异体表皮干细胞与猪脱细胞真皮构建复合皮移植6例

2005-01/2006-10在南昌大学第一附属医院烧伤科就诊的深度烧伤患者6例,均为四肢Ⅲ度烧伤创面.异种(猪)脱细胞真皮与异体表皮干细胞构建的复合皮由南昌大学第一附属医院烧伤中心提供.清创消毒后,6例患者均进行复合皮移植、自体刃厚皮移植,共移植复合皮12块,自体刃厚皮96块.复合皮移植是将复合皮剪成1.5 cm×1.5 cm,粗糙面向下、光滑面向上植于创面上;自体刃厚皮移植是将大片自体刃厚皮铺于矾土林纱布上,剪成1.5cm×1.5 cm,植于复合皮的四周.移植后3 d揭去创面外层纱布,见复合皮及自体刃厚皮与创面粘连好、湿润,呈淡红色:7 d复合皮及自体刃厚皮大部分成活,随后成活的皮片向四周扩展,至14 d大部分皮片接近融合,21 d时创面已基本愈合.移植的复合皮、自体刃厚皮成活数量比较,差异无显著性意义(P＞0.05).因复合皮扩展情况不如自体刃厚皮,所以复合皮移植后的创面愈合面积小于自体刃厚皮移植(P＜0.01).在临床观察中6例患者暂末发生不良事件和副反应.提示表皮干细胞和(猪)脱细胞真皮构建的人工复合皮移植到受区,可建立血液循环,并保持一定的活力,达到覆盖创面、防止感染、防止体液流失的目的.     

异种(猪)无细胞真皮基质与自体微粒皮复合移植修复深度烧伤创面的实验研究

目的　观察异种 (猪 )无细胞真皮支架与自体微粒皮加同种异体皮复合移植修复全层皮肤缺损的效果。方法　 4 8只 SD大鼠背部全层皮肤缺损创面 ,分别行异种 (猪 )无细胞真皮支架与自体微粒皮移植(复合皮组 )和单纯微粒皮移植 (对照组 ) ,术后定期观察创面愈合情况并行创面愈合率和收缩率的计算 ,同时取创面组织进行组织学观察。结果　复合皮组的创面愈合情况良好 ,未见明显挛缩 ,皮肤弹性较好 ,两组异体皮成活情况及创面愈合情况相近 ,但是复合皮组创面收缩率显著低于对照组。组织学观察复合皮组上皮化良好 ,胶原纤维排列有序 ,基底膜结构完整。结论　异种 (猪 )无细胞真皮支架与自体微粒皮复合移植能修复全层皮肤缺损 ,改善创面愈合质量。     

异体脱细胞真皮联合自体皮复合移植在创面修复中的应用及远期疗效观察

目的寻找功能部位深度烧伤创面与瘢痕畸形修复的理想覆盖材料。方法将功能部位的深度烧伤、瘢痕切除后创面或溃疡创面行脱细胞异体真皮＋自体刃厚皮复合移植。结果30例患者复合皮全部成活,复合皮光滑柔软,局部弹性好,关节功能恢复良好。结论脱细胞异体真皮＋自体皮是功能部位创面修复的理想覆盖材料。     

Xenogeneic acellular dermal matrix as a dermal substitute in rats.

Acellular dermal matrix (ADM) has been used as a dermal substitute for the treatment of deep burns, but the availability of cadaver skin for the production of ADM is limited. The usefulness of porcine ADM as a xenogeneic dermal substitute in rats was studied. With the use of Dispase II (Boehringer Mannheim, Indianapolis, Ind) and Triton X-100 (US Biochemicals, Cleveland, Ohio), xenogeneic ADM was prepared from commercially available, cryopreserved porcine skin, and allogeneic ADM from the rats was also prepared. Four full-thickness injuries 225 mm2 in size were created on the dorsum of each rat. One of these wounds was treated with xenogeneic ADM and 1 was treated with allogeneic ADM, and immediately a 0.005-in thick split-thickness skin graft was placed over the ADM. The other 2 wounds were covered with 0.005- or 0.017-in thick split-thickness skin grafts alone. The wounds were evaluated macro- and microscopically 10, 14, 20, and 30 days after grafting. At 30 days after grafting, contraction of the wounds that contained xenogeneic ADM was significantly greater than that of the wounds that contained allogeneic ADM. Graft take was poor in the wounds that contained xenogeneic ADM at 14 days after surgery and moderately good in those that contained allogeneic ADM. The use of thick autografts resulted in the best wound healing, whereas the use of thin autografts resulted in considerable wound contraction. Allogeneic ADM diminished this contraction, but wound healing was significantly worsened when xenogeneic ADM was used.     

