keratinocytes formed a hyperproliferative epidermis. The epidermis was thicker, had more cells per length of basement membrane, and had increased numbers of Ki-67-positive proliferating cells, many of which were suprabasal in location. Hyperproliferation subsided and the epidermis was equivalent to controls by 2 weeks, a time frame that coincides with healing of the graft. Transient hyperproliferation may be linked to the loss of factors present in the wound that activate HGF. These data suggest that genetically modified skin substitutes secreting HGF may have applications in wound closure and the promotion of wound healing.

Characterization of pigmented dermo-epidermal skin substitutes in a long-term in vivo assay

In our laboratory, we have been using human pigmented dermo-epidermal skin substitutes for short-term experiments since several years. Little is known, however, about the long-term biology of such constructs after transplantation. We constructed human, melanocyte-containing dermo-epidermal skin substitutes of different (light and dark) pigmentation types and studied them in a long-term animal experiment. Developmental and maturational stages of the epidermal and dermal compartment as well as signs of homoeostasis were analysed 15 weeks after transplantation. Keratinocytes, melanocytes and fibroblasts from human skin biopsies were isolated and assembled into dermo-epidermal skin substitutes. These were transplanted onto immuno-incompetent rats and investigated 15 weeks after transplantation. Chromameter evaluation showed a consistent skin colour between 3 and 4 months after transplantation. Melanocytes resided in the epidermal basal layer in physiological numbers and melanin accumulated in keratinocytes in a supranuclear position. Skin substitutes showed a mature epidermis in a homoeostatic state and the presence of dermal components such as Fibrillin and Tropoelastin suggested advanced maturation. Overall, pigmented dermo-epidermal skin substitutes show a promising development towards achieving near-normal skin characteristics and epidermal and dermal tissue homoeostasis. In particular, melanocytes function correctly over several months whilst remaining in a physiological, epidermal position and yield a pigmentation resembling original donor skin colour.

Plant-derived human collagen scaffolds for skin tissue engineering

Tissue engineering scaffolds are commonly formed using proteins extracted from animal tissues, such as bovine hide. Risks associated with the use of these materials include hypersensitivity and pathogenic contamination. Human-derived proteins lower the risk of hypersensitivity, but possess the risk of disease transmission. Methods engineering recombinant human proteins using plant material provide an alternate source of these materials without the risk of disease transmission or concerns regarding variability. To investigate the utility of plant-derived human collagen (PDHC) in the development of engineered skin (ES), PDHC and bovine hide collagen were formed into tissue engineering scaffolds using electrospinning or freeze-drying. Both raw materials were easily formed into two common scaffold types, electrospun nonwoven scaffolds and lyophilized sponges, with similar architectures. The processing time, however, was significantly lower with PDHC. PDHC scaffolds supported primary human cell attachment and proliferation at an equivalent or higher level than the bovine material. Interleukin-1 beta production was significantly lower when activated THP-1 macrophages where exposed to PDHC electrospun scaffolds compared to bovine collagen. Both materials promoted proper maturation and differentiation of ES. These data suggest that PDHC may provide a novel source of raw material for tissue engineering with low risk of allergic response or disease transmission.

Bioengineered skin substitutes

Bioengineered skin has great potential for use in regenerative medicine for treatment of severe wounds such as burns or chronic ulcers. Genetically modified skin substitutes have also been used as cell-based devices or "live bioreactors" to deliver therapeutics locally or systemically. Finally, these tissue constructs are used as realistic models of human skin for toxicological testing, to speed drug development and replace traditional animal-based tests in a variety of industries. Here we describe a method of generating bioengineered skin based on a natural scaffold, namely, decellularized human dermis and epidermal stem cells.

