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Advanced Review

Tissue scaffolds for skin wound


healing and dermal reconstruction
S. P. Zhong,1 Y. Z. Zhang2 and C. T. Lim1,3,4∗

One of the major applications of tissue-engineered skin substitutes for wound


healing is to promote the healing of cutaneous wounds. In this respect, many
important clinical milestones have been reached in the past decades. However,
currently available skin substitutes for wound healing often suffer from a range
of problems including wound contraction, scar formation, and poor integration
with host tissue. Engineering skin substitutes by tissue engineering approach has
relied upon the creation of three-dimensional scaffolds as extracellular matrix
(ECM) analog to guide cell adhesion, growth, and differentiation to form skin-
functional and structural tissue. The three-dimensional scaffolds can not only
cover wound and give a physical barrier against external infection as wound
dressing, but also can provide support both for dermal fibroblasts and the overlying
keratinocytes for skin tissue engineering. A successful tissue scaffold should exhibit
appropriate physical and mechanical characteristics and provide an appropriate
surface chemistry and nano and microstructures to facilitate cellular attachment,
proliferation, and differentiation. A variety of scaffolds have been fabricated
based on materials ranging from naturally occurring ones to those manufactured
synthetically. This review discusses a variety of commercial or laboratory-
engineered skin substitutes for wound healing. Central to the discussion are
the scaffolds/materials, fabrication techniques, and their characteristics associated
with wound healing. One specifically highlighted emerging fabrication technique
is electrospinning that allows the design and fabrication of biomimetic scaffolds
that offer tremendous potential applications in wound healing of skin .  2010 John
Wiley & Sons, Inc. WIREs Nanomed Nanobiotechnol 2010 2 510–525

S kin is the largest organ of the body in vertebrates


and plays a crucial role in many functions, such as
protecting against external insults, fluid homeostasis,
high impermeability is the outermost barrier of
our body controlling water loss and protecting
the body from external insults. The dermis is
sensory detection, and self-healing. Skin is composed composed of the predominating ECM [collagen,
of thin and high cellular epidermis and relatively elastin, and glycosaminoglycans (GAGs)] and the
acellular dermis of collagen-rich extracellular matrix fewer cellular constituents of mainly fibroblasts. This
(ECM).1 The epidermis mainly consists of layers layer mainly provides the physical strength as well
of keratinocytes separated from the dermis by as flexibility to skin and supports the extensive
the basement membrane. The epidermis having a vasculature, lymphatic system, and nerve bundles.2
Damage or loss of the integrity of skin caused
∗ Correspondence to: ctlim@nus.edu.sg by skin or cutaneous wound may impair the skin
1
Division of Bioengineering, National University of Singapore, functions at various extents ranging from significant
Singapore disability to even death.3,4 Skin wound can arise
2 Department of Bioengineering, College of Chemistry, Chemical from mechanical trauma, surgical procedures, reduced
Engineering and Biotechnology, Donghua University, Shanghai
201620, China blood circulations, burns, or aging.5 Most skin
3 Research Centre of Excellence in Mechanobiology, National wounds can heal naturally, but additional surgery
University of Singapore, Singapore necessitates immediate coverage using skin substitutes
4 Department of Mechanical Engineering, National University of to aid repair and regeneration when extensive or
Singapore, Singapore irreversible damages to skin are caused.6 Many
DOI: 10.1002/wnan.100 natural skin substitutes such as xenografts, allografts,

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WIREs Nanomedicine and Nanobiotechnology Tissue scaffolds for skin wound healing

