Geoffrey Gurtner

All Publications

Diabetes irreversibly depletes bone marrow-derived mesenchymal progenitor cell subpopulations. Diabetes Januszyk, M., Sorkin, M., Glotzbach, J. P., Vial, I. N., Maan, Z. N., Rennert, R. C., Duscher, D., Thangarajah, H., Longaker, M. T., Butte, A. J., Gurtner, G. C. 2014; 63 (9): 3047-3056
Abstract

Diabetic vascular pathology is largely attributable to impairments in tissue recovery from hypoxia. Circulating progenitor cells have been postulated to play a role in ischemic recovery and deficiencies in these cells have been well described in diabetic patients. Here, we examine bone marrow-derived mesenchymal progenitor cells (BM-MPCs) that have previously been shown to be important for new blood vessel formation, and demonstrate significant deficits in the context of diabetes. Further, we determine that this dysfunction is attributable to intrinsic defects in diabetic BM-MPCs that are not correctable by restoring glucose homeostasis. We identify two transcriptionally distinct subpopulations that are selectively depleted by both type 1 and type 2 diabetes, and these subpopulations have pro-vasculogenic expression profiles, suggesting that they are vascular progenitor cells. These results suggest that the clinically observed deficits in progenitor cells may be attributable to selective and irreversible depletion of progenitor cell subsets in patients with diabetes.

View details for DOI 10.2337/db13-1366

View details for PubMedID 24740572
Tracking the elusive fibrocyte: identification and characterization of collagen-producing hematopoietic lineage cells during murine wound healing. Stem cells Suga, H., Rennert, R. C., Rodrigues, M., Sorkin, M., Glotzbach, J. P., Januszyk, M., Fujiwara, T., Longaker, M. T., Gurtner, G. C. 2014; 32 (5): 1347-1360
Abstract

Fibrocytes are a unique population of circulating cells reported to exhibit characteristics of both hematopoietic and mesenchymal cells, and play an important role in wound healing. However, putative fibrocytes have been found to lose expression of hematopoietic surface markers such as CD45 during differentiation, making it difficult to track these cells in vivo with conventional methodologies. In this study, to distinguish hematopoietic and nonhematopoietic cells without surface markers, we took advantage of the gene vav 1, which is expressed solely on hematopoietic cells but not on other cell types, and established a novel transgenic mouse, in which hematopoietic cells are irreversibly labeled with green fluorescent protein and nonhematopoietic cells with red fluorescent protein. Use of single-cell transcriptional analysis in this mouse model revealed two discrete types of collagen I (Col I) expressing cells of hematopoietic lineage recruited into excisional skin wounds. We confirmed this finding on a protein level, with one subset of these Col I synthesizing cells being CD45+ and CD11b+, consistent with the traditional definition of a fibrocyte, while another was CD45- and Cd11b-, representing a previously unidentified population. Both cell types were found to initially peak, then reduce posthealing, consistent with a disappearance from the wound site and not a loss of identifying surface marker expression. Taken together, we have unambiguously identified two cells of hematopoietic origin that are recruited to the wound site and deposit collagen, definitively confirming the existence and natural time course of fibrocytes in cutaneous healing. Stem Cells 2014;32:1347-1360.

View details for DOI 10.1002/stem.1648

View details for PubMedID 24446236
Enhancement of mesenchymal stem cell angiogenic capacity and stemness by a biomimetic hydrogel scaffold BIOMATERIALS Rustad, K. C., Wong, V. W., Sorkin, M., Glotzbach, J. P., Major, M. R., Rajadas, J., Longaker, M. T., Gurtner, G. C. 2012; 33 (1): 80-90
Abstract

In this study, we examined the capacity of a biomimetic pullulan-collagen hydrogel to create a functional biomaterial-based stem cell niche for the delivery of mesenchymal stem cells (MSCs) into wounds. Murine bone marrow-derived MSCs were seeded into hydrogels and compared to MSCs grown in standard culture conditions. Hydrogels induced MSC secretion of angiogenic cytokines and expression of transcription factors associated with maintenance of pluripotency and self-renewal (Oct4, Sox2, Klf4) when compared to MSCs grown in standard conditions. An excisonal wound healing model was used to compare the ability of MSC-hydrogel constructs versus MSC injection alone to accelerate wound healing. Injection of MSCs did not significantly improve time to wound closure. In contrast, wounds treated with MSC-seeded hydrogels showed significantly accelerated healing and a return of skin appendages. Bioluminescence imaging and FACS analysis of luciferase+/GFP+ MSCs indicated that stem cells delivered within the hydrogel remained viable longer and demonstrated enhanced engraftment efficiency than those delivered via injection. Engrafted MSCs were found to differentiate into fibroblasts, pericytes and endothelial cells but did not contribute to the epidermis. Wounds treated with MSC-seeded hydrogels demonstrated significantly enhanced angiogenesis, which was associated with increased levels of VEGF and other angiogenic cytokines within the wounds. Our data suggest that biomimetic hydrogels provide a functional niche capable of augmenting MSC regenerative potential and enhancing wound healing.

View details for DOI 10.1016/j.biomaterials.2011.09.041

View details for Web of Science ID 000297399700009

View details for PubMedID 21963148
Focal adhesion kinase links mechanical force to skin fibrosis via inflammatory signaling. Nature medicine Wong, V. W., Rustad, K. C., Akaishi, S., Sorkin, M., Glotzbach, J. P., Januszyk, M., Nelson, E. R., Levi, K., Paterno, J., Vial, I. N., Kuang, A. A., Longaker, M. T., Gurtner, G. C. 2012; 18 (1): 148-152
Abstract

Exuberant fibroproliferation is a common complication after injury for reasons that are not well understood. One key component of wound repair that is often overlooked is mechanical force, which regulates cell-matrix interactions through intracellular focal adhesion components, including focal adhesion kinase (FAK). Here we report that FAK is activated after cutaneous injury and that this process is potentiated by mechanical loading. Fibroblast-specific FAK knockout mice have substantially less inflammation and fibrosis than control mice in a model of hypertrophic scar formation. We show that FAK acts through extracellular-related kinase (ERK) to mechanically trigger the secretion of monocyte chemoattractant protein-1 (MCP-1, also known as CCL2), a potent chemokine that is linked to human fibrotic disorders. Similarly, MCP-1 knockout mice form minimal scars, indicating that inflammatory chemokine pathways are a major mechanism by which FAK mechanotransduction induces fibrosis. Small-molecule inhibition of FAK blocks these effects in human cells and reduces scar formation in vivo through attenuated MCP-1 signaling and inflammatory cell recruitment. These findings collectively indicate that physical force regulates fibrosis through inflammatory FAK-ERK-MCP-1 pathways and that molecular strategies targeting FAK can effectively uncouple mechanical force from pathologic scar formation.

View details for DOI 10.1038/nm.2574

View details for PubMedID 22157678
Vascular anastomosis using controlled phase transitions in poloxamer gels NATURE MEDICINE Chang, E. I., Galvez, M. G., Glotzbach, J. P., Hamou, C. D., El-Ftesi, S., Rappleye, C. T., Sommer, K., Rajadas, J., Abilez, O. J., Fuller, G. G., Longaker, M. T., Gurtner, G. C. 2011; 17 (9): 1147-U160
Abstract

Vascular anastomosis is the cornerstone of vascular, cardiovascular and transplant surgery. Most anastomoses are performed with sutures, which are technically challenging and can lead to failure from intimal hyperplasia and foreign body reaction. Numerous alternatives to sutures have been proposed, but none has proven superior, particularly in small or atherosclerotic vessels. We have developed a new method of sutureless and atraumatic vascular anastomosis that uses US Food and Drug Administration (FDA)-approved thermoreversible tri-block polymers to temporarily maintain an open lumen for precise approximation with commercially available glues. We performed end-to-end anastomoses five times more rapidly than we performed hand-sewn controls, and vessels that were too small (<1.0 mm) to sew were successfully reconstructed with this sutureless approach. Imaging of reconstructed rat aorta confirmed equivalent patency, flow and burst strength, and histological analysis demonstrated decreased inflammation and fibrosis at up to 2 years after the procedure. This new technology has potential for improving efficiency and outcomes in the surgical treatment of cardiovascular disease.

View details for DOI 10.1038/nm.2424

View details for Web of Science ID 000294605100038

View details for PubMedID 21873986
Improving Cutaneous Scar Formation by Controlling the Mechanical Environment Large Animal and Phase I Studies ANNALS OF SURGERY Gurtner, G. C., Dauskardt, R. H., Wong, V. W., Bhatt, K. A., Wu, K., Vial, I. N., Padois, K., Korman, J. M., Longaker, M. T. 2011; 254 (2): 217-225
Abstract

To test the hypothesis that the mechanical environment of cutaneous wounds can control scar formation.Mechanical forces have been recognized to modulate myriad biologic processes, but the role of physical force in scar formation remains unclear. Furthermore, the therapeutic benefits of offloading cutaneous wounds with a device have not been rigorously tested.A mechanomodulating polymer device was utilized to manipulate the mechanical environment of closed cutaneous wounds in red Duroc swine. After 8 weeks, wounds subjected to different mechanical stress states underwent immunohistochemical analysis for fibrotic markers. In a phase I clinical study, 9 human patients undergoing elective abdominal surgery were treated postoperatively with a stress-shielding polymer on one side whereas the other side was treated as standard of care. Professional photographs were taken between 8 and 12 months postsurgery and evaluated using a visual analog scale by lay and professional panels. This study is registered with ClinicalTrials.gov, number NCT00766727.Stress shielding of swine incisions reduced histologic scar area by 6- and 9-fold compared to control and elevated stress states, respectively (P < 0.01 for both) and dramatically decreased the histologic expression of profibrotic markers. Closure of high-tension wounds induced human-like scar formation in the red Duroc, a phenotype effectively mitigated with stress shielding of wounds. In the study on humans, stress shielding of abdominal incisions significantly improved scar appearance (P = 0.004) compared with within-patient controls.These results indicate that mechanical manipulation of the wound environment with a dynamic stress-shielding polymer device can significantly reduce scar formation.

View details for DOI 10.1097/SLA.0b013e318220b159

View details for Web of Science ID 000292908700007

View details for PubMedID 21606834
An Information Theoretic, Microfluidic-Based Single Cell Analysis Permits Identification of Subpopulations among Putatively Homogeneous Stem Cells PLOS ONE Glotzbach, J. P., Januszyk, M., Vial, I. N., Wong, V. W., Gelbard, A., Kalisky, T., Thangarajah, H., Longaker, M. T., Quake, S. R., Chu, G., Gurtner, G. C. 2011; 6 (6)
Abstract

An incomplete understanding of the nature of heterogeneity within stem cell populations remains a major impediment to the development of clinically effective cell-based therapies. Transcriptional events within a single cell are inherently stochastic and can produce tremendous variability, even among genetically identical cells. It remains unclear how mammalian cellular systems overcome this intrinsic noisiness of gene expression to produce consequential variations in function, and what impact this has on the biologic and clinical relevance of highly 'purified' cell subgroups. To address these questions, we have developed a novel method combining microfluidic-based single cell analysis and information theory to characterize and predict transcriptional programs across hundreds of individual cells. Using this technique, we demonstrate that multiple subpopulations exist within a well-studied and putatively homogeneous stem cell population, murine long-term hematopoietic stem cells (LT-HSCs). These subgroups are defined by nonrandom patterns that are distinguishable from noise and are consistent with known functional properties of these cells. We anticipate that this analytic framework can also be applied to other cell types to elucidate the relationship between transcriptional and phenotypic variation.

View details for DOI 10.1371/journal.pone.0021211

View details for Web of Science ID 000292033700046

View details for PubMedID 21731674
The molecular basis for impaired hypoxia-induced VEGF expression in diabetic tissues PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Thangarajah, H., Yao, D., Chang, E. I., Shi, Y., Jazayeri, L., Vial, I. N., Galiano, R. D., Du, X., Grogan, R., Galvez, M. G., Januszyk, M., Brownlee, M., Gurtner, G. C. 2009; 106 (32): 13505-13510
Abstract

Diabetes is associated with poor outcomes following acute vascular occlusive events. This results in part from a failure to form adequate compensatory microvasculature in response to ischemia. Since vascular endothelial growth factor (VEGF) is an essential mediator of neovascularization, we examined whether hypoxic up-regulation of VEGF was impaired in diabetes. Both fibroblasts isolated from type 2 diabetic patients, and normal fibroblasts exposed chronically to high glucose, were defective in their capacity to up-regulate VEGF in response to hypoxia. In vivo, diabetic animals demonstrated an impaired ability to increase VEGF production in response to soft tissue ischemia. This resulted from a high glucose-induced decrease in transactivation by the transcription factor hypoxia-inducible factor-1alpha (HIF-1alpha), which mediates hypoxia-stimulated VEGF expression. Decreased HIF-1alpha functional activity was specifically caused by impaired HIF-1alpha binding to the coactivator p300. We identify covalent modification of p300 by the dicarbonyl metabolite methylglyoxal as being responsible for this decreased association. Administration of deferoxamine abrogated methylglyoxal conjugation, normalizing both HIF-1alpha/p300 interaction and transactivation by HIF-1alpha. In diabetic mice, deferoxamine promoted neovascularization and enhanced wound healing. These findings define molecular defects that underlie impaired VEGF production in diabetic tissues and offer a promising direction for therapeutic intervention.

View details for DOI 10.1073/pnas.0906670106

View details for Web of Science ID 000268877300065

View details for PubMedID 19666581
Wound repair and regeneration NATURE Gurtner, G. C., Werner, S., Barrandon, Y., Longaker, M. T. 2008; 453 (7193): 314-321
Abstract

The repair of wounds is one of the most complex biological processes that occur during human life. After an injury, multiple biological pathways immediately become activated and are synchronized to respond. In human adults, the wound repair process commonly leads to a non-functioning mass of fibrotic tissue known as a scar. By contrast, early in gestation, injured fetal tissues can be completely recreated, without fibrosis, in a process resembling regeneration. Some organisms, however, retain the ability to regenerate tissue throughout adult life. Knowledge gained from studying such organisms might help to unlock latent regenerative pathways in humans, which would change medical practice as much as the introduction of antibiotics did in the twentieth century.

View details for DOI 10.1038/nature07039

View details for Web of Science ID 000255868400038

View details for PubMedID 18480812
Decreasing intracellular superoxide corrects defective ischemia-induced new vessel formation in diabetic mice JOURNAL OF BIOLOGICAL CHEMISTRY Ceradini, D. J., Yao, D., Grogan, R. H., Callaghan, M. J., Edelstein, D., Brownlee, M., Gurtner, G. C. 2008; 283 (16): 10930-10938
Abstract

Tissue ischemia promotes vasculogenesis through chemokine-induced recruitment of bone marrow-derived endothelial progenitor cells (EPCs). Diabetes significantly impairs this process. Because hyperglycemia increases reactive oxygen species in a number of cell types, and because many of the defects responsible for impaired vasculogenesis involve HIF1-regulated genes, we hypothesized that HIF1 function is impaired in diabetes because of reactive oxygen species-induced modification of HIF1alpha by the glyoxalase 1 (GLO1) substrate methylglyoxal. Decreasing superoxide in diabetic mice by either transgenic expression of manganese superoxide dismutase or by administration of an superoxide dismutase mimetic corrected post-ischemic defects in neovascularization, oxygen delivery, and chemokine expression, and normalized tissue survival. In hypoxic fibroblasts cultured in high glucose, overexpression of GLO1 prevented reduced expression of both the EPC mobilizing chemokine stromal cell-derived factor-1 (SDF-1) and of vascular epidermal growth factor, which modulates growth and differentiation of recruited EPCs. In hypoxic EPCs cultured in high glucose, overexpression of GLO1 prevented reduced expression of both the SDF-1 receptor CXCR4, and endothelial nitric-oxide synthase, an enzyme essential for EPC mobilization. HIF1alpha modification by methylglyoxal reduced heterodimer formation and HIF1alpha binding to all relevant promoters. These results provide a basis for the rational design of new therapeutics to normalize impaired ischemia-induced vasculogenesis in patients with diabetes.

View details for DOI 10.1074/jbc.M707451200

View details for Web of Science ID 000254894700074

View details for PubMedID 18227068

View details for PubMedCentralID PMC2447622
Isolation of CD248-expressing stromal vascular fraction for targeted improvement of wound healing. Wound repair and regeneration Brett, E., Zielins, E. R., Chin, M., Januszyk, M., Blackshear, C. P., Findlay, M., Momeni, A., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2017
Abstract

Wound healing remains a global issue of disability, cost, and health. Addition of cells from the stromal vascular fraction (SVF) of adipose tissue has been shown to increase the rate of full thickness wound closure. This study aimed to investigate the angiogenic mechanisms of CD248+ SVF cells in the context of full thickness excisional wounds. Single cell transcriptional analysis was used to identify and cluster angiogenic gene-expressing cells, which was then correlated with surface marker expression. SVF cells isolated from human lipoaspirate were FACS sorted based on the presence of CD248. Cells were analyzed for angiogenic gene expression and ability to promote microvascular tubule formation in vitro. Following this, 6mm full thickness dermal wounds were created on the dorsa of immunocompromised mice and then treated with CD248+, CD248-, or unsorted SVF cells delivered in a pullalan-collagen hydrogel or the hydrogel alone. Wounds were measured every other day photometrically until closure. Wounds were also evaluated histologically at 7 and 14 days post-wounding and when fully healed to assess for reepithelialization and development of neovasculature. Wounds treated with CD248+ cells healed significantly faster than other treatment groups, and at 7 days, had quantitatively more reepithelialization. Concurrently, immunohistochemistry of CD31 revealed a much higher presence of vascularity in the CD248+ SVF cells treated group at the time of healing and at 14 days post-op, consistent with a pro-angiogenic effect of CD248+ cells in vivo. Therefore, using CD248+ pro-angiogenic cells obtained from SVF presents a viable strategy in wound healing by promoting increased vessel growth in the wound.

View details for DOI 10.1111/wrr.12542

View details for PubMedID 28464475
Comparison of the Hydroxylase Inhibitor Dimethyloxalylglycine and the Iron Chelator Deferoxamine in Diabetic and Aged Wound Healing. Plastic and reconstructive surgery Duscher, D., Januszyk, M., Maan, Z. N., Whittam, A. J., Hu, M. S., Walmsley, G. G., Dong, Y., Khong, S. M., Longaker, M. T., Gurtner, G. C. 2017; 139 (3): 695e-706e
Abstract

A hallmark of diabetes mellitus is the breakdown of almost every reparative process in the human body, leading to critical impairments of wound healing. Stabilization and activity of the transcription factor hypoxia-inducible factor (HIF)-1α is impaired in diabetes, leading to deficits in new blood vessel formation in response to injury. In this article, the authors compare the effectiveness of two promising small-molecule therapeutics, the hydroxylase inhibitor dimethyloxalylglycine and the iron chelator deferoxamine, for attenuating diabetes-associated deficits in cutaneous wound healing by enhancing HIF-1α activation.HIF-1α stabilization, phosphorylation, and transactivation were measured in murine fibroblasts cultured under normoxic or hypoxic and low-glucose or high-glucose conditions following treatment with deferoxamine or dimethyloxalylglycine. In addition, diabetic wound healing and neovascularization were evaluated in db/db mice treated with topical solutions of either deferoxamine or dimethyloxalylglycine, and the efficacy of these molecules was also compared in aged mice.The authors show that deferoxamine stabilizes HIF-1α expression and improves HIF-1α transactivity in hypoxic and hyperglycemic states in vitro, whereas the effects of dimethyloxalylglycine are significantly blunted under hyperglycemic hypoxic conditions. In vivo, both dimethyloxalylglycine and deferoxamine enhance wound healing and vascularity in aged mice, but only deferoxamine universally augmented wound healing and neovascularization in the setting of both advanced age and diabetes.This first direct comparison of deferoxamine and dimethyloxalylglycine in the treatment of impaired wound healing suggests significant therapeutic potential for topical deferoxamine treatment in ischemic and diabetic disease.

View details for DOI 10.1097/PRS.0000000000003072

View details for PubMedID 28234841

View details for PubMedCentralID PMC5327844
Excess Dermal Tissue Remodeling In Vivo: Does It Settle? Plastic and reconstructive surgery Leavitt, T., Hu, M. S., Zielins, E. R., Barnes, L. A., Marshall, C. D., Wan, D. C., Lorenz, H. P., Gurtner, G. C., Longaker, M. T. 2017; 139 (2): 415e-424e
Abstract

Surgical manipulation of skin may result in undesired puckering of excess tissue, which is generally assumed to settle over time. In this article, the authors address the novel question of how this excess tissue remodels.Purse-string sutures (6-0 nylon) were placed at the midline dorsum of 22 wild-type BALB/c mice in a circular pattern marked with tattoo ink. Sutures were cinched and tied under tension in the treatment group, creating an excess tissue deformity, whereas control group sutures were tied without tension. After 2 or 4 weeks, sutures were removed. The area of tattooed skin was measured up to 56 days after suture removal. Histologic analysis was performed on samples harvested 14 days after suture removal.The majority of excess tissue deformities flattened within 2 days after suture removal. However, the sutured skin in the treatment group decreased in area by an average of 18 percent from baseline (n = 9), compared to a 1 percent increase in the control group (n = 10) at 14 days after suture removal (p < 0.05). This was similarly observed at 28 days (treatment, -11.7 percent; control, 4.5 percent; n = 5; p = 0.0243). Despite flattening, deformation with purse-string suture correlated with increased collagen content of skin, in addition to increased numbers of myofibroblasts. Change in area did not correlate with duration of suture placement.Excess dermal tissue deformities demonstrate the ability to remodel with gross flattening of the skin, increased collagen deposition, and incomplete reexpansion to baseline area. Further studies will reveal whether our findings in this mouse model translate to humans.

View details for DOI 10.1097/PRS.0000000000003026

View details for PubMedID 28121870
Pharmacological rescue of diabetic skeletal stem cell niches. Science translational medicine Tevlin, R., Seo, E. Y., Marecic, O., McArdle, A., Tong, X., Zimdahl, B., Malkovskiy, A., Sinha, R., Gulati, G., Li, X., Wearda, T., Morganti, R., Lopez, M., Ransom, R. C., Duldulao, C. R., Rodrigues, M., Nguyen, A., Januszyk, M., Maan, Z., Paik, K., Yapa, K., Rajadas, J., Wan, D. C., Gurtner, G. C., Snyder, M., Beachy, P. A., Yang, F., Goodman, S. B., Weissman, I. L., Chan, C. K., Longaker, M. T. 2017; 9 (372)
Abstract

Diabetes mellitus (DM) is a metabolic disease frequently associated with impaired bone healing. Despite its increasing prevalence worldwide, the molecular etiology of DM-linked skeletal complications remains poorly defined. Using advanced stem cell characterization techniques, we analyzed intrinsic and extrinsic determinants of mouse skeletal stem cell (mSSC) function to identify specific mSSC niche-related abnormalities that could impair skeletal repair in diabetic (Db) mice. We discovered that high serum concentrations of tumor necrosis factor-α directly repressed the expression of Indian hedgehog (Ihh) in mSSCs and in their downstream skeletogenic progenitors in Db mice. When hedgehog signaling was inhibited during fracture repair, injury-induced mSSC expansion was suppressed, resulting in impaired healing. We reversed this deficiency by precise delivery of purified Ihh to the fracture site via a specially formulated, slow-release hydrogel. In the presence of exogenous Ihh, the injury-induced expansion and osteogenic potential of mSSCs were restored, culminating in the rescue of Db bone healing. Our results present a feasible strategy for precise treatment of molecular aberrations in stem and progenitor cell populations to correct skeletal manifestations of systemic disease.

View details for DOI 10.1126/scitranslmed.aag2809

View details for PubMedID 28077677
The Abnormal Architecture of Healed Diabetic Ulcers is the Result of FAK Degradation by Calpain 1. journal of investigative dermatology Liu, W., Ma, K., Kwon, S. H., Garg, R., Patta, Y. R., Fujiwara, T., Gurtner, G. C. 2017
Abstract

Delayed wound healing is a major complication of diabetes occurring in approximately 15% of chronic diabetic patients. It not only significantly affects patients' quality of life but also poses a major economic burden to the health care system. Most efforts have been focused on accelerating wound reepithelialization and closure. However, even after healing the quality of healed tissue in diabetics is abnormal and recurrence is common (50-75%). Thus, understanding how diabetes alters the ultimate mechanical properties of healed wounds will be important to develop more effective approaches for this condition. Focal adhesion kinase is an intracellular protein kinase that plays critical roles in cell migration, focal adhesion formation, and is an important component of cellular mechanotransduction. We have found that focal adhesion kinase expression is downregulated under a high glucose condition both in vitro and in vivo. This is secondary to increased activity of calpain 1, the primary enzyme responsible for focal adhesion kinase degradation, which becomes induced in hyperglycemia. We demonstrate that selective inhibition of calpain 1 activation improves wound healing and normalizes the mechanical properties of diabetic skin, suggesting a new therapeutic approach to prevent diabetic wound recurrence.

View details for DOI 10.1016/j.jid.2016.11.039

View details for PubMedID 28082186
The Role of Stem Cell Therapeutics in Wound Healing: Current Understanding and Future Directions. Plastic and reconstructive surgery Sorice, S., Rustad, K. C., Li, A. Y., Gurtner, G. C. 2016; 138 (3): 31S-41S
Abstract

Chronic wounds present unique challenges for healthcare providers as they place patients at increased risk for various morbidities and mortality. Advances in wound care technology have expanded the treatment options available for wound management, but few products fully address the underlying core deficiencies responsible for the development of poorly healing wounds. In the future, addressing these derangements will undoubtedly play a key role in the treatment of these patients. Broad enthusiasm has surrounded the field of stem cell biology, which has shown great promise in repairing damaged tissues across numerous disease phenotypes.In this review, we provide a comprehensive review of the literature and evaluate the present landscape of wound therapeutics while discussing the rationales and allure behind stem cell-based products. We further propose 2 challenges that remain as new stem cell-based therapies are being developed and as this technology moves toward clinical translation.Given the relatively young age of this newer technology in wound healing, numerous challenges continue to surround its effective use including identifying the ideal population of stem cells to use and determining the optimal cell delivery method. However, significant forward progress has been made, with several clinical trials beginning to demonstrate reliable clinical benefit.The upward trajectory of stem cell technologies provides an exciting opportunity to positively impact patient outcomes through the controlled application of regenerative cell-based therapy.

