Lars-Peter Kamolz · David Benjamin Lumenta Editors Dermal Replacements in General, Burn, aaannnddd PPPlllaaassstttiiiccc SSSuuurrrgggeeerrryyy Tissue Engineering in Clinical Practice Dermal Replacements in General, Burn, and Plastic Surgery Lars-Peter Kamolz (cid:129) D avid B enjamin L umenta Editors Dermal Replacements in General, Burn, and Plastic Surgery Tissue Engineering in Clinical Practice Editors Lars-Peter Kamolz, MD, MSc David Benjamin Lumenta, MD Division of Plastic Division of Plastic Aesthetic and Reconstructive Surgery Aesthetic and Reconstructive Surgery Research Unit for Tissue Regeneration Research Unit for Tissue Regeneration Repair and Reconstruction Repair and Reconstruction Department of Surgery Department of Surgery Medical University of Graz Medical University of Graz Graz Graz Austria Austria ISBN 978-3-7091-1585-5 ISBN 978-3-7091-1586-2 (eBook) DOI 10.1007/978-3-7091-1586-2 Springer Wien Heidelberg New York Dordrecht London Library of Congress Control Number: 2013941137 © Springer-Verlag Wien 2013 This work is subject to copyright. 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Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Contents 1 Skin: Architecture and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gerd G. Gauglitz and Jürgen Schauber 2 Skin Tissue Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Maike Keck, David Benjamin Lumenta, and Lars-Peter Kamolz 3 Use of Novel Biomaterial Design and Stem Cell Therapy in Cutaneous Wound Healing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 T. Hodgkinson and Ardeshir Bayat 4 In Vivo Visualisation of Skin Graft Revascularisation. . . . . . . . . . . . . 43 Nicole Lindenblatt and Alicia D. Knapik 5 The Role of Elastin in Wound Healing and Dermal Substitute Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Jelena Rnjak-Kovacina and Anthony S. Weiss 6 Surface Modi fi cation by Cold Gasplasma: A Method to Optimise the Vascularisation of Biomaterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Andrej Ring, Stefan Langer, and Jörg Hauser 7 Collagen Matrices with Enhanced Angiogenic and Regenerative Capabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Norbert Pallua, Marta Markowicz, Gerrit Grieb, and Guy Steffens 8 3D Visualisation of Skin Substitutes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 W.J. Weninger, Lars-Peter Kamolz, and S.H. Geyer 9 Wound Coverage Technologies in Burn Care-Established and Novel Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Marc G. Jeschke and Ludwik Branski 10 Collagen Implants in Hernia Repair and Abdominal Wall Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Alexander Petter-Puchner and Herwig Pokorny 11 The Use of Dermal Substitutes in Dermatosurgery . . . . . . . . . . . . . . 131 Gerd G. Gauglitz vv vi 12 The Use of Dermal Substitutes in Breast Reconstruction: An Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Stephan Spendel, Gerlinde Weigel, and Lars-Peter Kamolz 13 Reconstruction of the Skin in Posttraumatic Wounds . . . . . . . . . . . . 149 B. De Angelis, L. Brinci, D. Spallone, L. Palla, L. Lucarini, and V. Cervelli 14 Subdermal Tissue Regeneration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Wiltrud Meyer 15 Bioengineering and Analysis of Oral Mucosa Models . . . . . . . . . . . . 173 P. Golinski, S. Groeger, and J. Meyle 16 The Use of Dermal Substitutes in Burn Surgery: Acute Phase. . . . . 193 Anna I. Arno and Marc G. Jeschke 17 Burn Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Lars-Peter Kamolz Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 1 Skin: Architecture and Function Gerd G. Gauglitz and Jürgen Schauber 1.1 Introduction T he skin is the largest organ of the human body. It covers approximately 1–2 m 2 of surface area and accounts for around 12–16 % of an adult’s body weight. In direct contact with the outside environment, the skin provides the following essential functions: (cid:129) Retention of moisture and prevention of loss of other molecules (cid:129) Barrier function against harmful external in fl uences (cid:129) Immune function and protection of the body from microbes (cid:129) Sensory function (e.g. heat, cold, touch, pressure, vibration, tissue injury) (cid:129) Endocrine function (e.g. vitamin D production) (cid:129) Regulation of body temperature To understand cutaneous biology, wound healing and skin diseases, it is critical to be aware of the de fi ned structures and functions of normal human skin. Human skin consists of a strati fi ed, cellular epidermis and an underlying dermis of connec- tive tissue which together form the cutis (Fig. 1 .1 ). The dermal–epidermal junction is undulating and ridges of the epidermis, known as rete ridges, project into the dermis. The junction provides mechanical support for the epidermis and acts as a partial barrier against larger molecules. G. G. Gauglitz , MD, MMS (*) Department of Dermatology and Allergy , Ludwig Maximilian University , Munich , Germany Scar Clinic, Department of Aesthetics, Department of Infectious and Sexual Transmitted Diseases, Department of Dermatology and Allergy , Ludwig Maximilian University , Frauenlobstr. 