The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S
Tissue and cellular approaches to wound repair
Pablo A. Jimenez, M.D.a,*, Sydney E. Jimenez, M.D.b
a
Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, New Jersey 07936, USA
b
Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
Tissue engineering can be defined as the use of biomaterials
with or without small molecules, cells, genes, or gene prod-
ucts to maintain, replace, or repair organ function with the
objective of correcting the underlying pathology.
This new field of medicine is based on the use of engi-
neered cells, tissues, and synthetic materials that can poten-
tially extend and improve a patient’s life. At the present
time, treatments for organ or tissue loss include organ trans-
plants, surgical reconstruction, the use of mechanical de-
vices [1,2], and, recently, cellular therapy.
The research and development of tissues and cell-based
products have taken many approaches to advance the field
of regenerative medicine. This involves the use of ⱖ1 cell
lines and the inclusion of an extracellular matrix, thus form-
ing a tissue architecture, which allows communication
through cell-to-cell interactions and cell-to-matrix interac-
tions. Such interactions are essential for providing tissue
support and functionality through the release of a variety of
cytokines and growth factors.
Therapeutic approaches for cellular and tissue therapy
Three general strategies are currently used in the devel-
opment of tissue-engineered products. The first strategy
involves the use of cells without matrix. When transplanted,
these cells restore function to an injured organ or organ
system. Stem cell therapy and autologous cell transplant are
examples of this approach. The second strategy involves the
development of synthetic polymers or biomaterials that act
to restore organ system function when used alone (ie, syn-
thetic scaffold materials) or with the addition of proteins,
such as growth factors and cytokines, which may be re-
leased in a controlled fashion. The last therapeutic approach
involves the use of cells within a 3-dimensional matrix. For
example, bilayered skin substitutes composed of keratino-
* Corresponding author. Tel.: ⫹1-862-778-7518; fax: ⫹1-973-781-
6747.
E-mail address: pablo.jimenez@pharma.novartis.com
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved.
doi:10.1016/S0002-9610(03)00305-2
cytes and fibroblasts incorporate into biologic collagen ma-
trices or synthetic bioabsorbable scaffolds before implanta-
tion and serve to enhance or promote tissue repair processes.
The stem cell concept
A stem cell is an undifferentiated cell with the capacity
for self-renewal that gives rise to ⱖ1 highly differentiated
cell type [3]. Stem cells are derived from either embryonic
cells, referred to as pluripotent stem cells, or from fetal and
adult tissue, both referred to as multipotent stem cells [4].
Embryo-derived stem cells are pluripotent, capable of
giving rise to most tissues. They can be derived from the
inner cell mass of the preimplantation blastocyst or primor-
dial germ cells of embryos and are used for the development
of many cell-derived products because of their unique abil-
ity to divide for an indefinite period of time in cell culture
and to give rise to many lines of specialized cells.
Fetal stem cells, like adult-derived stem cells, are mul-
tipotent stem cells derived from either fetal or adult tissues,
which possess a high degree of plasticity. These cells can be
obtained from mesodermal tissues, such as muscle and bone
marrow, including hematopoietic, mesenchymal, and endo-
thelial stem cells, as well as ectodermal and endodermal
tissues, including neural, epidermal, intestinal, liver, and
pancreatic stem cells [4]. Multipotent stem cells are the
result of further specialization of pluripotent cells into par-
ticular cell lines, such as blood and skin. Both fetal and
adult-derived stem cells are being successfully developed
for multiple indications, including cardiomyocyte replace-
ment for heart conditions, chondrocyte replacement for os-
teoarthritis, and neuronal replacement, which has led to
symptom reversal for Parkinson and Huntington diseases
[5]. Recently, multiple studies have demonstrated that adult
stem cells possess a broader developmental capacity than
was previously thought. The plasticity of adult-derived stem
cells was illustrated when brain-derived adult neural stem
cells from mice contributed to the formation of a chimeric
chick and mouse embryo and gave rise to all germ layers
 P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S
[6]. Although adult-derived stem cells have shown this
broad developmental capacity, additional studies are needed
to confirm the in vitro and in vivo fate of these cells.
The bone marrow contains a population of stem cells.