Epithelial and stromal developmental patterns in a novel substitute of the human skin generated with fibrin-agarose biomaterials

Development of human skin substitutes by tissue engineering may offer new therapeutic alternatives to the use of autologous tissue grafts. For that reason, it is necessary to investigate and develop new biocompatible biomaterials that support the generation of a proper human skin construct. In this study, we generated a novel model of bioengineered human skin substitute using human cells obtained from skin biopsies and fibrin-agarose biomaterials and we evaluated this model both at the ex vivo and the in vivo levels. Once the dermal fibroblasts and the epithelial keratinocytes were isolated and expanded in culture, we used fibrin-agarose scaffolds for the development of a full-thickness human skin construct, which was evaluated after 1, 2, 3 and 4 weeks of development ex vivo. The skin substitutes were then grafted onto immune-deficient nude mice and analyzed at days 10, 20, 30 and 40 postimplantation using transmission electron microscopy, histochemistry and immunofluorescence. The results demonstrated that the fibrin-agarose artificial skin had adequate biocompatibility and proper biomechanical properties. A proper development of both the bioengineered dermis and epidermis was found after 30 days in vivo, although the tissues kept ex vivo and those implanted in the animal model for 10 or 20 days showed lower levels of differentiation. In summary, our model of fibrin-agarose skin equivalent was able to reproduce the structure and histological architecture of the native human skin, especially after long-term in vivo implantation, suggesting that these tissues could reproduce the native skin.

Acellular dermal matrix in the management of the burn patient

Although the principles of burn management are still primarily focused on survival, as advances are realized in resuscitation, nutrition, and wound management, the functional and aesthetic outcomes following burn injury have become increasingly important. Acellular dermal matrix materials, which allow surgeons to minimize skin graft donor site morbidity in the process of repairing injured areas, play a role in addressing these important issues. Many favorable reports have been published, but they are generally characterized by small sample sizes, limited objective testing, and retrospective analysis. There does appear to be some evidence for ADM application in patient populations in whom donor site availability (those with massive burns) or morbidity (children, the elderly) is a concern, but more studies are needed. In this article, the authors discuss the current applications for ADM in burn management, review the existing literature, and present opportunities for future research.

Vascularization of the dermal support enhances wound re-epithelialization by in situ delivery of epidermal keratinocytes

Despite significant advances in management of severe wounds such as burns and chronic ulcers, autologous split-thickness skin grafts are still the gold standard of care. The main problems with this approach include pain and discomfort associated with harvesting autologous tissue, limited availability of donor sites, and the need for multiple surgeries. Although tissue engineering has great potential to provide alternative approaches for tissue regeneration, several problems have hampered progress in translating technological advances to clinical reality. Specifically, engineering of skin substitutes requires long culture times and delayed vascularization after implantation compromises graft survival. To address these issues we developed a novel two-prong strategy for tissue regeneration in vivo: (1) vascularization of acellular dermal scaffolds by infiltration of angiogenic factors; and (2) generation of stratified epidermis by in situ delivery of epidermal keratinocytes onto the prevascularized dermal support. Using athymic mouse as a model system, we found that incorporation of angiogenic factors within acellular human dermis enhanced the density and diameter of infiltrating host blood vessels. Increased vascularization correlated with enhanced proliferation and stratification of the neoepidermis originating from the fibrin-keratinocyte cell suspension. This strategy promoted tissue regeneration in vivo with no need for engineering skin substitutes; therefore, it may be useful for treatment of major wounds when skin donor sites are scarce and rapid wound coverage is required.

Concentrated collagen-chondroitin sulfate scaffolds for tissue engineering applications

Collagen-chondroitin sulfate biomaterial scaffolds have been used in a number of tissue-engineered products under development or in the clinics. In this article, we describe a new approach based on centrifugation for obtaining highly concentrated yet porous collagen scaffolds. Water uptake, chondroitin sulfate retention, morphology, mechanical properties, and tissue-engineering potential of the concentrated scaffolds were investigated. Our results show that the new approach can lead to scaffolds containing four times as much collagen as that in conventional unconcentrated scaffolds. Further, water uptake in the concentrated scaffolds was significantly greater while chondroitin sulfate retention in the concentrated scaffolds was unaffected. The value of mean pore diameter in the concentrated scaffolds was smaller than that in the unconcentrated scaffolds and the walls of the pores in the former comprised of a continuous sheet of collagen. The mechanical properties measured as moduli of elasticity in compression and tension were improved by as much as 30 times in the concentrated scaffolds. In addition, our tissue culture results with human mesenchymal stem cells and foreskin keratinocytes show that the new scaffolds can be used for cartilage and skin tissue-engineering applications.