View details for DOI 10.1097/PRS.0000000000002646

View details for PubMedID 27556772
Enhanced Electrochemical Sensing with Carbon Nanotubes Modified with Bismuth and Magnetic Nanoparticles in a Lab-on-a-Chip CHEMNANOMAT Jothimuthu, P., Hsu, J. L., Chen, R., Inayathullah, M., Pothineni, V. R., Jan, A., Gurtner, G. C., Rajadas, J., Nicolls, M. R. 2016; 2 (9): 904-910
View details for DOI 10.1002/cnma.201600174

View details for Web of Science ID 000383766800009
Protecting Nipple Perfusion by Devascularization and Surgical Delay in Patients at Risk for Ischemic Complications During Nipple-Sparing Mastectomies ANNALS OF SURGICAL ONCOLOGY Bertoni, D. M., Dung Nguyen, D., Rochlin, D., Hernandez-Boussard, T., Meyer, S., Choy, N., Gurtner, G. C., Wapnir, I. L. 2016; 23 (8): 2665-2672
Abstract

Indications for nipple-sparing mastectomy (NSM) are expanding; however, high-risk patients have more ischemic complications. Surgical devascularization of the nipple-areolar complex (NAC) prior to NSM can reduce complications. This study reports perfusion patterns and complications in high-risk patients undergoing 2-stage NSM.Surgical devascularization of the NAC was performed 3-6 weeks prior to NSM in 28 women. Risk factors included ptosis, obesity, smoking, prior breast surgery, and radiation. Using indocyanine green (ICG)-based fluorescence and an infrared camera, blood inflow was visualized intraoperatively. NAC perfusion patterns were classified as: V1, underlying breast; V2, surrounding skin; V3 = V1 + V2, or V4, capillary fill following devascularization. Ischemic complications were analyzed.Baseline perfusion for 54 breasts was 35 % V1, 32 % V2, and 33 % V3. Increasing ptosis was associated with V1 pattern: 86 % for grade 3, 31 % for grade 2, and 18 % for grade 1. Postdevascularization epidermolysis was observed in 63 % of V1 baseline, 41 % of V2, and 22 % of V3 (P = .042) and after NSM in 26 % for V1, 7 % for V2, and 6 % for V3 (P = .131). Ptosis was significantly associated with epidermolysis postdevascularization (P = .002) and NSM (P = .002). Smoking and BMI ≥30 were related to increased ischemic complications. Two or more risk factors were associated with postdevascularization ischemic changes (P = .026), but were not significant after NSM. Nipple loss was not observed, but 2 patients underwent partial areolar resection.Adaptive circulatory changes after devascularization allow tissues to tolerate the additional ischemic challenge of mastectomy. Our findings support extending 2-staged operations to high-risk women previously considered unsuitable for NSM.

View details for DOI 10.1245/s10434-016-5201-8

View details for Web of Science ID 000379189900044

View details for PubMedID 27038458
Multiple Subsets of Brain Tumor Initiating Cells Coexist in Glioblastoma STEM CELLS Rennert, R. C., Achrol, A. S., Januszyk, M., Kahn, S. A., Liu, T. T., Liu, Y., Sahoo, D., Rodrigues, M., Maan, Z. N., Wong, V. W., Cheshier, S. H., Chang, S. D., Steinberg, G. K., Harsh, G. R., Gurtner, G. C. 2016; 34 (6): 1702-1707
Abstract

Brain tumor-initiating cells (BTICs) are self-renewing multipotent cells critical for tumor maintenance and growth. Using single-cell microfluidic profiling, we identified multiple subpopulations of BTICs co-existing in human glioblastoma, characterized by distinct surface marker expression and single-cell molecular profiles relating to distinct bulk tissue molecular subtypes. These data suggest BTIC subpopulation heterogeneity as an underlying source of intra-tumoral bulk tissue molecular heterogeneity, and will support future studies into BTIC subpopulation-specific therapies. This article is protected by copyright. All rights reserved.

View details for DOI 10.1002/stem.2359

View details for Web of Science ID 000378089500025

View details for PubMedID 26991945
Microfluidic single-cell transcriptional analysis rationally identifies novel surface marker profiles to enhance cell-based therapies NATURE COMMUNICATIONS Rennert, R. C., Januszyk, M., Sorkin, M., Rodrigues, M., Maan, Z. N., Duscher, D., Whittam, A. J., Kosaraju, R., Chung, M. T., Paik, K., Li, A. Y., Findlay, M., Glotzbach, J. P., Butte, A. J., Gurtner, G. C. 2016; 7
Abstract

Current progenitor cell therapies have only modest efficacy, which has limited their clinical adoption. This may be the result of a cellular heterogeneity that decreases the number of functional progenitors delivered to diseased tissue, and prevents correction of underlying pathologic cell population disruptions. Here, we develop a high-resolution method of identifying phenotypically distinct progenitor cell subpopulations via single-cell transcriptional analysis and advanced bioinformatics. When combined with high-throughput cell surface marker screening, this approach facilitates the rational selection of surface markers for prospective isolation of cell subpopulations with desired transcriptional profiles. We establish the usefulness of this platform in costly and highly morbid diabetic wounds by identifying a subpopulation of progenitor cells that is dysfunctional in the diabetic state, and normalizes diabetic wound healing rates following allogeneic application. We believe this work presents a logical framework for the development of targeted cell therapies that can be customized to any clinical application.

View details for DOI 10.1038/ncomms11945

View details for Web of Science ID 000379085200001

View details for PubMedID 27324848
Suction assisted liposuction does not impair the regenerative potential of adipose derived stem cells JOURNAL OF TRANSLATIONAL MEDICINE Duscher, D., Luan, A., Rennert, R. C., Atashroo, D., Maan, Z. N., Brett, E. A., Whittam, A. J., Ho, N., Lin, M., Hu, M. S., Walmsley, G. G., Wenny, R., Schmidt, M., Schilling, A. F., Machens, H., Huemer, G. M., Wan, D. C., Longaker, M. T., Gurtner, G. C. 2016; 14
Abstract

Adipose-derived stem cells (ASCs) have been identified as a population of multipotent cells with promising applications in tissue engineering and regenerative medicine. ASCs are abundant in fat tissue, which can be safely harvested through the minimally invasive procedure of liposuction. However, there exist a variety of different harvesting methods, with unclear impact on ASC regenerative potential. The aim of this study was thus to compare the functionality of ASCs derived from the common technique of suction-assisted lipoaspiration (SAL) versus resection.Human adipose tissue was obtained from paired abdominoplasty and SAL samples from three female donors, and was processed to isolate the stromal vascular fraction. Fluorescence-activated cell sorting was used to determine ASC yield, and cell viability was assayed. Adipogenic and osteogenic differentiation capacity were assessed in vitro using phenotypic staining and quantification of gene expression. Finally, ASCs were applied in an in vivo model of tissue repair to evaluate their regenerative potential.SAL specimens provided significantly fewer ASCs when compared to excised fat tissue, however, with equivalent viability. SAL-derived ASCs demonstrated greater expression of the adipogenic markers FABP-4 and LPL, although this did not result in a difference in adipogenic differentiation. There were no differences detected in osteogenic differentiation capacity as measured by alkaline phosphatase, mineralization or osteogenic gene expression. Both SAL- and resection-derived ASCs enhanced significantly cutaneous healing and vascularization in vivo, with no significant difference between the two groups.SAL provides viable ASCs with full capacity for multi-lineage differentiation and tissue regeneration, and is an effective method of obtaining ASCs for cell-based therapies.

View details for DOI 10.1186/s12967-016-0881-1

View details for Web of Science ID 000375475200004

View details for PubMedID 27153799
High-Resolution Microfluidic Single-Cell Transcriptional Profiling Reveals Clinically Relevant Subtypes among Human Stem Cell Populations Commonly Utilized in Cell-Based Therapies FRONTIERS IN NEUROLOGY Rennert, R. C., Schaefer, R., Bliss, T., Januszyk, M., Sorkin, M., Achrol, A. S., Rodrigues, M., Maan, Z. N., Kluba, T., Steinberg, G. K., Gurtner, G. C. 2016; 7
View details for DOI 10.3389/fneur.2016.00041

View details for Web of Science ID 000372534400001
Cell-Assisted Lipotransfer Improves Volume Retention in Irradiated Recipient Sites and Rescues Radiation-Induced Skin Changes STEM CELLS Luan, A., Duscher, D., Whittam, A. J., Paik, K. J., Zielins, E. R., Brett, E. A., Atashroo, D. A., Hu, M. S., Lee, G. K., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2016; 34 (3): 668-673
View details for DOI 10.1002/stem.2256

View details for Web of Science ID 000372552600013
Extracellular superoxide dismutase deficiency impairs wound healing in advanced age by reducing neovascularization and fibroblast function EXPERIMENTAL DERMATOLOGY Fujiwara, T., Duscher, D., Rustad, K. C., Kosaraju, R., Rodrigues, M., Whittam, A. J., Januszyk, M., Maan, Z. N., Gurtner, G. C. 2016; 25 (3): 206-211
View details for DOI 10.1111/exd.12909

View details for Web of Science ID 000373072800285
Extracellular superoxide dismutase deficiency impairs wound healing in advanced age by reducing neovascularization and fibroblast function. Experimental dermatology Fujiwara, T., Duscher, D., Rustad, K. C., Kosaraju, R., Rodrigues, M., Whittam, A. J., Januszyk, M., Maan, Z. N., Gurtner, G. C. 2016; 25 (3): 206-211
Abstract

Advanced age is characterized by impairments in wound healing, and evidence is accumulating that this may be due in part to a concomitant increase in oxidative stress. Extended exposure to reactive oxygen species (ROS) is thought to lead to cellular dysfunction and organismal death via the destructive oxidation of intra-cellular proteins, lipids and nucleic acids. Extracellular superoxide dismutase (ecSOD/SOD3) is a prime antioxidant enzyme in the extracellular space that eliminates ROS. Here, we demonstrate that reduced SOD3 levels contribute to healing impairments in aged mice. These impairments include delayed wound closure, reduced neovascularization, impaired fibroblast proliferation and increased neutrophil recruitment. We further establish that SOD3 KO and aged fibroblasts both display reduced production of TGF-β1, leading to decreased differentiation of fibroblasts into myofibroblasts. Taken together, these results suggest that wound healing impairments in ageing are associated with increased levels of ROS, decreased SOD3 expression and impaired extracellular oxidative stress regulation. Our results identify SOD3 as a possible target to correct age-related cellular dysfunction in wound healing.

View details for DOI 10.1111/exd.12909

View details for PubMedID 26663425
Ultrasound-Assisted Liposuction Does Not Compromise the Regenerative Potential of Adipose-Derived Stem Cells. Stem cells translational medicine Duscher, D., Atashroo, D., Maan, Z. N., Luan, A., Brett, E. A., Barrera, J., Khong, S. M., Zielins, E. R., Whittam, A. J., Hu, M. S., Walmsley, G. G., Pollhammer, M. S., Schmidt, M., Schilling, A. F., Machens, H., Huemer, G. M., Wan, D. C., Longaker, M. T., Gurtner, G. C. 2016; 5 (2): 248-257
Abstract

Human mesenchymal stem cells (MSCs) have recently become a focus of regenerative medicine, both for their multilineage differentiation capacity and their excretion of proregenerative cytokines. Adipose-derived mesenchymal stem cells (ASCs) are of particular interest because of their abundance in fat tissue and the ease of harvest via liposuction. However, little is known about the impact of different liposuction methods on the functionality of ASCs. Here we evaluate the regenerative abilities of ASCs harvested via a third-generation ultrasound-assisted liposuction (UAL) device versus ASCs obtained via standard suction-assisted lipoaspiration (SAL). Lipoaspirates were sorted using fluorescent assisted cell sorting based on an established surface-marker profile (CD34+/CD31-/CD45-), to obtain viable ASCs. Yield and viability were compared and the differentiation capacities of the ASCs were assessed. Finally, the regenerative potential of ASCs was examined using an in vivo model of tissue regeneration. UAL- and SAL-derived samples demonstrated equivalent ASC yield and viability, and UAL ASCs were not impaired in their osteogenic, adipogenic, or chondrogenic differentiation capacity. Equally, quantitative real-time polymerase chain reaction showed comparable expression of most osteogenic, adipogenic, and key regenerative genes between both ASC groups. Cutaneous regeneration and neovascularization were significantly enhanced in mice treated with ASCs obtained by either UAL or SAL compared with controls, but there were no significant differences in healing between cell-therapy groups. We conclude that UAL is a successful method of obtaining fully functional ASCs for regenerative medicine purposes. Cells harvested with this alternative approach to liposuction are suitable for cell therapy and tissue engineering applications. Significance: Adipose-derived mesenchymal stem cells (ASCs) are an appealing source of therapeutic progenitor cells because of their multipotency, diverse cytokine profile, and ease of harvest via liposuction. Alternative approaches to classical suction-assisted liposuction are gaining popularity; however, little evidence exists regarding the impact of different liposuction methods on the regenerative functionality of ASCs. Human ASC characteristics and regenerative capacity were assessed when harvested via ultrasound-assisted (UAL) versus standard suction-assisted liposuction. ASCs obtained via UAL were of equal quality when directly compared with the current gold standard harvest method. UAL is an adjunctive source of fully functional mesenchymal stem cells for applications in basic research and clinical therapy.

View details for DOI 10.5966/sctm.2015-0064

View details for PubMedID 26702129
Challenges and Opportunities in Drug Delivery for Wound Healing. Advances in wound care Whittam, A. J., Maan, Z. N., Duscher, D., Wong, V. W., Barrera, J. A., Januszyk, M., Gurtner, G. C. 2016; 5 (2): 79-88
Abstract

Significance: Chronic wounds remain a significant public health problem. Alterations in normal physiological processes caused by aging or diabetes lead to impaired tissue repair and the development of chronic and nonhealing wounds. Understanding the unique features of the wound environment will be required to develop new therapeutics that impact these disabling conditions. New drug-delivery systems (DDSs) may enhance current and future therapies for this challenging clinical problem. Recent Advances: Historically, physical barriers and biological degradation limited the efficacy of DDSs in wound healing. In aiming at improving and optimizing drug delivery, recent data suggest that combinations of delivery mechanisms, such as hydrogels, small molecules, RNA interference (RNAi), as well as growth factor and stem cell-based therapies (biologics), could offer exciting new opportunities for improving tissue repair. Critical Issues: The lack of effective therapeutic approaches to combat the significant disability associated with chronic wounds has become an area of increasing clinical concern. However, the unique challenges of the wound environment have limited the development of effective therapeutic options for clinical use. Future Directions: New platforms presented in this review may provide clinicians and scientists with an improved understanding of the alternatives for drug delivery in wound care, which may facilitate the development of new therapeutic approaches for patients.

View details for PubMedID 26862465
Sutureless Microsurgical Anastomosis Using an Optimized Thermoreversible Intravascular Poloxamer Stent. Plastic and reconstructive surgery Davis, C. R., Rappleye, C. T., Than, P. A., Rodrigues, M., Findlay, M. W., Bishop, S. N., Whitmore, A. J., Maan, Z. N., McGoldrick, R. B., Grobbelaar, A. O., Gurtner, G. C. 2016; 137 (2): 546-556
Abstract

Sutureless microvascular anastomosis has great translational potential to simplify microvascular surgery, shorten operative times, and improve clinical outcomes. The authors developed a transient thermoreversible microvascular stent using a poloxamer to maintain vessel lumen patency before application of commercially available adhesives to seal the anastomosis instead of sutures. Despite technical success, human application necessitates bovine serum albumin removal from existing formulations; rapid poloxamer transition between states; and increased stiffness for reliable, reproducible, and precise microvascular approximation.Two commercially available poloxamers were used in this study (P407 and P188). After removing bovine serum albumin, each poloxamer was tested at varying concentrations either alone or in combination to determine the optimal preparation for sutureless microvascular anastomosis. Transition temperature and formulation stiffness were tested in vitro by rheometry, with the most promising combinations tested in an established in vivo model.Increasing poloxamer concentration resulted in an increase in stiffness and decrease in transition temperature. Pure P188 without bovine serum albumin, dissolved in phosphate-buffered saline to a 45% concentration, demonstrated desirable rheologic behavior, with precise gel transition and increased gel stiffness compared with our previous formulation of 17% P407 (96 kPa versus 10 kPa). These characteristics were optimal for microsurgical intravascular use, offering surgical precision and control between liquid and solid states, depending on the surgically controlled local temperature.Use of 45% P188 without bovine serum albumin demonstrated optimal rheologic and translational properties as a microvascular stent for sutureless anastomosis. Rapid transition, increased stiffness, and safety profile demonstrate safe translational application for human clinical trials.

View details for DOI 10.1097/01.prs.0000475774.37267.3f

View details for PubMedID 26818289
Adipose-Derived Stem Cell-Seeded Hydrogels Increase Endogenous Progenitor Cell Recruitment and Neovascularization in Wounds TISSUE ENGINEERING PART A Kosaraju, R., Rennert, R. C., Maan, Z. N., Duscher, D., Barrera, J., Whittam, A. J., Januszyk, M., Rajadas, J., Rodrigues, M., Gurtner, G. C. 2016; 22 (3-4): 295-305
Abstract

Adipose-derived mesenchymal stem cells (ASCs) are appealing for cell-based wound therapies because of their accessibility and ease of harvest, but their utility is limited by poor cell survival within the harsh wound microenvironment. In prior work, our laboratory has demonstrated that seeding ASCs within a soft pullulan-collagen hydrogel enhances ASC survival and improves wound healing. To more fully understand the mechanism of this therapy, we examined whether ASC-seeded hydrogels were able to modulate the recruitment and/or functionality of endogenous progenitor cells. Employing a parabiosis model and fluorescence-activated cell sorting analysis, we demonstrate that application of ASC-seeded hydrogels to wounds, when compared with injected ASCs or a noncell control, increased the recruitment of provascular circulating bone marrow-derived mesenchymal progenitor cells (BM-MPCs). BM-MPCs comprised 23.0% of recruited circulating progenitor cells in wounds treated with ASC-seeded hydrogels versus 8.4% and 2.1% in those treated with controls, p < 0.05. Exploring the potential for functional modulation of BM-MPCs, we demonstrate a statistically significant increase in BM-MPC migration, proliferation, and tubulization when exposed to hydrogel-seeded ASC-conditioned medium versus control ASC-conditioned medium (73.8% vs. 51.4% scratch assay closure; 9.1% vs. 1.4% proliferation rate; 10.2 vs. 5.5 tubules/HPF; p < 0.05 for all assays). BM-MPC expression of genes related to cell stemness and angiogenesis was also significantly increased following exposure to hydrogel-seeded ASC-conditioned medium (p < 0.05). These data suggest that ASC-seeded hydrogels improve both progenitor cell recruitment and functionality to effect greater neovascularization.

View details for DOI 10.1089/ten.tea.2015.0277

View details for Web of Science ID 000369987900012

View details for PubMedID 26871860

View details for PubMedCentralID PMC4779321
Enrichment of Adipose-Derived Stromal Cells for BMPR1A Facilitates Enhanced Adipogenesis TISSUE ENGINEERING PART A Zielins, E. R., Paik, K., Ransom, R. C., Brett, E. A., Blackshear, C. P., Luan, A., Walmsley, G. G., Atashroo, D. A., Senarath-Yapa, K., Momeni, A., Rennert, R., Sorkin, M., Seo, E. Y., Chan, C. K., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2016; 22 (3-4): 214-221
Abstract

Reconstruction of soft tissue defects has traditionally relied on the use of grafts and flaps, which may be associated with variable resorption and/or significant donor site morbidity. Cell-based strategies employing adipose-derived stromal cells (ASCs), found within the stromal vascular fraction (SVF) of adipose tissue, may offer an alternative strategy for soft tissue reconstruction. In this study, we investigated the potential of a bone morphogenetic protein receptor type 1A (BMPR1A)(+) subpopulation of ASCs to enhance de novo adipogenesis.Human lipoaspirate was enzymatically digested to isolate SVF and magnetic-activated cell separation was utilized to obtain BMPR1A(+) and BMPR1A(-) cells. These cells, along with unenriched cells, were expanded in culture and evaluated for adipogenic gene expression and in vitro adipocyte formation. Cells from each group were also labeled with a green fluorescent protein (GFP) lentivirus and transplanted into the inguinal fat pads, an adipogenic niche, of immunocompromised mice to determine their potential for de novo adipogenesis. Confocal microscopy along with staining of lipid droplets and vasculature was performed to evaluate the formation of mature adipocytes by transplanted cells.In comparison to BMPR1A(-) and unenriched ASCs, BMPR1A(+) cells demonstrated significantly enhanced adipogenesis when cultured in an adipogenic differentiation medium, as evidenced by increased staining with Oil Red O and increased expression of peroxisome proliferator-activating receptor gamma (PPAR-γ) and fatty acid-binding protein 4 (FABP4). BMPR1A(+) cells also formed significantly more adipocytes in vivo, as demonstrated by quantification of GFP+ adipocytes. Minimal formation of mature adipocytes was appreciated by BMPR1A(-) cells.BMPR1A(+) ASCs show an enhanced ability for adipogenesis in vitro, as shown by gene expression and histological staining. Furthermore, within an adipogenic niche, BMPR1A(+) cells possessed an increased capacity to generate de novo fat compared to BMPR1A(-) and unenriched cells. This suggests utility for the BMPR1A(+) subpopulation in cell-based strategies for soft tissue reconstruction.

View details for DOI 10.1089/ten.tea.2015.0278

View details for Web of Science ID 000369987900004

View details for PubMedID 26585335

View details for PubMedCentralID PMC4779277
Murine Dermal Fibroblast Isolation by FACS JOVE-JOURNAL OF VISUALIZED EXPERIMENTS Walmsley, G. G., Maan, Z. N., Hu, M. S., Atashroo, D. A., Whittam, A. J., Duscher, D., Tevlin, R., Marecic, O., Lorenz, H. P., Gurtner, G. C., Longaker, M. T. 2016
View details for DOI 10.3791/53430

View details for Web of Science ID 000368577400023
Rapid identification of slow healing wounds. Wound repair and regeneration Jung, K., Covington, S., Sen, C. K., Januszyk, M., Kirsner, R. S., Gurtner, G. C., Shah, N. H. 2016; 24 (1): 181-188
Abstract

Chronic nonhealing wounds have a prevalence of 2% in the United States, and cost an estimated $50 billion annually. Accurate stratification of wounds for risk of slow healing may help guide treatment and referral decisions. We have applied modern machine learning methods and feature engineering to develop a predictive model for delayed wound healing that uses information collected during routine care in outpatient wound care centers. Patient and wound data was collected at 68 outpatient wound care centers operated by Healogics Inc. in 26 states between 2009 and 2013. The dataset included basic demographic information on 59,953 patients, as well as both quantitative and categorical information on 180,696 wounds. Wounds were split into training and test sets by randomly assigning patients to training and test sets. Wounds were considered delayed with respect to healing time if they took more than 15 weeks to heal after presentation at a wound care center. Eleven percent of wounds in this dataset met this criterion. Prognostic models were developed on training data available in the first week of care to predict delayed healing wounds. A held out subset of the training set was used for model selection, and the final model was evaluated on the test set to evaluate discriminative power and calibration. The model achieved an area under the curve of 0.842 (95% confidence interval 0.834-0.847) for the delayed healing outcome and a Brier reliability score of 0.00018. Early, accurate prediction of delayed healing wounds can improve patient care by allowing clinicians to increase the aggressiveness of intervention in patients most at risk.

View details for DOI 10.1111/wrr.12384

View details for PubMedID 26606167
High-Resolution Microfluidic Single-Cell Transcriptional Profiling Reveals Clinically Relevant Subtypes among Human Stem Cell Populations Commonly Utilized in Cell-Based Therapies. Frontiers in neurology Rennert, R. C., Schäfer, R., Bliss, T., Januszyk, M., Sorkin, M., Achrol, A. S., Rodrigues, M., Maan, Z. N., Kluba, T., Steinberg, G. K., Gurtner, G. C. 2016; 7: 41-?
Abstract

Stem cell therapies can promote neural repair and regeneration, yet controversy regarding optimal cell source and mechanism of action has slowed clinical translation, potentially due to undefined cellular heterogeneity. Single-cell resolution is needed to identify clinically relevant subpopulations with the highest therapeutic relevance. We combine single-cell microfluidic analysis with advanced computational modeling to study for the first time two common sources for cell-based therapies, human NSCs and MSCs. This methodology has the potential to logically inform cell source decisions for any clinical application.

View details for DOI 10.3389/fneur.2016.00041

View details for PubMedID 27047447
Stem Cells in Wound Healing: The Future of Regenerative Medicine? A Mini-Review. Gerontology Duscher, D., Barrera, J., Wong, V. W., Maan, Z. N., Whittam, A. J., Januszyk, M., Gurtner, G. C. 2016; 62 (2): 216-225
Abstract

The increased risk of disease and decreased capacity to respond to tissue insult in the setting of aging results from complex changes in homeostatic mechanisms, including the regulation of oxidative stress and cellular heterogeneity. In aged skin, the healing capacity is markedly diminished resulting in a high risk for chronic wounds. Stem cell-based therapies have the potential to enhance cutaneous regeneration, largely through trophic and paracrine activity. Candidate cell populations for therapeutic application include adult mesenchymal stem cells, embryonic stem cells and induced pluripotent stem cells. Autologous cell-based approaches are ideal to minimize immune rejection but may be limited by the declining cellular function associated with aging. One strategy to overcome age-related impairments in various stem cell populations is to identify and enrich with functionally superior stem cell subsets via single cell transcriptomics. Another approach is to optimize cell delivery to the harsh environment of aged wounds via scaffold-based cell applications to enhance engraftment and paracrine activity of therapeutic stem cells. In this review, we shed light on challenges and recent advances surrounding stem cell therapies for wound healing and discuss limitations for their clinical adoption.