These cells include hematopoietic stem cells, which give
rise to blood and lymphoid cells; mesenchymal stem cells,
or marrow stromal cells, which regenerate bone and marrow
cells (adipocytes, reticular cells); and endothelial stem cells
[7]. Bone marrow– derived mesenchymal stem cells have
been used to derive a range of cell types, including hepa-
tocytes and neurons [8]. Thus, although mesenchymal stem
cells are potentially less plastic than embryonic stem cells
and possess a predetermined differentiation capability, they
may be reprogrammed to derive new cell types through
extracellular signaling processes that revert precursor cells
to multipotential stem cells. For example, oligodendrocyte
precursor cells can be reprogrammed to revert to multipo-
tential neural stem cells and give rise to various neural
tissues, including neurons, astrocytes, and mature oligoden-
drocytes [9].
Advancements in new cell culture techniques and a
growing knowledge about optimal oxygen levels are en-
hancing the development of commercial quantities of stem
cells. Lowered oxygen levels (3%) in cell culture have been
shown to reduce apoptosis, increase the number of central
nervous system precursors, and increase differentiation
rates, all of which have resulted in a significant increase in
cell yield [10].
The potential therapeutic uses of stem cells in the ad-
vancing field of regenerative medicine currently under de-
velopment include cell transplantation, the development of
bioartificial tissues, and the induction of resident stem cell
proliferation and differentiation [4]. There are, however,
many safety and ethical issues associated with the use of
stem cells. Uncontrolled plasticity and proliferation with the
potential for teratocarcinomatous formation and epigenetic
instability [11], along with immunorejection and contami-
nation, are some of the disadvantages associated with this
approach [12]. At the present time, only differentiated so-
matic cells are available for commercial use, including al-
logeneic-derived keratinocytes and fibroblasts (Apligraf for
wound healing; Novartis, East Hanover, NJ), autologous-
derived keratinocytes (EpiDex [MODEX Thérapeutiques
SA, Lausanne, Switzerland] and Epicel [Genzyme Biosur-
gery, Cambridge, MA] for epidermal repair), and chondro-
cytes (Carticel for osteoarthritis; Genzyme Biosurgery).
Use of a matrix in tissue engineering
Matrices, consisting of biodegradable inert or organic
materials, such as collagen or polylactic acid, are used as
encapsulation materials to deliver cells, growth factors, or
small molecules to repair tissue injury.
For cellular-derived products, the use of an optimal ma-
trix is vital to the integrity of cell maintenance and growth,
57S
because cells are anchorage dependent and require an ap-
propriate milieu of mechanical strength, material support,
controlled porosity, and interconnected channeling [13]. In
addition to cell delivery, synthetic scaffold materials are
used to manufacture acellular functional tissues or cell en-
capsulation materials. These materials may contain growth
factors as well as protein hormones, antibodies, antigens,
and DNA that are released from the scaffold in a controlled
manner [14], promoting the migration, proliferation, and
differentiation of resident cells, thereby restoring function
to the injured tissue [15,16]. Examples of a synthetic matrix
delivery system include the use of human keratinocytes or
fibroblasts grown on polyethylene-coated silica beads en-
closed in fine mesh fabric to enhance skin wound healing
[17]. Hydrophilic acellular polymers (polyethylene glycol)
have been used experimentally to seal damaged nerve mem-
branes, leading to the partial recovery of damaged nerve
fibers in spinal cord injury [18]. Biodegradable materials,
which disappear from the implantation site after controlled
release, have also been used to release a variety of mole-
cules [19]. Fibrin sealant products including Tisseel (Baxter
BioScience, Mississauga, Ontario, Canada) are used as a
vehicle for the delivery of cells, including keratinocytes,
fibroblasts, and peptides [20 –22].
Development of cell-based products
The development of cell- and tissue-based products is
complex and requires some unique considerations that differ
from traditional therapeutic approaches to wound repair
involving small molecules, proteins, and antibodies. Safety
assessment and characterization of the cell line under de-
velopment are aspects requiring special attention. A screen-
ing donor program must be in place to minimize the poten-
tial for blood-borne pathogens, along with a system to detect
and eliminate contaminants, such as latent viruses. Full
characterization of cell lines by establishing identity, purity,
and potency must be performed while establishing cellular
proliferation and differentiation patterns, which are funda-
mental to understanding and minimizing oncogenic poten-
tial and establishing the correct cell phenotype. The poten-
tial for rejection of allogeneic cells by the recipient’s
immune response and the use of immunosuppression ther-
apy must also be addressed early in the development pro-
cess. Finally, manufacturing and storage of the final prod-
uct, by cryopreservation or other techniques that maintain
cell viability and efficacy, must be in place. The final goal
in the production process is to obtain a highly controlled and
robust manufacturing process, meeting regulatory guidance.
