ORIGINAL INVESTIGATION
Current Available Cellular and Tissue-Based Products
for Treatment of Skin Defects
Yukun Liu, MD; Adriana C. Panayi, MD; Lauren R. Bayer, PA-C; and Dennis P. Orgill, MD, PhD
ABSTRACT
Downloaded from http://journals.lww.com/aswcjournal by BhDMf5ePHKbH4TTImqenVBZZxeh5YHRLpV1WLFko7PPJU9SXk+VEWAXh65P5D3E5kgN+YYyMwwI= on 02/08/2019
The occurrence of diabetic foot ulcers and venous leg ulcers
is increasing because of aging population trends as well as
increases in the number of people with diabetes and obesity.
New technologies have been developed to treat these conditions,
whereas other technologies previously designed for burns and
traumatic wounds have been adapted. This article reviews the
development of selected skin replacement technologies, particularly
cellular and tissue-based products, highlighting their effectiveness
on diabetic foot ulcers, venous leg ulcers, and burns.
KEYWORDS: cellular and tissue-based products, diabetic foot
ulcers, skin replacement, skin substitutes, tissue engineering,
venous leg ulcers, wound healing
ADV SKIN WOUND CARE 2019;32:19Y25.
INTRODUCTION
Organ and tissue replacements are common goals of many
surgical procedures. Autogenous tissues work well but are often
in short supply and can leave scars or deform the donor site. Al-
logeneic tissues often result in immunologic rejection, whereas
permanent biomaterials can lead to infection and capsular con-
tracture (immune response to foreign materials).
The field of tissue engineering (the use of a combination of
cells, engineering materials, and suitable biochemical factors to
improve or replace biologic functions1) was established in an
attempt to reduce these complications. The term tissue engineer-
ing has also been used to define the integration of cells with acel-
lular matrices or synthetic biomaterials.
Cells provide both structural proteins and biochemical signal-
ing molecules critical in tissue engineering constructs. Autolo-
gous, allogeneic, or xenogeneic tissues have all been used. The
ability of stem cells to differentiate has made them a logical cell
source, but their applicability is limited by availability, safety con-
cerns, and regulatory hurdles.
Scaffolds are materials that provide a three-dimensional struc-
ture for cells and blood vessels to populate, allowing growth and
At Brigham and Women’s Hospital in Boston, Massachusetts, Yukun Liu, MD, was a Research Fellow at the time this manuscript was written; Adriana C. Panayi, MD, is a Research Fellow;
Lauren R. Bayer, PA-C, is Clinical Director of the Wound Care Center; and Dennis P. Orgill MD, PhD is Director of the Wound Care Center, Department of Surgery, Brigham and Women’s
Hospital; and Professor of Surgery, Harvard Medical School. Acknowledgment: Dr Orgill is a consultant and/or receives research funding from Integra LifeSciences Corporation, the
Musculoskeletal Research Foundation, Geistlich Corporation, Acell Corporation, and Professional Education and Research Incorporated. The authors have disclosed no other financial relation-
ships related to this article. Submitted May 18, 2018; accepted June 29, 2018.
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
regeneration of viable tissue. Scaffolds can be natural, synthetic,
or composite, as well as biodegradable or permanent. Growth fac-
tors, secreted by cells via signaling pathways, also play a crucial part
in processes related to tissue regeneration and wound healing.2
Regenerative medicine replaces or regenerates human cells,
tissues, or organs to restore or establish normal function.3 This
broader approach has been particularly effective in the treatment
of hematologic malignancies with the use of bone marrow trans-
plants and does not necessarily rely on scaffolds.
With the rapid development of tissue engineering and regener-
ative medicine, innovative strategies such as stem cellYbased therapy,
gene therapy, nanomedicine, and three-dimensional bioprinting
techniques are largely in preclinical testing, but also in some cases
have been translated into human clinical use.4 Recently, for ex-
ample, a patient with epidermolysis bullosa was treated with
gene-edited skin, showing great promise for these techniques.5
Despite tissue engineering approaches being extensively ap-
plied in multiple fields such as skin substitution, organ replace-
ment, tissue repair, and disease modulation, many problems
still exist. Limitations for routine practice include the immuno-
genic rejection of allogeneic cells, concerns about malignancy,
the challenges of harvesting adequate stem cells, the manufactur-
ing costs, and the complexity of clinical studies needed for regu-
latory approval. Establishment of adequate vascular perfusion of
the underlying tissue is important in effective use of these prod-
ucts as well as in wound healing, although peripheral arterial dis-
ease is a limiting factor. It has been reported that peripheral
arterial disease is 10 times more prevalent in developed countries
where these products are also more readily available.5Y7 A simple
ankle-to-brachial systolic blood pressure index can be used to
predict the likelihood of successful wound management with
these products to avoid impaired healing or poor outcomes.