View details for DOI 10.1159/000381877

View details for PubMedID 26045256
Rapid identification of slow healing wounds WOUND REPAIR AND REGENERATION Jung, K., Covington, S., Sen, C. K., Januszyk, M., Kirsner, R. S., Gurtner, G. C., Shah, N. H. 2016; 24 (1): 181-188
View details for DOI 10.1111/wrr.12384

View details for Web of Science ID 000372925500018
Short Hairpin RNA Silencing of PHD-2 Improves Neovascularization and Functional Outcomes in Diabetic Wounds and Ischemic Limbs. PloS one Paik, K. J., Maan, Z. N., Zielins, E. R., Duscher, D., Whittam, A. J., Morrison, S. D., Brett, E. A., Ransom, R. C., Hu, M. S., Wu, J. C., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2016; 11 (3)
Abstract

The transcription factor hypoxia-inducible factor 1-alpha (HIF-1α) is responsible for the downstream expression of over 60 genes that regulate cell survival and metabolism in hypoxic conditions as well as those that enhance angiogenesis to alleviate hypoxia. However, under normoxic conditions, HIF-1α is hydroxylated by prolyl hydroxylase 2, and subsequently degraded, with a biological half-life of less than five minutes. Here we investigated the therapeutic potential of inhibiting HIF-1α degradation through short hairpin RNA silencing of PHD-2 in the setting of diabetic wounds and limb ischemia. Treatment of diabetic mouse fibroblasts with shPHD-2 in vitro resulted in decreased levels of PHD-2 transcript demonstrated by qRT-PCR, higher levels of HIF-1α as measured by western blot, and higher expression of the downstream angiogenic genes SDF-1 and VEGFα, as measured by qRT-PCR. In vivo, shPHD-2 accelerated healing of full thickness excisional wounds in diabetic mice compared to shScr control, (14.33 ± 0.45 days vs. 19 ± 0.33 days) and was associated with an increased vascular density. Delivery of shPHD-2 also resulted in improved perfusion of ischemic hind limbs compared to shScr, prevention of distal digit tip necrosis, and increased survival of muscle tissue. Knockdown of PHD-2 through shRNA treatment has the potential to stimulate angiogenesis through overexpression of HIF-1α and upregulation of pro-angiogenic genes downstream of HIF-1α, and may represent a viable, non-viral approach to gene therapy for ischemia related applications.

View details for DOI 10.1371/journal.pone.0150927

View details for PubMedID 26967994

View details for PubMedCentralID PMC4788284
Successful Translation of Fluorescence Navigation During Oncologic Surgery: A Consensus Report JOURNAL OF NUCLEAR MEDICINE Rosenthal, E. L., Warram, J. M., de Boer, E., Basilion, J. P., Biel, M. A., Bogyo, M., Bouvet, M., Brigman, B. E., Colson, Y. L., DeMeester, S. R., Gurtner, G. C., Ishizawa, T., Jacobs, P. M., Keereweer, S., Liao, J. C., Nguyen, Q. T., Olson, J. M., Paulsen, K. D., Rieves, D., Sumer, B. D., Tweedle, M. F., Vahrmeijer, A. L., Weichert, J. P., Wilson, B. C., Zenn, M. R., Zinn, K. R., van Dam, G. M. 2016; 57 (1): 144-150
View details for DOI 10.2967/jnumed.115.158915

View details for Web of Science ID 000367862700025
Surveillance of Stem Cell Fate and Function: A System for Assessing Cell Survival and Collagen Expression In Situ TISSUE ENGINEERING PART A Walmsley, G. G., Senarath-Yapa, K., Wearda, T. L., Menon, S., Hu, M. S., Duscher, D., Maan, Z. N., Tsai, J. M., Zielins, E. R., Weissman, I. L., Gurtner, G. C., Lorenz, H. P., Longaker, M. T. 2016; 22 (1-2): 31-40
View details for DOI 10.1089/ten.tea.2015.0221

View details for Web of Science ID 000368520300005
Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland surgery Dua, M. M., Bertoni, D. M., Nguyen, D., Meyer, S., Gurtner, G. C., Wapnir, I. L. 2015; 4 (6): 497-505
Abstract

The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

View details for DOI 10.3978/j.issn.2227-684X.2015.04.15

View details for PubMedID 26645004
Fibroblast-Specific Deletion of Hypoxia Inducible Factor-1 Critically Impairs Murine Cutaneous Neovascularization and Wound Healing PLASTIC AND RECONSTRUCTIVE SURGERY Duscher, D., Maan, Z. N., Whittam, A. J., Sorkin, M., Hu, M. S., Walmsley, G. G., Baker, H., Fischer, L. H., Januszyk, M., Wong, V. W., Gurtner, G. C. 2015; 136 (5): 1004-1013
View details for Web of Science ID 000364092800001

View details for PubMedID 26505703
Skeletal Stem Cell Niche Aberrancies Underlie Impaired Fracture Healing in a Mouse Model of Type 2 Diabetes. Plastic and reconstructive surgery Tevlin, R., Young Seo, E., Marecic, O., Wearda, T., Mc Ardle, A., Januszyk, M., Gulati, G., Maan, Z., Hu, M. S., Walmsley, G. G., Gurtner, G. C., Chan, C. K., Weissman, I. L., Longaker, M. T. 2015; 136 (4): 73-?
View details for DOI 10.1097/01.prs.0000472372.96995.3e

View details for PubMedID 26397581
Progenitor Cell Dysfunctions Underlie Some Diabetic Complications AMERICAN JOURNAL OF PATHOLOGY Rodrigues, M., Wong, V. W., Rennert, R. C., Davis, C. R., Longaker, M. T., Gurtner, G. C. 2015; 185 (10): 2607-2618
View details for DOI 10.1016/j.ajpath.2015.05.003

View details for Web of Science ID 000362698300003

View details for PubMedID 26079815
High-Throughput Screening of Surface Marker Expression on Undifferentiated and Differentiated Human Adipose-Derived Stromal Cells TISSUE ENGINEERING PART A Walmsley, G. G., Atashroo, D. A., Maan, Z. N., Hu, M. S., Zielins, E. R., Tsai, J. M., Duscher, D., Paik, K., Tevlin, R., Marecic, O., Wan, D. C., Gurtner, G. C., Longaker, M. T. 2015; 21 (15-16): 2281-2291
Abstract

Adipose tissue contains an abundant source of multipotent mesenchymal cells termed "adipose-derived stromal cells" (ASCs) that hold potential for regenerative medicine. However, the heterogeneity inherent to ASCs harvested using standard methodologies remains largely undefined, particularly in regards to differences across donors. Identifying the subpopulations of ASCs predisposed toward differentiation along distinct lineages holds value for improving graft survival, predictability, and efficiency. Human ASCs (hASCs) from three different donors were independently isolated by density-based centrifugation from adipose tissue and maintained in culture or differentiated along either adipogenic or osteogenic lineages using differentiation media. Undifferentiated and differentiated hASCs were then analyzed for the presence of 242 human surface markers by flow cytometry analysis. By comprehensively characterizing the surface marker profile of undifferentiated hASCs using flow cytometry, we gained novel insights into the heterogeneity underlying protein expression on the surface of cultured undifferentiated hASCs across different donors. Comparison of the surface marker profile of undifferentiated hASCs with hASCs that have undergone osteogenic or adipogenic differentiation allowed for the identification of surface markers that were upregulated and downregulated by osteogenic or adipogenic differentiation. Osteogenic differentiation induced upregulation of CD164 and downregulation of CD49a, CD49b, CD49c, CD49d, CD55, CD58, CD105, and CD166 while adipogenic differentiation induced upregulation of CD36, CD40, CD146, CD164, and CD271 and downregulation of CD49b, CD49c, CD49d, CD71, CD105, and CD166. These results lend support to the notion that hASCs isolated using standard methodologies represent a heterogeneous population and serve as a foundation for future studies seeking to maximize their regenerative potential through fluorescence-activated cell sorting-based selection before therapy.

View details for DOI 10.1089/ten.tea.2015.0039

View details for Web of Science ID 000359812700014

View details for PubMedID 26020286

View details for PubMedCentralID PMC4529076
Studies in Fat Grafting: Part V. Cell-Assisted Lipotransfer to Enhance Fat Graft Retention Is Dose Dependent PLASTIC AND RECONSTRUCTIVE SURGERY Paik, K. J., Zielins, E. R., Atashroo, D. A., Maan, Z. N., Duscher, D., Luan, A., Walmsley, G. G., Momeni, A., Vistnes, S., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2015; 136 (1): 67-75
Abstract

Cell-assisted lipotransfer has shown much promise as a technique for improving fat graft take. However, the concentration of stromal vascular fraction cells required to optimally enhance fat graft retention remains unknown.Human lipoaspirate was processed for both fat transfer and harvest of stromal vascular fraction cells. Cells were then mixed back with fat at varying concentrations ranging from 10,000 to 10 million cells per 200 μl of fat. Fat graft volume retention was assessed by means of computed tomographic scanning over 8 weeks, and then fat grafts were explanted and compared histologically for overall architecture and vascularity.Maximum fat graft retention was seen at a concentration of 10,000 cells per 200 μl of fat. The addition of higher number of cells negatively impacted fat graft retention, with supplementation of 10 million cells producing the lowest final volumes, lower than fat alone. Interestingly, fat grafts supplemented with 10,000 cells showed significantly increased vascularity and decreased inflammation, whereas fat grafts supplemented with 10 million cells showed significant lipodegeneration compared with fat alone: The authors' study demonstrates dose dependence in the number of stromal vascular fraction cells that can be added to a fat graft to enhance retention. Although cell-assisted lipotransfer may help promote graft survival, this effect may need to be balanced with the increased metabolic load of added cells that may compete with adipocytes for nutrients during the postgraft period.

View details for DOI 10.1097/PRS.0000000000001367

View details for Web of Science ID 000357096300002

View details for PubMedID 25829158
The Foreign Body Response: At the Interface of Surgery and Bioengineering PLASTIC AND RECONSTRUCTIVE SURGERY Major, M. R., Wong, V. W., Nelson, E. R., Longaker, M. T., Gurtner, G. C. 2015; 135 (5): 1489-1498
Abstract

The surgical implantation of materials and devices has dramatically increased over the past decade. This trend is expected to continue with the broadening application of biomaterials and rapid expansion of aging populations. One major factor that limits the potential of implantable materials and devices is the foreign body response, an immunologic reaction characterized by chronic inflammation, foreign body giant cell formation, and fibrotic capsule formation.The English literature on the foreign body response to implanted materials and devices is reviewed.Fibrotic encapsulation can cause device malfunction and dramatically limit the function of an implanted medical device or material. Basic science studies suggest a role for immune and inflammatory pathways at the implant-host interface that drive the foreign body response. Current strategies that aim to modulate the host response and improve construct biocompatibility appear promising.This review article summarizes recent basic science, preclinical, and clinicopathologic studies examining the mechanisms driving the foreign body response, with particular focus on breast implants and synthetic meshes. Understanding these molecular and cellular mechanisms will be critical for achieving the full potential of implanted biomaterials to restore human tissues and organs.

View details for DOI 10.1097/PRS.0000000000001193

View details for Web of Science ID 000353647100060

View details for PubMedID 25919260
Identification and isolation of a dermal lineage with intrinsic fibrogenic potential SCIENCE Rinkevich, Y., Walmsley, G. G., Hu, M. S., Maan, Z. N., Newman, A. M., Drukker, M., Januszyk, M., Krampitz, G. W., Gurtner, G. C., Lorenz, H. P., Weissman, I. L., Longaker, M. T. 2015; 348 (6232): 302-?
View details for DOI 10.1126/science.aaa2151

View details for Web of Science ID 000352999000034
Skin fibrosis. Identification and isolation of a dermal lineage with intrinsic fibrogenic potential. Science Rinkevich, Y., Walmsley, G. G., Hu, M. S., Maan, Z. N., Newman, A. M., Drukker, M., Januszyk, M., Krampitz, G. W., Gurtner, G. C., Lorenz, H. P., Weissman, I. L., Longaker, M. T. 2015; 348 (6232)
Abstract

Dermal fibroblasts represent a heterogeneous population of cells with diverse features that remain largely undefined. We reveal the presence of at least two fibroblast lineages in murine dorsal skin. Lineage tracing and transplantation assays demonstrate that a single fibroblast lineage is responsible for the bulk of connective tissue deposition during embryonic development, cutaneous wound healing, radiation fibrosis, and cancer stroma formation. Lineage-specific cell ablation leads to diminished connective tissue deposition in wounds and reduces melanoma growth. Using flow cytometry, we identify CD26/DPP4 as a surface marker that allows isolation of this lineage. Small molecule-based inhibition of CD26/DPP4 enzymatic activity during wound healing results in diminished cutaneous scarring. Identification and isolation of these lineages hold promise for translational medicine aimed at in vivo modulation of fibrogenic behavior.

View details for DOI 10.1126/science.aaa2151

View details for PubMedID 25883361

View details for PubMedCentralID PMC5088503
Studies in Fat Grafting: Part IV. Adipose-Derived Stromal Cell Gene Expression in Cell-Assisted Lipotransfer PLASTIC AND RECONSTRUCTIVE SURGERY Garza, R. M., Rennert, R. C., Paik, K. J., Atashroo, D., Chung, M. T., Duscher, D., Januszyk, M., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2015; 135 (4): 1045-1055
Abstract

Fat graft volume retention remains highly unpredictable, but addition of adipose-derived stromal cells to fat grafts has been shown to improve retention. The present study aimed to investigate the mechanisms involved in adipose-derived stromal cell enhancement of fat grafting.Adipose-derived stromal cells isolated from human lipoaspirate were labeled with green fluorescent protein and luciferase. Fat grafts enhanced with adipose-derived stromal cells were injected into the scalp and bioluminescent imaging was performed to follow retention of adipose-derived stromal cells within the fat graft. Fat grafts were also explanted at days 1, 5, and 10 after grafting for adipose-derived stromal cell extraction and single-cell gene analysis. Finally, CD31 immunohistochemical staining was performed on fat grafts enriched with adipose-derived stromal cells.Bioluminescent imaging demonstrated significant reduction in luciferase-positive adipose-derived stromal cells within fat grafts at 5 days after grafting. A similar reduction in viable green fluorescent protein-positive adipose-derived stromal cells retrieved from explanted grafts was also noted. Single-cell analysis revealed expression of multiple genes/markers related to cell survival and angiogenesis, including BMPR2, CD90, CD105, FGF2, CD248, TGFß1, and VEGFA. Genes involved in adipogenesis were not expressed by adipose-derived stromal cells. Finally, CD31 staining revealed significantly higher vascular density in fat grafts explanted at day 10 after grafting.Although adipose-derived stromal cell survival in the hypoxic graft environment decreases significantly over time, these cells provide multiple angiogenic growth factors. Therefore, improved fat graft volume retention with adipose-derived stromal cell enrichment may be attributable to improved graft vascularization.

View details for DOI 10.1097/PRS.0000000000001104

View details for Web of Science ID 000351910200043

View details for PubMedID 25502860

View details for PubMedCentralID PMC4376612
Scarless wound healing: chasing the holy grail. Plastic and reconstructive surgery Walmsley, G. G., Maan, Z. N., Wong, V. W., Duscher, D., Hu, M. S., Zielins, E. R., Wearda, T., Muhonen, E., McArdle, A., Tevlin, R., Atashroo, D. A., Senarath-Yapa, K., Lorenz, H. P., Gurtner, G. C., Longaker, M. T. 2015; 135 (3): 907-917
Abstract

Over 100 million patients acquire scars in the industrialized world each year, primarily as a result of elective operations. Although undefined, the global incidence of scarring is even larger, extending to significant numbers of burn and other trauma-related wounds. Scars have the potential to exert a profound psychological and physical impact on the individual. Beyond aesthetic considerations and potential disfigurement, scarring can result in restriction of movement and reduced quality of life. The formation of a scar following skin injury is a consequence of wound healing occurring through reparative rather than regenerative mechanisms. In this article, the authors review the basic stages of wound healing; differences between adult and fetal wound healing; various mechanical, genetic, and pharmacologic strategies to reduce scarring; and the biology of skin stem/progenitor cells that may hold the key to scarless regeneration.

View details for DOI 10.1097/PRS.0000000000000972

View details for PubMedID 25719706
Live Fibroblast Harvest Reveals Surface Marker Shift In Vitro TISSUE ENGINEERING PART C-METHODS Walmsley, G. G., Rinkevich, Y., Hu, M. S., Montoro, D. T., Lo, D. D., McArdle, A., Maan, Z. N., Morrison, S. D., Duscher, D., Whittam, A. J., Wong, V. W., Weissman, I. L., Gurtner, G. C., Longaker, M. T. 2015; 21 (3): 314-321
Abstract

Current methods for the isolation of fibroblasts require extended ex vivo manipulation in cell culture. As a consequence, prior studies investigating fibroblast biology may fail to adequately represent cellular phenotypes in vivo. To overcome this problem, we describe a detailed protocol for the isolation of fibroblasts from the dorsal dermis of adult mice that bypasses the need for cell culture, thereby preserving the physiological, transcriptional, and proteomic profiles of each cell. Using the described protocol we characterized the transcriptional programs and the surface expression of 176 CD markers in cultured versus uncultured fibroblasts. The differential expression patterns we observed highlight the importance of a live harvest for investigations of fibroblast biology.

View details for DOI 10.1089/ten.tec.2014.0118

View details for Web of Science ID 000350043400009

View details for PubMedID 25275778
Exercise induces stromal cell-derived factor-1a-mediated release of endothelial progenitor cells with increased vasculogenic function. Plastic and reconstructive surgery Chang, E., Paterno, J., Duscher, D., Maan, Z. N., Chen, J. S., Januszyk, M., Rodrigues, M., Rennert, R. C., Bishop, S., Whitmore, A. J., Whittam, A. J., Longaker, M. T., Gurtner, G. C. 2015; 135 (2): 340e-50e
Abstract

Endothelial progenitor cells have been shown to traffic to and incorporate into ischemic tissues, where they participate in new blood vessel formation, a process termed vasculogenesis. Previous investigation has demonstrated that endothelial progenitor cells appear to mobilize from bone marrow to the peripheral circulation after exercise. In this study, the authors investigate potential etiologic factors driving this mobilization and investigate whether the mobilized endothelial progenitor cells are the same as those present at baseline.Healthy volunteers (n = 5) performed a monitored 30-minute run to maintain a heart rate greater than 140 beats/min. Venous blood samples were collected before, 10 minutes after, and 24 hours after exercise. Endothelial progenitor cells were isolated and evaluated.Plasma levels of stromal cell-derived factor-1α significantly increased nearly two-fold immediately after exercise, with a nearly four-fold increase in circulating endothelial progenitor cells 24 hours later. The endothelial progenitor cells isolated following exercise demonstrated increased colony formation, proliferation, differentiation, and secretion of angiogenic cytokines. Postexercise endothelial progenitor cells also exhibited a more robust response to hypoxic stimulation.Exercise appears to mobilize endothelial progenitor cells and augment their function by means of stromal cell-derived factor 1α-dependent signaling. The population of endothelial progenitor cells mobilized following exercise is primed for vasculogenesis with increased capacity for proliferation, differentiation, secretion of cytokines, and responsiveness to hypoxia. Given the evidence demonstrating positive regenerative effects of exercise, this may be one possible mechanism for its benefits.

View details for DOI 10.1097/PRS.0000000000000917

View details for PubMedID 25626819
Cell recruitment by amnion chorion grafts promotes neovascularization JOURNAL OF SURGICAL RESEARCH Maan, Z. N., Rennert, R. C., Koob, T. J., Januszyk, M., Li, W. W., Gurtner, G. C. 2015; 193 (2): 953-962
Abstract

Nonhealing wounds are a significant health burden. Stem and progenitor cells can accelerate wound repair and regeneration. Human amniotic membrane has demonstrated efficacy in promoting wound healing, though the underlying mechanisms remain unknown. A dehydrated human amnion chorion membrane (dHACM) was tested for its ability to recruit hematopoietic progenitor cells to a surgically implanted graft in a murine model of cutaneous ischemia.dHACM was subcutaneously implanted under elevated skin (ischemic stimulus) in either wild-type mice or mice surgically parabiosed to green fluorescent protein (GFP) + reporter mice. A control acellular dermal matrix, elevated skin without an implant, and normal unwounded skin were used as controls. Wound tissue was harvested and processed for histology and flow cytometric analysis.Implanted dHACMs recruited significantly more progenitor cells compared with controls (*P < 0.05) and displayed in vivo SDF-1 expression with incorporation of CD34 + progenitor cells within the matrix. Parabiosis modeling confirmed the circulatory origin of recruited cells, which coexpressed progenitor cell markers and were localized to foci of neovascularization within implanted matrices.In summary, dHACM effectively recruits circulating progenitor cells, likely because of stromal derived factor 1 (SDF-1) expression. The recruited cells express markers of "stemness" and localize to sites of neovascularization, providing a partial mechanism for the clinical efficacy of human amniotic membrane in the treatment of chronic wounds.

View details for DOI 10.1016/j.jss.2014.08.045

View details for Web of Science ID 000346244300056

View details for PubMedID 25266600
Reply: Studies in fat grafting: part I. Effects of injection technique on in vitro fat viability and in vivo volume retention; and studies in fat grafting: part II. Effects of injection mechanics on material properties of fat. Plastic and reconstructive surgery Wan, D. C., Gurtner, G. C., Longaker, M. T. 2015; 135 (2): 448e-9e
View details for DOI 10.1097/PRS.0000000000000978

View details for PubMedID 25626833
Transdermal deferoxamine prevents pressure-induced diabetic ulcers. Proceedings of the National Academy of Sciences of the United States of America Duscher, D., Neofytou, E., Wong, V. W., Maan, Z. N., Rennert, R. C., Inayathullah, M., Januszyk, M., Rodrigues, M., Malkovskiy, A. V., Whitmore, A. J., Walmsley, G. G., Galvez, M. G., Whittam, A. J., Brownlee, M., Rajadas, J., Gurtner, G. C. 2015; 112 (1): 94-99
Abstract

There is a high mortality in patients with diabetes and severe pressure ulcers. For example, chronic pressure sores of the heels often lead to limb loss in diabetic patients. A major factor underlying this is reduced neovascularization caused by impaired activity of the transcription factor hypoxia inducible factor-1 alpha (HIF-1α). In diabetes, HIF-1α function is compromised by a high glucose-induced and reactive oxygen species-mediated modification of its coactivator p300, leading to impaired HIF-1α transactivation. We examined whether local enhancement of HIF-1α activity would improve diabetic wound healing and minimize the severity of diabetic ulcers. To improve HIF-1α activity we designed a transdermal drug delivery system (TDDS) containing the FDA-approved small molecule deferoxamine (DFO), an iron chelator that increases HIF-1α transactivation in diabetes by preventing iron-catalyzed reactive oxygen stress. Applying this TDDS to a pressure-induced ulcer model in diabetic mice, we found that transdermal delivery of DFO significantly improved wound healing. Unexpectedly, prophylactic application of this transdermal delivery system also prevented diabetic ulcer formation. DFO-treated wounds demonstrated increased collagen density, improved neovascularization, and reduction of free radical formation, leading to decreased cell death. These findings suggest that transdermal delivery of DFO provides a targeted means to both prevent ulcer formation and accelerate diabetic wound healing with the potential for rapid clinical translation.

View details for DOI 10.1073/pnas.1413445112

View details for PubMedID 25535360
Impact of surgical innovation on tissue repair in the surgical patient. British journal of surgery Tevlin, R., Atashroo, D., Duscher, D., Mc Ardle, A., Gurtner, G. C., Wan, D. C., Longaker, M. T. 2015; 102 (2): e41-55
Abstract

Throughout history, surgeons have been prolific innovators, which is hardly surprising as most surgeons innovate daily, tailoring their intervention to the intrinsic uniqueness of each operation, each patient and each disease. Innovation can be defined as the application of better solutions that meet new requirements, unarticulated needs or existing market needs. In the past two decades, surgical innovation has significantly improved patient outcomes, complication rates and length of hospital stay. There is one key area that has great potential to change the face of surgical practice and which is still in its infancy: the realm of regenerative medicine and tissue engineering.A literature review was performed using PubMed; peer-reviewed publications were screened for relevance in order to identify key surgical innovations influencing regenerative medicine, with a focus on osseous, cutaneous and soft tissue reconstruction.This review describes recent advances in regenerative medicine, documenting key innovations in osseous, cutaneous and soft tissue regeneration that have brought regenerative medicine to the forefront of the surgical imagination.Surgical innovation in the emerging field of regenerative medicine has the ability to make a major impact on surgery on a daily basis.

View details for DOI 10.1002/bjs.9672

View details for PubMedID 25627135
Evaluating the Effect of Cell Culture on Gene Expression in Primary Tissue Samples Using Microfluidic-Based Single Cell Transcriptional Analysis. Microarrays (Basel, Switzerland) Januszyk, M., Rennert, R. C., Sorkin, M., Maan, Z. N., Wong, L. K., Whittam, A. J., Whitmore, A., Duscher, D., Gurtner, G. C. 2015; 4 (4): 540-550
Abstract

Significant transcriptional heterogeneity is an inherent property of complex tissues such as tumors and healing wounds. Traditional methods of high-throughput analysis rely on pooling gene expression data from hundreds of thousands of cells and reporting a population-wide average that is unable to capture differences within distinct cell subsets. Recent advances in microfluidic technology have permitted the development of large-scale single cell analytic methods that overcome this limitation. The increased granularity afforded by such approaches allows us to answer the critical question of whether expansion in cell culture significantly alters the transcriptional characteristics of cells isolated from primary tissue. Here we examine an established population of human adipose-derived stem cells (ASCs) using a novel, microfluidic-based method for high-throughput transcriptional interrogation, coupled with advanced bioinformatic analysis, to evaluate the dynamics of single cell gene expression among primary, passage 0, and passage 1 stem cells. We find significant differences in the transcriptional profiles of cells from each group, as well as a considerable shift in subpopulation dynamics as those subgroups better able to adhere and proliferate under these culture conditions gradually emerge as dominant. Taken together, these findings reinforce the importance of using primary or very early passage cells in future studies.