Decellularized dermis in combination with cultivated keratinocytes in a short- and long-term animal experimental investigation

Decellularized human dermis as a potentially ideal scaffold for dermal substitution in severe burns was examined in a two-staged animal experiment. In an initial step, an in vitro generated composite graft consisting of human keratinocytes and decellularized dermis (AlloDerm) was transplanted onto nude mice in a short-term trial (n = 20, 14 days). Subsequently, a combined one-step grafting of full thickness wounds with both decellularized dermis (in part preincubated with fibroblasts) and cultivated autologous keratinocytes as a cell suspension in fibrin glue was done in a long-term porcine animal model (n = 10, 6 months). In both series, macroscopic wound healing was evaluated by planimetry. Histological investigations included morphological as well as immunohistochemical parameters. The short-term study showed both successful integration of the composite grafts and reduction of wound contraction compared with the control group (epithelial grafts). The long-term porcine study displayed reduced myofibroblast formation and contraction in the wounds that had been treated with fibroblast-preincubated dermis. After 4 weeks, a decline of the structural integrity of the dermal matrix could be noticed. The utility of decellularized dermis as template for both dermal reconstitution and keratinocyte delivery vehicle was shown. The closure of full thickness wounds by a single-step combination of an autologous keratinocyte fibrin sealant suspension and acellular dermis in a pig animal model could be shown. Incorporation of fibroblasts led to reduced wound contraction but could not prevent the loss of dermal integrity. The engineered 'skin' remained viable and stable over a period of 6 months.

Artificial skin

Replacement of skin has been one of the most challenging aims for surgeons ever since the introduction of skin grafts in 1871. It took more than one century until the breakthrough of Rheinwald and Green in 1975 that opened new possibilities of skin replacement. The combination of cell culture and polymer chemistry finally led to the field of tissue engineering. Many researchers all over the world have been fascinated by the chance of creating a skin-like substitute ex vivo without any further harm to the patients, especially those with massive burns. Many different approaches to create new substitutes and further improvements in genetical and stem cell research led to today's skin equivalents. But still, the "gold standard" for wound coverage is the autologous split-thickness skin graft. Future research will aim at originating biologically and physiologically equal skin substitutes for the treatment of severe burns and chronic ulcers.

Cell colonization in degradable 3D porous matrices

Cell colonization is an important in a wide variety of biological processes and applications including vascularization, wound healing, tissue engineering, stem cell differentiation and biosensors. During colonization porous 3D structures are used to support and guide the ingrowth of cells into the matrix. In this review, we summarize our understanding of various factors affecting cell colonization in three-dimensional environment. The structural, biological and degradation properties of the matrix all play key roles during colonization. Further, specific scaffold properties such as porosity, pore size, fiber thickness, topography and scaffold stiffness as well as important cell material interactions such as cell adhesion and mechanotransduction also influence colonization.

Experimental study on repairing of nude mice skin defects with composite skin consisting of xenogeneic dermis and epidermal stem cells and hair follicle dermal papilla cells

OBJECTIVE

To investigate the influence of hair follicle dermal papilla cells (DPCs) on biological features of composite skin.

METHODS

In the test group, xenogeneic acellular dermal matrix was employed as the frame, DPCs were seeded on the subcutaneous side, and epithelial stem cells onto the dermal papilla side of the dermal frame so as to construct a composite skin. In the control group, there was no DPC in the frame. The two kinds of composite skin were employed to cover skin defects on the back of the nude mice. Wound healing was observed 4 weeks after grafting and area was analyzed and contraction rate was calculated. The tissue samples in the grafted area were harvested for HE staining and the state of the composite skin was observed. The stress-strain curve of the sampled skin was measured, so as to calculate the maximal breaking power of the sample. The data were collected and statistically analyzed.