This article focuses on selected cellular and tissue-based prod-
ucts (CTPs) that are available for sale in the US and used for
diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), and burns.
The FDA approval levels to be discussed include 510(k); premarket
approval (PMA); human cells, tissue, tissue-based products (HCT/
Ps); and humanitarian device exemption (HDE; Figure 1).
19 ADVANCES IN SKIN & WOUND CARE & JANUARY 2019
 ORIGINAL INVESTIGATION
Figure 1.
CLASSIFICATION BASED ON FDA APPROVAL
SKIN REPLACEMENT CONCEPTS
Skin is the largest human organ and consists of three layers:
the epidermis, dermis, and hypodermis (subcutaneous fat). The
epidermis, which provides a barrier function, is populated with
keratinocytes, melanocytes, and Langerhans cells. The dermis,
which provides structural integrity, is composed of fibroblasts
and the extracellular matrix (ECM), and contains important mac-
romolecules including collagen, elastin, and glycosaminoglycans.
Finally, the hypodermis, which protects the body from mechani-
cal stresses and assists in thermoregulation, is composed of fat
and connective tissues that provide a rich source of stem cells.
Further, the skin confers UV radiation protection, is an important
site for vitamin D metabolism, and provides visual signals critical
for aesthetics.8
Damage to the skin that occurs in DFUs, VLUs, burns, and
other skin conditions leads to wound formation. Wounds can
be classified according to the depth of injury: epidermal wounds
(superficial erosions), partial dermal wounds (partial-thickness
wounds or shallow ulcers), and wounds spanning the entire der-
mis (full-thickness wounds or deep dermal ulcers).9 Superficial
and partial-thickness dermal injuries, if treated properly, tend to
heal without surgical intervention. Full-thickness wounds can
also heal but result in the formation of scar tissue. In a study
ADVANCES IN SKIN & WOUND CARE & VOL. 32 NO. 1
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
on volunteers with variable-depth surgical incisions and no
comorbidities, Dunkin et al10 determined that skin injuries less
than 0.57 mm do not result in scar formation. Interestingly, this
value corresponds to the junction of the papillary and reticular
dermis.
In addition, the skin separates with deeper wounds because
of loss of tension. Given that full-thickness wounds do not have
direct access to the keratinocytes found in epidermal appendages,
they must rely on keratinocyte migration from the wound edge
for wound closure. Consequently, in large surface area wounds,
autologous skin grafts or flaps are necessary for repair.11 The lim-
ited skin graft donor sites for large defects spawned the develop-
ment of tissue engineering approaches that are now being applied
to smaller defects.
The ideal engineered skin replacements would provide a
scaffold that closely mimics the structure and biologic function
of native skin.8 Autologous or allogeneic cells have been com-
bined in vitro with biologic or synthetic materials to generate
tissue-engineered skin replacements. In addition, epidermal cell
suspensions and cell sheets have been used, as well as semisyn-
thetic and decellularized scaffolds. Previous research has summa-
rized the essential properties for skin replacements:12Y14
1. nontoxic
2. nonantigenic
3. cost effective
4. easy to handle and apply
5. long shelf life
6. provide a barrier against contamination
7. result in minimal inflammatory reaction
8. improve wound healing
9. appropriate resistance to mechanical forces
Unfortunately, there is currently no skin replacement technol-
ogy that completely satisfies all of these criteria.
FROM CONCEPT TO CREATION
The process of developing and approving a skin substitute fol-
lows a series of procedures. First, the concept of a new skin re-
placement is proposed and designed according to set criteria.15
This is followed by development and testing during preclinical
studies, both in vitro and in vivo. The initial proposed product,
as well as its components, needs to be tested for safety based
on good laboratory practices. Animal testing is often used to
test efficacy and clarify the mechanism of action.
Next, optimal manufacturing requires optimizing the inven-
tory, product storage, shipping, and shelf life. Further, products
need to be approved by the FDA. When a product is FDA ap-
proved, it is assessed for reimbursement, a process by which
the interests among individuals, insurance companies, and the
developer are balanced. The Centers for Medicare & Medicaid
20 WWW.WOUNDCAREJOURNAL.COM
 ORIGINAL INVESTIGATION

Services produces the Healthcare Common Procedure Coding

Figure 2.