and autografts have been used for wound healing. electrospinning and advantages of nanofibers when
However, these naturally derived skin substitutes used as wound cover or matrices for tissue repair and
cannot accomplish skin regeneration due to limited regeneration are emphasized.
donor sites, risk of infection, slow healing, and
association with the formation of scar.7,8
It is most urgent for skin wound therapy to CURRENT MATERIALS AND
provide the outmost barrier, i.e., epidermal coverage SCAFFOLDS IN WOUND HEALING
in order to prevent infection, reduce water/blood loss,
and control pain. However, an epidermal coverage
Collagen-Based Matrices
alone often fails to restore the structure and functions Collagen is a major ECM protein of the dermal
of the skin and many of the problems such as layer of skin, and it is very logical that the
fragility of the graft, wound contraction, and scar early studies on using biodegradable polymers for
formation often occur.9–11 Increasingly, apparent wound dressing or skin tissue engineering focused
evidences demonstrate that effective wound healing on using collagen. The structural and functional
always necessitates the presence of the dermis layer characteristics of collagen similar to native ECM
in the skin substitutes.12,13 The re-epithelialization stimulated the use of collagen matrices for wound
healing.18 A number of collagen-based dressings
of keratinocytes and take rate are promoted through
containing a variety of carriers/combining agents
dynamic dermal–epidermal interactions, and hence the
in the form of gel, sheet, lattice, or sponge are
graft exhibits higher resistance to wound contraction
and scarring. The restoration of dermis requires commercially available now (Promogram , Johnson
three-dimensional scaffolds to provide elasticity and & Johnson, and Puraply , Royce Medical). Many
strength to the epidermal graft and feed the of them have been used under various clinical
keratinocytes in epidermal layer. Hence, one crucial conditions as a temporary covering for ulcers and
factor in skin tissue engineering is the construction of burns with favorable results being achieved.19 Other
a tissue scaffold as template to guide restructuring of engineered acellular dermis, cellular epidermis/dermis,
cells and subsequent host infiltration of the skin graft. or bilayered skin equivalents involving collagen-based
Over the past three decades, extraordi- materials have been developed as biological skin
nary advances and improved understanding in substitutes for wound healing.
cell/molecular biology have led to achievements in A naturally derived dermis traded as AlloDerm
skin tissue regeneration for wound healing.1 Tissue (LifeCell Corporation) has a porous and fibrillar struc-
engineering skin, based on the concept of a cell–matrix ture similar to native dermis prepared using lyophiliza-
construct, has been a significant advancement in the tion technique after decellularization treatment as
field of wound healing. A number of products are shown in Figure 1A and B.20,21 AlloDerm has been
commercially available and many others are in devel- used as autograft in the resurfacing of burn wound
opment. Over 200,000 patients have been treated reconstruction due to its human origin.22 Another
with tissue-engineered skin products.14–17 Examples acellular natural product (Integra , Integra Life Sci-
of skin substitutes may be acellular or cellular. Acel- ences) was engineered using a porous composite of
lular products only contain the matrix based on bovine collagen-chondroitin-6-sulfate (8 wt%) with
natural or synthetic materials with the required phys- an outer silicone covering.23,24 The outer silicone layer
ical and chemical structure allowing easy access to (Figure 1C25 ) serves as a temporary barrier preventing
host cells during wound healing. Cellular products water loss and microbial invasion, and this layer can
with/without matrix include epidermal cell sheets, be removed 2–3 weeks after wound replacement upon
epidermal constructs, dermal replacements, and bilay- vasularization of the dermis. The porous collagen lay-
ered skin equivalents.16,17 However, currently none of ers (Figure 1D),26 manufactured by lyophilization of
these is fully satisfactory and can replace native skin a dispersion of collagen, crosslinking, and sterilization
autograft and allograft permanently. by chemical means, were designed to act as template
Based on the recent developments and an exten- for host fibroblast infiltration and capillary growth.
sive understanding of the wound healing process, this Integra has been widely used for split-thickness skin
article reviews tissue scaffolds used in commercial skin grafts or wound closure on severe burn wounds when
grafts and some of the new developments occurring donor sites are limited.27 But Integra faces the prob-
at the laboratory stage. The discussion will center on lems of high cost, the need for two surgeries, and the
the processing technique, characteristics, and mate- risk of infection complications.28 Recently, inclusion
rials of tissue scaffolds involving wound repair or of skin cells (keratinocytes, fibroblasts, or both) with
healing. Novel biomimetic scaffolds fabricated using Alloderm or Integra acellular dermis has been

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Advanced Review www.wiley.com/wires/nanomed

(a) (b)

FIGURE 1 | Acellular skin substitutes:


1B 50 µm (A) appearance of Alloderm native tissue
(Reprinted with permission from Ref 20.
Copyright 2010 emedicine.com), (B) SEM
(c) (d) micrograph of the surface (Reprinted with
permission from Ref 24. Copyright 1981
Elsevier). (C) Integra template with
silicon layer in situ (Reprinted with
permission from Ref 25. Copyright 2006
Elsevier). and (D) Porous sponge-like
collagen–glycosaminoglycans structure of
Integra . (Reprinted with permission
from Ref 26. Copyright 2007
http://www.ilstraining.com/idrt/idrt/
brs it 03.html).

performed to architect one cellular bilayered skin on the pioneer work on the cellular skin equivalent
equivalent in some studies.29–31 Fine capillary for- involving collagen.7,34 Briefly, dermal fibroblasts are
mation and accelerated healing rate can be achieved seeded in suspension mixed with bovine type I collagen
on the treatment of full-thickness wounds. However, solution and fibroblast–collagen interaction results in
poor ingrowth of dermal fibroblasts was found in the rearrangement and increased density of collagen
some fashions of Alloderm due to the denser struc- fibrils with a dermal–lattice equivalent formed in
ture of collagen fibrils.32,33 4–6 days. Keratinocytes cultured onto the surface
One of most advanced product of Apligraf of the dermal layer are exposed to an air–liquid
(Figure 2A,7 organogenesis) has been developed based interface to promote maturation and cornification

APLIGRAF Human skin

(a) (b)

FIGURE 2 | Bilayered skin substitutes: (A) Apligraf (Reprinted with permission from Ref 7. Copyright 2008 Elsevier). (B) Comparison of
Apligraf and natural human skin; Apligraf exhibits similar structure as the natural skin. (Reprinted with permission from Ref 36. Apligraf ).