View details for DOI 10.3390/microarrays4040540

View details for PubMedID 27600239

View details for PubMedCentralID PMC4996408
A rapid crosslinking injectable hydrogel for stem cell delivery, from multifunctional hyperbranched polymers via RAFT homopolymerization of PEGDA POLYMER CHEMISTRY Dong, Y., Qin, Y., Dubaa, M., Killion, J., Gao, Y., Zhao, T., Zhou, D., Duscher, D., Geever, L., Gurtner, G. C., Wang, W. 2015; 6 (34): 6182-6192
View details for DOI 10.1039/c5py00678c

View details for Web of Science ID 000360047700009
Impact of surgical innovation on tissue repair in the surgical patient. British journal of surgery Tevlin, R., Atashroo, D., Duscher, D., Mc Ardle, A., Gurtner, G. C., Wan, D. C., Longaker, M. T. 2015; 102 (2): e41-55
View details for DOI 10.1002/bjs.9672

View details for PubMedID 25627135
Loss of Keratinocyte Focal Adhesion Kinase Stimulates Dermal Proteolysis Through Upregulation of MMP9 in Wound Healing ANNALS OF SURGERY Wong, V. W., Garg, R. K., Sorkin, M., Rustad, K. C., Akaishi, S., Levi, K., Nelson, E. R., Tran, M., Rennert, R., Liu, W., Longaker, M. T., Dauskardt, R. H., Gurtner, G. C. 2014; 260 (6): 1138-1146
View details for DOI 10.1097/SLA.0000000000000219

View details for Web of Science ID 000345217200030
Aging disrupts cell subpopulation dynamics and diminishes the function of mesenchymal stem cells SCIENTIFIC REPORTS Duscher, D., Rennert, R. C., Januszyk, M., Anghel, E., Maan, Z. N., Whittam, A. J., Perez, M. G., Kosaraju, R., Hu, M. S., Walmsley, G. G., Atashroo, D., Khong, S., Butte, A. J., Gurtner, G. C. 2014; 4
View details for DOI 10.1038/srep07144

View details for Web of Science ID 000346178900001

View details for PubMedID 25413454
Reply: tension shielding with the embrace device: does it really improve scars? Plastic and reconstructive surgery Gurtner, G. C., Longaker, M. T. 2014; 134 (4): 664e-6e
View details for DOI 10.1097/PRS.0000000000000560

View details for PubMedID 25357068
A Randomized Controlled Trial of the embrace Advanced Scar Therapy Device to Reduce Incisional Scar Formation. Plastic and reconstructive surgery Longaker, M. T., Rohrich, R. J., Greenberg, L., Furnas, H., Wald, R., Bansal, V., Seify, H., Tran, A., Weston, J., Korman, J. M., Chan, R., Kaufman, D., Dev, V. R., Mele, J. A., Januszyk, M., Cowley, C., McLaughlin, P., Beasley, B., Gurtner, G. C. 2014; 134 (3): 536-546
Abstract

Scarring represents a significant biomedical burden in clinical medicine. Mechanomodulation has been linked to scarring through inflammation, but until now a systematic approach to attenuate mechanical force and reduce scarring has not been possible.The authors conducted a 12-month, prospective, open-label, randomized, multicenter clinical trial to evaluate abdominoplasty scar appearance following postoperative treatment with the embrace Advanced Scar Therapy device to reduce mechanical forces on healing surgical incisions. Incisions from 65 healthy adult subjects were randomized to receive embrace treatment on one half of an abdominoplasty incision and control treatment (surgeon's optimal care methods) on the other half. The primary endpoint for this study was the difference between assessments of scar appearance for the treated and control sides using the visual analogue scale scar score.Final 12-month study photographs were obtained from 36 subjects who completed at least 5 weeks of dressing application. The mean visual analogue scale score for embrace-treated scars (2.90) was significantly improved compared with control-treated scars (3.29) at 12 months (difference, 0.39; 95 percent confidence interval, 0.14 to 0.66; p = 0.027). Both subjects and investigators found that embrace-treated scars demonstrated significant improvements in overall appearance at 12 months using the Patient and Observer Scar Assessment Scale evaluation (p = 0.02 and p < 0.001, respectively). No serious adverse events were reported.These results demonstrate that the embrace device significantly reduces scarring following abdominoplasty surgery. To the authors' knowledge, this represents the first level I evidence for postoperative scar reduction.Therapeutic, II.

View details for DOI 10.1097/PRS.0000000000000417

View details for PubMedID 24804638
Capillary force seeding of hydrogels for adipose-derived stem cell delivery in wounds. Stem cells translational medicine Garg, R. K., Rennert, R. C., Duscher, D., Sorkin, M., Kosaraju, R., Auerbach, L. J., Lennon, J., Chung, M. T., Paik, K., Nimpf, J., Rajadas, J., Longaker, M. T., Gurtner, G. C. 2014; 3 (9): 1079-1089
Abstract

Effective skin regeneration therapies require a successful interface between progenitor cells and biocompatible delivery systems. We previously demonstrated the efficiency of a biomimetic pullulan-collagen hydrogel scaffold for improving bone marrow-derived mesenchymal stem cell survival within ischemic skin wounds by creating a "stem cell niche" that enhances regenerative cytokine secretion. Adipose-derived mesenchymal stem cells (ASCs) represent an even more appealing source of stem cells because of their abundance and accessibility, and in this study we explored the utility of ASCs for hydrogel-based therapies. To optimize hydrogel cell seeding, a rapid, capillary force-based approach was developed and compared with previously established cell seeding methods. ASC viability and functionality following capillary hydrogel seeding were then analyzed in vitro and in vivo. In these experiments, ASCs were seeded more efficiently by capillary force than by traditional methods and remained viable and functional in this niche for up to 14 days. Additionally, hydrogel seeding of ASCs resulted in the enhanced expression of multiple stemness and angiogenesis-related genes, including Oct4, Vegf, Mcp-1, and Sdf-1. Moving in vivo, hydrogel delivery improved ASC survival, and application of both murine and human ASC-seeded hydrogels to splinted murine wounds resulted in accelerated wound closure and increased vascularity when compared with control wounds treated with unseeded hydrogels. In conclusion, capillary seeding of ASCs within a pullulan-collagen hydrogel bioscaffold provides a convenient and simple way to deliver therapeutic cells to wound environments. Moreover, ASC-seeded constructs display a significant potential to accelerate wound healing that can be easily translated to a clinical setting.

View details for DOI 10.5966/sctm.2014-0007

View details for PubMedID 25038246

View details for PubMedCentralID PMC4149299
Noncontact, low-frequency ultrasound therapy enhances neovascularization and wound healing in diabetic mice. Plastic and reconstructive surgery Maan, Z. N., Januszyk, M., Rennert, R. C., Duscher, D., Rodrigues, M., Fujiwara, T., Ho, N., Whitmore, A., Hu, M. S., Longaker, M. T., Gurtner, G. C. 2014; 134 (3): 402e-11e
Abstract

Chronic wounds are a major source of morbidity for patients and represent a significant health burden. Implementing noninvasive techniques that accelerate healing of these wounds would provide great benefit. Ultrasound appears to be an effective modality for the treatment of chronic wounds in humans. MIST Therapy is a noncontact, low-frequency ultrasound treatment delivered through a saline mist. A variety of mechanisms have been proposed to explain the efficacy of ultrasound therapy, but the underlying molecular and cellular pathways impacted by this technique remain unclear. The in vivo effect of noncontact, low-frequency ultrasound was therefore examined in a humanized excisional wound model.The treatment group received noncontact, low-frequency ultrasound therapy three times per week, whereas the control group received a standard dressing change. Wounds were photographed at regular intervals to calculate healing kinetics. Wound tissue was harvested and processed for histology, quantitative polymerase chain reaction, and enzyme-linked immunosorbent assay.The MIST group demonstrated significantly accelerated wound healing, with 17.3 days to wound closure compared with 24 days in the controls (p < 0.05). This improvement became evident by day 9, with healing evidenced by significantly decreased mean wound area relative to original size (68 percent versus 80 percent; p < 0.01). Expression of markers of neovascularization (stromal cell-derived factor 1, vascular endothelial growth factor, and CD31) was also increased in the wound beds of noncontact, low-frequency ultrasound-treated mice compared with controls.Noncontact, low-frequency ultrasound treatment improves neovascularization and wound closure rates in excisional wounds for diabetic mice, likely because of the stimulated release of angiogenic factors.

View details for DOI 10.1097/PRS.0000000000000467

View details for PubMedID 25158717
The role of stem cells in aesthetic surgery: fact or fiction? Plastic and reconstructive surgery McArdle, A., Senarath-Yapa, K., Walmsley, G. G., Hu, M., Atashroo, D. A., Tevlin, R., Zielins, E., Gurtner, G. C., Wan, D. C., Longaker, M. T. 2014; 134 (2): 193-200
Abstract

Stem cells are attractive candidates for the development of novel therapies, targeting indications that involve functional restoration of defective tissue. Although most stem cell therapies are new and highly experimental, there are clinics around the world that exploit vulnerable patients with the hope of offering supposed stem cell therapies, many of which operate without credible scientific merit, oversight, or other patient protection.We review the potential, as well as drawbacks, for incorporation of stem cells in cosmetic procedures. A review of FDA-approved indications and ongoing clinical trials with adipose stem cells is provided. Furthermore, a "snapshot" analysis of websites using the search terms "stem cell therapy" or "stem cell treatment" or "stem cell facelift" was performed.Despite the protective net cast by regulatory agencies such as the FDA and professional societies such as the American Society of Plastic Surgeons, we are witnessing worrying advertisements for procedures such as stem cell facelifts, stem cell breast augmentations, and even stem cell vaginal rejuvenation. The marketing and promotion of stem cell procedures in aesthetic surgery is not adequately supported by clinical evidence in the majority of cases.Stem cells offer tremendous potential, but the marketplace is saturated with unsubstantiated and sometimes fraudulent claims that may place patients at risk. With plastic surgeons at the forefront of stem cell-based regenerative medicine, it is critically important that we provide an example of a rigorous approach to research, data collection, and advertising of stem cell therapies.

View details for DOI 10.1097/PRS.0000000000000404

View details for PubMedID 24732654
Studies in Fat Grafting: Part III. Fat Grafting Irradiated Tissue-Improved Skin Quality and Decreased Fat Graft Retention. Plastic and reconstructive surgery Garza, R. M., Paik, K. J., Chung, M. T., Duscher, D., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2014; 134 (2): 249-257
Abstract

Following radiation therapy, skin becomes fibrotic and can present a difficult problem for reconstructive surgeons. There is an increasing belief that fat grafting under irradiated skin can reverse the damage caused by radiation. The present study evaluated the effect of fat grafting on irradiated skin, along with fat graft quality and retention rates in irradiated tissue.Nine adult Crl:NU-Foxn1 CD-1 mice underwent 30-Gy external beam irradiation of the scalp. Four weeks after irradiation, scalp skin from irradiated and nonirradiated mice was harvested and compared histologically for dermal thickness, collagen content, and vascular density. Human fat grafts were then injected in the subcutaneous plane of the scalp. Skin assessment was performed in the irradiated group at 2 and 8 weeks after grafting, and fat graft retention was measured at baseline and every 2 weeks up to 8 weeks after grafting using micro-computed tomography. Finally, fat graft samples were explanted at 8 weeks, and quality scoring was performed.Fat grafting resulted in decreased dermal thickness, decreased collagen content, and increased vascular density in irradiated skin. Computed tomographic analysis revealed significantly decreased fat graft survival in the irradiated group compared with the nonirradiated group. Histologic scoring of explanted fat grafts demonstrated no difference in quality between the irradiated and nonirradiated groups.Fat grafting attenuates dermal collagen deposition and vessel depletion characteristic of radiation fibrosis. Although fat graft retention rates are significantly lower in irradiated than in nonirradiated tissue, the quality of retained fat between the groups is similar.

View details for DOI 10.1097/PRS.0000000000000326

View details for PubMedID 25068325

View details for PubMedCentralID PMC4116637
Studies in Fat Grafting: Part II. Effects of Injection Mechanics on Material Properties of Fat PLASTIC AND RECONSTRUCTIVE SURGERY Atashroo, D., Raphel, J., Chung, M. T., Paik, K. J., Parisi-Amon, A., McArdle, A., Senarath-Yapa, K., Zielins, E. R., Tevlin, R., Duldulao, C., Walmsley, G. G., Hu, M. S., Momeni, A., Domecus, B., Rimsa, J. R., Greenberg, L., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2014; 134 (1): 39-46
View details for DOI 10.1097/PRS.0000000000000289

View details for Web of Science ID 000338116400043
Studies in fat grafting: Part II. Effects of injection mechanics on material properties of fat. Plastic and reconstructive surgery Atashroo, D., Raphel, J., Chung, M. T., Paik, K. J., Parisi-Amon, A., McArdle, A., Senarath-Yapa, K., Zielins, E. R., Tevlin, R., Duldulao, C., Walmsley, G. G., Hu, M. S., Momeni, A., Domecus, B., Rimsa, J. R., Greenberg, L., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2014; 134 (1): 39-46
Abstract

Although fat grafting can address many soft-tissue deficits, results remain inconsistent. In this study, the authors compared physical properties of fat following injection using an automated, low-shear device or the modified Coleman technique.Lipoaspirate was obtained from nine patients and processed for injection using either a modified Coleman technique or an automated, low-shear device. Fat was passed through a 2-mm cannula and compared with minimally processed fat. A rheometer was used to measure the storage modulus and shear rate at which tissues began to lose their solid-like properties. Viscosity was also measured, and gross properties of treatment groups were evaluated qualitatively with a glass slide test.Fat injected through an automated, low-shear device closely matched physical properties of minimally processed fat. The storage modulus (G') of fat for the device group was greater than for the modified Coleman group, and the onset of breakdown was delayed. Similarly, viscosity measurement of fat from the automated device closely matched minimally processed fat and was greater than that of othe modified Coleman group.The physical properties of lipoaspirate processed using an automated, low-shear device with a 2-mm cannula preserved the intactness of fat more than the modified Coleman technique. The authors' rheologic data demonstrate less damage using an automated device compared with the modified Coleman technique and potentially support its use for improved fat graft integrity.

View details for DOI 10.1097/PRS.0000000000000289

View details for PubMedID 25028817
Studies in fat grafting: Part I. Effects of injection technique on in vitro fat viability and in vivo volume retention. Plastic and reconstructive surgery Chung, M. T., Paik, K. J., Atashroo, D. A., Hyun, J. S., McArdle, A., Senarath-Yapa, K., Zielins, E. R., Tevlin, R., Duldulao, C., Hu, M. S., Walmsley, G. G., Parisi-Amon, A., Momeni, A., Rimsa, J. R., Commons, G. W., Gurtner, G. C., Wan, D. C., Longaker, M. T. 2014; 134 (1): 29-38
Abstract

Fat grafting has become increasingly popular for the correction of soft tissue deficits at many sites throughout the body. Long-term outcomes, however, depend on delivery of fat in the least traumatic fashion to optimize viability of the transplanted tissue. In this study, we compare the biologic properties of fat following injection using two methods.Lipoaspiration samples were obtained from five female donors and cellular viability, proliferation, and lipolysis were evaluated following injection using either a modified Coleman technique or an automated, low shear device. Comparisons were made to minimally processed, uninjected fat. Volume retention was also measured over twelve weeks following injection of fat under the scalp of immunodeficient mice using either the modified Coleman technique or the Adipose Tissue Injector. Finally, fat grafts were analyzed histologically.Fat viability and cellular proliferation were both significantly greater with the Adipose Tissue Injector relative to injection with the modified Coleman technique. In contrast, significantly less lipolysis was noted using the automated device. In vivo fat volume retention was significantly greater than with the modified Coleman technique at 4, 6, 8, and 12 week time points. This corresponded with significantly greater histological scores for healthy fat and lower scores for injury following injection with the device.Biological properties of injected tissues reflect how disruptive and harmful techniques for placement of fat may be, and our in vitro and in vivo data both support the use of the automated, low shear devices compared to the modified Coleman technique.

View details for DOI 10.1097/PRS.0000000000000290

View details for PubMedID 24622574
Gene expression in fetal murine keratinocytes and fibroblasts JOURNAL OF SURGICAL RESEARCH Hu, M. S., Januszyk, M., Hong, W. X., Walmsley, G. G., Zielins, E. R., Atashroo, D. A., Maan, Z. N., McArdle, A., Takanishi, D. M., Gurtner, G. C., Longaker, M. T., Lorenz, H. P. 2014; 190 (1): 344-357
Abstract

Early fetuses heal wounds without the formation of a scar. Many studies have attempted to explain this remarkable phenomenon. However, the exact mechanism remains unknown. Herein, we examine the predominant cell types of the epidermis and dermis-the keratinocyte and fibroblast-during different stages of fetal development to better understand the changes that lead to scarring wound repair versus regeneration.Keratinocytes and fibroblasts were harvested and cultured from the dorsal skin of time-dated BALB/c fetuses. Total RNA was isolated and microarray analysis was performed using chips with 42,000 genes. Significance analysis of microarrays was used to select genes with >2-fold expression differences with a false discovery rate <2. Enrichment analysis was performed on significant genes to identify differentially expressed pathways.By comparing the gene expression profile of keratinocytes from E16 versus E18 fetuses, we identified 24 genes that were downregulated at E16. Analysis of E16 and E18 fibroblasts revealed 522 differentially expressed genes. Enrichment analysis showed the top 20 signaling pathways that were downregulated in E16 keratinocytes and upregulated or downregulated in E16 fibroblasts.Our data reveal 546 differentially expressed genes in keratinocytes and fibroblasts between the scarless and scarring transition. In addition, a total of 60 signaling pathways have been identified to be either upregulated or downregulated in these cell types. The genes and pathways recognized by our study may prove to be essential targets that may discriminate between fetal wound regeneration and adult wound repair.

View details for DOI 10.1016/j.jss.2014.02.030

View details for Web of Science ID 000338444700051
Studies in Fat Grafting: Part I. Effects of Injection Technique on In Vitro Fat Viability and In Vivo Volume Retention PLASTIC AND RECONSTRUCTIVE SURGERY Chung, M. T., Paik, K. J., Atashroo, D. A., Hyun, J. S., McArdle, A., Senarath-Yapa, K., Zielins, E. R., Tevlin, R., Duldulao, C., Hu, M. S., Walmsley, G. G., Parisi-Amon, A., Momeni, A., Rimsa, J. R., Commons, G. W., Gurtner, G. C., Wan, D. C., Longaker, M. T. 2014; 134 (1): 29-38
View details for DOI 10.1097/PRS.0000000000000290

View details for Web of Science ID 000338116400042
Mechanotransduction and fibrosis JOURNAL OF BIOMECHANICS Duscher, D., Maan, Z. N., Wong, V. W., Rennert, R. C., Januszyk, M., Rodrigues, M., Hu, M., Whitmore, A. J., Whittam, A. J., Longaker, M. T., Gurtner, G. C. 2014; 47 (9): 1997-2005
Abstract

Scarring and tissue fibrosis represent a significant source of morbidity in the United States. Despite considerable research focused on elucidating the mechanisms underlying cutaneous scar formation, effective clinical therapies are still in the early stages of development. A thorough understanding of the various signaling pathways involved is essential to formulate strategies to combat fibrosis and scarring. While initial efforts focused primarily on the biochemical mechanisms involved in scar formation, more recent research has revealed a central role for mechanical forces in modulating these pathways. Mechanotransduction, which refers to the mechanisms by which mechanical forces are converted to biochemical stimuli, has been closely linked to inflammation and fibrosis and is believed to play a critical role in scarring. This review provides an overview of our current understanding of the mechanisms underlying scar formation, with an emphasis on the relationship between mechanotransduction pathways and their therapeutic implications.

View details for DOI 10.1016/j.jbiomech.2014.03.031

View details for Web of Science ID 000338621900009
Diabetes impairs the angiogenic potential of adipose-derived stem cells by selectively depleting cellular subpopulations STEM CELL RESEARCH & THERAPY Rennert, R. C., Sorkin, M., Januszyk, M., Duscher, D., Kosaraju, R., Chung, M. T., Lennon, J., Radiya-Dixit, A., Raghvendra, S., Maan, Z. N., Hu, M. S., Rajadas, J., Rodrigues, M., Gurtner, G. C. 2014; 5
View details for DOI 10.1186/scrt468

View details for Web of Science ID 000338465500001
Transcriptional profiling of rapamycin-treated fibroblasts from hypertrophic and keloid scars. Annals of plastic surgery Wong, V. W., You, F., Januszyk, M., Gurtner, G. C., Kuang, A. A. 2014; 72 (6): 711-719
Abstract

Excess scar formation after cutaneous injury can result in hypertrophic scar (HTS) or keloid formation. Modern strategies to treat pathologic scarring represent nontargeted approaches that produce suboptimal results. Mammalian target of rapamycin (mTOR), a central mediator of inflammation, has been proposed as a novel target to block fibroproliferation. To examine its mechanism of action, we performed genomewide microarray on human fibroblasts (from normal skin, HTS, and keloid scars) treated with the mTOR inhibitor, rapamycin. Hypertrophic scar and keloid fibroblasts demonstrated overexpression of collagen I and III that was effectively abrogated with rapamycin. Blockade of mTOR specifically impaired fibroblast expression of the collagen biosynthesis genes PLOD, PCOLCE, and P4HA, targets significantly overexpressed in HTS and keloid scars. These data suggest that pathologic scarring can be abrogated via modulation of mTOR pathways in procollagen and collagen processing.

View details for DOI 10.1097/SAP.0b013e31826956f6

View details for PubMedID 24835866
Poly-l-Arginine Topical Lotion Tested in a Mouse Model for Frostbite Injury. Wilderness & environmental medicine Auerbach, L. J., DeClerk, B. K., Garrison Fathman, C., Gurtner, G. C., Auerbach, P. S. 2014; 25 (2): 160-165
Abstract

Frostbite injury occurs when exposure to cold results in frozen tissue. We recently reported a novel mouse model for frostbite injury to be used in screening potentially therapeutic drugs and other modalities.We used the mouse skin frostbite model to evaluate the effect of poly-l-arginine contained in lotion (PAL) applied topically to involved skin.Sixty mice were studied in a randomized, double-blind method. Standardized 2.9-cm-diameter circles were tattooed on the mouse dorsum. Magnets snap frozen in dry ice (-78.5°C) were used to create a frostbite injury on skin within the circle as a continuous 5-minute freeze. Mice were treated with prefreeze placebo, postthaw placebo, combined prefreeze and postthaw placebo, prefreeze with PAL, postthaw with PAL, or combined prefreeze and postthaw with PAL. Appearance, healing rate, tissue loss, and histology were recorded until the wounds were healed.Application of PAL before inducing frostbite injury resulted in decreased tissue loss as compared with other treatment conditions.Applying PAL topically to frostbitten mouse skin caused decreased tissue loss. Poly-l-arginine should be studied further to determine whether it is a beneficial therapeutic modality for frostbite injury.

View details for DOI 10.1016/j.wem.2014.01.006

View details for PubMedID 24631228
The Stanford Microsurgery and Resident Training (SMaRT) Scale: validation of an on-line global rating scale for technical assessment. Annals of plastic surgery Satterwhite, T., Son, J., Carey, J., Echo, A., Spurling, T., Paro, J., Gurtner, G., Chang, J., Lee, G. K. 2014; 72: S84-8
Abstract

We previously reported results of our on-line microsurgery training program, showing that residents who had access to our website significantly improved their cognitive and technical skills. In this study, we report an objective means for expert evaluators to reliably rate trainees' technical skills under the microscope, with the use of our novel global rating scale."Microsurgery Essentials" (http://smartmicrosurgery.com) is our on-line training curriculum. Residents were randomly divided into 2 groups: 1 group reviewed this online resource and the other did not. Pre- and post-tests consisted of videotaped microsurgical sessions in which the trainee performed "microsurgery" on 3 different models: latex glove, penrose drain, and the dorsal vessel of a chicken foot. The SMaRT (Stanford Microsurgery and Resident Training) scale, consisting of 9 categories graded on a 5-point Likert scale, was used to assess the trainees. Results were analyzed with ANOVA and Student t test, with P less than 0.05 indicating statistical significance.Seventeen residents participated in the study. The SMaRT scale adequately differentiated the performance of more experienced senior residents (PGY-4 to PGY-6, total average score = 3.43) from less experienced junior residents (PGY-1 to PGY-3, total average score = 2.10, P < 0.0001). Residents who viewed themselves as being confident received a higher score on the SMaRT scale (average score 3.5), compared to residents who were not as confident (average score 2.1) (P < 0.001). There were no significant differences in scoring among all 3 evaluators (P > 0.05). Additionally, junior residents who had access to our website showed a significant increase in their graded technical performance by 0.7 points when compared to residents who did not have access to the website who showed an improvement of only 0.2 points (P = 0.01).Our SMaRT scale is valid and reliable in assessing the microsurgical skills of residents and other trainees. Current trainees are more likely to use self-directed on-line education because of its easy accessibility and interactive format. Our global rating scale can help ensure residents are achieving appropriate technical milestones.

