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Chronic wounds occur as a consequence of a prolonged inflammatory phase during the healing process, which precludes skin regeneration. Typical treatment for chronic wounds includes application of autografts, allografts collected from cadaver, and topical delivery of antioxidant, anti-inflammatory, and antibacterial agents. Nevertheless, the mentioned therapies are not sufficient for extensive or deep wounds. Moreover, application of allogeneic skin grafts carries high risk of rejection and treatment failure. Advanced therapies for chronic wounds involve application of bioengineered artificial skin substitutes to overcome graft rejection as well as topical delivery of mesenchymal stem cells to reduce inflammation and accelerate the healing process. This review focuses on the concept of skin tissue engineering, which is a modern approach to chronic wound treatment. The aim of the article is to summarize common therapies for chronic wounds and recent achievements in the development of bioengineered artificial skin constructs, including analysis of biomaterials and cells widely used for skin graft production. This review also presents attempts to reconstruct nerves, pigmentation, and skin appendages (hair follicles, sweat glands) using artificial skin grafts as well as recent trends in the engineering of biomaterials, aiming to produce nanocomposite skin substitutes (nanofilled polymer composites) with controlled antibacterial activity. Finally, the article describes the composition, advantages, and limitations of both newly developed and commercially available bioengineered skin substitutes.

Background Full‐thickness skin grafts are widely used in plastic and reconstructive surgery. The main limitation of skin grafting is the poor textural durability and associated contracture, which often needs further corrective surgery. Excessive inflammation is the main reason for skin graft contractions, which involve overactivation of myofibroblasts. These problems have prompted the development of new therapeutic approaches, including macrophage polarization modulation and stem cell–based therapies. Currently, adipose‐derived stem cells (ASCs) have shown promise in promoting skin grafts survival and regulating macrophage phenotypes. However, the roles of ASCs on macrophages in decreasing skin grafts contraction remain unknown. Materials and Methods Rat adipose‐derived stem cells (rASCs) were isolated from rat inguinal adipose tissues. Full‐thickness skin graft model was constructed on male rats divided into control group and rASCs treatment group. Skin graft was assessed for concentration, elasticity modulus and stiffness. Rat bone marrow‐derived macrophages (rBMDMs) were isolated from rat femurs, and subsequent RT‐qPCR and coculture assays were carried out to explore the cellular mechanisms. Immunohistochemical and immunofluorescence staining were used to verify mechanisms in vivo. Results In vivo results showed that after injection of ASCs, improved texture, increased survival and inhibited contraction of skin grafts were seen. Vascularization was also improved as illustrated by laser perfusion image and vascular endothelial growth factor (VEGF) concentration. Histological analysis revealed that ASCs injection significantly reduced expression of pro‐inflammatory cytokines (TNF‐a, IL‐1β) and increased expression of anti‐inflammatory (IL‐10) and pro‐healing cytokines (IGF‐1). At cellular level, after co‐culturing with rASCs, rat bone marrow derived macrophages (rBMDMs) favored M2 polarization even under inflammatory stimulus. Conclusion ASCs treatment enhanced vascularization via angiogenic cytokines secretion and alleviated inflammatory environment in skin grafts by driving M2 macrophages polarization, which improved survival and decreased skin grafts contraction. Our work showed that ASCs transplantation can be harnessed to enhance therapeutic efficacy of skin grafting in cutaneous defects treatment.

We aimed to compare the scar quality and recovery rate of joint activity for patients with joint‐involved burn injuries receiving either artificial dermis (AD) with split‐thickness skin graft (STSG) or full‐thickness skin graft (FTSG) for reconstruction. The primary outcomes were %skin graft (SG) take. Secondary outcomes included complications such as the infection rate and donor site morbidity, 12‐month scar quality evaluated using the Vancouver scar scale (VSS), recovery rate of joint activity and incidence of scar contracture requiring further revision. Twenty‐eight patients between 1 August 2021, and 1 August 2023, were enrolled. Twelve patients received AD‐STSG while the other 16 patients underwent FTSG for reconstruction. The median %SG take was 95.0% (interquartile range [IQR] 6.3%) and 96.0% (IQR 10.0%) for the AD‐STSG and FTSG groups (p = 0.71). The FTSG group had significantly better 12‐month scar quality (median VSS 4.0 [IQR 1.3] vs. 6.0 [IQR1.5], p < 0.01) and recovery rate of joint activity (median 82.5% [IQT 15.0%] vs. 70.0% [IQR 7.5%], p < 0.01) compared with AD‐STSG group. However, two patients in the FTSG group (12.5%) suffered partial wound dehiscence of the donor site, whereas no patients experienced donor site morbidity in the AD‐STSG group (p = 0.49). The incidence of scar contracture requiring further revision was 25.0% (3/12) in the AD‐STSG group and 12.5% (2/16) in the FTSG group (p = 0.62). In conclusion, AD‐STSG could be an alternative treatment over FTSG for larger joint‐involved burn wounds (>200 cm2) owing to lesser donor site morbidity with admissible cosmetic outcomes and functional recovery.