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WIREs Nanomedicine and Nanobiotechnology Tissue scaffolds for skin wound healing

of the stratified epidermal layer, which can support biostability can also extend the clinical durability of
long-term maintenance of the fibroblasts.35 Much like the graft. Besides, incorporation of ECM components
human skin, Apligraf contains key structure and into collagen such as fibronectin, elastin, and GAGs
components similar to human skin (Figure 2B36 ). The plays an important role in guiding the cell physiol-
vascularization and well integration of Apligraf into ogy and behavior in wound healing.13,51,52 Especially,
the wound bed was observed within 14 days and an fibronectin plays an integral role in the attachment of
improved healing was found for chronic venous leg keratinocytes and re-epithelialization.52 GAGs such as
ulcers and diabetic foot ulcers.37–39 Orcel (Ortec hyaluronic acid and chondroitin 6-sulfate have multi-
International) is another bilayered cellular product functional facilitators for wound healing and inhibit
using porous collagen sponge with one side coated wound contraction as well.53 Combining chitosan,
with collagen gel. Dermal fibroblasts are cultured on as one analog to GAGs, with collagen can inhibit
and within the porous sponge side of the collagen its degradation, improve its mechanical strength, and
matrix and keratinocytes are seeded on the gel- accelerate its wound healing.53
coated side and thus ingrowth of keratinocytes can Recently, Seo et al.54 developed a novel rein-
be prevented.40 Accelerated healing rate and reduced forced collagen scaffold used for constructing one
scar formation were achieved with this graft compared artificial dermis layer. The collagen sponge was rein-
with conventional therapy with Biobrane-L.41 But forced by incorporation of collagen-knitted mesh
there are limited clinical trial data available on this fabricated by stacking multilayered collagen thread
graft compared with Apligraf . as shown in Figure 3.54 Continuous collagen thread
Major forms of collagen dressings or matrices was fabricated by extrusion of collagen acid solution
for skin tissue engineering are hydrogel, sponge, into a coagulation bath and multilayered knitted col-
and lattice. Initial collagen gel such as floating lagen mesh was fabricated by cross joining methods.
or anchored gel was introduced to form dermal The study showed that significantly increased ten-
equivalent to investigate the effect of cellular force on sile strength was achieved on the reinforced collagen
collagen contraction, which was linked to subsequent sponge compared with a typical collagen sponge, and
wound contraction.42 The culture work and clinical rapid and firm cell adhesion to the surface and consid-
procedures necessitated the use of denser collagen such erable cell infiltration into the pores were observed.
as lattice or sponge with higher viscosity and strength. Although the abovementioned modification and
Collagen lattice condensed from fibroblast-populated improvement have been achieved, using collagen-
collagen solution was used to mimic the in vivo dermal based polymers for wound healing still creates
layer. However, there was up to 20% contraction problems such as wound contraction and scarring.
of lattice even after transplantation, which inhibited Other concerns discouraging collagen applications
effective wound covering and closure. Besides, the include the high cost of pure collagen, variability
decreased synthesis of collagen was due to the cell in the physicochemical and degradation properties
confinement.43,44 Dehydrated collagen sponges are depending on source and processing.55 Some other
normally produced by freeze drying a dispersion of natural or synthetic polymers have been attempted to
collagen gel or acidic solution.45 Collagen sponge overcome these concerns.56,57
is solid with stronger mechanical properties than
hydrated collagen gel, and sponge implant has been
efficient in the use for recovery of skin, and various Other Natural Polymers
types of artificial skin in the form of sponge were Some other natural polymers including chitosan,
developed.41,46,47 fibrin, elastin, gelatin, and hyaluronic acid have been
However, collagen-based scaffold or dressing investigated for wound healing. Although some of
often has poor biostability and low mechanical prop- their dressing products have been commercialized,
erties and wound contraction easily occurs.42,48,49 their cellular skin grafts are only in the laboratory
Extensive modifications by crosslinking treatment or stage and further clinical data are needed for FDA
combining other natural or synthetic polymers, such approval or commercialization.
as ECM, GAGs, chitosan, polycaprolactone (PCL), Chitosan is another natural polymer most
and PLGA are used to form intra- and interchain widely used next to collagen in wound healing due
bridges between/within collagen molecules with or to its many advantages including biocompatibility,
without external crosslinking agents.50 As a result, the biodegradability, hemostatic activity, and antibacte-
increased mechanical properties can prevent the colla- rial properties.58–60 Chitosan can stimulate collagen
gen matrix from contracting during the culture period synthesis and well incorporate into fibroblast growth
and the wound healing process and the increased factor due to the electrostatic function of chitosan,