View details for DOI 10.1097/SAP.0000000000000139

View details for PubMedID 24691332
The Stanford Microsurgery and Resident Training (SMaRT) Scale: Validation of an On-Line Global Rating Scale for Technical Assessment. Annals of plastic surgery Satterwhite, T., Son, J., Carey, J., Echo, A., Spurling, T., Paro, J., Gurtner, G., Chang, J., Lee, G. K. 2014; 72: S84-8
View details for DOI 10.1097/SAP.0000000000000139

View details for PubMedID 24691332
A histological and mechanical analysis of the cardiac lead-tissue interface: implications for lead extraction. Acta biomaterialia Rennert, R. C., Rustad, K., Levi, K., Harwood, M., Sorkin, M., Wong, V. W., Al-Ahmad, A., Zei, P., Hsia, H., Beygui, R. E., Norton, L., Wang, P., Gurtner, G. C. 2014; 10 (5): 2200-2208
Abstract

The major risks of pacemaker and implantable cardioverter defibrillator extraction are attributable to the fibrotic tissue that encases them in situ, yet little is known about the cellular and functional properties of this response. In the present research, we performed a histological and mechanical analysis of human tissue collected from the lead-tissue interface to better understand this process and provide insights for the improvement of lead design and extraction. The lead-tissue interface consisted of a thin cellular layer underlying a smooth, acellular surface, followed by a circumferentially organized collagen-rich matrix. 51.8±4.9% of cells were myofibroblasts via immunohistochemistry, with these cells displaying a similar circumferential organization. Upon mechanical testing, samples exhibited a triphasic force-displacement response consisting of a toe region during initial tensioning, a linear elastic region and a yield and failure region. Mean fracture load was 5.6±2.1N, and mean circumferential stress at failure was 9.5±4.1MPa. While the low cellularity and fibrotic composition of tissue observed herein is consistent with a foreign body reaction to an implanted material, the significant myofibroblast response provides a mechanical explanation for the contractile forces complicating extractions. Moreover, the tensile properties of this tissue suggest the feasibility of circumferential mechanical tissue disruption, similar to balloon angioplasty devices, as a novel approach to assist with lead extraction.

View details for DOI 10.1016/j.actbio.2014.01.008

View details for PubMedID 24434537
The Role of Hypoxia-Inducible Factor in Wound Healing. Advances in wound care Hong, W. X., Hu, M. S., Esquivel, M., Liang, G. Y., Rennert, R. C., McArdle, A., Paik, K. J., Duscher, D., Gurtner, G. C., Lorenz, H. P., Longaker, M. T. 2014; 3 (5): 390-399
Abstract

Significance: Poor wound healing remains a significant health issue for a large number of patients in the United States. The physiologic response to local wound hypoxia plays a critical role in determining the success of the normal healing process. Hypoxia-inducible factor-1 (HIF-1), as the master regulator of oxygen homeostasis, is an important determinant of healing outcomes. HIF-1 contributes to all stages of wound healing through its role in cell migration, cell survival under hypoxic conditions, cell division, growth factor release, and matrix synthesis throughout the healing process. Recent Advances: Positive regulators of HIF-1, such as prolyl-4-hydroxylase inhibitors, have been shown to be beneficial in enhancing diabetic ischemic wound closure and are currently undergoing clinical trials for treatment of several human-ischemia-based conditions. Critical Issues: HIF-1 deficiency and subsequent failure to respond to hypoxic stimuli leads to chronic hypoxia, which has been shown to contribute to the formation of nonhealing ulcers. In contrast, overexpression of HIF-1 has been implicated in fibrotic disease through its role in increasing myofibroblast differentiation leading to excessive matrix production and deposition. Both positive and negative regulators of HIF-1 therefore provide important therapeutic targets that can be used to manipulate HIF-1 expression where an excess or deficiency in HIF-1 is known to correlate with pathogenesis. Future Directions: Targeting HIF-1 during wound healing has many important clinical implications for tissue repair. Counteracting the detrimental effects of excessive or deficient HIF-1 signaling by modulating HIF-1 expression may improve future management of poorly healing wounds.

View details for PubMedID 24804159

View details for PubMedCentralID PMC4005494
Mechanical offloading of incisional wounds is associated with transcriptional downregulation of inflammatory pathways in a large animal model ORGANOGENESIS Januszyk, M., Wong, V. W., Bhatt, K. A., Vial, I. N., Paterno, J., Longaker, M. T., Gurtner, G. C. 2014; 10 (2): 186-193
Abstract

Cutaneous scarring is a major source of morbidity and current therapies to mitigate scar formation remain ineffective. Although wound fibrosis and inflammation are highly linked, only recently have mechanical forces been implicated in these pathways. Our group has developed a topical polymer device that significantly reduces post-injury scar formation via the manipulation of mechanical forces. Here we extend these studies to examine the genomewide transcriptional effects of mechanomodulation during scar formation using a validated large animal model, the red Duroc pig. We demonstrate that mechanical loading of incisional wounds upregulates expression of genes associated with inflammatory and fibrotic pathways, and that device-mediated offloading of these wounds reverses these effects. Validation studies are needed to clarify the clinical significance of these findings.

View details for DOI 10.4161/org.28818

View details for Web of Science ID 000341807300005

View details for PubMedID 24739276
Abstract 151: short hairpin RNA interference therapy for diabetic murine wound closure and hindlimb ischemia. Plastic and reconstructive surgery Paik, K. J., Rennert, R., Chung, M. T., Sorkin, M., Duscher, D., Atashroo, D., Chen, H., Morrison, S. D., Zimmermann, A., Nauta, A., Ko, S., Tevlin, R., Zielins, E., Hu, M. S., McArdle, A., Walmsley, G., Senarath-Yapa, K., Hong, W. X., Garza, R. M., Duldulao, C., Wearda, T., Momeni, A., Wu, J. C., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2014; 133 (3): 167-168
View details for DOI 10.1097/01.prs.0000444979.14443.08

View details for PubMedID 25942261
Abstract 8: SDF-1 Regulates Adipose Niche Homeostasis and Adipose Derived Stromal Cell Function. Plastic and reconstructive surgery Maan, Z. N., Rennert, R. C., Duscher, D., Januszyk, M., Paik, K., Chung, M. T., Paik, K., Fujiwara, T., Rodrigues, M., Ho, N., Baker, H., Perez, M., Hu, M., Sorkin, M., Longaker, M. T., Gurtner, G. C. 2014; 133 (3): 15-16
View details for DOI 10.1097/01.prs.0000444941.23852.ce

View details for PubMedID 25942119
Abstract 10: Global and Endothelial Cell Specific Deletion of SDF-1 Results in Delayed Wound Healing. Plastic and reconstructive surgery Maan, Z. N., Ho, N., Rennert, R. C., Duscher, D., Sorkin, M., Rodrigues, M., Chen, J., Vial, I. N., Januszyk, M., Findlay, M., Hu, M., Walmsley, G., Longaker, M. T., Gurtner, G. C. 2014; 133 (3): 20-?
View details for DOI 10.1097/01.prs.0000444963.66915.ba

View details for PubMedID 25942121
Abstract 33: Stress Offloading through Mechanomodulation is Associated with Down-Regulation of Inflammatory Pathways in a Large Animal Model. Plastic and reconstructive surgery Januszyk, M., Wong, V. W., Bhatt, K., Vial, I. N., Dauskardt, R., Longaker, M. T., Gurtner, G. C. 2014; 133 (3): 44-?
View details for DOI 10.1097/01.prs.0000445066.09978.3b

View details for PubMedID 25942144
Abstract 15: Characterization of the Endothelial Progenitor Cell from Adult Tissue using Vav/Cre RFP-GFP Murine Model and Single Cell Microfluidics. Plastic and reconstructive surgery Rodrigues, M., Rennert, R. C., Bishop, S., Januszyk, M., Maan, Z., Sorkin, M., Duscher, D., Gurtner, G. C. 2014; 133 (3): 25-?
View details for DOI 10.1097/01.prs.0000445018.79483.78

View details for PubMedID 25942126
Reduced BMPR2 expression induces GM-CSF translation and macrophage recruitment in humans and mice to exacerbate pulmonary hypertension. journal of experimental medicine Sawada, H., Saito, T., Nickel, N. P., Alastalo, T., Glotzbach, J. P., Chan, R., Haghighat, L., Fuchs, G., Januszyk, M., Cao, A., Lai, Y., Perez, V. d., Kim, Y., Wang, L., Chen, P., Spiekerkoetter, E., Mitani, Y., Gurtner, G. C., Sarnow, P., Rabinovitch, M. 2014; 211 (2): 263-280
Abstract

Idiopathic pulmonary arterial hypertension (PAH [IPAH]) is an insidious and potentially fatal disease linked to a mutation or reduced expression of bone morphogenetic protein receptor 2 (BMPR2). Because intravascular inflammatory cells are recruited in IPAH pathogenesis, we hypothesized that reduced BMPR2 enhances production of the potent chemokine granulocyte macrophage colony-stimulating factor (GM-CSF) in response to an inflammatory perturbation. When human pulmonary artery (PA) endothelial cells deficient in BMPR2 were stimulated with tumor necrosis factor (TNF), a twofold increase in GM-CSF was observed and related to enhanced messenger RNA (mRNA) translation. The mechanism was associated with disruption of stress granule formation. Specifically, loss of BMPR2 induced prolonged phospho-p38 mitogen-activated protein kinase (MAPK) in response to TNF, and this increased GADD34-PP1 phosphatase activity, dephosphorylating eukaryotic translation initiation factor (eIF2α), and derepressing GM-CSF mRNA translation. Lungs from IPAH patients versus unused donor controls revealed heightened PA expression of GM-CSF co-distributing with increased TNF and expanded populations of hematopoietic and endothelial GM-CSF receptor α (GM-CSFRα)-positive cells. Moreover, a 3-wk infusion of GM-CSF in mice increased hypoxia-induced PAH, in association with increased perivascular macrophages and muscularized distal arteries, whereas blockade of GM-CSF repressed these features. Thus, reduced BMPR2 can subvert a stress granule response, heighten GM-CSF mRNA translation, increase inflammatory cell recruitment, and exacerbate PAH.

View details for DOI 10.1084/jem.20111741

View details for PubMedID 24446489
Paracrine Mechanism of Angiogenesis in Adipose-Derived Stem Cell Transplantation ANNALS OF PLASTIC SURGERY Suga, H., Glotzbach, J. P., Sorkin, M., Longaker, M. T., Gurtner, G. C. 2014; 72 (2): 234-241
Abstract

INTRODUCTION: Adipose-derived stem cells (ASCs) have shown potential for cell-based therapy in the field of plastic surgery. However, the fate of ASCs after transplantation and the mechanism(s) of their biologic capabilities remain unclear. METHODS: We isolated and cultured ASCs from transgenic mice that express both luciferase and green fluorescent protein and injected the cells into the inguinal fat pads of wild-type mice. We tested 4 experimental groups, namely, ischemic fat pads with/without ASCs and control fat pads with/without ASCs. RESULTS: Transplanted ASCs were tracked with bioluminescence imaging. The luminescence gradually decreased over 28 days, indicating cell death after transplantation. More ASCs were retained in ischemic fat pads on day 7 compared to control fat pads. On day 14, adipose tissue vascular density was higher in the ASC transplantation groups compared to those without ASCs. On day 28, there was decreased atrophy of adipose tissue in ASC-treated ischemic fat pads. Transplanted ASCs were detected as nonproliferating green fluorescent protein-positive cells, whereas native endothelial cells adjacent to the transplanted ASCs were proliferative. Protein analysis demonstrated higher expression of hepatocyte growth factor and vascular endothelial growth factor in the ASC transplantation groups, suggesting a paracrine mechanism, which was confirmed by in vitro experiments with conditioned media from ASCs. CONCLUSIONS: Transplanted ASCs are preferentially retained in ischemic adipose tissue, although most of the cells eventually undergo cell death. They exert an angiogenic effect on adipose tissue mainly through a paracrine mechanism. Increased understanding of these effects will help develop ASCs as a tool for cell-based therapy.

View details for DOI 10.1097/SAP.0b013e318264fd6a

View details for Web of Science ID 000338013700024
The embrace Device Significantly Decreases Scarring following Scar Revision Surgery in a Randomized Controlled Trial. Plastic and reconstructive surgery Lim, A. F., Weintraub, J., Kaplan, E. N., Januszyk, M., Cowley, C., McLaughlin, P., Beasley, B., Gurtner, G. C., Longaker, M. T. 2014; 133 (2): 398-405
Abstract

Mechanically offloading or shielding an incision significantly reduces scarring in both animal and first-in-human studies. Whether or not this strategy would be effective following scar revision surgery was previously unknown. In this article, the authors report that the embrace device, which uses principles of mechanomodulation, significantly improves aesthetic outcomes following scar revision surgery.A prospective, open-label, randomized, single-center study was conducted to evaluate the appearance of scars following revision and embrace treatment. Revision surgery was performed on 12 patients, each acting as his or her own control, and outcomes were assessed at 6 months. A visual analogue scale was used to evaluate each scar, rated by four independent surgeons who were not involved in the study.Evaluation of 6-month scar images by four independent surgeons using the visual analogue scale demonstrated a highly significant improvement in scar appearance following embrace treatment (p < 0.005).The embrace device represents a powerful new technology for significantly improving scar appearance following revision surgery.Therapeutic, II.

View details for DOI 10.1097/01.prs.0000436526.64046.d0

View details for PubMedID 24105084
Epidermal or Dermal Specific Knockout of PHD-2 Enhances Wound Healing and Minimizes Ischemic Injury. PloS one Zimmermann, A. S., Morrison, S. D., Hu, M. S., Li, S., Nauta, A., Sorkin, M., Meyer, N. P., Walmsley, G. G., Maan, Z. N., Chan, D. A., Gurtner, G. C., Giaccia, A. J., Longaker, M. T. 2014; 9 (4)
View details for DOI 10.1371/journal.pone.0093373

View details for PubMedID 24695462
Diabetes impairs the angiogenic potential of adipose-derived stem cells by selectively depleting cellular subpopulations. Stem cell research & therapy Rennert, R. C., Sorkin, M., Januszyk, M., Duscher, D., Kosaraju, R., Chung, M. T., Lennon, J., Radiya-Dixit, A., Raghvendra, S., Maan, Z. N., Hu, M. S., Rajadas, J., Rodrigues, M., Gurtner, G. C. 2014; 5 (3): 79-?
Abstract

Pathophysiologic changes associated with diabetes impair new blood vessel formation and wound healing. Mesenchymal stem cells derived from adipose tissue (ASCs) have been used clinically to promote healing, although it remains unclear whether diabetes impairs their functional and therapeutic capacity.In this study, we examined the impact of diabetes on the murine ASC niche, as well as on the potential of isolated cells to promote neovascularization in vitro and in vivo. A novel single cell analytical approach was used to interrogate ASC heterogeneity and subpopulation dynamics in this pathologic setting.Our results demonstrate that diabetes alters the ASC niche in situ, and that diabetic ASCs are compromised in their ability to establish a vascular network both in vitro and in vivo. Moreover, these diabetic cells were ineffective in promoting soft tissue neovascularization and wound healing. Single cell transcriptional analysis identified a subpopulation of cells which was diminished in both type 1 and type 2 models of diabetes. These cells were characterized by the high expression of genes known to be important for new blood vessel growth.Perturbations in specific cellular subpopulations, visible only on a single cell level, represent a previously unreported mechanism for the dysfunction of diabetic ASCs. These data suggest that the utility of autologous ASCs for cell-based therapies in diabetic patients may be limited, and that interventions to improve cell function before application are warranted.

View details for DOI 10.1186/scrt468

View details for PubMedID 24943716
Organ-Level Tissue Engineering Using Bioreactor Systems and Stem Cells: Implications for Transplant Surgery CURRENT STEM CELL RESEARCH & THERAPY Rennert, R. C., Sorkin, M., Wong, V. W., Gurtner, G. C. 2014; 9 (1): 2-9
Abstract

Vascularized composite allotransplantation (VCA) enables surgeons to address complex problems that exceed the possibilities of traditional autologous reconstruction. However, logistical and immunologic challenges currently limit the widespread application of VCA. Recent breakthroughs in the field of stem cells and tissue engineering have direct implications for the advancement of VCA. Specifically, the use of bioreactors may prolong ex vivo allograft survival and enable allograft modulations that mitigate immunogenicity and enhance graft function. Additionally, novel approaches utilizing bioreactor systems for stem cell seeding of vascularized bioscaffolds provide a blueprint for the de novo generation of complex tissues. These promising bioreactor-based strategies have the potential to expand the reconstructive applications of VCA, and could one day allow the fabrication of customized complex tissue grafts.

View details for Web of Science ID 000331889800002

View details for PubMedID 24180421
Aging disrupts cell subpopulation dynamics and diminishes the function of mesenchymal stem cells. Scientific reports Duscher, D., Rennert, R. C., Januszyk, M., Anghel, E., Maan, Z. N., Whittam, A. J., Perez, M. G., Kosaraju, R., Hu, M. S., Walmsley, G. G., Atashroo, D., Khong, S., Butte, A. J., Gurtner, G. C. 2014; 4: 7144-?
Abstract

Advanced age is associated with an increased risk of vascular morbidity, attributable in part to impairments in new blood vessel formation. Mesenchymal stem cells (MSCs) have previously been shown to play an important role in neovascularization and deficiencies in these cells have been described in aged patients. Here we utilize single cell transcriptional analysis to determine the effect of aging on MSC population dynamics. We identify an age-related depletion of a subpopulation of MSCs characterized by a pro-vascular transcriptional profile. Supporting this finding, we demonstrate that aged MSCs are also significantly compromised in their ability to support vascular network formation in vitro and in vivo. Finally, aged MSCs are unable to rescue age-associated impairments in cutaneous wound healing. Taken together, these data suggest that age-related changes in MSC population dynamics result in impaired therapeutic potential of aged progenitor cells. These findings have critical implications for therapeutic cell source decisions (autologous versus allogeneic) and indicate the necessity of strategies to improve functionality of aged MSCs.

View details for DOI 10.1038/srep07144

View details for PubMedID 25413454

View details for PubMedCentralID PMC4239576
Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies. Annals of surgical oncology Wapnir, I., Dua, M., Kieryn, A., Paro, J., Morrison, D., Kahn, D., Meyer, S., Gurtner, G. 2014; 21 (1): 100-106
Abstract

Nipple-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. Ischemic complications involving the nipple-areolar complex (NAC) occur in 3-37 % of cases. Skin perfusion can be monitored intraoperatively using indocyanine green (IC-GREEN™, ICG) and a specialized infrared camera-computer system (SPY Elite™). The blood flow pattern to the breast skin and the NAC were evaluated and a classification scheme was developed.Preincision baseline and postmastectomy skin perfusion studies were performed intraoperatively using 3 mL of ICG. The pattern of arterial blood inflow was classified according to whether perfusion appeared to originate predominantly from the underlying breast tissue (V1), the surrounding skin (V2), or a combination of V1 and V2 (V3). Ischemia, resection, or delayed complications of NAC were recorded.Thirty-nine breasts were interrogated. Seven (18 %) demonstrated a V1 pattern, 18 (46 %) a V2 pattern, and 14 (36 %) a V3 pattern. Seven (18 %) NACs were removed; six intraoperatively and the seventh in a delayed fashion. Notably, five of the seven resected NACs had a V1 pattern. Overall, 71 % of all V1 cases demonstrated profound ischemic changes by intraoperative clinical judgment and SPY imaging. The rates of resection of the NAC differed significantly between perfusion patterns (Fisher's exact test, p = 0.0003).Three perfusion patterns for the NAC are defined. The V1 pattern had the highest rate of NAC ischemia in NSM. Imaging NAC and skin perfusion during NSMs is a useful adjunctive tool with potential to direct placement of mastectomy incisions and minimize ischemic complications.

View details for DOI 10.1245/s10434-013-3214-0

View details for PubMedID 24046104
Epidermal or dermal specific knockout of PHD-2 enhances wound healing and minimizes ischemic injury. PloS one Zimmermann, A. S., Morrison, S. D., Hu, M. S., Li, S., Nauta, A., Sorkin, M., Meyer, N. P., Walmsley, G. G., Maan, Z. N., Chan, D. A., Gurtner, G. C., Giaccia, A. J., Longaker, M. T. 2014; 9 (4)
Abstract

Hypoxia-inducible factor (HIF)-1α, part of the heterodimeric transcription factor that mediates the cellular response to hypoxia, is critical for the expression of multiple angiogenic growth factors, cell motility, and the recruitment of endothelial progenitor cells. Inhibition of the oxygen-dependent negative regulator of HIF-1α, prolyl hydroxylase domain-2 (PHD-2), leads to increased HIF-1α and mimics various cellular and physiological responses to hypoxia. The roles of PHD-2 in the epidermis and dermis have not been clearly defined in wound healing.Epidermal and dermal specific PHD-2 knockout (KO) mice were developed in a C57BL/6J (wild type) background by crossing homozygous floxed PHD-2 mice with heterozygous K14-Cre mice and heterozygous Col1A2-Cre-ER mice to get homozygous floxed PHD-2/heterozygous K14-Cre and homozygous floxed PHD-2/heterozygous floxed Col1A2-Cre-ER mice, respectively. Ten to twelve-week-old PHD-2 KO and wild type (WT) mice were subjected to wounding and ischemic pedicle flap model. The amount of healing was grossly quantified with ImageJ software. Western blot and qRT-PCR was run on protein and RNA from primary cells cultured in vitro.qRT-PCR demonstrated a significant decrease of PHD-2 in keratinocytes and fibroblasts derived from tissue specific KO mice relative to control mice (*p<0.05). Western blot analysis showed a significant increase in HIF-1α and VEGF protein levels in PHD-2 KO mice relative to control mice (*p<0.05). PHD-2 KO mice showed significantly accelerated wound closure relative to WT (*p<0.05). When ischemia was analyzed at day nine post-surgery in a flap model, the PHD-2 tissue specific knockout mice showed significantly more viable flaps than WT (*p<0.05).PHD-2 plays a significant role in the rates of wound healing and response to ischemic insult in mice. Further exploration shows PHD-2 KO increases cellular levels of HIF-1α and this increase leads to the transcription of downstream angiogenic factors such as VEGF.

View details for DOI 10.1371/journal.pone.0093373

View details for PubMedID 24695462
Angiogenic properties of dehydrated human amnion/chorion allografts: therapeutic potential for soft tissue repair and regeneration. Vascular cell Koob, T. J., Lim, J. J., Massee, M., Zabek, N., Rennert, R., Gurtner, G., Li, W. W. 2014; 6: 10-?
Abstract

Chronic wounds are associated with a number of deficiencies in critical wound healing processes, including growth factor signaling and neovascularization. Human-derived placental tissues are rich in regenerative cytokines and have been shown in randomized clinical trials to be effective for healing chronic wounds. In this study, PURION® Processed (MiMedx Group, Marietta, GA) dehydrated human amnion/chorion membrane tissue allografts (dHACM, EpiFix®, MiMedx) were evaluated for properties to support wound angiogenesis.Angiogenic growth factors were identified in dHACM tissues using enzyme-linked immunosorbent assays (ELISAs), and the effects of dHACM extract on human microvascular endothelial cell (HMVEC) proliferation and production of angiogenic growth factors was determined in vitro. Chemotactic migration of human umbilical vein endothelial cells (HUVECs) toward pieces of dHACM tissue was determined using a standard in vitro transwell assay. Neovascularization of dHACM in vivo was determined utilizing a murine subcutaneous implant model.Quantifiable levels of the angiogenic cytokines angiogenin, angiopoietin-2 (ANG-2), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), heparin binding epidermal growth factor (HB-EGF), hepatocyte growth factor (HGF), platelet derived growth factor BB (PDGF-BB), placental growth factor (PlGF), and vascular endothelial growth factor (VEGF) were measured in dHACM. Soluble cues promoted HMVEC proliferation in vitro and increased endogenous production of over 30 angiogenic factors by HMVECs, including granulocyte macrophage colony-stimulating factor (GM-CSF), angiogenin, transforming growth factor β3 (TGF-β3), and HB-EGF. 6.0 mm disks of dHACM tissue were also found to recruit migration of HUVECs in vitro. Moreover, subcutaneous dHACM implants displayed a steady increase in microvessels over a period of 4 weeks, indicative of a dynamic intra-implant neovascular process.TAKEN TOGETHER, THESE RESULTS DEMONSTRATE THAT DHACM GRAFTS: 1) contain angiogenic growth factors retaining biological activity; 2) promote amplification of angiogenic cues by inducing endothelial cell proliferation and migration and by upregulating production of endogenous angiogenic growth factors by endothelial cells; and 3) support the formation of blood vessels in vivo. dHACM grafts are a promising wound care therapy with the potential to promote revascularization and tissue healing within poorly vascularized, non-healing wounds.

View details for DOI 10.1186/2045-824X-6-10

View details for PubMedID 24817999
Wound healing: an update REGENERATIVE MEDICINE Zielins, E. R., Atashroo, D. A., Maan, Z. N., Duscher, D., Walmsley, G. G., Marecic, O., Hu, M., Senarath-Yapa, K., McArdle, A., Tevlin, R., Wearda, T., Paik, K. J., Duldulao, C., Hong, W. X., Gurtner, G. C., Longaker, M. T. 2014; 9 (6): 817-830
View details for DOI 10.2217/RME.14.54

View details for Web of Science ID 000345620600012
From Germ Theory to Germ Therapy: Skin Microbiota, Chronic Wounds, and Probiotics PLASTIC AND RECONSTRUCTIVE SURGERY Wong, V. W., Martindale, R. G., Longaker, M. T., Gurtner, G. C. 2013; 132 (5): 854E-861E
Abstract

Microorganisms living throughout the body comprise the human "microbiota" and play an important role in health and disease. Recent research suggests that alterations in the skin microbiota may underlie chronic wound pathology. Probiotics are bacteria or yeast that confer a health benefit on the host and may have a role in preventing and treating nonhealing wounds by modulating host-microbe interactions.The English literature on skin microbiota, chronic wounds, biofilms, and probiotics is reviewed.Recent evidence indicates that disruption of microbial communities and bacteria-host interactions may contribute to impaired wound healing. Preclinical and human studies highlight the potential of probiotics to prevent or treat various infectious, immune-mediated, and inflammatory diseases.Advances in molecular sequencing and microbiology have shed light on the importance of the human microbiota in development, health, and disease. Probiotics represent a novel approach to altering the microbial environment with beneficial bacteria. Ongoing challenges include the need for better understanding of therapeutic mechanisms, improved regulation of manufacturing practices, and validation in controlled human trials. Current evidence suggests that probiotic-based therapies have considerable potential to exploit host-microbe relationships and improve clinical outcomes.