微孔异种无细胞真皮复合移植用于烧伤创面烧伤创面F功能评估

目的 观察微孔异种无细胞真皮 (acellular xeno- drmal matrix,ADM)与自体皮片复合移植的临床效果. 方法 将打孔的无细胞真皮与自体的大张刃厚皮、网状皮、邮票皮微粒皮等复合移植 ,用于深度烧伤创面的修复 ,观察自体皮片存活率及创面愈合的色素沉着、弹性与柔韧性等 ,并与单纯自体皮片移植部位进行比较. 结果 微孔无细胞真皮与自体刃厚皮、网状皮及邮票皮移植 ,存活率达 100% ,而与微粒皮移植存活率较低.与单纯自体皮片移植相比 ,复合移植后 3个月 ,色素沉着浅 ,富有弹性与柔韧性 ,明显改善创面愈合质量. 结论 微孔无细胞真皮具有完整的基底膜结构 ,胶原排列规则有序 ,可重建高质量真皮层 ,提高柔韧性、耐磨与耐压性.     

复合皮移植在整形外科中的应用

目的:总结脱细胞异体真皮与自体刃厚皮复合移植在整形中的应用体会与经验。方法:本组16例,其中男14例,女2例,年龄2~48岁。总共19个部位;受皮区面积最小为20cm2,最大260 cm2。结果:本组16例19个部位全部成活。功能部位植皮区外观平整,柔软度和弹性可以满足功能部位需要,颜色接近正常皮肤。结论:复合皮可以替代自体中厚皮,其存活率高,能减少供皮区瘢痕,术后恢复功能。     

Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting

Early tangential excision of nonviable burn tissue, followed by immediate skin grafting with autograft or allograft, has resulted in the improvement of burn patient survival. The aim of this study was to add split-thickness dermal grafts (STDGs) as a new source of auto-skin grafting tool to our reconstructive armamentarium in deep partial- and full-thickness burns and soft tissue defects. The authors successfully applied STDGs along with split-thickness skin grafts as a new source of auto-skin grafting in 11 deep partial- and full-thickness burns over a period of 1 year without any significant donor site morbidity. Dermal graft take was complete in all but one patient. There was no donor site healing problem, and donor site epithelization was completed generally 1 week later than split-thickness skin graft by semi-open technique. Autologous split-thickness skin grafting still remains the standard therapy for burn wound closure but may be in limited availability in severe burns. The authors conclude that STDGs may be a new source of auto-skin grafting tool in extensive deep partial- and full-thickness burns.     

全层皮肤缺损创面移植异种脱细胞真皮基质与薄自体皮重塑基底膜的实验观察

背景异种脱细胞真皮基质与薄自体皮复合移植修复全层皮肤缺损创面取得了良好的效果,但对移植后基底膜的重塑尚不十分清楚.目的观察异种(猪)脱细胞真皮基质与薄自体皮复合移植模型中基底膜重塑的变化规律.设计随机对照实验研究.地点和材料动物实验在上海市烧伤研究所完成,指标检测在上海第二医科大学细胞生物学教研室完成.清洁级雄性SD大鼠(由中国医学科学院上海实验动物中心提供),体质量200～250 g.干预将SD大鼠随机分为两组,每组42只.所有动物均饲养在层流房间内,恒定的湿度与温度,单笼饲养.A组单纯移植薄自体皮组;B组脱细胞猪真皮基质(江苏启东医疗用品研究所提供)+薄自体皮复合移植.将异种(猪)脱细胞真皮基质与薄自体皮复合移植于大鼠创面,分别于移植后1,2,3,4,8,12,16周留取标本,采用免疫组化、透射电镜等方法.主要观察指标观察基底膜中层粘连蛋白的变化规律及12周时基底膜的超微结构,同时以单纯薄自体皮移植进行对照.结果B组移植后1,2,3,4,8,12,16周,层粘连蛋白的表达分别为88.32±2.72,89.22±2.16,88.84±3.43,93.49 ±4.59,87.57±3.33,95.87±1.84,86.57±2.45,A组分别为78.96±1.68,85.37±5.41,82.49±3.73,84.27±2.69,72.88±3.57,88.19±3.36,82.82±2.86,12周时复合皮移植组基底膜结构清晰连续,而单纯移植薄自体皮组基底膜模糊、不连续.结论异种脱细胞真皮基质与薄自体皮复合移植后,基底膜中层粘连蛋白表达增高,可能有利于复合皮移植后基底膜的重塑,增强表皮和真皮之间的连接,进而改善创面愈合质量.     