System codes, integral to reimbursement for medical devices
LOWER LEG VENOUS STASIS ULCER
(Table).16 Some products never reach mass production because
of failure to receive reimbursement from third-party payers.

Premarket Approval
Premarket approval is required by the FDA when no similar
product exists on the market or when a substantial change
has been made to a preexisting product. The process requires
adequate and well-controlled clinical studies in order for the
product to be approved. Products and devices that go through
the PMA process eventually receive approval from the FDA,
and the approval serves as a patent for the company. A clinical
case using a PMA-approved product is shown in Figure 2.
Integra Dermal Regeneration Template (IDRT; Integra
LifeSciences Corporation, Plainsboro, New Jersey). Devel-
oped by Burke and Yannas in 1980, the IDRT was first reported
in a small clinical trial by Burke17 and later in a multicenter
postapproval clinical trial.18 It was subsequently manufactured
by Integra LifeSciences Corporation and approved by the FDA
in 1996.
The IDRT is an artificial bilayer material in which the lower
layer is composed of a highly porous collagen and chondroitin-6-
sulfate copolymer that is covered with a semipermeable silicone
elastomer that provides a moisture and bacterial barrier. The lower
layer is optimized for pore size, degradation rate, and the percent-
age of glycosaminoglycan present to reduce wound contraction.
The silicone layer is replaced by split-thickness skin graft after 2
to 3 weeks or for smaller wounds closed by epidermal migration
from the wound margins.19 It is approved for the treatment of
second- and third-degree burns and since 2002 for scar recon-
struction.20 The effectiveness and safety of IDRT treating burns
were evaluated in a multicenter postapproval clinical trial with
216 burn injury patients. These patients were treated with IDRT
followed with a thin skin graft on the surface. The results showed

Table.

HEALTHCARE COMMON PROCEDURE

CODING SYSTEM FOR SKIN SUBSTITUTES
Q4100 Skin substitute, not otherwise specified
This is a 65-year-old woman with a left lower leg venous stasis ulcer. Debridement of the
Q4101 Apligraf, per square centimeter wound was performed first, and then Apligraf (Organogenesis) was applied to the wound
Q4102 Oasis wound matrix, per square centimeter twice with a month between applications.
Q4104 Integra bilayer matrix wound dressing, per square centimeter
Q4105 Integra dermal regeneration template or Integra Omnigraft dermal a lower infection and higher uptake rate. These results highlight
regeneration matrix, per square centimeter the use of IDRT as a safe and effective treatment for burn patients.21
Q4106 Dermagraft, per square centimeter
Q4107 GRAFTJACKET, per square centimeter A clinical case using the dermal matrix is shown in Figure 3.
Q4108 Integra matrix, per square centimeter Currently, this product has been used for treating DFUs as
Q4110 PriMatrix, per square centimeter an additional indication under the name Omnigraft Dermal Re-
Q4116 AlloDerm, per square centimeter
Q4128 FlexHD, AllopatchHD, or MatrixHD, per square centimeter generation Matrix. A multicenter, randomized, controlled, parallel-
group clinical trial on 307 subjects with DFUs was conducted
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 ORIGINAL INVESTIGATION

Figure 3.
TREATMENT OF PG WITH DERMAL MATRIX

Above (left), patient developed PG after sternotomy. Preoperative view, final debridement. Above (center), after debridement. Above (right), Integra and Acticoat were placed on day 9 after
debridement. Below (left), 4-week appearance after Integra placement. Silicone layer is starting to peel off. Below (center), 11 weeks after Integra placement. The wound is completely granulated.
Below (right), 28 weeks after Integra implanting, the wound is nearly healed. Reprinted from Climov M, Bayer LR, Moscoso AV, Matsumine H, Orgill DP. The role of dermal matrices in treating
inflammatory and diabetic wounds. Plast Reconstr Surg 2016;138 (3 Suppl):148S-57S.

under an Investigational Device Exemption. The experimental
group (154 patients) was treated with IDRT, and the control
group was treated with sodium chloride gel. The treatment lasted
for at least 16 weeks and was followed up for 12 weeks. The re-
sults documented successful DFU closure during the treatment
phase; these rates were significantly higher with IDRT treatment
(51%) than with the control treatment (32%; P = .001) at week
16. There was complete DFU closure at 43 days in comparison
to 78 days for patients treated with standard of care alone.22
The clinical trial laid the foundation for Omnigraft approval for
the treatment of partial- and full-thickness neuropathic DFUs
that are longer than 6 weeks in duration, with no capsule and
tendon or bone exposed. The skin substitute must be used in con-
junction with standard care. In addition, it is approved for the
treatment of life-threatening third-degree burns, especially when
the donor site is not sufficient.