View details for DOI 10.1097/PRS.0b013e3182a3c11e

View details for Web of Science ID 000329991000017

View details for PubMedID 24165637
High-Throughput Single-Cell Analysis for Wound Healing Applications. Advances in wound care Januszyk, M., Gurtner, G. C. 2013; 2 (9): 457-469
Abstract

Wound repair is a complex biological process that integrates multiple physiologic pathways to restore skin homeostasis after a wide array of gross and anatomical insults. As such, a scientific examination of the wound typically requires broad sampling of numerous factors and is commonly achieved through DNA microarray analysis.In the last several years, it has become increasingly evident that the granularity afforded by such traditional population-based assays may be insufficient to capture the complex relationships in heterogeneous processes such as those associated with wound healing and stem cell biology.Several emerging technologies have recently become available that permit high-throughput single-cell gene expression analysis in a manner which provides novel insights into the relationships of complex tissue. The most prominent among these employs microfluidic-based devices to achieve a high-resolution analysis of tissue samples.The intrinsically heterogeneous nature of injured tissue, in conjunction with its temporal dynamics, makes wound repair and tissue regeneration an attractive target for high-throughput single-cell analysis. Given the staggering costs associated with chronic and non-healing wounds, the development of predictive and diagnostic tools using this technology would likely be attractive to healthcare providers.

View details for PubMedID 24527358
Biological therapies for the treatment of cutaneous wounds: Phase III and launched therapies EXPERT OPINION ON BIOLOGICAL THERAPY Rennert, R. C., Rodrigues, M., Wong, V. W., Duscher, D., Hu, M., Maan, Z., Sorkin, M., Gurtner, G. C., Longaker, M. T. 2013; 13 (11): 1523-1541
Abstract

Normal wound healing mechanisms can be overwhelmed in the setting of complex acute and chronic tissue injury. Biological therapies are designed to augment and/or restore the body's natural wound healing abilities. There are a variety of available and emerging technologies utilizing this approach that have demonstrated the ability to augment wound healing.In this review, the clinical data on launched and emerging biological therapies for wound healing applications are summarized. The methodologies discussed include biological skin equivalents, growth factors/small molecules and stem cell-based therapies.While many products possess convincing clinical data demonstrating their efficacy in comparison to standard treatment options, more robust, controlled studies are needed to determine the relative value among established and emerging biological therapies. Future bioengineering and stem cell-based approaches are of particular interest due to the simultaneous correction of multiple deficiencies present in the nonhealing wound.

View details for DOI 10.1517/14712598.2013.842972

View details for Web of Science ID 000325712100007

View details for PubMedID 24093722
Isolation of human adipose-derived stromal cells using laser-assisted liposuction and their therapeutic potential in regenerative medicine. Stem cells translational medicine Chung, M. T., Zimmermann, A. S., Paik, K. J., Morrison, S. D., Hyun, J. S., Lo, D. D., McArdle, A., Montoro, D. T., Walmsley, G. G., Senarath-Yapa, K., Sorkin, M., Rennert, R., Chen, H., Chung, A. S., Vistnes, D., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2013; 2 (10): 808-817
Abstract

Harvesting adipose-derived stromal cells (ASCs) for tissue engineering is frequently done through liposuction. However, several different techniques exist. Although third-generation ultrasound-assisted liposuction has been shown to not have a negative effect on ASCs, the impact of laser-assisted liposuction on the quality and differentiation potential of ASCs has not been studied. Therefore, ASCs were harvested from laser-assisted lipoaspirate and suction-assisted lipoaspirate. Next, in vitro parameters of cell yield, cell viability and proliferation, surface marker phenotype, osteogenic differentiation, and adipogenic differentiation were performed. Finally, in vivo bone formation was assessed using a critical-sized cranial defect in athymic nude mice. Although ASCs isolated from suction-assisted lipoaspirate and laser-assisted lipoaspirate both successfully underwent osteogenic and adipogenic differentiation, the cell yield, viability, proliferation, and frequency of ASCs (CD34(+)CD31(-)CD45(-)) in the stromal vascular fraction were all significantly less with laser-assisted liposuction in vitro (p < .05). In vivo, quantification of osseous healing by micro-computed tomography revealed significantly more healing with ASCs isolated from suction-assisted lipoaspirate relative to laser-assisted lipoaspirate at the 4-, 6-, and 8-week time points (p < .05). Therefore, as laser-assisted liposuction appears to negatively impact the biology of ASCs, cell harvest using suction-assisted liposuction is preferable for tissue-engineering purposes.

View details for DOI 10.5966/sctm.2012-0183

View details for PubMedID 24018794

View details for PubMedCentralID PMC3785265
Nipple Reconstruction: Risk Factors and Complications after 189 Procedures. European journal of plastic surgery Momeni, A., Ghaly, M., Gupta, D., Karanas, Y. L., Kahn, D. M., Gurtner, G. C., Lee, G. K. 2013; 36 (10): 633-638
Abstract

A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction.Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy.A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001).While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead.IV.

View details for PubMedID 24072956

View details for PubMedCentralID PMC3780439
The role of focal adhesion complexes in fibroblast mechanotransduction during scar formation DIFFERENTIATION Rustad, K. C., Wong, V. W., Gurtner, G. C. 2013; 86 (3): 87-91
Abstract

Historically, great efforts have been made to elucidate the biochemical pathways that direct the complex process of wound healing; however only recently has there been recognition of the importance that mechanical signals play in the process of tissue repair and scar formation. The body's physiologic response to injury involves a dynamic interplay between mechanical forces and biochemical cues which directs a cascade of signals leading ultimately to the formation of fibrotic scar. Fibroblasts are a highly mechanosensitive cell type and are also largely responsible for the generation of the fibrotic matrix during scar formation and are thus a critical player in the process of mechanotransduction during tissue repair. Mechanotransduction is initiated at the interface between the cell membrane and the extracellular matrix where mechanical signals are first translated into a biochemical response. Focal adhesions are dynamic multi-protein complexes through which the extracellular matrix links to the intracellular cytoskeleton. These focal adhesion complexes play an integral role in the propagation of this initial mechanical cue into an extensive network of biochemical signals leading to widespread downstream effects including the influx of inflammatory cells, stimulation of angiogenesis, keratinocyte migration, fibroblast proliferation and collagen synthesis. Increasing evidence has demonstrated the importance of the biomechanical milieu in healing wounds and suggests that an integrated approach to the discovery of targets to decrease scar formation may prove more clinically efficacious than previous purely biochemical strategies.

View details for DOI 10.1016/j.diff.2013.02.003

View details for Web of Science ID 000325741000003

View details for PubMedID 23623400
Biological properties of dehydrated human amnion/chorion composite graft: implications for chronic wound healing INTERNATIONAL WOUND JOURNAL Koob, T. J., Rennert, R., Zabek, N., Massee, M., Lim, J. J., Temenoff, J. S., Li, W. W., Gurtner, G. 2013; 10 (5): 493-500
Abstract

Human amnion/chorion tissue derived from the placenta is rich in cytokines and growth factors known to promote wound healing; however, preservation of the biological activities of therapeutic allografts during processing remains a challenge. In this study, PURION® (MiMedx, Marietta, GA) processed dehydrated human amnion/chorion tissue allografts (dHACM, EpiFix®, MiMedx) were evaluated for the presence of growth factors, interleukins (ILs) and tissue inhibitors of metalloproteinases (TIMPs). Enzyme-linked immunosorbent assays (ELISA) were performed on samples of dHACM and showed quantifiable levels of the following growth factors: platelet-derived growth factor-AA (PDGF-AA), PDGF-BB, transforming growth factor α (TGFα), TGFβ1, basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), placental growth factor (PLGF) and granulocyte colony-stimulating factor (GCSF). The ELISA assays also confirmed the presence of IL-4, 6, 8 and 10, and TIMP 1, 2 and 4. Moreover, the relative elution of growth factors into saline from the allograft ranged from 4% to 62%, indicating that there are bound and unbound fractions of these compounds within the allograft. dHACM retained biological activities that cause human dermal fibroblast proliferation and migration of human mesenchymal stem cells (MSCs) in vitro. An in vivo mouse model showed that dHACM when tested in a skin flap model caused mesenchymal progenitor cell recruitment to the site of implantation. The results from both the in vitro and in vivo experiments clearly established that dHACM contains one or more soluble factors capable of stimulating MSC migration and recruitment. In summary, PURION® processed dHACM retains its biological activities related to wound healing, including the potential to positively affect four distinct and pivotal physiological processes intimately involved in wound healing: cell proliferation, inflammation, metalloproteinase activity and recruitment of progenitor cells. This suggests a paracrine mechanism of action for dHACM when used for wound healing applications.

View details for DOI 10.1111/iwj.12140

View details for Web of Science ID 000325090300004

View details for PubMedID 23902526
Molecular analysis and differentiation capacity of adipose-derived stem cells from lymphedema tissue. Plastic and reconstructive surgery Levi, B., Glotzbach, J. P., Sorkin, M., Hyun, J., Januszyk, M., Wan, D. C., Li, S., Nelson, E. R., Longaker, M. T., Gurtner, G. C. 2013; 132 (3): 580-589
Abstract

Many breast cancer patients are plagued by the disabling complication of upper limb lymphedema after axillary surgery. Conservative treatments using massage and compression therapy do not offer a lasting relief, as they fail to address the chronic transformation of edema into excess adipose tissue. Liposuction to address the adipose nature of the lymphedema has provided an opportunity for a detailed analysis of the stromal fraction of lymphedema-associated fat to clarify the molecular mechanisms for this adipogenic transformation.Adipose-derived stem cells were harvested from human lipoaspirate of the upper extremity from age-matched patients with lymphedema (n = 3) or subcutaneous adipose tissue from control patients undergoing cosmetic procedures (n = 3). Immediately after harvest, adipose-derived stem cells were analyzed using single-cell transcriptional profiling techniques. Osteogenic, adipogenic, and vasculogenic gene expression and differentiation were assessed by quantitative real-time polymerase chain reaction and standard in vitro differentiation assays.Differential transcriptional clusters of adipose-derived stem cells were found between lymphedema and subcutaneous fat. Interestingly, lymphedema-associated stem cells had a much higher adipogenic gene expression and enhanced ability to undergo adipogenic differentiation. Conversely, they had lower vasculogenic gene expression and diminished capability to form tubules in vitro, whereas the osteogenic differentiation capacity was not significantly altered.Adipose-derived stem cells from extremities affected by lymphedema appear to exhibit transcriptional profiles similar to those of abdominal adipose-derived stem cells; however, their adipogenic differentiation potential is strongly increased and their vasculogenic capacity is compromised. These results suggest that the underlying pathophysiology of lymphedema drives adipose-derived stem cells toward adipogenic differentiation.

View details for DOI 10.1097/PRS.0b013e31829ace13

View details for PubMedID 23985633
Nipple reconstruction after implant-based breast reconstruction: A "matched-pair" outcome analysis focusing on the effects of radiotherapy. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Momeni, A., Ghaly, M., Gupta, D., Gurtner, G., Kahn, D. M., Karanas, Y. L., Lee, G. K. 2013; 66 (9): 1202-1205
Abstract

BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

View details for DOI 10.1016/j.bjps.2013.04.052

View details for PubMedID 23664573
Enabling stem cell therapies for tissue repair: Current and future challenges BIOTECHNOLOGY ADVANCES Wong, V. W., Sorkin, M., Gurtner, G. C. 2013; 31 (5): 744-751
Abstract

Stem cells embody the tremendous potential of the human body to develop, grow, and repair throughout life. Understanding the biologic mechanisms that underlie stem cell-mediated tissue regeneration is key to harnessing this potential. Recent advances in molecular biology, genetic engineering, and material science have broadened our understanding of stem cells and helped bring them closer to widespread clinical application. Specifically, innovative approaches to optimize how stem cells are identified, isolated, grown, and utilized will help translate these advances into effective clinical therapies. Although there is growing interest in stem cells worldwide, this enthusiasm must be tempered by the fact that these treatments remain for the most part clinically unproven. Future challenges include refining the therapeutic manipulation of stem cells, validating these technologies in randomized clinical trials, and regulating the global expansion of regenerative stem cell therapies.

View details for DOI 10.1016/j.biotechadv.2012.11.006

View details for Web of Science ID 000322058900020

View details for PubMedID 23178704
Molecular analysis and differentiation capacity of adipose-derived stem cells from lymphedema tissue. Plastic and reconstructive surgery Levi, B., Glotzbach, J. P., Sorkin, M., Hyun, J., Januszyk, M., Wan, D. C., Li, S., Nelson, E. R., Longaker, M. T., Gurtner, G. C. 2013; 132 (3): 580-589
View details for DOI 10.1097/PRS.0b013e31829ace13

View details for PubMedID 23985633
Wound healing: a paradigm for regeneration. Mayo Clinic proceedings. Mayo Clinic Wong, V. W., Gurtner, G. C., Longaker, M. T. 2013; 88 (9): 1022-1031
Abstract

Human skin is a remarkably plastic organ that sustains insult and injury throughout life. Its ability to expeditiously repair wounds is paramount to survival and is thought to be regulated by wound components such as differentiated cells, stem cells, cytokine networks, extracellular matrix, and mechanical forces. These intrinsic regenerative pathways are integrated across different skin compartments and are being elucidated on the cellular and molecular levels. Recent advances in bioengineering and nanotechnology have allowed researchers to manipulate these microenvironments in increasingly precise spatial and temporal scales, recapitulating key homeostatic cues that may drive regeneration. The ultimate goal is to translate these bench achievements into viable bedside therapies that address the growing global burden of acute and chronic wounds. In this review, we highlight current concepts in cutaneous wound repair and propose that many of these evolving paradigms may underlie regenerative processes across diverse organ systems.

View details for DOI 10.1016/j.mayocp.2013.04.012

View details for PubMedID 24001495
Direct contact of fibroblasts with neuronal processes promotes differentiation to myofibroblasts and induces contraction of collagen matrix in vitro WOUND REPAIR AND REGENERATION Fujiwara, T., Kubo, T., Kanazawa, S., Shingaki, K., Taniguchi, M., Matsuzaki, S., Gurtner, G. C., Tohyama, M., Hosokawa, K. 2013; 21 (4): 588-594
Abstract

Wound healing is often delayed in the patients whose sensory and autonomic innervation is impaired. We hypothesized that existence of neurites in the skin may promote wound healing by inducing differentiation of fibroblasts into myofibroblasts with consequent wound contraction. In the current study, we examined the effect of neurons on differentiation of fibroblasts and contraction of collagen matrix in vitro using a new co-culture model. Neuronal cell line, PC12 cells, of which the neurite outgrowth can be controlled by adding nerve growth factor, was used. Rat dermal fibroblasts were co-cultured with PC12 cells extending neurites or with PC12 cells lacking neurites. Then, differentiation of fibroblasts into myofibroblasts and contraction of the collagen matrix was evaluated. Finally, we examined whether direct or indirect contact with neurites of PC12 cells promoted the differentiation of fibroblasts. Our results showed that fibroblasts co-cultured with PC12 extending neurites differentiated into myofibroblasts more effectively and contracted the collagen matrix stronger than those with PC12 lacking neurites. Direct contact of fibroblasts with neurites promoted more differentiation than indirect contact. In conclusion, direct contact of fibroblasts with neuronal processes is important for differentiation into myofibroblasts and induction of collagen gel contraction, leading to promotion of wound healing.

View details for DOI 10.1111/wrr.12059

View details for Web of Science ID 000321186200013

View details for PubMedID 23758129
A novel mouse model for frostbite injury. Wilderness & environmental medicine Auerbach, L. J., Galvez, M. G., De Clerck, B. K., Glotzbach, J., Wehner, M. R., Chang, E. I., Gurtner, G. C., Auerbach, P. S. 2013; 24 (2): 94-104
Abstract

Frostbite injury occurs when exposure to cold results in frozen tissue. To screen drugs and other field therapies that might improve the outcome for a frostbite victim, it would be helpful to have a reliable and cost-effective preclinical in vivo model.We sought to create a novel mouse skin model of induced frostbite injury. This model would allow quantification of the surface area of involved skin, histology of the wound, rate of wound healing, and skin loss in a standardized fashion after the frostbite injury.Thirty-six mice were studied. Standardized 2.9-cm diameter circles were tattooed on the mouse dorsum. Magnets frozen in dry ice (-78.5°C) were used to create a frostbite injury on skin within the circle, either as a continuous 5-minute freeze or as 3 repeated freeze (1-minute) and thaw (3-minute) cycles. Appearance, healing rate, skin surface area loss, and histology were recorded until the wounds were healed.The amount of skin surface area loss was approximately 50% for both freeze methods. Although the time to surface skin healing was similar for both freeze methods, the initial healing rate was significantly (P = .001) slower in mice exposed to the freeze-thaw cycles compared with the continuous freeze model. Histopathology reflected inflammatory changes, cell death, and necrosis.This novel in vivo mouse model for frostbite allows quantification of affected skin surface area, histology, healing rate, and skin loss and has the potential of being utilized to screen future treatment modalities.

View details for DOI 10.1016/j.wem.2012.11.020

View details for PubMedID 23481507
A Mechanomodulatory Device to Minimize Incisional Scar Formation. Advances in wound care Wong, V. W., Beasley, B., Zepeda, J., Dauskardt, R. H., Yock, P. G., Longaker, M. T., Gurtner, G. C. 2013; 2 (4): 185-194
Abstract

To mechanically control the wound environment and prevent cutaneous scar formation.We subjected various material substrates to biomechanical testing to investigate their ability to modulate skin behavior. Combinations of elastomeric materials, adhesives, and strain applicators were evaluated to develop topical stress-shielding devices. Noninvasive imaging modalities were utilized to characterize anatomic site-specific differences in skin biomechanical properties in humans. The devices were tested in a validated large animal model of hypertrophic scarring. Phase I within-patient controlled clinical trials were conducted to confirm their safety and efficacy in scar reduction in patients undergoing abdominoplasty surgery.Among the tested materials and device applicators, a polymer device was developed that effectively off-loaded high tension wounds and blocked pro-fibrotic pathways and excess scar formation in red Duroc swine. In humans, different anatomic sites exhibit unique biomechanical properties that may correlate with the propensity to form scars. In the clinical trial, utilization of this device significantly reduced incisional scar formation and improved scar appearance for up to 12 months compared with control incisions that underwent routine postoperative care.This is the first device that is able to precisely control the mechanical environment of incisional wounds and has been demonstrated in multiple clinical trials to significantly reduce scar formation after surgery.Mechanomodulatory strategies to control the incisional wound environment can significantly reduce pathologic scarring and fibrosis after surgery.

View details for PubMedID 24527342

View details for PubMedCentralID PMC3656628
Adipose-derived Stromal Cells Overexpressing Vascular Endothelial Growth Factor Accelerate Mouse Excisional Wound Healing MOLECULAR THERAPY Nauta, A., Seidel, C., Deveza, L., Montoro, D., Grova, M., Ko, S. H., Hyun, J., Gurtner, G. C., Longaker, M. T., Yang, F. 2013; 21 (2): 445-455
Abstract

Angiogenesis is essential to wound repair, and vascular endothelial growth factor (VEGF) is a potent factor to stimulate angiogenesis. Here, we examine the potential of VEGF-overexpressing adipose-derived stromal cells (ASCs) for accelerating wound healing using nonviral, biodegradable polymeric vectors. Mouse ASCs were transfected with DNA plasmid encoding VEGF or green fluorescent protein (GFP) using biodegradable poly (β-amino) esters (PBAE). Cells transfected using Lipofectamine 2000, a commercially available transfection reagent, were included as controls. ASCs transfected using PBAEs showed enhanced transfection efficiency and 12-15-fold higher VEGF production compared with cells transfected using Lipofectamine 2000 (*P < 0.05). When transplanted into a mouse wild-type excisional wound model, VEGF-overexpressing ASCs led to significantly accelerated wound healing, with full wound closure observed at 8 days compared to 10-12 days in groups treated with ASCs alone or saline control (*P < 0.05). Histology and polarized microscopy showed increased collagen deposition and more mature collagen fibers in the dermis of wound beds treated using PBAE/VEGF-modified ASCs than ASCs alone. Our results demonstrate the efficacy of using nonviral-engineered ASCs to accelerate wound healing, which may provide an alternative therapy for treating many diseases in which wound healing is impaired.

View details for DOI 10.1038/mt.2012.234

View details for Web of Science ID 000314434600021

View details for PubMedID 23164936

View details for PubMedCentralID PMC3594010
Evidence that mast cells are not required for healing of splinted cutaneous excisional wounds in mice. PloS one Nauta, A. C., Grova, M., Montoro, D. T., Zimmermann, A., Tsai, M., Gurtner, G. C., Galli, S. J., Longaker, M. T. 2013; 8 (3)
Abstract

Wound healing is a complex biological process involving the interaction of many cell types to replace lost or damaged tissue. Although the biology of wound healing has been extensively investigated, few studies have focused on the role of mast cells. In this study, we investigated the possible role of mast cells in wound healing by analyzing aspects of cutaneous excisional wound healing in three types of genetically mast cell-deficient mice. We found that C57BL/6-Kit(W-sh/W-sh), WBB6F1-Kit(W/W-v), and Cpa3-Cre; Mcl-1(fl/fl) mice re-epithelialized splinted excisional skin wounds at rates very similar to those in the corresponding wild type or control mice. Furthermore, at the time of closure, scars were similar in the genetically mast cell-deficient mice and the corresponding wild type or control mice in both quantity of collagen deposition and maturity of collagen fibers, as evaluated by Masson's Trichrome and Picro-Sirius red staining. These data indicate that mast cells do not play a significant non-redundant role in these features of the healing of splinted full thickness excisional cutaneous wounds in mice.

View details for DOI 10.1371/journal.pone.0059167

View details for PubMedID 23544053
Cellular response to a novel fetal acellular collagen matrix: implications for tissue regeneration. International journal of biomaterials Rennert, R. C., Sorkin, M., Garg, R. K., Januszyk, M., Gurtner, G. C. 2013; 2013: 527957-?
Abstract

Introduction. PriMatrix (TEI Biosciences Inc., Boston, MA, USA) is a novel acellular collagen matrix derived from fetal bovine dermis that is designed for use in partial- and full-thickness wounds. This study analyzes the cellular response to PriMatrix in vivo, as well as the ability of this matrix to facilitate normal tissue regeneration. Methods. Five by five mm squares of rehydrated PriMatrix were implanted in a subcutaneous fashion on the dorsum of wild-type mice. Implant site tissue was harvested for histology, immunohistochemistry (IHC), and flow cytometric analyses at multiple time points until day 28. Results. PriMatrix implants were found to go through a biological progression initiated by a transient infiltrate of inflammatory cells, followed by mesenchymal cell recruitment and vascular development. IHC analysis revealed that the majority of the implanted fetal dermal collagen fibers persisted through day 28 but underwent remodeling and cellular repopulation to form tissue with a density and morphology consistent with healthy dermis. Conclusions. PriMatrix implants undergo progressive in vivo remodeling, facilitating the regeneration of histologically normal tissue through a mild inflammatory and progenitor cell response. Regeneration of normal tissue is especially important in a wound environment, and these findings warrant further investigation of PriMatrix in this setting.

View details for DOI 10.1155/2013/527957

View details for PubMedID 23970899
Adult stem cells in small animal wound healing models. Methods in molecular biology (Clifton, N.J.) Nauta, A. C., Gurtner, G. C., Longaker, M. T. 2013; 1037: 81-98
Abstract

This chapter broadly reviews the use of stem cells as a means to accelerate wound healing, focusing first on the properties of stem cells that make them attractive agents to influence repair, both alone and as vehicles for growth factor delivery. Major stem cell reservoirs are described, including adult, embryonic, and induced pluripotent cell sources, outlining the advantages and limitations of each source as wound healing agents, as well as the possible mechanisms responsible for wound healing acceleration. Finally, the chapter includes a materials and methods section that provides an in-depth description of adult tissue harvest techniques.

View details for DOI 10.1007/978-1-62703-505-7_5

View details for PubMedID 24029931
Murine models of human wound healing. Methods in molecular biology (Clifton, N.J.) Chen, J. S., Longaker, M. T., Gurtner, G. C. 2013; 1037: 265-274
Abstract

In vivo wound healing experiments remain the most predictive models for studying human wound healing, allowing an accurate representation of the complete wound healing environment including various cell types, environmental cues, and paracrine interactions. Small animals are economical, easy to maintain, and allow researchers to take advantage of the numerous transgenic strains that have been developed to investigate the specific mechanisms involved in wound healing and regeneration. Here we describe three reproducible murine wound healing models that recapitulate the human wound healing process.