Cellular-derived tissue-engineered products may consist
of single cell lines (eg, chondrocytes, keratinocytes, or do-
paminergic neurons) or multiple cell lines. These products
consist of fully mature cellular structures, such as keratin-
ocytes or fibroblasts within an acellular matrix. These cells
are capable of cross-talk between cell lines, which is vital to
58S P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S

Table 1
Partial list of cytokines and growth factors produced from human keratinocytes and fibroblasts

Keratinocytes Fibroblasts

● IL-1␣ and IL-1␤ [23,24] ● KGF-1, -2 (FGF-7, -10) [25–27]

● IL-1ra [24] ● TGF-␤1, -2, -3 [28–30]
● IL-1, -3, -6, -8, -10, -18 [24,31–35] ● CTGF [36,37]
● G-CSF, M-CSF, and GM-CSF [24] ● FGF-2 (basic) [38]
● TGF-␣, -␤1 [24,39–43] ● PDGF-A [25,44]
● PDGF [24,27,45] ● IGF-1 [25]
● VEGF [27,46–48] ● VEGF [25,47]
● TNF-␣ and -␤ [24,30] ● HGF [25]
● INF-␥ [24] ● IL-6, -8 [25]
● IGF-1 [27] ● TNF-␣ [25]
● b-FGF [24], FGF-22 [42] ● GM-CSF and G-CSF [25,33,34]
● FGF-22 [42]
● IGF-1 [27]

b-FGF ⫽ basic fibroblast growth factor; CTGF ⫽ connective tissue growth factor; FGF ⫽
fibroblast growth factor; G-CSF ⫽ granulocyte colony-stimulating factor; GM-CSF ⫽ granulocyte/
monocyte colony-stimulating factor; HGF ⫽ hepatocyte growth factor; IGF ⫽ insulinlike growth
factor; IL ⫽ interleukin; INF ⫽ interferon; KGF ⫽ keratinocyte growth factor; M-CSF ⫽ monocyte
colony-stimulating factor; PDGF ⫽ platelet-derived growth factor; TGF ⫽ transforming growth
factor; TNF ⫽ tumor necrosis factor; VEGF ⫽ vascular endothelial growth factor.

the therapeutic response leading to the regulation of gene
expression and subsequent growth factor or cytokine re-
lease. As depicted in Table 1 [23– 48], both keratinocyte and
fibroblast cell lines used as biologic drug delivery systems
secrete a number of potentially beneficial molecules for skin
repair. In addition, modified cells may be constructed by
inserting particular genes to produce either a desired agent
or to control the duration and level of biologic effect re-
quired to achieve a therapeutic response. For example,
ex vivo modification of keratinocytes to overexpress plate-
let-derived growth factor (PDGF)–A has been shown to
enhance healing [49], and transplants of genetically modi-
fied fibroblasts secreting brain-derived nerve growth factor
in an animal model of spinal cord injury have been shown
to survive, cover the lesion, and promote the ingrowth of
axons [50]. Transduction levels of gene expression vary
according to the vector system used. Retroviral transduction
in keratinocytes, for example, has a transfection efficiency
of 40% to 80% [51,52], depending on the presence of stem
cells in cutaneous epithelium [53], which leads to long-term
or permanent incorporation of the virus into the human
chromosome(s). Alternatively, adenoviral gene transfer,
which has an improved 95% transfection efficiency, main-
tains its episomal status, minimizing its integration into the
human genome, maintaining stable gene expression for at
least 2 to 6 weeks in vitro and at least 2 weeks in vivo
[54 –56].
Tissue-engineered products for wound repair: a
cellular approach
Tissue-engineered wound-healing products may be cel-
lular or acellular. Acellular matrix products interact with the
host by binding to the surrounding tissue, aggregating cells,
and may act as a DNA delivery system by containing viral
vectors or plasmids, which release growth factors that en-
hance repair processes. Acellular matrices have been shown
to stimulate angiogenesis and modulate endogenous growth
factor functions. Some examples of acellular components
used in the manufacturing process include fibrin, fibronec-
tin, hyaluronic acid, porcine tissue, bovine collagen, and
decellularized cadaver dermis. Fibrin glue is often used in
skin grafts and tissue-engineered skin replacement for mul-
tiple reasons, including hemostasis, which prevents bacte-
rial proliferation in blood clots [57].