These clinical studies investigated the effectiveness of IDRT-
related products; they indicated that it is safe and effective and
demonstrates improved graft take properties. However, the risk
of infection and scar formation is not negligible, as well as the
need for a second operation that increases the length of hospital
stay. In addition, the high cost of IDRT products limits wide-
spread application.21,22
Dermagraft (Organogenesis, Canton, Massachusetts).
Dermagraft is a unilayer cultured skin replacement (UCSR)
that uses a provisional, tear-resistant, bioresorbable polyglactin
mesh seeded with cultured fibroblasts that require cryopreserva-
tion. Over time, this mesh is replaced by ECM produced by the

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 ORIGINAL INVESTIGATION
replacement fibroblasts.23 Following application, the cells continue
to secrete growth factors and ECM components until the mesh
resorbs in about 3 to 4 weeks.24 Although initial success was
reported in a prelinical experiment, it was not until 2001 that
the product was approved by the FDA for the treatment of chronic
wounds including DFUs.25,26
A randomized, controlled, multicenter study of 314 patients
with a DFU was conducted in the US to evaluate complete wound
closure using UCSR or regular treatment for 12 weeks. The results
determined that 30% of UCSR patients healed versus 18.3% of
control patients,27 demonstrating that UCSR is an effective treat-
ment for chronic DFUs.
The effectiveness of UCSR in treating VLUs has also been
confirmed and approved for marketing in the US.25 In a prospective,
multicenter, randomized, controlled study, 186 patients with
VLUs were treated with UCSR plus compression therapy, and
180 patients were treated with compression therapy alone and
followed up for 12 weeks. In ulcers with less than 12 months’ du-
ration, 52% of patients in the UCSR group versus 37% of patients
in the control group healed at 12 weeks. This was statistically sig-
nificant (P = .029). This study suggested that the earlier use of
UCSR as an adjuvant therapy would be beneficial to patients.28
Although there are no actual FDA-approved indications for
UCSR on burn injuries, there are published studies.29 A multi-
center clinical trial compared UCSR with cryopreserved human
cadaver skin for temporary coverage on 66 patients with burn
wounds. In this study, UCSR led to clinical improvement with
no epidermal slough and less bleeding.30
510(k) Clearance
A 510(k) is a premarket submission made to the FDA to demon-
strate that a product to be marketed is at least as safe and effective,
or “substantially equivalent,” to a legally marketed device. Substan-
tial equivalence refers to similarity in construction, design, use, safety,
effectiveness, and so on. Once the device or product is determined
to be substantially equivalent, it can be marketed in the US.
EZ Derm (Brennen Medical, Inc; St Paul, Minnesota).
Because of its similarity to human skin, porcine skin has been
used for wound coverage since 1960s.31 EZ Derm is a porcine-
derived xenograft temporary wound dressing. Previous studies
have stated its properties include ready availability, easy han-
dling, adherence to the wound surface, reduced pain, and pre-
vention of water loss from wound.32,33 It has 510(k) clearance
for the treatment of partial-thickness burns, venous ulcers, di-
abetic neurotrophic foot ulcers, and pressure injuries. A 4-year
retrospective review study was conducted for 157 burn patients
treated by EZ Derm, and researchers concluded that it is an effec-
tive and durable wound dressing with low rates of complications
such as infection (3.0%), the need for additional excision and
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grafting (4.5%), and hypertrophic scars (3.3%).34 Another retro-
spective medical record review of 164 burn patients in a pediatric
burn center indicated that porcine xenograft can be used to pro-
vide useful wound coverage with pain relief and reduced need for
dressing changes.
Oasis Wound Matrix (Cook Biotech Inc, West Lafayette,
Indiana). Oasis Wound Matrix is a xenogeneic collagen scaf-
fold derived from porcine small intestinal mucosa. As a three-
dimensional collagenous ECM, it allows molecular adhesion, cell
growth, and cytokine secretion.35 The natural ECM of this prod-
uct provides a scaffold for tissue repair and wound healing. It has
a long shelf life and can be stored at room temperature. In 2000, it
was cleared by the FDA for the management of partial- and full-
thickness wounds.20 At least one study has demonstrated its
effect in DFUs.36 A prospective, randomized, controlled multi-
center trial of 120 patients with VLUs treated by OASIS Wound
Matrix combined with compression therapy demonstrated im-
proved results compared with compression therapy alone.37
Human Cells, Tissues, and Cellular and Tissue-Based Products
Although these products are considered part of human tissue
banks, these products are not strictly regulated by the FDA. Man-
ufacturers of HCT/Ps are, however, required to list their products
with the FDA’s Center for Biologics Evaluation and Research as
well as ensure they appropriately establish donor eligibility and
follow good tissue practices and other procedures to prevent the
introduction, transmission, and spread of communicable diseases.