Due to groundbreaking and pioneering developments in the last century, significant improvements in the care of burn patients have been achieved. In addition to the still valid therapeutic standard of autologous split-thickness skin grafting, various commercially available skin substitutes are currently available. Significant progress in the field of tissue engineering has led to the development of promising therapeutic approaches. However, scientific advances in the field of allografting and transplant immunology are of great importance. The achievement of various milestones over the past decades has provided thought-provoking impulses in the field of skin allotransplantation. Thus, biologically viable skin allotransplantation is still not a part of the clinical routine. The purpose of this article is to review the achievements in burn surgery with regards to skin allotransplantation in recent years.

Wound coverage by split‐thickness skin graft (SSG) and epidermal graft (EG) shortens healing time, with comparable outcomes. However, the healing mechanism of EG is not as well understood as SSG. The difference in the healing mechanisms of EG and SSG was investigated using gap junctional proteins, proliferative marker, and cytokeratin markers. Paired punch biopsies were taken from the wound edge and wound bed from patients undergoing EG and SSG at weeks 0 and 1 to investigate wound edge keratinocyte migratory activities (connexins 43, 30, and 26), wound bed activation (Ki67), and the presence of graft integration to the wound bed (cytokeratins 14 and 6). Twenty‐four paired biopsies were taken at weeks 0 and 1 (EG, n = 12; SSG, n = 12). Wound edge biopsies demonstrated down‐regulation of connexins 43 (P = .023) and 30 (P = .027) after EG, indicating accelerated healing from the wound edge. At week 1, increased expression of Ki67 (P < .05) was seen after EG, indicating activation of cells within the wound bed. Keratinocytes expressing cytokeratins 6 and 14 were observed on all wounds treated with SSG but were absent at week 1 after EG, indicating the absence of graft integration following EG. Despite EG and SSG both being autologous skin grafts, they demonstrate different mechanisms of wound healing. EG accelerates wound healing from the wound edges and activates the wound bed despite not integrating into the wound bed at week 1 post‐grafting as opposed to SSG, hence demonstrating properties comparable with a bioactive dressing instead of a skin substitute.