9-11 , Munich 80337 , Germany e-mail: [email protected] J. Schauber , MD Department of Dermatology and Allergy , Ludwig Maximilian University , Munich , Germany L.-P. Kamolz, D.B. Lumenta (eds.), 1 Dermal Replacements in General, Burn, and Plastic Surgery, DOI 10.1007/978-3-7091-1586-2_1, © Springer-Verlag Wien 2013 2 G.G. Gauglitz and J. Schauber Hair Arrector pili muscle Sweat pore Apocrine sweat gland E p Dermal papilla Horny cell layer id e Epidermal rete ridge rm Papillary dermisis Subpapillary Epidermal basement membrance Infundibulum dermis Eccrine sweat gland D e Sebaceous gland Reticular dermis rm is Hair bulge Hair follicle Dermal hair papilla Hair bulb Hair matrix S u Sfautbcutaneous bcuta n e o u s tissu e Fascia M u scle Fig. 1.1 Structure of the skin (From Nakagawa 2 001 ) Below the dermis, a fatty layer, the panniculus adiposus, exists, usually desig- nated as ‘subcutaneous fat’. It is separated from the rest of the body by a vestigial layer of striated muscle, the panniculus carnosus (Fig. 1 .1 ). Two variants of human skin can be differentiated: Glabrous skin (non-hairy skin), found on the palms and soles, is grooved and its surface shows individually unique con fi gurations by continuously alternating ridges and sulci, known as dermatoglyphics. It is characterised by a thick epidermis divided into several well-marked layers includ- ing a compact stratum corneum, by the presence of encapsulated sense organs within the dermis and by a lack of hair follicles and sebaceous glands. Hair-bearing skin, on the other hand, has both hair follicles and sebaceous glands but lacks encapsulated sense organs. Hair-bearing skin shows a wide variation between different body sites. The motor innervation of the skin is autonomic and includes a cholinergic com- ponent to the eccrine sweat glands and adrenergic components to both the eccrine and apocrine glands, to the smooth muscle and the arterioles and to the arrector pili muscle. Several sensory nerves are found in skin: Some show free endings, some terminate in hair follicles and others have expanded tips. Only in glabrous skin some nerve endings are encapsulated. 1 Skin: Architecture and Function 3 1.2 Epidermis The epidermis is the outer layer of the skin and acts as the body’s major barrier against a hostile environment. The epidermis is a multilayered epithelium com- posed of 4–5 layers depending on the respective region of skin. In humans, it is thinnest on the eyelids and thickest on the palms and soles. The layers in ascending order are the basal/germinal layer (stratum basale/germinativum), the spinous layer (stratum spinosum), the granular layer (stratum granulosum), the clear/translucent layer (stratum lucidum) and the corni fi ed layer (stratum corneum). The epidermis is aneural and avascular, nourished by diffusion from the dermis, and contains keratinocytes, melanocytes, Langerhans cells, Merkel cells and in fl ammatory cells. Keratinocytes are the major resident cells constituting 95 % of the epidermis. 1.2.1 Stratum Germinativum or Basal Layer The innermost layer of the epidermis which lies adjacent to the dermis comprises mainly dividing and non-dividing keratinocytes which are attached to the basement membrane by hemidesmosomes. As keratinocytes divide and differentiate, they move from this deeper layer to the surface. Melanin-producing melanocytes make up a small proportion of the basal cell population. These cells are characterised by dendritic processes which stretch between relatively large numbers of neighbouring keratinocytes (Bensouilah and Buck 2 006 ) . Merkel cells are also found in the basal layer predominantly in touch-sensitive sites such as the fi ngertips and lips. They are closely associated with cutaneous nerves and seem to be involved in light touch sensation. 1.2.2 Stratum Spinosum As basal cells reproduce and mature, they move towards the outer layer of skin, initially forming the stratum spinosum. Intercellular bridges, the desmosomes, which appear as ‘prickle’ at a microscopic level, connect the cells. Langerhans cells are dendritic, immunologically active cells derived from the bone marrow and are found on all epidermal surfaces but are mainly located in the middle of this layer. They play an important role in immune reactions of the skin, acting as antigen- presenting cells (Bensouilah and Buck 2 006 ) . 1.2.3 Stratum Granulosum Continuing their transition to the surface the cells continue to fl atten, lose their nuclei and their cytoplasm appears granular at this level.