Allopatch (Musculoskeletal Transplant Foundation, Edison,
New Jersey). AlloPatch is an aseptically processed human retic-
ular acellular dermal matrix (HR-ADM) that contains cytokines
and growth factors. Because it is derived from the deeper, reticu-
lar layer of dermis, it retains its inherent mechanical and biologic
properties. With a more open and uniform structure, it facilitates
vascular in-growth and cellular integration.38 Two advantages of
HR-ADM are its readiness for use in wound care and its ability to
be stored at room temperature.39 As banked human tissue, it has
been approved by the FDA as an adjunct therapy in the treatment
of chronic, uninfected, full-thickness DFUs.20 One prospective
randomized controlled trial compared HR-ADM with standard
wound care on nonhealing DFUs. At 12 weeks, the proportion
of 20 DFUs treated with HR-ADM that healed was 80%, com-
pared with 20% of DFUs that received standard care alone, a dif-
ference reported to be statistically significant.40 The study concluded
that HR-ADM was both superior and more cost-effective than
standard therapy.
Humanitarian Device Exception
In order to qualify for HDE approval, a product or device must
aid in the treatment or cure of a disease or condition that
23 ADVANCES IN SKIN & WOUND CARE & JANUARY 2019
 ORIGINAL INVESTIGATION
affects a population of no more than 8,000 per year. The applicant
must first obtain humanitarian use device designation from the
FDA’s Office of Orphaned Products Development and then sub-
mit an HDE to the appropriate FDA premarket review center.
Similar to premarket approval, the device or product cannot be
comparable to a device that is already legally marketed for the
same intended use. Further, HDE approval does not require
demonstration of effectiveness. The company must not profit
from the sale of the product or device.
Epicel (Genzyme Biosurgery, Cambridge, Massachusetts).
Cultured epithelial autografts (CEAs) have been a major con-
ceptual development in the care of burn victims. Keratinocytes
produce the skin barrier by going through a sequential matura-
tion and senescence process that eventually results in a flexible,
semipermeable membrane (stratum corneum). Many investiga-
tors have stressed that the reestablishment of the critical barrier
structure is a fundamental goal in the treatment of patients with
large surface area thermal injuries. This need has led to the devel-
opment of numerous constructs.41 In 1975, Rheinwald and Green42
pioneered keratinocyte cell culturing. This was subsequently
commercialized into Epicel, which can be derived from a small
skin biopsy and expanded in a commercial facility over 2 to 3
weeks.43 As a permanent wound covering, it decreases the re-
quirement for donor skin harvesting.
Epicel is approved by the FDA under the HDE in the treat-
ment of deep dermal or full-thickness burns, including a burn
surface area of greater than 30%.20 It can be used alone or in
combination with allogeneic or autologous split-thickness skin
grafts, especially when there is a lack of donor site skin. A 5-year
prospective controlled trial carried out in 1996 compared the use
of cultured keratinocytes with conventional therapy on the treat-
ment of massive burns. There was a significant reduction in mor-
tality in the CEA group versus the control group.44 The results
reported a beneficial effect of CEAs in the management of severe
burn patients with a total surface burn area greater than 60%.45
However, the fragility, long cultivation time, and susceptibility
to infection of autologous cells remain to be addressed.30
Most clinicians use CEAs in combination with allografts,
where the epidermis is removed prior to grafting with CEAs.