Observations on stability and contraction of composite skin grafts: xenodermis or allodermis with an isograft overlay

Composite skin grafts of xenodermis or allodermis with a thin split-thickness isograft overlay were evaluated for stability and contraction. Male inbred Lewis rats were used as recipients, with Buffalo rats serving as allogeneic dermis donors. Cryopreserved human skin was used for xenodermis grafts. The two components of the composite graft, the xenodermis or allodermis and the isograft overlay, were grafted in one operation to a surgically created wound. Wounds were observed for 1 year. The composite skin grafts took fairly well, although spotty loss of the overlaid isograft was noted. The xenodermis and allodermis remained grossly intact even at 1 year after grafting. However, composite skin grafts in this animal model contracted more than did sheet isografts alone.     

Overexpression of vascular endothelial growth factor accelerates early vascularization and improves healing of genetically modified cultured skin substitutes.

Cultured skin substitutes (CSS) lack a vascular plexus, leading to slower vascularization after grafting than split-thickness skin autograft. CSS containing keratinocytes genetically modified to overexpress vascular endothelial growth factor (VEGF) were previously shown to exhibit enhanced vascularization up to 2 weeks after grafting to athymic mice. The present study examines whether enhanced vascularization compared with controls persists after stable engraftment is achieved and analyzes VEGF expression, wound contraction, and engraftment. Control and VEGF-modified (VEGF+) CSS were grafted onto full-thickness wounds in athymic mice. VEGF expression was detected in VEGF+ CSS 14 weeks after grafting. Graft contraction was significantly lower in VEGF+ CSS compared with controls, suggesting more stable engraftment and better tissue development. Positive HLA-ABC staining, indicating persistence of human cells, was seen in 86.7% (13/15) of grafted VEGF+ CSS, compared with 58.3% (7/12) of controls. Differences in dermal vascularization between control and VEGF+ grafts were significant 1 week after surgery, but not at later times. However, the distribution of vessels was different, with more vessels in the upper dermis of VEGF+ grafts. These results suggest that VEGF overexpression in genetically modified CSS acts to accelerate early graft vascularization and can contribute to improved healing of full-thickness skin wounds.     

深度手烧伤的治疗及功能康复

目的 :探讨深度手烧伤早期创面修复及功能康复最好的治疗方法。方法 :应用中厚皮、异体去细胞真皮基质作支架加自体刃厚皮片移植 ,腹部真皮血管网皮片及超薄皮瓣移植等手术方式 ,进行深度手烧伤早期切削痂。结果 :2 94例 4 6 2只手功能良好者 138例 2 32只手 (5 0 % ) ,功能较好者 79例 134只手 (2 9% ) ,功能障碍者 77例 96只手 (2 1% )。结论 :应用早期切削痂植皮的方法可减少瘢痕增生和畸形 ,使深度手烧伤后获得满意的外形和功能     

The application of acellular dermal matrix allograft in functional position of patients with post-barns plastic operation

AIM: To investigate the effect of allogeneic acellular dermal matrix(ADM) on cograft in joint functional positions of patients with post-burn plastic operation. METHODS: 9 patients vrith hypertrophic scar and joint dysfunction after severe burns were used After pre-treating with trypsin and TritonX-100, 13 reticulated ADM were overlapped with autogenous ultrathin split-thickness skin grafts (USTS), and were transplanted to the scar excision wounds in the joints of four limbs at the same time. The neighbouring autogenous thin split-thickness skin grafts(TSTS) were used as control RESULTS: The composite skin grafts as well as the controls were all survived The rejection and hypertrophic scars were not found during (1-5) years follow-up studies. The appearance, fiber and function of composite skin grafts were near to normal skins. CONCLUSION: The ADM could be used to joint functional positions of patients with post-burn hypertrophic scan and could produce satisfactory plastic results as dermal substitute.     