To investigate the clinical application effects of artificial dermis scaffold and autologous split‐thickness skin composite grafts combined with vacuum‐assisted closure (V.A.C) in refractory wounds. A retrospective analysis was performed on 70 patients with refractory wounds admitted to the First Affiliated Hospital of Soochow University from June 2019 to December 2021 (44 males and 25 females, with an average age of 49.3 ± 21.4 years). There were 26 patients with chronic ulcers; 3 patients with cancerous wounds; 16 patients with hot crush injuries; and 25 patients with traumatic wounds, including 21 cases of hands, 33 cases of feet, 6 cases of upper limbs, and 10 cases of lower limbs. The patients were divided into an artificial dermis scaffold group (35 patients, including 21 males and 14 females, aged 49.5 ± 21.3 years) and a skin graft group (35 patients, including 23 males and 11 females, aged 49.1 ± 21.5 years). In the artificial dermis scaffold group, after debridement, the artificial dermis scaffold was transplanted for approximately 2 weeks until the wound surface was well vascularized, after which the autologous split‐thick skin graft was transplanted. Negative pressure wound therapy was performed throughout the treatment. In the skin grafting group, after debridement, the autologous split‐thickness skin graft (aSTSG) was transplanted, and negative pressure wound therapy was performed continuously. The wound healing rate; skin graft survival rate; postoperative wound infection; exudative fluid volume; subcutaneous haematoma; hospitalisation time; hospitalisation cost; Vancouver Scar Scale (VSS) score, used to evaluate the scar of the recipient area at 6 months after the operation; and the sensory disorder grading method, used to evaluate the sensory recovery of the recipient area, were compared between the two groups. All 70 refractory wounds healed. In the artificial dermis scaffold group, the skin graft survival rate was 90% (86%–95%), the hospitalisation time was 38 (29–45) days, the hospitalisation cost was 148 102 (118242–192327) yuan, and the VSS score was 1.9 ± 1.3. There were significant differences in skin graft survival rate (70% [60%–80%]), length of hospital stay (21 [14–28] days), hospitalisation cost (76 201 [39228–135 919] yuan) and VSS score [6.1 ± 3.6] between the skin graft group and the artificial dermis scaffold group (P < .05). The skin graft survival rate, scar hyperplasia and sensory recovery of the recipient area in the artificial dermis scaffold group were better than those in the skin graft group, but the hospitalisation time was relatively longer, and the hospitalisation cost was relatively higher. Wound healing rate, postoperative wound infection, exudate volume, and subcutaneous haematoma of patients in the two groups were similar, and there were no significant differences (P > .05). The artificial dermis scaffold and composite transplantation of autologous aSTSG with V.A.C can promote painless wound healing and improve the skin survival rate, skin colour and lustre, and flexible smooth texture and is conducive to less scar hyperplasia and postoperative functional exercise and recovery. This method provides a reasonable and effective scheme for the treatment of clinical refractory wounds.

Full‐thickness skin graft (FTSG) reconstructions of lower limbs are especially prone to wound complications. Negative pressure wound therapy (NPWT) enhances wound healing, but no broad evidence exists if it promotes graft take of lower leg FTSGs. In this investigator‐initiated, prospective, randomised and controlled trial, 20 patients with ambulatory FTSG reconstruction for lower limb skin cancers were randomised for postoperative treatment with either NPWT, or conventional dressings. As outcomes, adherence of the skin graft 1 week postoperatively, any wound complications within 3 months, including ≥3 weeks delayed wound healing, and the number of additional postoperative visits were compared. In both groups, grafts adhered equally well (p = 0.47); 80% of NPWT‐treated and 100% of control group grafts adhered >90%. There was no significant difference in the number of postoperative complications/delayed wound healing (p = 0.65); 70% of patients in the NPWT and 50% in the control group developed a wound complication. Both groups had an equal number of patients with at least three additional control visits (p = 1.0). The study was discontinued after 20 patients were recruited, as no benefit from NPWT was seen. To conclude, the study showed no benefit from NPWT for lower limb FTSGs.

In this paper, we present our experience with acute and chronic penile ulcers resulting from injection of an exogenous substance and their surgical treatment.In this paper, we present our experience with acute and chronic penile ulcers resulting from injection of an exogenous substance and their surgical treatment.

Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. Retrospective review 2007–2018 evaluating outcomes of patients undergoing single-stage surgery. 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible. •Severe forms of hidradenitis suppurativa require excision and skin grafting.•We explored one-stage surgical treatment as an alternative for commonly performed multi-stage procedure.•Success rate was 71%; higher for skin graft at 75% vs. 60% with primary closure.•One-stage operations are a feasible, cost-effective alternative.

Hidradenitis suppurativa is a chronic disease that significantly reduces patients’ quality of life. Patients are chronically treated with systemic therapies, which are often ineffective. Surgical treatment for severe cases of hidradenitis suppurativa is one option for affected patients. Surgical treatment has its limitations, and wound closure may be particularly problematic. This requires the use of reconstructive techniques. The methods of choice for wound closure are split-thickness skin grafts or local flaps reconstructions. However, each method has its limitations. This is a presentation of a new reconstructive surgical method in hidradenitis suppurativa surgery: the use of a co-graft of Acellular dermal matrix and split thickness skin graft as a novel method in wound closure after wide excisions, based on two cases. The results of this method are very promising: we achieved very fast wound closure with good aesthetic results regarding scar formation. In this paper, we used several examinations: laser speckle analysis, cutometer tests, and health-related quality of life (QoL) questionnaire to check the clinical impact of this method. Our initial results are very encouraging. ADM with STSG as a co-graft could be widely used in reconstructive surgery. This is a preliminary study, which should be continued in further, extended research.