In addition, it has been used in the treatment of VLUs and
corneal replacement.46 An earlier multicenter study was conducted
on 30 patients evaluating the effectiveness of cryopreserved alloge-
neic cultured epithelium VLU patients. Results showed 66.6% of
the patients healed completely within 12 weeks.47
QUESTIONS AND FUTURE PROSPECTS
Although promising, widespread use of CTPs is currently hin-
dered by limitations. Skin replacements composed of living cells
require a long cell culture period, have a short shelf life, and are
ADVANCES IN SKIN & WOUND CARE & VOL. 32 NO. 1
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difficult to transport. Allogeneic cell-based skin replacements are
at risk of graft rejection and disease transmission.48 Biosynthetic
and animal-based skin replacements can be applied only as tem-
porary dressings, whereas xenogeneic matrices may result in im-
munogenic rejection. Further, infection and scar formation are
usually unavoidable.49 Like allogeneic cell-based skin replacements,
nonliving tissue skin replacements can, in some cases, result in dis-
ease transmission. The use of amniotic membrane substitutes,
which preserve the native skin properties better than other skin
replacement therapies, is limited to temporary wound dressings
or in combination with other materials because of their antigenic
potential, risk of spreading infection, and fast degradation rates.12
Future experiments should focus on enhancing the ability of
CTPs to promote wound healing. Past research has established
the role of stem cells in wound healing and laid the foundation
for developing stem cells with tissue engineering.50,51 In recent
years, researchers have focused on inducing stem cells to dif-
ferentiate into specific types of cells, including keratinocytes and
fibroblasts, and then incorporating them into biomaterial scaf-
folds.52 Hair follicles contain epithelial stem cells capable of
forming skin tissue that may be used in wound healing in the
near future.53,54
In terms of scaffolding, materials are still being optimized to
create better-quality engineered skin. Vascularization is neces-
sary for wound healing, and prevascularized skin grafts are be-
ing studied in order to develop blood vessel networks using
cellular strategies or growth factor delivery systems.55,56 There
is high level of interest in creating three-dimensional models that
better imitate the properties and functions of mature skin. Ad-
vanced techniques, including three-dimensional bioprinting, have
been used in the creation of the next generation of scaffolding
models.57,58 The regeneration of skin components, including sweat
glands and hair follicles, has been achieved in animal models but
not yet in humans.59,60
Other innovative strategies include the combination of nano-
technology and regenerative medicine; gene therapy strategies
are also currently in development.44,61 These strategies are not,
however, completely understood. Overall, the need for further
research and clinical trials is imperative before widespread clinical
application of CTPs can occur.
&
REFERENCES
1. Langer R, Vacanti JP. Tissue engineering. Science 1993;260(5110):920-6.
2. Martino MM, Tortelli F, Mochizuki M, et al. Engineering the growth factor microenvironment
with fibronectin domains to promote wound and bone tissue healing. Sci Transl Med 2011;
3(100):100ra189.
3. Mason C, Dunnill P. A brief definition of regenerative medicine. Regen Med 2008;3(1):1-5.
4. Salgado AJ, Oliveira JM, Martins A, et al. Tissue engineering and regenerative medicine:
past, present, and future. Int Rev Neurobiol 2013;108:1-33.
24 WWW.WOUNDCAREJOURNAL.COM
 ORIGINAL INVESTIGATION
5. Hirsch T, Rothoeft T, Teig N, et al. Regeneration of the entire human epidermis using
transgenic stem cells. Nature 2017;551(7680):327-32.
6. Jockenhöfer F, Gollnick H, Herberger K, et al. Aetiology, comorbidities and cofactors of
chronic leg ulcers: retrospective evaluation of 1 000 patients from 10 specialised dermatological
wound care centers in Germany. Int Wound J. 2016;13(5):821-8.
7. Sampson UK, Fowkes FG, McDermott MM, et al. Global and regional burden of death
and disability from peripheral artery disease: 21 world regions, 1990 to 2010. Glob Heart
2014;9(1):145-158.e21.
8. Lei P, You H, Andreadis ST. Bioengineered skin substitutes. Methods Mol Biol 2013;1001:
267-78.
9. Papini R. Management of burn injuries of various depths. BMJ 2004;329(7458):158-60.
10. Dunkin CS, Pleat JM, Gillespie PH, Tyler MP, Roberts AH, McGrouther DA. Scarring occurs at
a critical depth of skin injury: precise measurement in a graduated dermal scratch in human
volunteers. Plast Reconstr Surg 2007;119(6):1722-32.
11. Stanton RA, Billmire DA. Skin resurfacing for the burned patient. Clin Plast Surg 2002;
29(1):29-51.
12. Haddad AG, Giatsidis G, Orgill DP, Halvorson EG. Skin substitutes and bioscaffolds: temporary
and permanent coverage. Clin Plast Surg 2017;44(3):627-34.
13. Nyame TT, Chiang HA, Orgill DP. Clinical applications of skin substitutes. Surg Clin North Am
2014;94(4):839-50.
14. Metcalfe AD, Ferguson MW. Tissue engineering of replacement skin: the crossroads of
biomaterials, wound healing, embryonic development, stem cells and regeneration. J R
Soc Interface 2007;4(14):413-37.
15. Nicholas MN, Jeschke MG, Amini-Nik S. Methodologies in creating skin substitutes. Cell
Mol Life Sci 2016;73(18):3453-72.