View details for DOI 10.1007/978-1-62703-505-7_15

View details for PubMedID 24029941
In vivo directed differentiation of pluripotent stem cells for skeletal regeneration PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Levi, B., Hyun, J. S., Montoro, D. T., Lo, D. D., Chan, C. K., Hu, S., Sun, N., Lee, M., Grova, M., Connolly, A. J., Wu, J. C., Gurtner, G. C., Weissman, I. L., Wan, D. C., Longaker, M. T. 2012; 109 (50): 20379-20384
Abstract

Pluripotent cells represent a powerful tool for tissue regeneration, but their clinical utility is limited by their propensity to form teratomas. Little is known about their interaction with the surrounding niche following implantation and how this may be applied to promote survival and functional engraftment. In this study, we evaluated the ability of an osteogenic microniche consisting of a hydroxyapatite-coated, bone morphogenetic protein-2-releasing poly-L-lactic acid scaffold placed within the context of a macroenvironmental skeletal defect to guide in vivo differentiation of both embryonic and induced pluripotent stem cells. In this setting, we found de novo bone formation and participation by implanted cells in skeletal regeneration without the formation of a teratoma. This finding suggests that local cues from both the implanted scaffold/cell micro- and surrounding macroniche may act in concert to promote cellular survival and the in vivo acquisition of a terminal cell fate, thereby allowing for functional engraftment of pluripotent cells into regenerating tissue.

View details for DOI 10.1073/pnas.1218052109

View details for Web of Science ID 000312605600055

View details for PubMedID 23169671

View details for PubMedCentralID PMC3528603
Soft tissue mechanotransduction in wound healing and fibrosis SEMINARS IN CELL & DEVELOPMENTAL BIOLOGY Wong, V. W., Longaker, M. T., Gurtner, G. C. 2012; 23 (9): 981-986
Abstract

Recent evidence suggests that mechanical forces can significantly impact the biologic response to injury. Integrated mechanical and chemical signaling networks have been discovered that enable physical cues to regulate disease processes such as pathologic scar formation. Distinct molecular mechanisms control how tensional forces influence wound healing and fibrosis. Conceptual frameworks to understand cutaneous repair have expanded beyond traditional cell-cytokine models to include dynamic interactions driven by mechanical force and the extracellular matrix. Strategies to manipulate these biomechanical signaling networks have tremendous therapeutic potential to reduce scar formation and promote skin regeneration.

View details for DOI 10.1016/j.semcdb.2012.09.010

View details for Web of Science ID 000311962800006

View details for PubMedID 23036529
Introduction: Wound repair SEMINARS IN CELL & DEVELOPMENTAL BIOLOGY Longaker, M. T. 2012; 23 (9): 945-945
View details for DOI 10.1016/j.semcdb.2012.10.002

View details for Web of Science ID 000311962800001

View details for PubMedID 23059792
Stem cell recruitment after injury: lessons for regenerative medicine REGENERATIVE MEDICINE Rennert, R. C., Sorkin, M., Garg, R. K., Gurtner, G. C. 2012; 7 (6): 833-850
Abstract

Tissue repair and regeneration are thought to involve resident cell proliferation as well as the selective recruitment of circulating stem and progenitor cell populations through complex signaling cascades. Many of these recruited cells originate from the bone marrow, and specific subpopulations of bone marrow cells have been isolated and used to augment adult tissue regeneration in preclinical models. Clinical studies of cell-based therapies have reported mixed results, however, and a variety of approaches to enhance the regenerative capacity of stem cell therapies are being developed based on emerging insights into the mechanisms of progenitor cell biology and recruitment following injury. This article discusses the function and mechanisms of recruitment of important bone marrow-derived stem and progenitor cell populations following injury, as well as the emerging therapeutic applications targeting these cells.

View details for DOI 10.2217/RME.12.82

View details for Web of Science ID 000310656000018

View details for PubMedID 23164083
Regenerative Surgery: Tissue Engineering in General Surgical Practice WORLD JOURNAL OF SURGERY Wong, V. W., Wan, D. C., Gurtner, G. C., Longaker, M. T. 2012; 36 (10): 2288-2299
Abstract

Tissue engineering is a broad interdisciplinary field that aims to develop complex tissue and organ constructs through a combination of cell-, biomaterial-, and molecular-based approaches. This approach has the potential to transform the surgical treatment for diseases including trauma, cancer, and congenital malformations. A fundamental knowledge of key concepts in regenerative medicine is imperative for surgeons to maintain a leading role in developing and implementing these technologies. Researchers have started to elucidate the biologic mechanisms that maintain organ homeostasis throughout life, indicating that humans may have the latent capacity to regenerate complex tissues. By exploiting this intrinsic potential of the body, we can move even closer to developing functional, autologous replacement parts for a wide range of surgical diseases.

View details for DOI 10.1007/s00268-012-1710-1

View details for Web of Science ID 000309559800003

View details for PubMedID 22777416
Tissue engineering for the management of chronic wounds: current concepts and future perspectives EXPERIMENTAL DERMATOLOGY Wong, V. W., Gurtner, G. C. 2012; 21 (10): 729-734
Abstract

Chronic wounds constitute a significant and growing biomedical burden. With the increasing growth of populations prone to dysfunctional wound healing, there is an urgent and unmet need for novel strategies to both prevent and treat these complications. Tissue engineering offers the potential to create functional skin, and the synergistic efforts of biomedical engineers, material scientists, and molecular and cell biologists have yielded promising therapies for non-healing wounds. However, traditional paradigms for wound healing focus largely on the role of inflammatory cells and fail to incorporate more recent research highlighting the importance of stem cells and matrix dynamics in skin repair. Approaches to chronic wound healing centred on inflammation alone are inadequate to guide the development of regenerative medicine-based technologies. As the molecular pathways and biologic defects underlying non-healing wounds are further elucidated, multifaceted bioengineering systems must advance in parallel to exploit this knowledge. In this viewpoint essay, we highlight the current concepts in tissue engineering for chronic wounds and speculate on areas for future research in this increasingly interdisciplinary field.

View details for DOI 10.1111/j.1600-0625.2012.01542.x

View details for Web of Science ID 000310217000002

View details for PubMedID 22742728
Mesenchymal Stem Cells Home to Sites of Injury and Inflammation. Advances in wound care Rustad, K. C., Gurtner, G. C. 2012; 1 (4): 147-152
Abstract

Mesenchymal stem cells (MSCs) have shown significant therapeutic potential in preclinical animal models of wound healing. However, the translation of MSC-based therapeutics to clinical practice has been delayed by questions including the mechanisms of MSC homing, engraftment, and ultimate function.Experimental models of MSC-based wound therapies often involve intravenous injection of cells followed by sacrifice of animals at various time points and detection of MSCs in wounds by histological methods. However, this methodology is limited by its sampling of only specific tissue at a single time point and provides no information about how exogenously transplanted MSCs home to the wound environment.Most systemically injected MSCs initially become entrapped within the lungs before migrating out to the liver and spleen in the normal state. When an injury is present, after the initial lung entrapment, MSCs migrate in response to inflammatory mediators and home to sites of wounding.As MSC-based wound therapies continue to advance toward clinical trials, the availability of noninvasive methods to track cells after injection into patients affords the opportunity to monitor stem cell behavior post-transplantation.MSCs have demonstrated great promise as an emerging therapeutic for wound management. However, further preclinical studies will be needed to elucidate the reparative mechanisms of these cells and to determine how to optimize their regenerative potential.

View details for PubMedID 24527296

View details for PubMedCentralID PMC3623614
Microsurgery Education in Residency Training Validating an Online Curriculum Annual Conference of the California-Society-of-Plastic-Surgeons Satterwhite, T., Son, J., Carey, J., Zeidler, K., Bari, S., Gurtner, G., Chang, J., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2012: 410–14
Abstract

Plastic surgery training has traditionally been modeled as an "apprenticeship," where faculty teach surgical skills to residents on live patients. Although this is a well-established process, the demand by the public and healthcare agencies for improved patient care, outcomes, and patient safety has led to the development of adjunct methods of teaching. The goal of this project is to assess the effectiveness of a web-based microsurgical curriculum.We developed an interactive Web site to teach essential microsurgical competencies. Residents were randomly divided into 2 cohorts: one experimental group completed this online resource and the other control group did not. Pre- and postassessments were administered, consisting of a written test and a recorded microsurgery skills session.A total of 17 plastic surgery residents of various training levels participated in the study. Residents who completed the web-based curriculum showed dramatic improvement in their knowledge and skills, with a 17-percentage point increase in their test scores (P = 0.01) compared with controls (P = 0.80). The experimental group was more likely to perform microanastomoses faster with an average of 4.5-minute improvement compared with 1.25-minute change among the control group. Residents performed self-assessments, and those who rated themselves as "very confident" had higher overall test scores (85% test score vs. 59%, P = 0.004), as well as shorter times to complete the microsurgical task (7.5 minutes vs. 13.6 minutes, P = 0.007). Overall, 62% of residents rated the online webpage as extremely valuable. The majority of residents reported the webpage improved their knowledge and markedly improved their microsurgical technique, which was confirmed by faculty experts.Our interactive Web-based curriculum is a novel resource, teaching microsurgery in an organized, competency-based manner, which we believe is the first Web site of this nature. An individualized, self-paced Web site is ideal for plastic surgery trainees of all levels. Overall, the widespread implementation of our proposed curriculum--online self-directed training combined with regular practice sessions--will establish a strong foundation of microsurgery knowledge and skills acquisition for all plastic surgery residents.

View details for DOI 10.1097/SAP.0b013e31823b6a1a

View details for Web of Science ID 000301800600019

View details for PubMedID 22421490
Delivery Strategies for Stem Cell-Based Therapy JOURNAL OF HEALTHCARE ENGINEERING Glotzbach, J. P., Wong, V. W., Levi, B., Longaker, M. T., Gurtner, G. C. 2012; 3 (1): 1-20
View details for DOI 10.1260/2040-2295.3.1.1

View details for Web of Science ID 000311674000001
Enhancement of Human Adipose-Derived Stromal Cell Angiogenesis through Knockdown of a BMP-2 Inhibitor PLASTIC AND RECONSTRUCTIVE SURGERY Levi, B., Nelson, E. R., Hyun, J. S., Glotzbach, J. P., Li, S., Nauta, A., Montoro, D. T., Lee, M., Commons, G. C., Hu, S., Wu, J. C., Gurtner, G. C., Longaker, M. T. 2012; 129 (1): 53-66
Abstract

Previous studies have demonstrated the role of noggin, a bone morphogenetic protein-2 inhibitor, in vascular development and angiogenesis. The authors hypothesized that noggin suppression in human adipose-derived stromal cells would enhance vascular endothelial growth factor secretion and angiogenesis in vitro and in vivo to a greater extent than bone morphogenetic protein-2 alone.Human adipose-derived stromal cells were isolated from human lipoaspirate (n = 6) noggin was knocked down using lentiviral techniques. Knockdown was confirmed and angiogenesis was assessed by tubule formation and quantitative real-time polymerase chain reaction. Cells were seeded onto scaffolds and implanted into a 4-mm critical size calvarial defect. In vivo angiogenic signaling was assessed by immunofluorescence and immunohistochemistry.Human adipose-derived stromal cells with noggin suppression secreted significantly higher amounts of angiogenic proteins, expressed higher levels of angiogenic genes, and formed more tubules in vitro. In vivo, calvarial defects seeded with noggin shRNA human adipose-derived stromal cells exhibited a significantly higher number of vessels in the defect site than controls by immunohistochemistry (p < 0.05). In addition, bone morphogenetic protein-2-releasing scaffolds significantly enhanced vascular signaling in the defect site.Human adipose-derived stromal cells demonstrate significant increases in angiogenesis in vitro and in vivo with both noggin suppression and BMP-2 supplementation. By creating a cell with noggin suppressed and by using a scaffold with increased bone morphogenetic protein-2 signaling, a more angiogenic niche can be created.

View details for DOI 10.1097/PRS.0b013e3182361ff5

View details for Web of Science ID 000298857100075

View details for PubMedID 21915082

View details for PubMedCentralID PMC3246067
Therapeutic potential of bone marrow-derived mesenchymal stem cells for cutaneous wound healing FRONTIERS IN IMMUNOLOGY Chen, J. S., Wong, V. W., Gurtner, G. C. 2012; 3
View details for DOI 10.3389/fimmu.2012.00192

View details for Web of Science ID 000209501300188
Therapeutic potential of bone marrow-derived mesenchymal stem cells for cutaneous wound healing. Frontiers in immunology Chen, J. S., Wong, V. W., Gurtner, G. C. 2012; 3: 192-?
Abstract

Despite advances in wound care, many wounds never heal and become chronic problems that result in significant morbidity and mortality to the patient. Cellular therapy for cutaneous wounds has recently come under investigation as a potential treatment modality for impaired wound healing. Bone marrow-derived mesenchymal stem cells (MSCs) are a promising source of adult progenitor cells for cytotherapy as they are easy to isolate and expand and have been shown to differentiate into various cell lineages. Early studies have demonstrated that MSCs may enhance epithelialization, granulation tissue formation, and neovascularization resulting in accelerated wound closure. It is currently unclear if these effects are mediated through cellular differentiation or by secretion of cytokines and growth factors. This review discusses the proposed biological contributions of MSCs to cutaneous repair and their clinical potential in cell-based therapies.

View details for DOI 10.3389/fimmu.2012.00192

View details for PubMedID 22787462
Focal adhesion kinase links mechanical force to skin fibrosis via inflammatory signaling NATURE MEDICINE Wong, V. W., Rustad, K. C., Akaishi, S., Sorkin, M., Glotzbach, J. P., Januszyk, M., Nelson, E. R., Levi, K., Paterno, J., Vial, I. N., Kuang, A. A., Longaker, M. T., Gurtner, G. C. 2012; 18 (1): 148-152
View details for DOI 10.1038/nm.2574

View details for Web of Science ID 000299018600041
Stem cell niches for skin regeneration. International journal of biomaterials Wong, V. W., Levi, B., Rajadas, J., Longaker, M. T., Gurtner, G. C. 2012; 2012: 926059-?
Abstract

Stem cell-based therapies offer tremendous potential for skin regeneration following injury and disease. Functional stem cell units have been described throughout all layers of human skin and the collective physical and chemical microenvironmental cues that enable this regenerative potential are known as the stem cell niche. Stem cells in the hair follicle bulge, interfollicular epidermis, dermal papillae, and perivascular space have been closely investigated as model systems for niche-driven regeneration. These studies suggest that stem cell strategies for skin engineering must consider the intricate molecular and biologic features of these niches. Innovative biomaterial systems that successfully recapitulate these microenvironments will facilitate progenitor cell-mediated skin repair and regeneration.

View details for DOI 10.1155/2012/926059

View details for PubMedID 22701121
Stem Cells: Update and Impact on Craniofacial Surgery JOURNAL OF CRANIOFACIAL SURGERY Levi, B., Glotzbach, J. P., Wong, V. W., Nelson, E. R., Hyun, J., Wan, D. C., Gurtner, G. C., Longaker, M. T. 2012; 23 (1): 319-322
View details for DOI 10.1097/SCS.0b013e318241dbaf

View details for Web of Science ID 000300234900099

View details for PubMedID 22337434
Nonintegrating Knockdown and Customized Scaffold Design Enhances Human Adipose-Derived Stem Cells in Skeletal Repair STEM CELLS Levi, B., Hyun, J. S., Nelson, E. R., Li, S., Montoro, D. T., Wan, D. C., Jia, F. J., Glotzbach, J. C., James, A. W., Lee, M., Huang, M., Quarto, N., Gurtner, G. C., Wu, J. C., Longaker, M. T. 2011; 29 (12): 2018-2029
Abstract

An urgent need exists in clinical medicine for suitable alternatives to available techniques for bone tissue repair. Human adipose-derived stem cells (hASCs) represent a readily available, autogenous cell source with well-documented in vivo osteogenic potential. In this article, we manipulated Noggin expression levels in hASCs using lentiviral and nonintegrating minicircle short hairpin ribonucleic acid (shRNA) methodologies in vitro and in vivo to enhance hASC osteogenesis. Human ASCs with Noggin knockdown showed significantly increased bone morphogenetic protein (BMP) signaling and osteogenic differentiation both in vitro and in vivo, and when placed onto a BMP-releasing scaffold embedded with lentiviral Noggin shRNA particles, hASCs more rapidly healed mouse calvarial defects. This study therefore suggests that genetic targeting of hASCs combined with custom scaffold design can optimize hASCs for skeletal regenerative medicine.

View details for DOI 10.1002/stem.757

View details for Web of Science ID 000297220000012

View details for PubMedID 21997852

View details for PubMedCentralID PMC4353732
Mechanical force prolongs acute inflammation via T-cell-dependent pathways during scar formation FASEB JOURNAL Wong, V. W., Paterno, J., Sorkin, M., Glotzbach, J. P., Levi, K., Januszyk, M., Rustad, K. C., Longaker, M. T., Gurtner, G. C. 2011; 25 (12): 4498-4510
Abstract

Mechanical force significantly modulates both inflammation and fibrosis, yet the fundamental mechanisms that regulate these interactions remain poorly understood. Here we performed microarray analysis to compare gene expression in mechanically loaded wounds vs. unloaded control wounds in an established murine hypertrophic scar (HTS) model. We identified 853 mechanically regulated genes (false discovery rate <2) at d 14 postinjury, a subset of which were enriched for T-cell-regulated pathways. To substantiate the role of T cells in scar mechanotransduction, we applied the HTS model to T-cell-deficient mice and wild-type mice. We found that scar formation in T-cell-deficient mice was reduced by almost 9-fold (P < 0.001) with attenuated epidermal (by 2.6-fold, P < 0.01) and dermal (3.9-fold, P < 0.05) proliferation. Mechanical stimulation was highly associated with sustained T-cell-dependent Th2 cytokine (IL-4 and IL-13) and chemokine (MCP-1) signaling. Further, T-cell-deficient mice failed to recruit systemic inflammatory cells such as macrophages or monocytic fibroblast precursors in response to mechanical loading. These findings indicate that T-cell-regulated fibrogenic pathways are highly mechanoresponsive and suggest that mechanical forces induce a chronic-like inflammatory state through immune-dependent activation of both local and systemic cell populations.

View details for DOI 10.1096/fj.10-178087

View details for Web of Science ID 000298138100040

View details for PubMedID 21911593
Antimycotic Ciclopirox Olamine in the Diabetic Environment Promotes Angiogenesis and Enhances Wound Healing PLOS ONE Ko, S. H., Nauta, A., Morrison, S. D., Zhou, H., Zimmermann, A., Gurtner, G. C., Ding, S., Longaker, M. T. 2011; 6 (11)
Abstract

Diabetic wounds remain a major medical challenge with often disappointing outcomes despite the best available care. An impaired response to tissue hypoxia and insufficient angiogenesis are major factors responsible for poor healing in diabetic wounds. Here we show that the antimycotic drug ciclopirox olamine (CPX) can induce therapeutic angiogenesis in diabetic wounds. Treatment with CPX in vitro led to upregulation of multiple angiogenic genes and increased availability of HIF-1α. Using an excisional wound splinting model in diabetic mice, we showed that serial topical treatment with CPX enhanced wound healing compared to vehicle control treatment, with significantly accelerated wound closure, increased angiogenesis, and increased dermal cellularity. These findings offer a promising new topical pharmacologic therapy for the treatment of diabetic wounds.

View details for DOI 10.1371/journal.pone.0027844

View details for Web of Science ID 000297789200029

View details for PubMedID 22125629
CD105 Protein Depletion Enhances Human Adipose-derived Stromal Cell Osteogenesis through Reduction of Transforming Growth Factor beta 1 (TGF-beta 1) Signaling JOURNAL OF BIOLOGICAL CHEMISTRY Levi, B., Wan, D. C., Glotzbach, J. P., Hyun, J., Januszyk, M., Montoro, D., Sorkin, M., James, A. W., Nelson, E. R., Li, S., Quarto, N., Lee, M., Gurtner, G. C., Longaker, M. T. 2011; 286 (45): 39497-39509
Abstract

Clinically available sources of bone for repair and reconstruction are limited by the accessibility of autologous grafts, infectious risks of cadaveric materials, and durability of synthetic substitutes. Cell-based approaches for skeletal regeneration can potentially fill this need, and adipose tissue represents a promising source for development of such therapies. Here, we enriched for an osteogenic subpopulation of cells derived from human subcutaneous adipose tissue utilizing microfluidic-based single cell transcriptional analysis and fluorescence-activated cell sorting (FACS). Statistical analysis of single cell transcriptional profiles demonstrated that low expression of endoglin (CD105) correlated with a subgroup of adipose-derived cells with increased osteogenic gene expression. FACS-sorted CD105(low) cells demonstrated significantly enhanced in vitro osteogenic differentiation and in vivo bone regeneration when compared with either CD105(high) or unsorted cells. Evaluation of the endoglin pathway suggested that enhanced osteogenesis among CD105(low) adipose-derived cells is likely due to identification of a subpopulation with lower TGF-β1/Smad2 signaling. These findings thus highlight a potential avenue to promote osteogenesis in adipose-derived mesenchymal cells for skeletal regeneration.

View details for DOI 10.1074/jbc.M111.256529

View details for Web of Science ID 000296759800067

View details for PubMedID 21949130

View details for PubMedCentralID PMC3234773
Pullulan Hydrogels Improve Mesenchymal Stem Cell Delivery into High-Oxidative-Stress Wounds MACROMOLECULAR BIOSCIENCE Wong, V. W., Rustad, K. C., Glotzbach, J. P., Sorkin, M., Inayathullah, M., Major, M. R., Longaker, M. T., Rajadas, J., Gurtner, G. C. 2011; 11 (11): 1458-1466
Abstract

Cell-based therapies for wound repair are limited by inefficient delivery systems that fail to protect cells from the acute inflammatory environment. Here, a biomimetic hydrogel system is described that is based on the polymer pullulan, a carbohydrate glucan known to exhibit potent antioxidant capabilities. It is shown that pullulan hydrogels are an effective cell delivery system and improve mesenchymal stem cell survival and engraftment in high-oxidative-stress environments. The results suggest that glucan hydrogel systems may prove beneficial for progenitor-cell-based approaches to skin regeneration.

View details for DOI 10.1002/mabi.201100180

View details for Web of Science ID 000297555500002

View details for PubMedID 21994074
Pushing Back: Wound Mechanotransduction in Repair and Regeneration JOURNAL OF INVESTIGATIVE DERMATOLOGY Wong, V. W., Akaishi, S., Longaker, M. T., Gurtner, G. C. 2011; 131 (11): 2186-2196
Abstract

Human skin is a highly specialized mechanoresponsive interface separating our bodies from the external environment. It must constantly adapt to dynamic physical cues ranging from rapid expansion during embryonic and early postnatal development to ubiquitous external forces throughout life. Despite the suspected role of the physical environment in cutaneous processes, the fundamental molecular mechanisms responsible for how skin responds to force remain unclear. Intracellular pathways convert mechanical cues into biochemical responses (in a process known as mechanotransduction) via complex mechanoresponsive elements that often blur the distinction between physical and chemical signaling. For example, cellular focal adhesion components exhibit dual biochemical and scaffolding functions that are critically modulated by force. Moreover, the extracellular matrix itself is increasingly recognized to mechanically regulate the spatiotemporal distribution of soluble and matrix-bound ligands, underscoring the importance of bidirectional crosstalk between cells and their physical environment. It seems likely that a structural hierarchy exists to maintain both cells and matrix in mechanical homeostasis and that dysregulation of this architectural integrity may underlie or contribute to various skin disorders. An improved understanding of these interactions will facilitate the development of novel biophysical materials and mechanomodulatory approaches to augment wound repair and regeneration.

View details for DOI 10.1038/jid.2011.212

View details for Web of Science ID 000296240100012

View details for PubMedID 21776006
Wound healing and regenerative strategies ORAL DISEASES Nauta, A., Gurtner, G. C., Longaker, M. T. 2011; 17 (6): 541-549
Abstract

Wound healing is a complex biological process that affects multiple tissue types. Wounds in the oral cavity are particularly challenging given the variety of tissue types that exist in close proximity to one another. The goal of regenerative medicine is to facilitate the rapid replacement of lost or damaged tissue with tissue that is functional, and physiologically similar to what previously existed. This review provides a general overview of wound healing and regenerative medicine, focusing specifically on how recent advances in the fields of stem cell biology, tissue engineering, and oral disease could translate into improved clinical outcomes.

View details for DOI 10.1111/j.1601-0825.2011.01787.x

View details for Web of Science ID 000292985000001

View details for PubMedID 21332599
Comparative Healing of Human Cutaneous Surgical Incisions Created by the PEAK PlasmaBlade, Conventional Electrosurgery, and a Standard Scalpel PLASTIC AND RECONSTRUCTIVE SURGERY Ruidiaz, M. E., Messmer, D., Atmodjo, D. Y., Vose, J. G., Huang, E. J., Kummel, A. C., Rosenberg, H. L., Gurtner, G. C. 2011; 128 (1): 104-111
Abstract

The authors investigated thermal injury depth, inflammation, and scarring in human abdominal skin by comparing the histology of incisions made with a standard "cold" scalpel blade, conventional electrosurgery, and the PEAK PlasmaBlade, a novel, low-thermal-injury electrosurgical instrument.Approximately 6 and 3 weeks before abdominoplasty, full-thickness incisions were created in the abdominal pannus skin of 20 women, using a scalpel (scalpel), the PlasmaBlade, and a conventional electrosurgical instrument. Fresh (0-week) incisions were made immediately before surgery. After abdominoplasty, harvested incisions were analyzed for scar width, thermal injury depth, burst strength, and inflammatory response.Acute thermal injury depth was reduced 74 percent in PlasmaBlade incisions compared with conventional electrosurgical instrument (p < 0.001). Significant differences in inflammatory response were observed at 3 weeks, with mean CD3 response (T-lymphocytes) 40 percent (p = 0.01) and 21 percent (p ≈ 0.12) higher for the conventional electrosurgical instrument and PlasmaBlade, respectively, compared with the scalpel. CD68 response (monocytes/macrophages) was 52 percent (p = 0.05) and 16 percent (p ≈ 0.35) greater for a conventional electrosurgical instrument and the PlasmaBlade, respectively. PlasmaBlade incisions demonstrated 65 percent (p < 0.001) and 42 percent (p < 0.001) stronger burst strength than a conventional electrosurgical instrument, with equivalence to the scalpel at the 3- and 6-week time points, respectively. Scar width was equivalent for the PlasmaBlade and the scalpel at both time points, and 25 percent (p = 0.01) and 12 percent (p = 0.15) less than for electrosurgery, respectively.PlasmaBlade incisions demonstrated reduced thermal injury depth, inflammatory response, and scar width in healing skin compared with electrosurgery. These results suggest that the PlasmaBlade may provide clinically meaningful advantages over conventional electrosurgery during human cutaneous wound healing.Therapeutic, II.(Figure is included in full-text article.).