Acellular matrices may be used as DNA delivery sys-
tems. For example, type I collagen matrix, containing an
adenoviral DNA vector or plasmid-encoding human PDGF-A
and PDGF-B, have been found to increase granulation tissue
formation, vascularization, and reepithelialization in animal
models of tissue repair [58]. Poly(lactide-coglycolide) ma-
trix containing a plasmid encoding PDGF-BB has also been
shown to enhance granulation tissue formation and neovas-
cularization [59]. In addition, a collagen matrix containing a
plasmid-encoding parathyroid hormone has been used in
bone defects with positive outcomes [60]. Examples of
unilaminar matrix products in this category include E-Ma-
trix (Encelle, Inc, Raleigh, NC), a biosynthetic acellular
xenograft; Oasis (Cook Biotech, Lafayette, IN), a porcine
small intestinal submucosa acellular collagen matrix [46]; a
human cryopreserved decellularized dermis (LifeCell Cor-
poration, Branchbury, NJ); Integra (Integra Life Sciences
Corporation, Plainsboro, NJ), a bovine collagen and chon-
droitin-6-sulfate with silicone; and EZ Derm (Brennan
Medical, Inc, St. Paul, MN), an acellular porcine xenoge-
neic collagen matrix. Bilaminar matrix products, including
Biobrane (Bertek Pharmaceuticals Inc., Research Triangle
 P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S
Park, NC), are constructed of a silicone film with knitted
elastic nylon fabric embedded into the film. Most of these
products are commercially available; however, their role in
surgical practice remains to be elucidated.
Cellular approaches to wound repair
Cellular-derived products for wound healing contain liv-
ing cells, such as keratinocytes and fibroblasts, within a
collagen or polyglactin mesh matrix. Autologous human
skin, such as split-thickness skin grafts used in burn
wounds, is considered the “gold standard” for the treatment
of burns. However, successful outcome is limited by tissue
availability and the lack of controlled clinical trials on the
effectiveness of skin grafting [61]. In addition, donor-site
wound complications, including delayed healing, scarring,
pain, and risk of infection, are associated with autografts.
Ideally, a bioengineered skin substitute should restore the
functional properties of both the epidermis, a product of
terminal keratinocyte differentiation, which reestablishes a
barrier function, and the dermis, which allows for extracel-
lular matrix synthesis, remodeling, and keratinocyte growth
and differentiation. Autologous-derived cellular products
include, among others, the use of cultured epithelial grafts
through the Green technique [62], EpiDex, and Epicel.
Cultured epithelial grafts provide an epithelial covering for
extensive burn wounds within 2 weeks. While the cultured
epithelial graft is prepared, the patient’s wounds are covered
with allogeneic cryopreserved cadaver skin. Autologous
keratinocytes are obtained through a biopsy specimen and
cultured on a layer of feeder fibroblasts. A functional dermis
is obtained after 3 to 5 years [63,64]. EpiDex consists of
autologous skin cells that are derived from the outer root
sheath of plucked anagen human hair follicles to produce
keratinocyte sheets [65]. EpiDex is a product based on the
finding that adult pluripotent stem cells are located in the
bulge of hair follicles of humans and may be used to
promote wound-healing processes [66]. Epicel is derived
from autologous skin after biopsy that is expanded in cul-
ture for 2 to 3 weeks to obtain epidermal cells. Both Epicel
and EpiDex are permanent epidermal skin grafts that pro-
vide wound coverage and promote formation of granulation
tissue. Other approaches provide a dermal equivalent that
increases the viability of the epidermal layer through dy-
namic dermal– epidermal interactions, allowing for extra-
cellular matrix synthesis, remodeling, and keratinocyte
growth and differentiation.
Allogeneic products include, among others, Apligraf,
OrCel (Ortec International, New York, NY), and Derma-
graft (Smith and Nephew/Advanced Tissue Sciences, Lon-
don, United Kingdom). They are available without the need
of a biopsy. This type of product, using living cells within
a matrix to cover the wound bed, has been defined by the
United States Food and Drug Administration (FDA) as an
59S
interactive wound dressing. OrCel is a bilayered, allogeneic
product consisting of both dermal and epidermal layers
supported within a bilaminar bovine type I porous collagen
matrix. This promising technology is advantageous because
it contains 2 cell types (keratinocytes and fibroblasts). OrCel
is currently indicated only for the treatment of epidermol-
ysis bullosa and skin donor site healing, whereas clinical
trials are underway for possible application in chronic
wounds. Dermagraft is a 3-dimensional, allogeneic, cryo-
preserved human fibroblast– derived dermal substitute. It is
approved only for diabetic foot ulcers. It is composed of
living fibroblasts derived from neonatal foreskin, extra-
cellular matrix, and a biodegradable scaffold [67,68]. The
fibroblasts contained in Dermagraft secrete growth factors
including vascular endothelial growth factor (VEGF),
PDGF-A, insulinlike growth factor (IGF)–1, granulocyte/
macrophage colony-stimulating factor (GM-CSF), interleu-
kin (IL)-8, IL-6, tumor necrosis factor (TNF)–␣, transform-
ing growth factor (TGB)–␤1, and matrix proteins involved
in the wound-healing process [25,67,69]. Currently, it is
approved for diabetic foot ulcers. However, because of the
limited clinical trial data available, its real clinical effec-
tiveness needs to be elucidated.
