Invited commentary

Invited commentary domized double-blind controlled clinical studies obvi- ously need to be completed to determine the true validity of this technique. The reader, however, is cautioned M.J. Morykwas, L.C. Argenta about applying overly rigid scientific criteria before at Department of Plastic and Reconstructive Surgery, least trying a new technique. Our studies indicate that Bowman Gray School of Medicine of Wake Forest University, there are approximately 37 variables that affect healing 300 South Hawthorne Road, Winston-Salem, NC 27103, USA of chronic wounds. The prospective randomized studies of chronic wounds will require huge numbers of patients and extended periods of time. The reader is thus cau- This is an interesting article which is based on the sim- tioned that definitive studies on healing of chronic ple physiologic principle of directly supplying nutrients wounds will probably not be available for 5 to 10 years. to the cells near the surface of chronic wounds. Chronic We have found cultured epidermal (keratinocyte) wounds are characterized by a peripheral border of allografts to be very effective in accelerating the rate of edematous tissue in which blood flow in minimal. Thus re-epithelialization of chronic ulcers, probably acting by the delivery of nutrients, oxygen and systemically ad- releasing growth factors directly into the wound. A ministered antibiotics to the cells in the wound proper is mechanism of action proposed by the authors is that the compromised. This is a "zone of stasis" which has been supplied nutrients and hormones allow cells in the classicaly discussed with burn injury. In fact, a zone of wound to synthesize the matrix molecules and growth stasis probably exists around all chronic wounds. This is factors required for healing. A comparison of the effica- the area in which viable cells hang in a precarious bal- cy of the described technique compared to cultured kera- ance between life and death. A disruption in this balance tinocyte grafts would be extremely valuable and infor- determines if the wound is to heal or progress. In this ar- mative. ticle, Lindenbaum et al. describe the efficacy of the ap- The reported infection rate of 1.1% (1 of 92 pts.) is plication of serum-free medium supplemented with thy- lower than would be presumed. Every chronic open roxin, growth hormone, insulin, transferrin and sodium wound is colonized, and any microorganisms present selenite in 1% agarose in increasing the rate of healing would compete with the host cells for the supplied nutri- of chronic ulcers. The authors had previously successful- ents. The low infection rate may be related to the report- ly tested the technique in an animal model [1]. Similarly, ed increase in granulation tissue formation. topically applied cell culture medium on the take of skin In summary, application of serum free culture medi- grafts in an athymic mouse model increased the percent um in an agarose vehicle appears to be a viable tech- take of skin grafts [2]. The described technique, in con- nique for treatment of these very difficult to heal cept, bypasses the nutrient inflow to the wound normally wounds, especially in centers which do not have the fa- delivered by the capillary system. Whether these nutri- cilities to grow cultured keratinocyte grafts. ents directly influence cellular metabolism to induce mi- tosis and then produce healing or whether they "upregu- late" compromised cells to produce growth factors that promote healing awaits further study. References The drop out rate of 45.5% (42/92) is high, but is to 1. Lindenbaum ES, Tendler M, Beach D (1995) Serum-free cell be expected in a study of this type with a broad-based culture medium induces acceleration of wound healing in inclusion criteria. The average treatment times of 11.5 guinea-pigs. Burns 21 :l 10-115 weeks for non-diabetic patients and 14 weeks for diabet- 2. Boyce ST, Supp AR Harrigan MD, Greenhalgh DG, Warden ic patients are encouraging, and would seem to be reflec- GD (1995) Topical nutrients promote engraftment and inhibit tive of accelerated healing in a population with the type wound contraction of cultured skin substitutes in athymic of wounds and systemic pathologies described. The ran- mice. J Invest Dermatol 104:345-349 European Journal of Plastic Surgery Springer Journals
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Copyright © 1997 by Springer-Verlag
Medicine & Public Health; Plastic Surgery
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