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Advanced Review www.wiley.com/wires/nanomed

(a) (b)

FIGURE 3 | Optical
(c) (d) microscopic photographs of
collagen thread mesh (A),
reinforced collagen sponge
with collagen mesh (B), SEM
micrographs of collagen
sponge reinforced by collagen
mesh (C), and the fibroblasts
growing and filling the
collagen mesh (D). (Reprinted
with permission from Ref 54.
Copyright 2008 Springer).

which can enhance the wound healing rate.61,62 and well organization of fibroblasts within fibrin
Chitosan materials can be easily fabricated into differ- matrices were found in culture models and good take
ent structures under various process conditions. The rate was achieved for subsequent wound healing.70–73
films, gels, or sponges of chitosan have recently been Coating of synthetic polymer surface using fibrin
investigated for use in full-thickness burn wounds.63 glue was used to produce more suitable scaffolds
However, chitosan has rapid biodegradability espe- for civilizing keratinocytes with higher strength and
cially in acid environment that is often formed in acceptable biocompatibility.74
wound healing.64 Various crosslinking treatments Gelatin as one protein derived from collagen has
have been used to increase the structural stability of been investigated as matrices in the dehydrated form
chitosan.56 Also, it is highly desirable to incorporate such as sponge or film for skin tissue engineering,
chitosan into another one or two different polymers to and promoted epithelialization and granulation tissue
balance its advantages and disadvantages.65,66 Large formation were shown in wound healing.75 But this
number of amino groups in chitosan plays a significant material has the limitation of low mechanical strength
role in bridging and crosslinking between/within chi- and is effectively used only as incorporated component
toscan and/or other polymers such as collagen, gelatin,
with others polymers to promote or modify the
and GAGs.67 The increased crosslinking efficiency
biological or mechanical properties.76–78
may improve the biostability and mechanical proper-
Hyaluronic acid or hyaluronan-based scaf-
ties of scaffolds. Ma casted chitosan film onto collagen
folds have been studied due to its excellent
sponge to form one bilayer structure for skin tissue
biocompatibility.79 One non-woven fleece of 100%
engineering.68 This chitosan layer with denser struc-
ture can enhance the functions of the artificial dermis benzyl-esterified derivative of hyaluronic acid was
with increased controlled fluid loss and antibacterial already marked as Hyaff (Fidia Advanced Biopoly-
activity. However, some disadvantages of chitosan mers) and its efficacy used for cultured epidermal
such as unsatisfactory mechanical properties, severe graft (Laserskin ) or dermal graft (Hyalograft 3D)
shrinkage, and deformation after drying discouraged was demonstrated in extensive burns.80,81 Fibrob-
its application in tissue engineering field.69 last–keratinocyte composite based on this Laserskin
Fibrin glues in suspension, gel, membrane, or membrane with the promoted three dimension can
sheet form have been used as a dressing or co-culture produce skin equivalent, and promising in vitro results
system for delivering keratinocytes to treat burn suggested the potential application for burns and
wound. Rapid re-epithelialization of keratinocytes chronic wounds.82

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WIREs Nanomedicine and Nanobiotechnology Tissue scaffolds for skin wound healing