RESULTS

HE staining indicated that the epithelial depth was increased (more than 10 layers of cells) in test group, with only 6-7 layers in control group. The skin contraction rate in test group on the 4th week after skin grafting (3.94+/-0.013)% was much lower than that in control group (29.07+/-0.018)% (P<0.05). It was indicated by biomechanical test that the stress-strain curve of the composite skin in the test group was closer to that of normal nude mice skin in comparison to that in control group. The maximal breaking force of the composite skin in test group was (1.835+/-0.035)N (Newton), while that in control group was (1.075+/-0.065)N (P<0.01).

CONCLUSION

Reconstruction of epidermis in composite skin was promoted by dermal DPCs seeded in the dermal matrix frame. As a result, there was less skin contraction in the composite skin with DPCs, so that the biological characteristics of the skin were improved.

The Roles of Hypoxia in theIn VitroEngineering of Tissues

Oxygen is a potent modulator of cell function and wound repair in vivo. The lack of oxygen (hypoxia) can create a potentially lethal environment and limit cellular respiration and growth or, alternatively, enhance the production of the specific extracellular matrix components and increase angiogenesis through the hypoxia-inducible factor-1 pathway. For the in vitro generation of clinically relevant tissue-engineered grafts, these divergent actions of hypoxia should be addressed. Diffusion through culture medium and tissue typically limits oxygen transport in vitro, leading to hypoxic regions and limiting the viable tissue thickness. Approaches to overcoming the transport limitations include culture with bioreactors, scaffolds with artificial microvasculature, oxygen carriers, and hyperbaric oxygen chambers. As an alternate approach, angiogenesis after implantation may be enhanced by incorporating endothelial cells, genetically modified cells, or specific factors (including vascular endothelial growth factor) into the scaffold or exposing the graft to a hypoxic environment just before implantation. Better understanding of the roles of hypoxia will help prevent common problems and exploit potential benefits of hypoxia in engineered tissues.

Isolation of a mesenchymal cell population from murine dermis that contains progenitors of multiple cell lineages

The skin contains two known subpopulations of stem cells/epidermal progenitors: a basal keratinocyte population found in the interfollicular epithelium and cells residing in the bulge region of the hair follicle. The major role of the interfollicular basal keratinocyte population may be epidermal renewal, whereas the bulge population may only be activated and recruited to form a cutaneous epithelium in case of trauma. Using 3-dimensional cultures of murine skin under stress conditions in which only reserve epithelial cells would be expected to survive and expand, we demonstrate that a mesenchymal population resident in neonatal murine dermis has the unique potential to develop an epidermis in vitro. In monolayer culture, this dermal subpopulation has long-term survival capabilities in restricted serum and an inducible capacity to evolve into multiple cell lineages, both epithelial and mesenchymal, depending on culture conditions. When grafted subcutaneously, this dermal subpopulation gave rise to fusiform structures, reminiscent of disorganized muscle, that stained positive for smooth muscle actin and desmin; on typical epidermal grafts, abundant melanocytes appeared throughout the dermis that were not associated with hair follicles. The multipotential cells can be repeatedly isolated from neonatal murine dermis by a sequence of differential centrifugation and selective culture conditions. These results suggest that progenitors capable of epidermal differentiation exist in the mesenchymal compartment of an abundant tissue source and may have a function in mesenchymal-epithelial transition upon insult. Moreover, these cells could be available in sufficient quantities for lineage determination or tissue engineering applications.

Hyperbaric oxygen stimulates epidermal reconstruction in human skin equivalents

The crucial role of oxygen during the complex process of wound healing has been extensively described. In chronic or nonhealing wounds, much evidence has been reported indicating that a lack of oxygen is a major contributing factor. Although still controversial, the therapeutic application of hyperbaric oxygen (HBO) therapy can aid the healing of chronic wounds. However, how HBO affects reepithelization, involving processes such as keratinocyte proliferation and differentiation, remains unclear. We therefore used a three-dimensional human skin-equivalent (HSE) model to investigate the effects of daily 90-minute HBO treatments on the reconstruction of an epidermis. Epidermal markers of proliferation, differentiation, and basement membrane components associated with a developing epidermis, including p63, collagen type IV, and cytokeratins 6, 10, and 14, were evaluated. Morphometric analysis of hematoxylin and eosin-stained cross sections revealed that HBO treatments significantly accelerated cornification of the stratum corneum compared with controls. Protein expression as determined by immunohistochemical analysis confirmed the accelerated epidermal maturation. In addition, early keratinocyte migration was enhanced by HBO. Thus, HBO treatments stimulate epidermal reconstruction in an HSE. These results further support the importance of oxygen during the process of wound healing and the potential role of HBO therapy in cutaneous wound healing.

