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Outcome of Split Thickness Skin Grafts on Excised Burns with Different Dermal Compositions

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Outcome of Split Thickness Skin Grafts on Excised Burns with Different Dermal Compositions Department of Plastic Surgery and Department of Pharmacology Faculty of Medicine University of Helsinki Finland Outcome of split thickness skin grafts on excised burns with different dermal compositions Heli Lagus Academic dissertation To be presented, with the permission of the Faculty of Medicine of the University of Helsinki, for public examination Porthania lecture hall P674, Helsinki, on June 26th 2020, at 12 o’clock noon. Helsinki 2020 Supervised by Professor Jyrki Vuola, M.D., Ph.D. Department of Plastic Surgery Helsinki Burn Centre Helsinki University Hospital and University of Helsinki Finland Docent Esko Kankuri, M.D., Ph.D. Department of Pharmacology University of Helsinki Finland Reviewed by Julian Dye, MA (Oxon), Ph.D. (Lon) CBiol, FRSB Institute of Biomedical Engineering University of Oxford United Kingdom Docent Ilkka Kaartinen, M.D., Ph.D. Department of Plastic Surgery Tampere University Hospital Finland Opponent Professor Esther Middelkoop, Ph.D. in biochemistry Plastic, Reconstructive and Hand Surgery Amsterdam UMC - Vrije Universiteit Amsterdam The Netherlands The Faculty of Medicine uses the Urkund system (plagiarism recognition) to examine all doctoral dissertations. ISBN: 978-951-51-6066-9 (print) ISBN: 978-951-51-6067-6 (on-line) University Printing House Helsinki 2020 To my family 3 Table of Contents List of original publications........................................................................................................... 6 Abbreviations ................................................................................................................................ 7 Abstract ......................................................................................................................................... 8 1. Introduction ............................................................................................................................... 9 2. Review of the literature ........................................................................................................... 10 2.1 Function and structure of skin ................................................................................. 10 2.1.1 Epidermis ............................................................................................................. 10 2.1.2 Basement membrane ........................................................................................... 12 2.1.3 Dermis ................................................................................................................. 12 2.1.4 Subcutis or hypodermis ....................................................................................... 15 2.1.5 Skin homeostasis and maintenance by ECM and dermal fibroblasts .................. 15 2.2 Cell structure and function ...................................................................................... 15 2.2.1 Cell cycle ............................................................................................................. 16 2.2.2 Gene expression ................................................................................................... 16 2.2.3 Cell signaling ....................................................................................................... 17 2.3 Wound healing ........................................................................................................ 25 2.3.1 Wound healing phases ......................................................................................... 26 2.3.2 Factors affecting wound healing .......................................................................... 34 2.4 Temporary and permanent wound covers ............................................................... 35 2.4.1 Temporary wound covers .................................................................................... 35 2.4.2 Permanent wound covers/ skin replacements ...................................................... 35 2.4.3 Dermo-epidermal substitutes /composite skin substitutes ................................... 37 2.4.4 Bioengineered wound covers............................................................................... 37 2.5 Scar assessment methods ........................................................................................ 41 2.5.1 Scar assessment scales currently available .......................................................... 41 2.5.2 Objective scar measuring devices ........................................................................ 42 2.5.3 Protein profiling methods .................................................................................... 43 2.6 Psoriasis .................................................................................................................. 44 3. Aims of the study .................................................................................................................... 46 4. Materials and methods ............................................................................................................. 47 4.1 Patients .................................................................................................................... 47 4.1.1 Burn patients ........................................................................................................ 47 4.1.2 Psoriasis patients ................................................................................................. 47 4.1.3 Healthy controls ................................................................................................... 47 4.2 Wounds and wound cover materials ....................................................................... 47 4.2.1 Burn wound type and location ............................................................................. 47 4.2.2 Timeline of the study ........................................................................................... 48 4.2.3 Skin samples (I, II, and III).................................................................................. 49 Assessment and analysis methods .......................................................................................... 51 4.2.4 Vancouver Scar Scale .......................................................................................... 51 4.2.5 Proteomics ........................................................................................................... 51 4.2.6 Imaging and image analysis ................................................................................ 52 4.2.7 Statistical and biostatistical analyses, tools and databases .................................. 53 4.2.8 Cell stimulation experiments ............................................................................... 54 5. Results ..................................................................................................................................... 57 5.1 Histology and immunohistochemistry .................................................................... 57 5.1.1 Inflammation ....................................................................................................... 57 5.1.2 Proliferation ......................................................................................................... 57 5.1.3 Remodeling phase 3 weeks to 12 months ............................................................ 58 5.2 Clinical findings-VSS ............................................................................................. 60 5.3 Proteomics .............................................................................................................. 62 5.3.1 Gene expression analyses .................................................................................... 65 4 5.3.2 Cell stimulation experiments ............................................................................... 65 6. Discussion ............................................................................................................................... 67 6.1 The effects of different treatment materials on wound healing and on STSGs, and long-term outcome one year after surgery, studies I & II .................................. 67 6.1.1 Biocompatibility and biodegradability ................................................................ 68 6.1.2 Inflammation ....................................................................................................... 68 6.1.3 Proliferation phase ............................................................................................... 69 6.2 The long-term effects of different early wound-bed treatment materials detected in proteomics and reflected to psoriasis, study III ................................................... 75 6.2.1 Proteomic findings in skin samples of burn patients ........................................... 75 6.2.2 Validations ........................................................................................................... 76 6.2.3 IPA and TRANSFAC® analyses ........................................................................ 77 6.2.4 DNAH10 mRNA splice variants ......................................................................... 77 6.2.5 DNAH10 expression in inflammatory skin pathology psoriasis ......................... 78 6.2.6 DNAH10 in cell stimulation experiments ........................................................... 78 7. Conclusions ............................................................................................................................. 81 8. Future prospects .....................................................................................................................
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