In summary, the success from the use of natural Polyurethane (PU) has been extensively studied
biodegradable cell matrices has been encouraging as materials for wound dressing due to its semiperme-
and continues to facilitate broader use in the ability. PU wound dressings are impermeable to bacte-
future. However, many problems occurring with ria and water but permeable to gas with moist environ-
natural polymers include low mechanical strength, ment desirable for wound healing to occur. PU-based
shrinkage/contraction, difficulty in handling, and membranes have been commercially available for
risks of immunological rejection.57 Use of synthetic wound dressing (Tegaderm, 3M Health Care and
polymer or incorporating synthetic polymer into
OpSite, Smith & Nephew). The products are cost-
natural polymer may be favorable when higher
effective for covering small-sized, split-thickness skin
mechanical properties and more flexible fabrication
ability of synthetic polymers are highly desirable.12 graft, but limited adherence to wound bed was found.
Nylon material, one widely used material in suture, is
also widely used for wound cover in the form of nylon
Synthetic Polymer Scaffolds mesh (Biobrane, Dow B. Hickam, Inc.). Collagen
Generally, synthetic polymers possess lot-to-lot uni- or collagen-derived peptide is coated to improve cell
formity and have less expensive and more reliable adherence or tissue biocompatibility. These wound
sources of raw material. They can be tailored using dressings have been used as a standard control of cell
various fabrication techniques to provide a wide range carrier to compare their in vitro biocompatibility with
of physical properties. Although some work indicated those of some natural or synthetic dressings.84
that acceptable epithelialization of keratinocytes can A knitted polyglycolic acid/polylactic acid
be achieved on synthetic polymer surface, currently
(PGA/PLA or namely Polyglactin) mesh as typically
no successful epidermal graft using synthetic poly-
shown in Figure 4A85 was cultured with human
mers has been achieved due to their limited cellular
recognition and tissue compatibility.83 The studies neonatal fibroblasts leading to the development
using synthetic polymers for skin substitutes are of one commercial product of cryopreserved
already focusing on the combination with natural Dermagraft (Advanced Tissue Sciences) (Figure
polymers used as matrices for temporary dressing, 4B).86 Dermagraft has been used successfully to treat
epidermal/dermal cell carriers, or full-thickness skin full-thickness diabetic foot ulcers. The knitted PLGA
equivalent. meshes support homogenous cell distribution and

(a) (b)

100 µm

FIGURE 4 | Polyglactin mesh (A),


Dermagraf as received from a pack
(B), dermal fibroblasts cultured on (c) (d)
polyglactin mesh (C), and
collagen-hybridized polyglactin mesh
(D), collagen promotes adhesion and
growth of fibroblasts after 5 days of
culture (A, C, D reprinted with
permission from Ref 86. Copyright
2004 Expert Review of Medical
Devices, and B reprinted with
permission from Ref 86. Copyright
2004 Expert Review of Medical
68.7 µm 68.7 µm
Devices).

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Advanced Review www.wiley.com/wires/nanomed

withstand the cell contractile force (Figure 4C). How- as fiber drawing, template synthesis, temperature-
ever, the PLGA scaffold has the problems of surface induced phase separation, molecular self-assembly,
hydrophobicity and limited cell adhesion. One modi- and electrospinning.94 However, only electrospinning
fied knitted PLGA mesh hybridized with collagen has has emerged as an efficient technique to produce
been investigated as a three-dimensional culture sys- a variety of polymeric nanofibers.95 Electrospinning
tem for skin tissue engineering85 or some other tissues generally involves the application of an electrostatic
construction.87,88 These web-like collagen sponges force between polymer solution (or melt) kept in
can facilitate seeding, uniform distribution, and a syringe or pipette and a counter metal electrode
ECM synthesis of dermal fibroblasts (Figure 4D).85 (collector plate) kept at a certain distance from
TransCyte , formerly known as dermagraft-TC, is a the polymer solution as shown in Figure 5A. The
cell-seeded Biobrane product, composed of a semiper- electrospinning technique has gained attention and
meable silicone membrane and newborn human popularity in the last 10 years due to an increased
fibroblast cells cultured on a collagen-coated nylon interest in nanoscale properties and technologies.
mesh. But it is only a temporary covering due to the One major attractive feature of electrospinning is
poor biodegradability of nylon.89,90 the simplicity and inexpensive nature of its setup.
Many other synthetic polymers used in Electrospun scaffolds provide high surface area to
restorable sutures or wound covering have been volume ratio, which has been proved to promote
investigated as matrix materials for dermal substi- cell–matrix interaction at the nanoscale.96,97
tutes or full-thickness skin equivalent. They include This high surface area to volume ratio of
PCL, poly(l-lactide) (PLLA), PGA, and copoly- electrospun scaffolds facilitates oxygen permeability
mer poly(ethyleneglycolterephthalate)-poly (butylenes and allows fluid accumulation, which are highly
terephthalate).12,91 However, limited clinical success desirable in the wound healing course. Besides, the
was achieved because synthetic polymers often have pores in non-woven form of electrospun scaffolds
lower rates of cell attachment and proliferation due (normally 1–10 µm) are small enough to prevent
to the limited biological signals. The combination of bacterial penetration.95,102 Much attention has been
two or more different polymers including natural or drawn to the use of electrospun scaffolds as wound
synthetic is necessary to produce suitable scaffolds for dressing or cellular carrier for skin substitutes
skin regeneration when the advantages or disadvan- made of a variety of materials including collagen,
tages of each material are well balanced. Although gelatin, fibrinogen, chitosan, PU, PCL, PLA, and
the overall research is encouraging, our knowledge PLGA,103–106 or some blends of them.107,108 Current
and understanding of the skin substitute and wound work using electrospun nanofibrous membranes as
healing involving biology and material science still medical dressings or skin regeneration for wound
need to be improved. In the past 10 years, the devel- healing is still at an early stage.
opment of nanotechnology involving fabrication and
characterization methods has encouraged the research
community to investigate the potential of applying Electrospun Natural and Synthetic
nanofibrous scaffolds in the tissue engineering field. Nanofibers for Wound Healing
Feasibility of electrospinning collagen was first
reported by Bowlin et al.98 using calf skin type I col-
lagen dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol
ELECTROSPUN BIOMIMETIC (HFP) as shown in Figure 5B. Structural and bio-
NANOFIBROUS SCAFFOLDS logical characterizations were conducted to confirm
FOR WOUND HEALING that the structural and biological properties of native
collagen were maintained after solvent dissolution
Characteristics of Electrospinning and and electrospinning. Subsequently many research
Electrospun Scaffolds works extended the application of electrospun col-
As we know, native ECM in dermis layer is lagen to several tissue engineering fields such as skin,
composed of collagen nanoscale fibers and it provides cornea, and blood vascular system.109–112 Electro-
structural integrity and mechanical strength to spun collagen was found to be the most biomimetic
skin tissues. Thus, a biologically inspired scaffold nanofibrous scaffolds due to its structure and origin
fabrication approach for wound healing is to create closely similar to the native ECM of dermis. Several
ECM analogs composed of nanoscale fibers with studies already demonstrated that collagen nanofi-
mimicking structure and functions to native ECM.92,93 brous matrices exhibited excellent biocompatibility to
There are many fiber fabrication methods such dermal fibroblast and keratinocytes, and significantly