表皮干细胞联合脱细胞真皮构建人工皮肤促进创面愈合的实验研究

目的探讨表皮干细胞联合脱细胞真皮构建人工皮肤促进创面愈合的可行性。方法（1）用胰蛋白酶和EDTA联合消化法分离表皮,用Ⅳ型胶原快速黏附法分离、纯化人表皮干细胞,以含表皮生长因子、角质细胞无血清培养液等组成人表皮干细胞培养基进行体外培养,测定克隆形成率。（2）将培养人表皮干细胞接种于制备的脱细胞真皮支架中,构建组织工程人工皮肤,移植治疗兔全层皮肤缺损创面,观察创面修复效果。（3）取新西兰白兔常规制作背部全层皮肤缺损创面,随机分为4组：A、B、C组分别用含表皮干细胞的组织工程皮肤、含角质细胞的组织工程皮肤和单纯脱细胞真皮移植于皮肤缺损创面;D组用创面空置为对照。观察创面修复情况、局部炎症反应,并记录创面愈合时间。结果体外培养的人表皮干细胞增殖稳定,克隆形成率明显高于角质细胞对照组（P〈0．05）。移植后A组创面愈合良好,局部炎症反应轻微,无出血、积脓、坏死,创面愈合时间较B、C、D组明显缩短（P〈0．05或P〈0．01）。结论以表皮干细胞作为种子细胞联合脱细胞真皮构建人工皮肤可用于皮肤缺损创面的修复治疗。     

Split skin graft application over an integrating, biodegradable temporizing polymer matrix: immediate and delayed

The objective of this study is to further investigate the NovoSorb? biodegradable polyurethane in generating dermal scaffolds; to perform a pilot study comparing the previously used spun mat against a recently developed NovoSorb? foam, ascertaining the optimum structure of the matrix; and to evaluate the successful matrix as an immediate adjunct to split skin grafting and as a temporizing matrix in a prospective six-pig study. A pilot study comparing a previously investigated form of the polymer (spun mat) against a new structural form, a foam, was performed. This was followed by a six-pig study of the foam matrix with three treatment arms-autologous split skin graft alone, polymer foam with immediate engraftment, and polymer foam with delayed engraftment. The foams allowed less wound contraction than the spun mats. The foam structure is less dense (cheaper to produce and having less degradation products). The material remained in situ despite clinical wound infection. Proof of concept was achieved in both treatment modalities in the main study. Split skin graft applied immediately over the polymer foam was able to engraft successfully. The result was "thicker" to pinch and "flush" with the skin surrounding the wound. There was no significant difference in the degree of wound contraction between the graft alone and the polymer plus immediate graft groups. Split skin graft also "took" when applied to the surface of a polymer that had been applied to a wound 11 days earlier, again with a thicker result, flush with the surrounding skin. Split skin grafts alone left a persisting depression. However, a significant degree of wound contraction (compared with the other two groups) was observed in the polymer plus delayed graft group. This has prompted further investigation into "sealing" the polymer foam with a membrane, to prevent evaporative water loss, when the foam is to be used as a biodegradable temporizing matrix. The studies indicate that the NovoSorb? platform will allow the creation of two inexpensive dermal matrix products; an immediate scaffold to allow a thicker grafting result and a biodegradable temporizing matrix (BTM) for wound integration after burn debridement while donor sites become reharvestable. However, further modification on the BTM structure is necessary to further reduce wound contraction pregrafting.     

Weak direct current accelerates split-thickness graft healing on tangentially excised second-degree burns

We have examined the effects of direct current (DC) conducted through silver-nylon dressings on the healing time and morphologic maturation of split-thickness grafts placed on tangentially excised deep partial-thickness burn wounds. Male guinea pigs (n = 120) were used as the experimental hosts. The DC-treated animals required 2 days for complete revascularization of their grafts; control animals required 7 days (p less than 0.01). The DC-treated animals had increased epithelial proliferation at the graft-wound interface as compared with controls (p less than 0.01). Grafts from DC-treated animals were firmly adherent within 4 days, whereas graft adherence in controls was weak before 7 days after grafting. At 3 months after grafting, control animal grafts had mild contraction with moderate hair loss and thick subepidermal fibrosis; the grafts in DC-treated animals expanded with the growth of the animals and had abundant hair growth and significantly reduced dermal fibrosis (p less than 0.01).     