Apligraf is a living bilayered skin construct. Similar to
normal skin, it consists of an epidermis and a dermis. The
epidermis of Apligraf consists of a basal and all suprabasal
keratinocyte layers. Basal keratinocytes are shown to divide
with a mitotic rate similar to human skin. The suprabasal
epidermis displays keratinocyte morphology similar to that
of normal skin, with well-defined spinous and granular
layers and a cornified layer containing basket-weave kera-
tinocytes [70]. The dermal layer contains human fibroblasts
supported by an extracellular collagen matrix composed of
both bovine and human collagen. It does not contain mela-
nocytes, macrophages, lymphocytes, Langerhans cells,
blood vessels, hair follicles, or sweat glands. Apligraf has
FDA approval for the treatment of venous stasis ulcers and
diabetic foot ulcers. In addition to chronic wounds, this
product has also been used to treat a variety of acute
wounds, including donor sites, surgical excisional wounds,
and epidermolysis bullosa [71–74].
Although the mechanism of action of cellular bilayered
skin products remains to be elucidated, it is believed that
Apligraf creates a microenvironment that stimulates healing
in chronic wounds. This means that it provides a physical
and biological barrier against wound infection and behaves
as cellular therapy through the expression of proteins that
are known to be induced in response to injury and to have
a function in wound healing.
Immunostaining for matrix metalloproteinases (MMPs)
indicates that Apligraf keratinocytes produce MMP-2 and
MMP-9, which are involved in regulating keratinocyte mi-
gration [75] and may contribute to the elimination of non-
viable tissue. The presence of tissue inhibitory factors of
MMP, such as tissue inhibitor of MMP-2 (TIMP-2) has also
been demonstrated in Apligraf dermis, thereby suggesting
60S P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S

Fig. 1. Potential mechanism of action during initial phase of wound healing in chronic wounds with Apligraf. bFGF ⫽ basic fibroblast growth factor; FGF ⫽
fibroblast growth factor; GM-CSF ⫽ granulocyte/monocyte colony-stimulating factor; IGF ⫽ insulinlike growth factor; IL ⫽ interleukin; MMPs ⫽ matrix
metalloproteinases; PDGF ⫽ platelet-derived growth factor; TGF ⫽ transforming growth factor; TNF ⫽ tumor necrosis factor; VEGF ⫽ vascular endothelial
growth factor.

regulatory activity between MMPs and TIMPs. Separation
of the Apligraf dermis from the epidermis results in en-
hanced production and activation of MMP-9 by the epider-
mal layer, and secretion of latent and active MMP-2 by the
dermal layer. Moreover, the incubation media of the sepa-
rated epidermis demonstrates stronger MMP activity than
intact Apligraf or its dermal component. These observations
suggest that epidermal– dermal interactions suppress epider-
mal gelatinase activity. Because TIMPs and fibronectin are
expressed in the Apligraf dermis, the presence of an MMP
regulation system within the tissue-engineered product is
strongly suggested [76].
One potential advantage of a product that contains fully
differentiated cells is the ability to self-heal when injured.
When a wound is created on the epidermal surface of
Apligraf, the product achieves complete healing with reepi-
thelialization and granulation tissue deposition 5 days after
wounding. The proliferative potential of Apligraf keratino-
cytes is greater than that of normal adult skin, as suggested
by the immunostaining of the cell proliferation marker Ki67
antibody. The increased regenerative capability observed in
Apligraf keratinocytes may be related to the origin of the
cells from human foreskin, which has been reported to
contain keratinocyte stem cells [77]. Similar to normal skin,
Apligraf epidermis showed Ki67-positive cells in the basal
layer of keratinocytes; however, the intensity was signifi-
cantly increased in Apligraf. This finding suggests that
although skin constructs such as Apligraf may have a his-
 P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S 61S

Fig. 2. Potential mechanism of action during the late phase of wound healing in chronic wounds with Apligraf. bFGF ⫽ basic fibroblast growth factor; FGF
⫽ fibroblast growth factor; GM-CSF ⫽ granulocyte/monocyte colony-stimulating factor; IGF ⫽ insulinlike growth factor; IL ⫽ interleukin; MMPs ⫽ matrix
metalloproteinases; PDGF ⫽ platelet-derived growth factor; TGF ⫽ transforming growth factor; TNF ⫽ tumor necrosis factor; VEGF ⫽ vascular endothelial
growth factor.