Effect of In Vitro Gingival Fibroblast Seeding on the In Vivo Incorporation of Acellular Dermal Matrix Allografts in Dogs

BACKGROUND

Acellular dermal matrix allograft (ADMA) has been used in various periodontal procedures with successful results. Because ADMA has no blood vessels or cells, slower healing and incorporation are observed compared to a subepithelial connective tissue graft. Fibroblasts accelerate the healing process by regulation of matrix deposition and synthesis of a variety of growth factors. Thus, the objective of this study was to evaluate histologically if gingival fibroblasts affect healing and incorporation of ADMA in dogs when used as a subepithelial allograft.

METHODS

Gingival fibroblasts were established from explant culture from the connective tissue of keratinized gingiva collected from the maxilla of seven mongrel dogs. ADMA was seeded with gingival fibroblasts and transferred to dogs. Surgery was performed bilaterally, and the regions were divided into two groups: ADMA+F (ADMA containing fibroblasts) and ADMA (ADMA only). Biopsies were performed after 2, 4, and 8 weeks of healing.

RESULTS

The quantity of blood vessels was significantly higher in the ADMA+F group at 2 weeks of healing (Kruskal-Wallis; P <0.05). There was no statistical difference (P >0.05) in the number of cell layers, epithelial area, or inflammatory infiltrate between the two groups at any stage of healing.

CONCLUSION

The enhanced vascularization in vivo in early stages supports the important role of fibroblasts in improving graft performance and wound healing of cultured graft substitutes.

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

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

Biomimetic bilayered gelatin-chondroitin 6 sulfate-hyaluronic acid biopolymer as a scaffold for skin equivalent tissue engineering

In order to develop an adequate scaffold for skin tissue engineering, a bilayered gelatin-chondroitin 6 sulfate-hyaluronic acid membrane with a different pore size on either side was prepared. A rete ridges-like topographic microporous structure, which provided the paracrine crosstalk in the epithelial-mesenchymal interactions, was formed. Chondroitin-6-sulfate and hyaluronic acid were incorporated within the gelatin membrane to mimic skin composition and create an appropriate microenvironment for cell proliferation, differentiation, and migration. In the study, the lower layer of the membrane (pore size: 150 microm) was seeded with dermal fibroblasts and acted as the feeder layer for keratinocyte inoculation. Meanwhile, the upper layer (pore size: 20-50 microm) was seeded with keratinocytes for epidermalization. The dermal fibroblasts were dynamically seeded in a self-designed spinner flask for more even cell distribution. The keratinocytes were cultured in submerged conditions for 5 days and then in an air-liquid interface condition for further differentiation. After being cultured for 21 days, the upper layer, seeded with keratinocytes, developed into an epidermis-like structure while the lower part, which was seeded with dermal fibroblasts developed into a dermis-like structure. A histological examination and immunostain were used to prove that keratinocytes maintain their phenotype and stratified epidermis layers were formed within 21 days. In brief, the bilayered skin substitute with biological dermal analog and epidermal structure was successfully fabricated. From this study, we can suggest that the culture model is suitable for autologous skin equivalent preparation.