16. Nusgart M. HCPCS coding: an integral part of your reimbursement strategy. Adv Wound
Care 2013;2(10):576-82.
17. Burke JF, Yannas IV, Quinby WC Jr, Bondoc CC, Jung WK. Successful use of a physiologically
acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 1981;194(4):
413-28.
18. Heimbach D, Luterman A, Burke J, et al. Artificial dermis for major burns. A multi-center
randomized clinical trial. Ann Surg 1988;208(3):313-20.
19. Yannas IV, Burke JF. Design of an artificial skin. I. Basic design principles. J Biomed Mat Res
1980;14(1):65-81.
20. BlueShield of Northeastern New York. Protocol: Bioengineered Skin and Soft Tissue Substitutes.
2012. https://securews.bsneny.com/web/content/dam/BSNENY/Provider/Protocols/B/prov_
prot_701113.pdf. Last accessed September 28, 2018.
21. Driver VR, Lavery LA, Reyzelman AM, et al. A clinical trial of Integra Template for diabetic foot
ulcer treatment. Wound Repair Regen 2015;23(6):891-900.
22. Heimbach DM, Warden GD, Luterman A, et al. Multicenter postapproval clinical trial of
Integra dermal regeneration template for burn treatment. J Burn Care Rehabil 2003;24(1):
42-8.
23. Cooper ML, Hansbrough JF, Spielvogel RL, Cohen R, Bartel RL, Naughton G. In vivo optimization
of a living dermal substitute employing cultured human fibroblasts on a biodegradable
polyglycolic acid or polyglactin mesh. Biomater 1991;12(2):243-8.
24. Debels H, Hamdi M, Abberton K, Morrison W. Dermal matrices and bioengineered skin
substitutes: a critical review of current options. Plast Reconstr Surg 2015;3(1):e284.
25. Hart CE, Loewen-Rodriguez A, Lessem J. Dermagraft: use in the treatment of chronic
wounds. Adv Wound Care 2012;1(3):138-41.
26. Stark HJ, Willhauck MJ, Mirancea N, et al. Authentic fibroblast matrix in dermal equivalents
normalises epidermal histogenesis and dermoepidermal junction in organotypic co-culture.
Eur J Cell Biol 2004;83(11-12):631-45.
27. Marston WA, Hanft J, Norwood P, Pollak R. The efficacy and safety of Dermagraft in improving
the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes
Care 2003;26(6):1701-5.
28. Harding K, Sumner M, Cardinal M. A prospective, multicentre, randomised controlled study
of human fibroblast-derived dermal substitute (Dermagraft) in patients with venous leg ulcers.
Int Wound J 2013;10(2):132-7.
29. Pham C, Greenwood J, Cleland H, Woodruff P, Maddern G. Bioengineered skin substi-
tutes for the management of burns: a systematic review. Burns 2007;33(8):946-57.
30. Hefton JM, Caldwell D, Biozes DG, Balin AK, Carter DM. Grafting of skin ulcers with cultured
autologous epidermal cells. J Am Acad Dermatol 1986;14(3):399-405.
31. Bromberg BE, Song IC, Mohn MP. The use of pig skin as a temporary biological dressing.
Plast Reconstr Surg 1965;36:80-90.
32. Lawin PB, Silverstein P, Still JM Jr. E-Z Derm a porcine heterograft material. Am J Clin
Dermatol 2002;3(7):507.
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
33. Chiu T, Shah M. Porcine xenograft dressing for facial burns: beware of the mesh imprint. Burns
2002;28(3):279-82.
34. Troy J, Karlnoski R, Downes K, et al. The use of EZ Derm in partial-thickness burns: an
institutional review of 157 patients. Eplasty 2013;13:e14.
35. Shi L, Ronfard V. Biochemical and biomechanical characterization of porcine small in-
testinal submucosa (SIS): a mini review. Int J Burns Trauma 2013;3(4):173-9.
36. Hodde JP, Ernst DM, Hiles MC. An investigation of the long-term bioactivity of endog-
enous growth factor in OASIS Wound Matrix. J Wound Care 2005;14(1):23-5.
37. Mostow EN, Haraway GD, Dalsing M, Hodde JP, King D. Effectiveness of an extracellular
matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized
clinical trial. J Vasc Surg 2005;41(5):837-43.
38. Dasgupta A, Orgill D, Galiano RD, et al. A novel reticular dermal graft leverages architectural
and biological properties to support wound repair. Plast Reconstr Surg 2016;4(10):e1065.