tologic appearance similar to normal skin, the metabolic
pathways and cellular activities are highly enhanced in
Apligraf.
Stimulators of extracellular matrix formation, including
TGF-␤ and PDGF, are expressed in Apligraf. The level of
expression is similar to that seen in newly formed granula-
tion tissue.
Gene expression (messenger RNA) profiling using gene
chips can be used to study the differences in gene expres-
sion in cellular-based products. This profiling may help to
further elucidate Apligraf’s mechanism of action through
the discovery of gene patterns and the proteins expressed,
which may in turn serve as markers of both efficacy and
toxicity. For example, high expression levels of keratin-14
(involved in epidermolysis bullosa simplex) and ␤-defen-
sin-2 (natural antibiotic) have been recently demonstrated in
Apligraf using this approach [78].
Mechanism of action of cell-based wound-healing
products
The mechanism of action of cell-based wound-healing
products in chronic wounds is poorly understood. The cells
contained in the Apligraf grow and proliferate, producing
growth factors, collagens, and extracellular matrix proteins,
which stimulate reepithelialization, formation of granula-
tion tissue, angiogenesis, and neutrophil and monocyte che-
motaxis. Extensive clinical experience suggests that Apli-
62S P.A. Jimenez, S.E. Jimenez / The American Journal of Surgery 187 (Suppl to May 2004) 56S– 64S
graf acts as a potent cellular therapy that can provide an
adaptable response and may act differently in acute and
chronic wounds. After Apligraf application in chronic
wounds, outgrowth of previously dormant keratinocytes at
the wound edge is observed, suggesting that Apligraf re-
leases factors that activate keratinocytes and stimulate mi-
gration and reepithelialization [79 – 81]. It is believed that
Apligraf stimulates wound healing in 2 phases. During the
initial phase, the release of growth factors from Apligraf
cells results in healing from the indolent skin (edge effect).
Apligraf both covers the wound, providing a barrier, and
interacts with the wound bed [82]. This interaction alters the
nonhealing status of the wound to an actively healing status.
There is cross-talk between the tissue-engineered product
and the host tissue through an endogenous cellular response
from the skin cells and other cells attracted to the wound site
with the subsequent release of wound-healing–related
growth factors and cytokines (Fig. 1). This type of product
is not a graft; it provides a temporally dynamic relationship
between the product and the underlying wound. Apligraf
persists in the wound bed of a chronic wound for only a
limited period (6 to 8 weeks). During this time, cells stim-
ulate wound healing through the orderly release of impor-
tant wound-healing factors.
The need for an external stimulus to initiate the healing
response in chronic wounds is demonstrated by the decrease
in proliferative potential and the presence of cellular senes-
cence in fibroblasts, which are isolated within venous stasis
or diabetic foot ulcers [23], whereas macrophages, present
at the wound edge of chronic leg ulcers, fail to show acti-
vation markers [31]. It is believed that Apligraf helps to
restore the healing environment, in part by providing this
external stimulus through the release of multiple growth
factors, inflammatory cytokines, and angiogenic factors.
These proteins are expressed by the living cells of Apligraf,
which are involved in the regulation of growth differentia-
tion, remodeling, and extracellular matrix deposition
[83,84]. Remnants of Apligraf are still detected on the
actively healing wound bed during the late phase of wound
healing. During this phase, a yellow exudatelike material is
found at the application site. Thickened and swollen-ap-
pearing Apligraf dermis has been observed in the residual
tissue after Apligraf application. The exudatelike material is
composed of mucin, which is observed in both patient and
Apligraf dermis, indicating production of ground substance
[85] (Fig. 2).
Conclusion
Tissue and cellular approaches to wound repair are part
of a rapidly evolving field. Although the mechanism of
action of cell-based products is not fully understood, the use
of therapies containing living cells has proved valuable in
the treatment of chronic wounds.
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