516  2010 Jo h n Wiley & So n s, In c. Vo lu me 2, September/Octo ber 2010


WIREs Nanomedicine and Nanobiotechnology Tissue scaffolds for skin wound healing

(a) (b)

High voltage Polymer


solution

Polymer jet
(c)

Collector

FIGURE 5 | Electrospinning and


electrospun nanofibers. (A) Schematic
diagram of the electrospinning setup,
(B) collagen nanofibers, (reprinted with 100 nm

permission from Ref 99. Copyright 2007 John


Wiley & Sons, Inc.), scale bar = 100 nm,
(e) (d)
(C) PVA/AgNO3 nanofiber, (reprinted with
permission from Ref 98. Copyright 2002 Nanofiber scaffold

ACS), (D) core–shell polycaprolactone/


collagen nanofiber with the insert of the
coaxial spinner, (reprinted with permission
from Ref 100. Copyright 2005 ACS), and
(E) polycaprolactone/gelatin nanofiber
scaffold collected with Tegaderm Tegaderm
wound dressing
membrane. (Reprinted with permission from 0.2 µm
Ref 101. Copyright 2007 Elsevier).

accelerated wound healing and inhibited wound con- organization, and excellent barrier desirable for
traction (compared with collagen sponge) were found wound healing were discussed.104,116 However these
in early-stage wound healing.103,109 However, one studies suggested that combination with synthetic
recent report provided very direct evidences that over- polymers (PU or PCL) is highly desirable to provide
whelming denaturation of collagen into gelatin occurs higher mechanical properties of scaffold.
with those commonly used fluorinated alcohols such Some other natural polymers including silk
as HFP or 2,2,2-trifluoroethanol (TFE) as the dis- fibroin, chitin/chitosan, fibrinogen, or their blends
solving solvent for collagen.113 Considering the high have been electrospun as wound dressing or cellular
cost of collagen material, further investigations are matrix, and efficient cell attachment, growth, or
needed to clarify the effect of collagen denaturation infiltration has been demonstrated in in vitro
on the biological activity and structural mechanical culture,117–119 but limited clinical trial has been
integrity, which are highly desirable in mimicking reported. Recently, hemoglobin and myoglobin have
native ECM. been electrospun as wound dressing aimed to
Gelatin, as an alternative protein to collagen, is promote oxygen delivery to the healing tissue using
commercially available at significantly lower cost and hemoglobin’s functional analog of red blood cells.
preserves many merits of collagen such as biological Increased oxygen delivery was deemed to increase
origin, biodegradability, and biocompatibility. Gelatin the metabolic rate and infectious resistance of the
was successfully electrospun into nanofibers using wound, and thus wound healing was supposed to be
several solvents such as TFE, HFP, and formic accelerated.120
acid.104,114,115 Potential application of electrospun Natural electrospun nanofibers normally require
gelatin as wound dressing and optimal fiber density crosslinking treatment to stabilize the structures of
to provide high cell viability, and optimal cell nanofibers before in vitro or in vivo use. However,