Vascularization and engraftment of a human skin substitute using circulating progenitor cell-derived endothelial cells

We seeded tissue engineered human skin substitutes with endothelial cells (EC) differentiated in vitro from progenitors from umbilical cord blood (CB-EC) or adult peripheral blood (AB-EC), comparing the results to previous work using cultured human umbilical vein EC (HUVEC) with or without Bcl-2 transduction. Vascularized skin substitutes were prepared by seeding Bcl-2-transduced or nontransduced HUVEC, CB-EC, or AB-EC on the deep surface of decellularized human dermis following keratinocyte coverage of the epidermal surface. These skin substitutes were transplanted onto C.B-17 SCID/beige mice receiving systemic rapamycin or vehicle control and were analyzed 21 d later. CB-EC and Bcl-2-HUVEC formed more human EC-lined vessels than AB-EC or control HUVEC; CB-EC, Bcl-2-HUVEC, and AB-EC but not control HUVEC promoted ingrowth of mouse EC-lined vessels. Bcl-2 transduction increased the number of human and mouse EC-lined vessels in grafts seeded with HUVEC but not with CB-EC or AB-EC. Both CB-EC and AB-EC-induced microvessels became invested by smooth muscle cell-specific alpha-actin-positive mural cells, indicative of maturation. Rapamycin inhibited ingrowth of mouse EC-lined vessels but did not inhibit formation of human EC-lined vessels. We conclude that EC differentiated from circulating progenitors can be utilized to vascularize human skin substitutes even in the setting of compromised host angiogenesis/vasculogenesis.

Modelling cancer in human skin tissue

The capacity to induce neoplasia in human tissue in the laboratory has recently provided a new platform for cancer research. Malignant conversion can be achieved in vivo by expressing genes of interest in human tissue that has been regenerated on immune-deficient mice. Induction of cancer in regenerated human skin recapitulates the three-dimensional architecture, tissue polarity, basement membrane structure, extracellular matrix, oncogene signalling and therapeutic target proteins found in intact human skin in vivo. Human-tissue cancer models therefore provide an opportunity to elucidate fundamental cancer mechanisms, to assess the oncogenic potency of mutations associated with specific human cancers and to develop new cancer therapies.

Allogeneic versus xenogeneic immune reaction to bioengineered skin grafts

There are conflicting reports on the survival and immune reaction to allografts and xenografts of cultured skin substitutes (CSS). In this study, we investigated the allogeneic and xenogeneic responses to CSS of human keratinocytes and genetically engineered CSS expressing keratinocyte growth factor (KGF) that forms a hyperproliferative epidermis. CSS (control and KGF modified) and neonatal human foreskins were evaluated by immunohistochemistry for the expression of MHC class I and II. To study allograft rejection, grafts were transplanted to human peripheral blood mononuclear cell (huPBMC)-reconstituted SCID mice. To study xenograft rejection, grafts were transplanted to immunocompetent mice. Graft survival and immune reaction were assessed visually and microscopically. After transplantation, control CSS formed a normal differentiated epidermis, whereas KGF CSS formed a hyperproliferative epidermis. Control and KGF CSS expressed class I similar to neonatal foreskin, but did not express class II. In the allograft model, rejection of neonatal foreskins was between 5 and 9 days. In contrast, neither control nor KGF CSS was rejected by huPBMC-SCID mice. Histology showed dense mononuclear cell infiltration in human foreskins, with few, if any, mononuclear cells in control or KGF CSS. In contrast to the allogeneic reaction, CSS (control and KGF) were rejected in the xenograft model, but rejection was delayed (9-21 days) compared with neonatal skin (5-8 days). Humanized SCID mice rejected allografts of human neonatal foreskins, but did not reject control CSS or KGF CSS, even though the KGF CSS formed a hyperproliferative epidermis. Rejection of control and KGF CSS by immunocompetent mice in a xenograft model was comparable and their survival was significantly prolonged compared with neonatal skin. These results demonstrate that control CSS and hyperproliferative KGF CSS are less immunogenic than normal human skin and that sustained hyperproliferation of the epidermis does not accelerate rejection.