Reduced wound contraction after grafting of full-thickness burns with a collagen and chondroitin-6-sulfate (GAG) dermal skin substitute and coverage with biobrane

Full-thickness burns destroy both the epidermal and dermal tissues of the skin. This study evaluates a collagen and chondroitin-6-sulfate dermal skin substitute (graft) that was applied to excised full-thickness burns and covered with Biobrane. Experimental conditions included: (a) no burn, subcutaneous implantation of the graft; (b) burn, excision, graft, coverage with Biobrane and bandages; (c) burn, excision, no graft, coverage with Biobrane and bandages; (d) burn only. forty-one days post-surgery, subcutaneous implantation (N = 3) of the graft caused no detectable contraction or necrosis of the overlying skin, whereas all burn wounds contracted. Measurements of wounds (percentage of original wound size) showed statistically significant differences between the following treatments; (a) graft plus Biobrane (N = 10), 34%; (b) no graft plus Biobrane (N = 9), 25%; (c) untreated burns (N = 6), 16%. Semi-quantitative evaluation of time to healing indicated by spontaneous detachment of Biobrane from wounds showed that grafted, excised wounds healed in an average of 2.7 weeks, while ungrafted, excised wounds required an average of 4.3 weeks to heal. Histological appearance of healed wounds after grafting and coverage with Biobrane resembles undamaged skin without epidermal adnexal structures. Excision of full-thickness burn eschar, followed by grafting with a collagen and chondroitin-6-sulfate dermal skin substitute and coverage with Biobrane provides reduced wound contraction within a six-week period of observation compared to non-excised wounds. Both more rapid and more complete wound healing took place compared to excised wounds that were not grafted.     

脱细胞异体真皮与自体大张薄皮修复功能部位创面的疗效观察

目的：总结功能部位创面用脱细胞异体真皮与自体大张薄皮修复后的疗效。方法：对感染创面清创，控制感染。移植脱细胞异体真皮与自体大张薄皮封闭创面。结果：该技术操作简单，皮片成活良好，外观平整,皮肤弹性好,修复区无功能障碍。结论：关节功能部位创面用脱细胞异体真皮与自体大张薄皮移植能恢复关节功能，避免或减少后期整形。     

网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损

目的：探讨网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损的疗效。方法：对19例皮肤撕脱伤创面及皮肤坏死创面患者均采用网状中厚皮片移植,以VSD材料覆盖植皮创面,修剪边缘后缝合固定于周围健康皮肤,封闭整个植皮区。24 h持续负压吸引5-7 d。结果：17例移植皮片全部存活,创面愈合。2例皮片存活95%以上,经换药后创面愈合。随诊0.5-1 a,创面外观、功能恢复良好。结论：网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损能及早封闭创面,降低感染的发生,促进皮片与创面良好贴附,有利于皮片存活,是一种简便、有效的修复皮肤软组织缺损创面的治疗方法。     

异种(猪)脱细胞真皮基质治疗小儿Ⅱ度烧伤的护理

目的:探讨异种(猪)脱细胞真皮基质一次性覆盖创面治疗患儿Ⅱ度烧伤的护理。方法:159例Ⅱ度烧伤患儿采用真皮基质覆盖创面后,加强生命体征的监测、准确补液抗休克、密切观察创面情况及加强营养供给。结果:159例患儿全部安全渡过休克期,真皮基质包扎治疗Ⅱ度烧伤患儿,疗效好,愈合时间缩短,疤痕增生轻。结论:正确的创面处理方法,及时有效的护理措施及准确无误的病情监测等是增进患儿烧伤治疗效果的关键,真皮基质是一种良好的生物敷料,值得推广。     

异种(猪)脱细胞真皮基质移植对皮肤弹性的影响

目的 比较异种(猪)脱细胞真皮基质(PADM)与自体薄厚皮、自体薄厚皮覆盖缺损创面后,与正常皮肤在黏弹性方面的差异性.方法 选用10只清洁级日本大耳白兔,每只白兔背部制作3个全层缺损创面,根据创面不同处理方式分为三组:PADM+自体薄厚皮(PADM组)、自体薄厚皮(TS组)和正常皮肤组(NS组).术后30 d时测量愈合创面挛缩率,行病理观察、离体松弛和应力应变生物力学测定.对结果进行统计学分析.结果 术后30 d,PADM组创面挛缩率低,与TS组比较差异有统计学意义(P<0.05).组织学观察见真皮基质基本完整,纤维结构致密,有少量纤维组织长入.三组生物力学关系为:NS组与TS组差异无统计学意义(P>0.05),PADM组较NS组与TS组差(P<0.05).PADM组生物力学曲线距离正常皮肤组最远,TS组与正常皮肤组最为接近.结论 与正常皮肤相比,异种(猪)脱细胞真皮基质与自体薄厚皮修复后创面弹性最差,自体薄厚皮弹性稍好.