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Advanced Review www.wiley.com/wires/nanomed

choosing efficient crosslinking for electrospun natural the scaffolds suitable for tissue engineering skin with
polymer needs to proceed with extra care as aqueous a good balance of mechanical strength and biological
degradation or swelling of natural polymer in the properties. In our laboratory, Zhang et al. showed
early stage of crosslinking easily damages the pores of that PCL/collagen nanofibers in core–shell form
matrix or impairs the porosity of the electrospun mats. fabricated using coaxial core/shell electrospinning
As suggested in several studies, glutaraldehyde vapor (Figure 5D) exhibited higher biological affinity than
crosslinking is a highly efficient method, and nanoscale the PCL nanofibers simply coated with collagen.100
dimension and porous structure of collagen, gelatin, or More recently, PCL/gelatin nanofibrous scaffold
fibrinogen nanofibers can be preserved.105,114,121,122 and layered dermal reconstitution were evaluated
Electrospun synthetic polymers such as PU, for wound healing. PCL/gelatin was electrospun
PCL, PLLA, and poly (vinyl phenol) have been onto one commercial PU membrane of Tegaderm
proposed for wound dressing application in wound (Tegaderm, 3M Medical) as shown in Figure 5E.
healing.101,102,116 Early studies using electrospun Tegaderm membrane can facilitate clinical handling,
synthetic polymers for wound dressing, together provide a protective barrier to external infections as
with some electrospun natural polymers, have synthetic epidermis, and control water loss. Significant
created wound healing scaffolds with such inherent cell adhesion, growth, and infiltration achieved
properties of the electrospun material. Controlled on the PCL/gelatin produced a fibroblast-populated
evaporative water loss, excellent oxygen permeability, three-dimensional dermal analog. This cost-effective
and promoted fluid drainage have been revealed on composite could be promising wound dressing or
most of the electrospun mats used. In some recent tissue scaffolds for skin construct.
studies, the addition of drugs into nanofibers as The potential application for PLGA/dextran
controlled release system has been investigated for was investigated as tissue scaffolds for skin tis-
wound dressing to provide the required protection and sue engineering.129 A complete cell biological
pain management. Some antibiotic or antibacterial response of dermal fibroblasts was tested on
drugs/components such as cefazolin, liodocaine, electrospun PLGA/dextran nanofibers. The results
mupirocin, or Ag particles have been electrospun showed that favorable fibroblasts interacted with
into synthetic nanofibers in the blended form the scaffolds and resembled a dermal-like archi-
(Figure 5C), and increased or controlled antimicrobial tecture. Aimed to overcome poor infiltration of
or antibiotic ability desirable for wound healing has fibroblasts into electrospun mats, a novel three-
been achieved with a sustained controlled release rate dimensional multilayered cell–nanofiber constructs of
of drugs.99,115,123–125 These drug delivery systems dermis was fabricated by architecting layer-by-layer
using electrospun nanofibers exhibit pain relief and of nanofibers–cells alternated using electrospinning
extended antibacterial activity with great potential of nanofibers of PCL/collagen and seeding human dermal
the applications in wound healing. fibroblasts (Figure 6).130 Dermal tissue or bilayered
For the use of electrospun pure synthetic poly- skin equivalent was produced by continuous cul-
mer in skin tissue engineering, only limited synthetic turing of fibroblast/fiber-layered constructs or inclu-
polymers such as PLLA, PLGA, blended poly(dl- sion of keratinocytes seeded onto the dermal layer.
lactide), and poly(ethylene glycol) having acceptable Several other composites including PLGA/collagen,
hydrophilicity have been reported for the potential PLLA/gelatin, and PVA/chitosan have been electro-
application in skin tissue scaffolding.106,126,127 It is spun and their characteristics oriented for the appli-
widely accepted that the incorporation of natural poly- cation in skin tissue engineering were discussed.98,118
mer into electrospun synthetic nanofibers is desirable These scaffolds showed their efficacy for wound cov-
in skin tissue engineering to promote the biological erage or cell growth biocompatibility, but further
activity of scaffolds. Composite polymeric nanofibers clinical studies are needed.
can be electrospun using mixed solution,107 using Previous work using this nanofabrication tech-
dual or co-electrospinning method in separate solvent nique already suggested great potential of applying
systems111 or coaxial core/shell electrospinning.100 nanofibrous scaffolds for wound dressing or skin
Nanofibrous composite of PCL/collagen was tissue engineering. However, very limited in vivo
electrospun, as the one in early model of composite applications for skin repair and regeneration have
used to support dermal fibroblasts. Heather et al. been reported. More effort is still needed to seek
investigated the association of mechanical strength FDA approval for use and to prove their effectiveness
and biological affinity of blended PCL/collagen in repairing and regenerating skin. Electrospun
scaffolds with various ratios of PCL/collagen.128 scaffolds have been extensively used in vitro to study
Minimal addition of PCL (10%) to collagen produces cell–scaffold interactions, and further understanding