Epithelial-mesenchymal interactions allow for epidermal cells to display an in vivo-like phenotype in vitro

We here report that preservation of the basic epithelial-mesenchymal interactions allows for highly complex ex vivo function of epidermal cells. The approach taken is based on the preparation of organ fragments that preserve the basic epithelial/mesenchymal interactions but also ensure appropriate diffusion of nutrients and gases to all cells. Human and mice keratinocytes in such organ fragments, remain viable, proliferate and express epidermal-specific gene products when cultured in serum-free medium without added growth factors, for several weeks in vitro. When implanted into syngeneic animals they remain viable, become vascularized and continue to function and transcribe tissue-specific gene products for several months. Such fragments allow primary cells ex vivo to preserve most of the functional attributes of the in vivo system. Clearly, the effect of the extracellular matrix is critical in this system in order for the cells to proliferate and differentiate ex vivo. We are not aware of any other system which allows for localized expression of epidermal-specific genes ex vivo for significant periods in culture in defined serum-free medium.

Gene transfer to epidermal stem cells: implications for tissue engineering

The skin is an attractive target for gene therapy because it is easily accessible and shows great potential as an ectopic site for protein delivery in vivo. Genetically modified epidermal cells can be used to engineer three-dimensional skin substitutes, which when transplanted can act as in vivo 'bioreactors' for delivery of therapeutic proteins locally or systemically. Although some gene transfer technologies have the potential to afford permanent genetic modification, differentiation and eventual loss of genetically modified cells from the epidermis results in temporary transgene expression. Therefore, to achieve stable long-term gene expression, it is critical to deliver genes to epidermal stem cells, which possess unlimited growth potential and self-renewal capacity. This review discusses the recent advances in epidermal stem cell isolation, gene transfer and engineering of skin substitutes. Recent efforts that employ gene therapy and tissue engineering for the treatment of genetic diseases, chronic wounds and systemic disorders, such as leptin deficiency or diabetes, are reviewed. Finally, the use of gene-modified tissue-engineered skin as a biological model for understanding tissue development, wound healing and epithelial carcinogenesis is also discussed.

Intradermal injection of lentiviral vectors corrects regenerated human dystrophic epidermolysis bullosa skin tissue in vivo

Dystrophic epidermolysis bullosa (DEB) is a family of inherited mechanobullous disorders caused by mutations in the gene, COL7A1, that codes for type VII, (anchoring fibril), collagen, which is critical for epidermal-dermal adherence. Most gene therapy approaches have been ex vivo, involving cell culture and culture graft transplantation, which is logistically difficult. To develop a more simplified approach, we engineered a self-inactivating lentiviral vector expressing human type VII collagen and injected this vector intradermally into hairless, immunodeficient mice and into a human DEB composite skin equivalent grafted onto immunodeficient mice. In both situations, the vector transduced dermal cells, which in turn synthesized and exported type VII collagen into the extracellular space. Remarkably, the type VII collagen selectively adhered to and incorporated into the basement membrane zone (BMZ) between the dermis and the epidermis, where it formed anchoring fibril structures. In the case of the DEB skin equivalent, the newly expressed type VII collagen reversed the DEB phenotype characterized by poor epidermal-dermal adherence and anchoring fibril defects. A single lentiviral vector injection provided stable type VII collagen at the BMZ for at least 3 months. These data demonstrate efficient and long-term type VII collagen gene transfer in vivo using direct intradermal injection of an engineered lentiviral vector.

Experimental model of cultured skin graft

One of the most used animal models of cultured keratinocytes autografting is based on xenografting of human keratinocytes to the rat or athymic mice, immunological neutral recipient that acts as biological carrier. It could be studied in this model many facts that occur after transplant without the ethical aspect in the clinical study. The proposition of the experimental model is related to the sequence of the total or partial skin transplant, as autografting or xenografting, cultured or not, to the back of athymic mice. The model presents the possibility of study in vivo athymic animal, when the in vivo study in anima nobili is not ethical. It permits the xenografting evaluation of cultured cells graft or of the genetically modified cells and of the association of the cultured cells and the dermal substitutes, the composite grafts, and of the autografting.