39. Zelen CM, Kaufman J, Lang A. Use of AlloPatch Pliable, a human acellular dermal matrix, as
an adjunctive therapy for chronic non-healing diabetic foot ulcers: case studies and clinical
review. MTF Wound Care. 2017. www.mtfbiologics.org/docs/default-source/clinical/allopatch-
pliable-case-studies-final-10-28-15.pdf. Last accessed September 20, 2018.
40. Zelen CM, Orgill DP, Serena T, et al. A prospective, randomised, controlled, multicentre
clinical trial examining healing rates, safety and cost to closure of an acellular reticular
allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers.
Int Wound J 2017;14(2):307-15.
41. Hancock K, Leigh IM. Cultured keratinocytes and keratinocyte grafts. BMJ 1989;299(6709):
1179-80.
42. Rheinwald JG, Green H. Serial cultivation of strains of human epidermal keratinocytes:
the formation of keratinizing colonies from single cells. Cell 1975;6(3):331-43.
43. Cerqueira MT, Pirraco RP, Martins AR, Santos TC, Reis RL, Marques AP. Cell sheet
technology-driven re-epithelialization and neovascularization of skin wounds. Acta Biomater
2014;10(7):3145-55.
44. Bleiziffer O, Eriksson E, Yao F, Horch RE, Kneser U. Gene transfer strategies in tissue
engineering. J Cell Mol Med 2007;11(2):206-23.
45. Blot SI, Monstrey SJ, Hoste EA, Carsin H, et al. Cultured epithelial autografts in extensive burn
coverage of severely traumatized patients: a five year single-center experience with 30 patients.
Burns 2001;27(4):418-9.
46. Pellegrini G, Traverso CE, Franzi AT, Zingirian M, Cancedda R, de Luca M. Long-term
restoration of damaged corneal surfaces with autologous cultivated corneal epithelium.
Lancet 1997;349(9057):990-3.
47. De Luca M, Albanese E, Cancedda R, et al. Treatment of leg ulcers with cryopreserved
allogeneic cultured epithelium. A multicenter study. Arch Dermatol 1992;128(5):633-8.
48. Matthews RN. Transmission of HIV infection by amniotic membrane dressing. Burns 1990;16(4):313.
49. Catalano E, Cochis A, Varoni E, Rimondini L, Azzimonti B. Tissue-engineered skin substitutes:
an overview. J Artif Organs 2013;16(4):397-403.
50. Hassan WU, Greiser U, Wang W. Role of adipose-derived stem cells in wound healing.
Wound Repair Regen 2014;22(3):313-25.
51. Gauglitz GG, Jeschke MG. Combined gene and stem cell therapy for cutaneous wound
healing. Mol Pharm 2011;8(5):1471-9.
52. Han SK, Yoon TH, Lee DG, Lee MA, Kim WK. Potential of human bone marrow stromal
cells to accelerate wound healing in vitro. Ann Plast Surg 2005;55(4):414-9.
53. Tumbar T. Epithelial skin stem cells. Methods Enzymol 2006;419:73-99.
54. Zheng Y, Du X, Wang W, Boucher M, Parimoo S, Stenn K. Organogenesis from dissociated
cells: generation of mature cycling hair follicles from skin-derived cells. J Invest Dermatol
2005;124(5):867-76.
55. Costa-Almeida R, Gomez-Lazaro M, Ramalho C, Granja PL, Soares R, Guerreiro SG. Fibroblast-
endothelial partners for vascularization strategies in tissue engineering. Tissue Eng Part A
2015;21(5-6):1055-65.
56. Costa-Almeida R, Granja PL, Soares R, Guerreiro SG. Cellular strategies to promote vascularisation
in tissue engineering applications. Eur Cell Mater 2014;28:51-66.
57. Bhardwaj N, Chouhan D, Mandal BB. Tissue engineered skin and wound healing: current
strategies and future directions. Curr Pharm Des 2017;23(24):3455-82.
58. Chua CK, Yeong WY, An J. Special issue: 3D printing for biomedical engineering. Materials
(Basel) 2017;10(3).
59. Takagi R, Ishimaru J, Sugawara A, et al. Bioengineering a 3D integumentary organ system
from iPS cells using an in vivo transplantation model. Sci Adv 2016;2(4):e1500887.
60. Blanpain C, Horsley V, Fuchs E. Epithelial stem cells: turning over new leaves. Cell 2007;
128(3):445-58.
61. Bhardwaj N, Kundu SC. Electrospinning: a fascinating fiber fabrication technique. Biotechnol
Adv 2010;28(3):325-47.
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