518  2010 Jo h n Wiley & So n s, In c. Vo lu me 2, September/Octo ber 2010


WIREs Nanomedicine and Nanobiotechnology Tissue scaffolds for skin wound healing

Step 1: Fiber spinning (1 layer fiber) Step 2: Cell seeding (1 layer cell)

FIGURE 6 | Schematic Fiber


illustration of layer-by-layer dermal Cell
reconstruction using nanofibrous Cell
scaffold. (Reprinted with Fiber
permission from Ref 130. Copyright Cell
2009 Mary Ann Liebert, Inc.
Publishers). Repeat step 1 & step 2 until desirable layers of fibers and cells On site layer-by-layer tissue generation

of the cellular response of nanofibrous scaffolds might Although the potential risks and benefits of com-
ultimately lead to the success in tissue repair or regen- posite scaffolds need to be further evaluated in clinical
eration of skin. trials, it is acceptable that they offer a new significant
direction for the treatment of wounds. Composite of
natural and synthetic polymers provides a compro-
mised solution for overcoming the shortcomings of
CONCLUSIONS AND FUTURE natural and synthetic polymers and can result in a new
OUTLOOK biomaterial with appropriate biocompatibility and
mechanical, physical, and chemical properties. Elec-
Tissue scaffolds have been demonstrated to be useful trospinning can produce new type nanofibrous scaf-
in wound dressing or skin tissue engineering in a folds for wound dressing or skin tissue engineering.
variety of wound conditions. Tissue scaffolds can not This electrospun type scaffold exhibits an appropriate
only can cover the wound and provide a physical porous structure that can mimic the collagenous struc-
barrier, but can also can offer a cellular skin ture of native dermis. The electrospun PCL/gelatin
with excretive biological components to stimulate scaffolds developed in our laboratory exhibit excellent
re-epithelialization and formation of granulation biocompatibility and biodegradability. The low cost
tissue. A variety of scaffolds fabricated based on and existing FDA approval for use of PCL and gelatin
materials ranging from naturally occurring materials and their proven efficiency in tissue engineering con-
and those manufactured synthetically have been tribute to the ease of FDA approval for clinical use and
reviewed in this article. Collagen-based materials commercialization of the final artificial skin using this
have been investigated extensively and significant scaffold. In future, the directions in scaffold design-
success has been achieved in a variety of commercial ing would be to incorporate molecules such as ECM,
or laboratory-engineered skin substitutes for wound growth factors, or cytokines associated with enhanc-
healing. However, many problems associated with ing wound healing into the right scaffolds. A relatively
the current scaffolds and artificial skin substitutes, clearer understanding of the approaches involving
which include contraction, delayed vascularization, material design and cellular/molecular process has
high cost, and scarring, have been emerging and they been achieved.
vary in their severity. It is hoped that a combination However, there are still many challenges
of appropriate biomaterials and techniques can collectively faced by bioengineers, cell biologists, and
overcome many of these problems in order to eliminate clinicians, and further development in this area will
or reduce the risk of failure in skin graft. require ongoing interactions and collaborations.93

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Advanced Review www.wiley.com/wires/nanomed

New technologies are being developed to provide hope proved that stem cells can contribute to skin reconsti-
for future regenerative skin technologies. For example, tution in skin wounds.134,135 The limited regenerative
stem cell technology is making new milestones with capacity of epidermal keratinocytes could be over-
advances in the efficiency of cell culturing. Stem cells come by using self-renewing keratinocyte stem cells.
Locating hair follicle stem cells can bring possible
are defined by their capacity of self-renewal and mul-
hope of forming hair follicle in future bioengineered
tilineage differentiation, which make them attractive
skin products.132,134,135 Stem cell techniques will bring
in treating a broad spectrum of human diseases using new breakthroughs in skin tissue engineering. The for-
regenerative medicine approaches.131,132 Significant mation of a new generation of skin substitutes with
advances have been made in identifying and locating complete functions and structures of native skin fully
the stem cells in the skin,133 and several studies have restored can potentially be achieved in the next decade.

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