In Vivo Model of Wound Healing Based on Transplanted Tissue-Engineered Skin

Advances in understanding the complex process of wound healing and development of novel growth factor and gene therapies would benefit from models that mimic closely the physiology of human wounds. To this end, we developed a hybrid wound-healing model based on human tissue-engineered skin transplanted onto athymic mice. Grafted tissues were infiltrated with mouse mesenchymal cells as native and foreign dermal regions fused together. Immunohistochemical staining for human involucrin revealed that the transplanted epithelium maintained its human origin, whereas the dermis was infiltrated by numerous mouse fibroblasts and blood vessels. Grafted tissues were wounded with a 4-mm punch to create full-thickness excisional wounds. At 1 and 2 weeks, the tissues were excised and assessed for reepithelialization, differentiation, and neovascularization. Interestingly, the average rate of keratinocyte migration (120 microm/day) was similar to migration rates observed in human subjects and significantly lower than migration in mouse epidermis. Immunohistochemical staining for keratin 10, laminin, and involucrin revealed a normal pattern of differentiation in the neoepidermis. Neovascularization was significantly elevated in the granulation tissue at 1 week and subsided to the level of unwounded tissue at 2 weeks postwounding. Our data suggest that skin equivalents grafted to a mouse model may serve as a realistic model of human wound regeneration. Because skin equivalents can be prepared with patient cells and genetically modified to stimulate or suppress gene expression, this model may be ideal for addressing mechanistic questions and evaluating the efficacy of biomaterials and gene therapeutics for promoting wound healing.

Injection of recombinant human type VII collagen restores collagen function in dystrophic epidermolysis bullosa

Dystrophic epidermolysis bullosa (DEB) is a family of inherited mechano-bullous disorders that are caused by mutations in the type VII collagen gene and for which ex vivo gene therapy has been considered. To develop a simpler approach for treating DEB, we evaluated the feasibility of protein-based therapy by intradermally injecting human recombinant type VII collagen into mouse skin and a DEB human skin equivalent transplanted onto mice. The injected collagen localized to the basement membrane zone of both types of tissues, was organized into human anchoring fibril structures and reversed the features of DEB disease in the DEB skin equivalent.

Comparison of Long-Term Survival of Pigmented Epidermal Reconstructs Cultured In Vitro vs. Xenografted on Nude Mice

Epidermal reconstructs incorporating pigment cells have been used in vitro over the last decade to study the physiology of the epidermal melanin unit. However, the major limitation of this technology is the duration of the assays, which need to be completed within 2-3 weeks to obviate the problem of epidermal senescence and excessive terminal differentiation. This becomes a major problem for studying long-term biological phenomena in photoprotection and epidermal skin cancers. We report here a simplified surgical technique in immunotolerant mice allowing long-term studies. The creation of a vascularized mouse skin flap is the key point of the surgical procedure. Long-term pigmentation of the xenografts seemed macroscopically successful, but surprisingly microscopy at 11 and 16 weeks postgrafting showed mostly dermal pigment aggregates and rare Melan-A positive dermal and epidermal pigment cells. In the same reconstructs maintained in vitro, dermal pigment and dermal pigment cells were never noted. It could be speculated that in our model, the colonization of the xenografted dead human dermis by murine cells influences melanocyte survival.

Engraftment of a vascularized human skin equivalent

Clinical performance of currently available human skin equivalents is limited by failure to develop perfusion. To address this problem we have developed a method of endothelial cell transplantation that promotes vascularization of human skin equivalents in vivo. Enhancement of vascularization by Bcl-2 overexpression was demonstrated by seeding human acellular dermis grafts with human umbilical vein endothelial cells (HUVEC) transduced with the survival gene Bcl-2 or an EGFP control transgene, and subcutaneous implantation in immunodeficient mice (n=18). After 1 month the grafts with Bcl-2-transduced cells contained a significantly greater density of perfused HUVEC-lined microvessels (55.0/mm3) than controls (25.4/mm3,P=0.026). Vascularized skin equivalents were then constructed by sequentially seeding the apical and basal surfaces of acellular dermis with cultured human keratinocytes and Bcl-2-transduced HUVEC, respectively. Two weeks after orthotopic implantation onto mice, 75% of grafts (n=16) displayed both a differentiated human epidermis and perfusion through HUVEC-lined microvessels. These vessels, which showed evidence of progressive maturation, accelerated the rate of graft vascularization. Successful transplantation of such vascularized human skin equivalents should enhance clinical utility, especially in recipients with impaired angiogenesis.