View details for DOI 10.1097/PRS.0b013e31821741ed

View details for Web of Science ID 000292499600040

View details for PubMedID 21701326
Regenerative Medicine CURRENT PROBLEMS IN SURGERY Glotzbach, J. P., Wong, V. W., Gurtner, G. C., Longaker, M. T. 2011; 48 (3): 148-212
View details for DOI 10.1067/j.cpsurg.2010.11.002

View details for Web of Science ID 000287543600002

View details for PubMedID 21295632
In brief: Regenerative medicine. Current problems in surgery Glotzbach, J. P., Wong, V. W., Gurtner, G. C., Longaker, M. T. 2011; 48 (3): 142-146
View details for DOI 10.1067/j.cpsurg.2010.11.001

View details for PubMedID 21295631
Engineered Pullulan-Collagen Composite Dermal Hydrogels Improve Early Cutaneous Wound Healing TISSUE ENGINEERING PART A Wong, V. W., Rustad, K. C., Galvez, M. G., Neofyotou, E., Glotzbach, J. P., Januszyk, M., Major, M. R., Sorkin, M., Longaker, M. T., Rajadas, J., Gurtner, G. C. 2011; 17 (5-6): 631-644
Abstract

New strategies for skin regeneration are needed to address the significant medical burden caused by cutaneous wounds and disease. In this study, pullulan-collagen composite hydrogel matrices were fabricated using a salt-induced phase inversion technique, resulting in a structured yet soft scaffold for skin engineering. Salt crystallization induced interconnected pore formation, and modification of collagen concentration permitted regulation of scaffold pore size. Hydrogel architecture recapitulated the reticular distribution of human dermal matrix while maintaining flexible properties essential for skin applications. In vitro, collagen hydrogel scaffolds retained their open porous architecture and viably sustained human fibroblasts and murine mesenchymal stem cells and endothelial cells. In vivo, hydrogel-treated murine excisional wounds demonstrated improved wound closure, which was associated with increased recruitment of stromal cells and formation of vascularized granulation tissue. In conclusion, salt-induced phase inversion techniques can be used to create modifiable pullulan-collagen composite dermal scaffolds that augment early wound healing. These novel biomatrices can potentially serve as a structured delivery template for cells and biomolecules in regenerative skin applications.

View details for DOI 10.1089/ten.tea.2010.0298

View details for Web of Science ID 000287801600005

View details for PubMedID 20919949
Surgical Approaches to Create Murine Models of Human Wound Healing JOURNAL OF BIOMEDICINE AND BIOTECHNOLOGY Wong, V., Sorkin, M., Glotzbach, J. P., Longaker, M. T., Gurtner, G. C. 2011
Abstract

Wound repair is a complex biologic process which becomes abnormal in numerous disease states. Although in vitro models have been important in identifying critical repair pathways in specific cell populations, in vivo models are necessary to obtain a more comprehensive and pertinent understanding of human wound healing. The laboratory mouse has long been the most common animal research tool and numerous transgenic strains and models have been developed to help researchers study the molecular pathways involved in wound repair and regeneration. This paper aims to highlight common surgical mouse models of cutaneous disease and to provide investigators with a better understanding of the benefits and limitations of these models for translational applications.

View details for DOI 10.1155/2011/969618

View details for Web of Science ID 000286250000001

View details for PubMedID 21151647
Akt-mediated mechanotransduction in murine fibroblasts during hypertrophic scar formation WOUND REPAIR AND REGENERATION Paterno, J., Vial, I. N., Wong, V. W., Rustad, K. C., Sorkin, M., Shi, Y., Bhatt, K. A., Thangarajah, H., Glotzbach, J. P., Gurtner, G. C. 2011; 19 (1): 49-58
Abstract

Although numerous factors are implicated in skin fibrosis, the exact pathophysiology of hypertrophic scarring remains unknown. We recently demonstrated that mechanical force initiates hypertrophic scar formation in a murine model, potentially enhancing cellular survival through Akt. Here, we specifically examined Akt-mediated mechanotransduction in fibroblasts using both strain culture systems and our murine scar model. In vitro, static strain increased fibroblast motility, an effect blocked by wortmannin (a phosphoinositide-3-kinase/Akt inhibitor). We also demonstrated that high-frequency cyclic strain was more effective at inducing Akt phosphorylation than low frequency or static strain. In vivo, Akt phosphorylation was induced by mechanical loading of dermal fibroblasts in both unwounded and wounded murine skin. Mechanically loaded scars also exhibited strong expression of α-smooth muscle actin, a putative marker of pathologic scar formation. In vivo inhibition of Akt increased apoptosis but did not significantly abrogate hypertrophic scar development. These data suggest that although Akt signaling is activated in fibroblasts during mechanical loading of skin, this is not the critical pathway in hypertrophic scar formation. Future studies are needed to fully elucidate the critical mechanotransduction components and pathways which activate skin fibrosis.

View details for DOI 10.1111/j.1524-475X.2010.00643.x

View details for Web of Science ID 000286214600032

View details for PubMedID 21134033
Statistics in Medicine PLASTIC AND RECONSTRUCTIVE SURGERY Januszyk, M., Gurtner, G. C. 2011; 127 (1): 437-444
Abstract

The scope of biomedical research has expanded rapidly during the past several decades, and statistical analysis has become increasingly necessary to understand the meaning of large and diverse quantities of raw data. As such, a familiarity with this lexicon is essential for critical appraisal of medical literature. This article attempts to provide a practical overview of medical statistics, with an emphasis on the selection, application, and interpretation of specific tests. This includes a brief review of statistical theory and its nomenclature, particularly with regard to the classification of variables. A discussion of descriptive methods for data presentation is then provided, followed by an overview of statistical inference and significance analysis, and detailed treatment of specific statistical tests and guidelines for their interpretation.

View details for DOI 10.1097/PRS.0b013e3181f95dd2

View details for Web of Science ID 000285992100060

View details for PubMedID 21200241
The Role of Stem Cells in Cutaneous Wound Healing: What Do We Really Know? PLASTIC AND RECONSTRUCTIVE SURGERY Ko, S. H., Nauta, A., Wong, V., Glotzbach, J., Gurtner, G. C., Longaker, M. T. 2011; 127 (1): 10S-20S
Abstract

Wound repair is a complex process involving the orchestrated interaction of multiple growth factors, cytokines, chemokines, and cell types. Dysregulation of this process leads to problems such as excessive healing in the form of keloids and hypertrophic scars and chronic, nonhealing wounds. These issues have broad global implications. Stem cells offer enormous potential for enhancing tissue repair and regeneration following injury. The rapidly developing fields of stem cell biology and skin tissue engineering create translational opportunities for the development of novel stem cell-based wound-healing therapies.

View details for DOI 10.1097/PRS.0b013e3181fbe2d8

View details for Web of Science ID 000286122400003

View details for PubMedID 21200267
Diathermy or Surgical Scalpel for Abdominal Skin Incisions What Is the Impact On Clinical Practice? ANNALS OF SURGERY Longaker, M. T., Gurtner, G. C. 2011; 253 (1): 14-15
View details for DOI 10.1097/SLA.0b013e318205718a

View details for Web of Science ID 000286179100004

View details for PubMedID 21294284
Quantifying migration and polarization of murine mesenchymal stem cells on different bone substitutes by confocal laser scanning microscopy JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY Roldan, J. C., Chang, E., Kelantan, M., Jazayeri, L., Deisinger, U., Detsch, R., Reichert, T. E., Gurtner, G. C. 2010; 38 (8): 580-588
Abstract

Cell migration is preceded by cell polarization. The aim of the present study was to evaluate the impact of the geometry of different bone substitutes on cell morphology and chemical responses in vitro.Cell polarization and migration were monitored temporally by using confocal laser scanning microscopy (CLSM) to follow green fluorescent protein (GFP)±mesenchymal stem cells (MSCs) on anorganic cancellous bovine bone (Bio-Oss(®)), β-tricalcium phosphate (β-TCP) (chronOS(®)) and highly porous calcium phosphate ceramics (Friedrich-Baur-Research-Institute for Biomaterials, Germany). Differentiation GFP±MSCs was observed using pro-angiogenic and pro-osteogenic biomarkers.At the third day of culture polarized vs. non-polarized cellular sub-populations were clearly established. Biomaterials that showed more than 40% of polarized cells at the 3rd day of culture, subsequently showed an enhanced cell migration compared to biomaterials, where non-polarized cells predominated (p<0.003). This trend continued untill the 7th day of culture (p<0.003). The expression of vascular endothelial growth factor was enhanced in biomaterials where cell polarization predominated at the 7th day of culture (p=0.001).This model opens an interesting approach to understand osteoconductivity at a cellular level. MSCs are promising in bone tissue engineering considering the strong angiogenic effect before differentiation occurs.

View details for DOI 10.1016/j.jcms.2010.01.004

View details for Web of Science ID 000284971700006

View details for PubMedID 20189818
The Basic Science of Vascular Biology: Implications for the Practicing Surgeon PLASTIC AND RECONSTRUCTIVE SURGERY Glotzbach, J. P., Levi, B., Wong, V. W., Longaker, M. T., Gurtner, G. C. 2010; 126 (5): 1527-1537
View details for DOI 10.1097/PRS.0b013e3181ef8ccf

View details for Web of Science ID 000283844700014
The basic science of vascular biology: implications for the practicing surgeon. Plastic and reconstructive surgery Glotzbach, J. P., Levi, B., Wong, V. W., Longaker, M. T., Gurtner, G. C. 2010; 126 (5): 1528-1538
Abstract

A thorough understanding of vascular biology will assist the reconstructive surgeon in both operative planning and development of novel surgical approaches to treat chronic wounds and tissue loss, and to optimize regenerative strategies for tissue reconstruction. In this review, several fundamental concepts of the basic science of vascular biology are discussed, with specific emphasis on the clinical implications most relevant to the reconstructive surgeon. Topics include the vascular physiology of tissue flaps and grafts, the principles of neovascularization including angiogenesis and vasculogenesis, and the basic concepts of bioengineering of vascularized tissue constructs for use in reconstruction. As basic science research increases our collective understanding of vascular physiology--specifically, in the areas of neovascularization and tissue engineering--reconstructive surgeons will be able to improve treatment of the sequelae of ischemic injuries, tissue loss, and chronic wounds.

View details for DOI 10.1097/PRS.0b013e3181ef8ccf

View details for PubMedID 21042110
Stem Cells PLASTIC AND RECONSTRUCTIVE SURGERY Behr, B., Ko, S. H., Wong, V. W., Gurtner, G. C., Longaker, M. T. 2010; 126 (4): 1163-1171
Abstract

Stem cells are self-renewing cells capable of differentiating into multiple cell lines and are classified according to their origin and their ability to differentiate. Enormous potential exists in use of stem cells for regenerative medicine. To produce effective stem cell-based treatments for a range of diseases, an improved understanding of stem cell biology and better control over stem cell fate are necessary. In addition, the barriers to clinical translation, such as potential oncologic properties of stem cells, need to be addressed. With renewed government support and continued refinement of current stem cell methodologies, the future of stem cell research is exciting and promises to provide novel reconstructive options for patients and surgeons limited by traditional paradigms.

View details for DOI 10.1097/PRS.0b013e3181ea42bb

View details for Web of Science ID 000282559100003

View details for PubMedID 20555302
Effectiveness of the Asteame Nipple Guard (TM) in maintaining projection following nipple reconstruction: A prospective randomised controlled trial 42nd Congress of the European-Society-for-Surgical-Research Rosing, J. H., Momeni, A., Kamperman, K., Kahn, D., Gurtner, G., Lee, G. K. ELSEVIER SCI LTD. 2010: 1592–96
Abstract

As the final step in breast reconstruction, nipple reconstruction is considered a minor surgical procedure. However, despite the multitude of techniques and postoperative dressings proposed, none have proven to resist the tendency of the reconstructed nipple to gradually flatten over time. A prospective randomized controlled trial was conducted assessing the value of using the Asteame Nipple Guard™ compared to standard gauze dressing in maintaining nipple projection postoperatively. A total of 30 nipple reconstructions in 22 patients were included in the study with randomisation of 15 nipples to each study arm. Nipple projection was measured at various time points postoperatively with calculation of the percent changes in nipple projection. The mean decrease in long-term nipple projection at 6 months in the experimental group was 46.6% vs. 71.8% in the control group (p<0.05). In conclusion, the Nipple Guard™ helps in maintaining nipple projection postoperatively.

View details for DOI 10.1016/j.bjps.2009.10.006

View details for Web of Science ID 000281655500003

View details for PubMedID 19897430
Tissue Engineering in Plastic Surgery: A Review PLASTIC AND RECONSTRUCTIVE SURGERY Wong, V. W., Rustad, K. C., Longaker, M. T., Gurtner, G. C. 2010; 126 (3): 858-868
Abstract

Novel tissue- and organ-engineering strategies are needed to address the growing need for replacement biological parts. Collective progress in stem cell technology, biomaterials, engineering, and molecular medicine has advanced the state of regenerative medicine, yet many hurdles to clinical translation remain. Plastic surgeons are in an ideal position to capitalize on emerging technologies and will be at the forefront of transitioning basic science research into the clinical reconstructive arena. This review highlights fundamental principles of bioengineering, recent progress in tissue-specific engineering, and future directions for this exciting and rapidly evolving area of medicine.

View details for DOI 10.1097/PRS.0b013e3181e3b3a3

View details for Web of Science ID 000281606700016

View details for PubMedID 20811219
Bone formation and degradation of a highly porous biphasic calcium phosphate ceramic in presence of BMP-7, VEGF and mesenchymal stem cells in an ectopic mouse model JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY Roldan, J. C., Detsch, R., Schaefer, S., Chang, E., Kelantan, M., Waiss, W., Reichert, T. E., Gurtner, G. C., Deisinger, U. 2010; 38 (6): 423-430
Abstract

Angiogenesis and mesenchymal stem cells (MSCs) promote osteogenesis. The aim of the present study was to evaluate whether bone morphogenetic protein (BMP-7) promoted osteoinduction could be enhanced by combining it with vascular endothelial growth factor (VEGF) or MSCs in highly porous biphasic calcium phosphate (BCP) ceramics.BCP ceramic blocks were implanted in an ectopic site in 24 mice (BMP-7 vs. BMP-7/VEGF; BMP-7 vs. BMP-7/MSCs and BMP-7 vs. Control; each group n=8). Specimens were analysed 12 weeks after surgery by environmental scanning electron microscopy (ESEM) and Giemsa staining.In all implanted scaffolds, newly formed bone was observed, even in the control site. No statistical differences in the amount of new bone were found in the presence of BMP-7 compared to BMP-7/VEGF (p=1.0) or BMP-7/MSCs (p=0.786). ESEM revealed a degradation of the scaffolds. A higher degradation was observed in areas where no bone-implant contact was present compared to areas where the ceramic was integrated in newly formed bone.Neither VEGF nor MSCs enhanced BMP-7 induced bone formation under the selected conditions. The present ceramic seemed to be osteoinductive and degradable, making this material suitable for bone tissue engineering.

View details for DOI 10.1016/j.jcms.2010.01.003

View details for Web of Science ID 000281172800003

View details for PubMedID 20189819
Strategies for organ level tissue engineering ORGANOGENESIS Rustad, K. C., Sorkin, M., Levi, B., Longaker, M. T., Gurtner, G. C. 2010; 6 (3): 151-157
Abstract

The field of tissue engineering has made considerable strides since it was first described in the late 1980s. The advent and subsequent boom in stem cell biology, emergence of novel technologies for biomaterial development and further understanding of developmental biology have contributed to this accelerated progress. However, continued efforts to translate tissue-engineering strategies into clinical therapies have been hampered by the problems associated with scaling up laboratory methods to produce large, complex tissues. The significant challenges faced by tissue engineers include the production of an intact vasculature within a tissue-engineered construct and recapitulation of the size and complexity of a whole organ. Here we review the basic components necessary for bioengineering organs-biomaterials, cells and bioactive molecules-and discuss various approaches for augmenting these principles to achieve organ level tissue engineering. Ultimately, the successful translation of tissue-engineered constructs into everyday clinical practice will depend upon the ability of the tissue engineer to "scale up" every aspect of the research and development process.

View details for DOI 10.4161/org.6.3.12139

View details for Web of Science ID 000290266200003

View details for PubMedID 21197216
The Plastic Surgery Research Council - Welcome from the Chairman PLASTIC AND RECONSTRUCTIVE SURGERY Gurtner, G. C. 2010; 125: 4-4
View details for DOI 10.1097/01.prs.0000371958.30432.fc

View details for Web of Science ID 000278497100001
The SNaP System: Biomechanical and Animal Model Testing of a Novel Ultraportable Negative-Pressure Wound Therapy System PLASTIC AND RECONSTRUCTIVE SURGERY Fong, K. D., Hu, D., Eichstadt, S., Gupta, D. M., Pinto, M., Gurtner, G. C., Longaker, M. T., Lorenz, H. P. 2010; 125 (5): 1362-1371
Abstract

Negative-pressure wound therapy is traditionally achieved by attaching an electrically powered pump to a sealed wound bed and applying subatmospheric pressure by means of gauze or foam. The Smart Negative Pressure (SNaP) System (Spiracur, Inc., Sunnyvale, Calif.) is a novel ultraportable negative-pressure wound therapy system that does not require an electrically powered pump.Negative pressure produced by the SNaP System, and a powered pump, the wound vacuum-assisted closure advanced-therapy system (Kinetic Concepts, Inc., San Antonio, Texas), were compared in vitro using bench-top pressure sensor testing and microstrain and stress testing with pressure-sensitive film and micro-computed tomographic scan analysis. In addition, to test in vivo efficacy, 10 rats underwent miniaturized SNaP (mSNaP) device placement on open wounds. Subject rats were randomized to a system activation group (approximately -125 mmHg) or a control group (atmospheric pressure). Wound measurements and histologic data were collected for analysis.Bench measurement revealed nearly identical negative-pressure delivery and mechanical strain deformation patterns between both systems. Wounds treated with the mSNaP System healed faster, with decreased wound size by postoperative day 7 (51 percent versus 12 percent reduction; p < 0.05) and had more rapid complete reepithelialization (21 days versus 32 days; p < 0.05). The mSNaP device also induced robust granulation tissue formation.The SNaP System and an existing electrically powered negative-pressure wound therapy system have similar biomechanical properties and functional wound-healing benefits. The potential clinical efficacy of the SNaP device for the treatment of wounds is supported.

View details for DOI 10.1097/PRS.0b013e3181d62b25

View details for Web of Science ID 000276886600008

View details for PubMedID 20440156
Intraoperative Perfusion Mapping with Laser-Assisted Indocyanine Green Imaging Can Predict and Prevent Complications in Immediate Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Komorowska-Timek, E., Gurtner, G. C. 2010; 125 (4): 1065-1073
Abstract

Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability.Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed.In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors.This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

View details for DOI 10.1097/PRS.0b013e3181d17f80

View details for Web of Science ID 000276644000003

View details for PubMedID 20335859
Discussion: Construction and Clinical Application of a Human Tissue-Engineered Epidermal Membrane PLASTIC AND RECONSTRUCTIVE SURGERY Wong, V. W., Gurtner, G. C. 2010; 125 (3): 910-912
View details for DOI 10.1097/PRS.0b013e3181cb6438

View details for Web of Science ID 000275714700019

View details for PubMedID 20195118
Meta Analysis of the Effectiveness of Surgical Scalpel or Diathermy in Making Abdominal Skin Incisions. Annals of surgery 2010
View details for DOI 10.1097/SLA.0b013e318205718a

View details for PubMedID 21135686
SUPERCHARGED REVERSE PEDICLE ANTEROLATERAL THIGH FLAP IN RECONSTRUCTION OF A MASSIVE DEFECT: A CASE REPORT MICROSURGERY Komorowska-Timek, E., Gurtner, G., Lee, G. K. 2010; 30 (5): 397-400
Abstract

Secondary reconstruction of lower extremity defects using local tissues is demanding and fraught with potential complications. Reconstructive efforts may be challenged by pre-existing scarring, paucity of recipient vessels, and patient co-morbidities limiting tolerance for prolonged and extensive surgery. We present a case of an 81-year-old male with a recurrent malignant melanoma invading the proximal and middle third of the tibia, who previously underwent reconstruction with the medial gastrocnemius muscle and a skin graft. After wide local re-excision and tibia fixation, a 12 cm x 28 cm reverse anterolateral thigh flap was used for soft tissue coverage. Because of the relatively large size of the flap based upon retrograde flow, we elected to supercharge the flap to augment its blood supply. Supercharging of the flap pedicle was accomplished by anastamosing the lateral circumflex femoral vessels to the anterior tibial vessels. The donor site wasclosed primarily. The flap survived entirely and successfully endured subsequent radiation therapy. Supercharging enhances reliability of the reverse anterolateral thigh flap, and thus, permits harvest of large tissue bulk for coverage of up to proximal two-thirds of the tibia.This is the first report describing successful supercharging of a large reverse anterolateral thigh flap which resulted in entire flap survival.

View details for DOI 10.1002/micr.20761

View details for Web of Science ID 000280085900010

View details for PubMedID 20238382
Imaging the Unfolded Protein Response in Primary Tumors Reveals Microenvironments with Metabolic Variations that Predict Tumor Growth CANCER RESEARCH Spiotto, M. T., Banh, A., Papandreou, I., Cao, H., Galvez, M. G., Gurtner, G. C., Denko, N. C., Le, Q. T., Koong, A. C. 2010; 70 (1): 78-88
Abstract

Cancer cells exist in harsh microenvironments that are governed by various factors, including hypoxia and nutrient deprivation. These microenvironmental stressors activate signaling pathways that affect cancer cell survival. While others have previously measured microenvironmental stressors in tumors, it remains difficult to detect the real-time activation of these downstream signaling pathways in primary tumors. In this study, we developed transgenic mice expressing an X-box binding protein 1 (XBP1)-luciferase construct that served as a reporter for endoplasmic reticulum (ER) stress and as a downstream response for the tumor microenvironment. Primary mammary tumors arising in these mice exhibited luciferase activity in vivo. Multiple tumors arising in the same mouse had distinct XBP1-luciferase signatures, reflecting either higher or lower levels of ER stress. Furthermore, variations in ER stress reflected metabolic and hypoxic differences between tumors. Finally, XBP1-luciferase activity correlated with tumor growth rates. Visualizing distinct signaling pathways in primary tumors reveals unique tumor microenvironments with distinct metabolic signatures that can predict for tumor growth.

View details for DOI 10.1158/0008-5472.CAN-09-2747

View details for Web of Science ID 000278404300011

View details for PubMedID 20028872
HIF-1 alpha dysfunction in diabetes CELL CYCLE Thangarajah, H., Vial, I. N., Grogan, R. H., Yao, D., Shi, Y., Januszyk, M., Galiano, R. D., Chang, E. I., Galvez, M. G., Glotzbach, J. P., Wong, V. W., Brownlee, M., Gurtner, G. C. 2010; 9 (1): 75-79
Abstract

Diabetic wounds are a significant public health burden, with slow or nonhealing diabetic foot ulcers representing the leading cause of non-traumatic lower limb amputation in developed countries. These wounds heal poorly as a result of compromised blood vessel formation in response to ischemia. We have recently shown that this impairment in neovascularization results from a high glucose-induced defect in transactivation of hypoxia-inducible factor-1alpha (HIF-1alpha), the transcription factor regulating vascular endothelial growth factor (VEGF) expression. HIF-1 dysfunction is the end result of reactive oxygen species-induced modification of its coactivator p300 by the glycolytic metabolite methylglyoxal. Use of the iron chelator-antioxidant deferoxamine (DFO) reversed these effects and normalized healing of humanized diabetic wounds in mice. Here, we present additional data demonstrating that HIF-1alpha activity, not stability, is impaired in the high glucose environment. We demonstrate that high glucose-induced impairments in HIF-1alpha transactivation persist even in the setting of constitutive HIF-1alpha protein overexpression. Further, we show that high glucose-induced hydroxylation of the C-terminal transactivation domain of HIF-1alpha (the primary pathway regulating HIF-1alpha/p300 binding) does not alter HIF-1alpha activity. We extend our study of DFO's therapeutic efficacy in the treatment of impaired wound healing by demonstrating improvements in tissue viability in diabetic mice with DFO-induced increases in VEGF expression and vascular proliferation. Since DFO has been in clinical use for decades, the potential of this drug to treat a variety of ischemic conditions in humans can be evaluated relatively quickly.

View details for Web of Science ID 000273236800025

View details for PubMedID 20016290
Comparative Healing of Surgical Incisions Created by the PEAK PlasmaBlade, Conventional Electrosurgery, and a Scalpel PLASTIC AND RECONSTRUCTIVE SURGERY Loh, S. A., Carlson, G. A., Chang, E. I., Huang, E., Palanker, D., Gurtner, G. C. 2009; 124 (6): 1849-1859
Abstract

The PEAK PlasmaBlade is a new electrosurgical device that uses pulsed radiofrequency to generate a plasma-mediated discharge along the exposed rim of an insulated blade, creating an effective cutting edge while the blade stays near body temperature.Full-thickness incisions were made on the dorsums of pigs with the PlasmaBlade, a conventional electrosurgical device, and a scalpel, and blood loss was quantified. Wounds were harvested at designated time points, tested for wound tensile strength, and examined histologically for scar formation and tissue damage.Bleeding was reduced significantly (59 percent) in PlasmaBlade incisions compared with scalpel incisions, and acute thermal damage from the PlasmaBlade (66 +/- 5 microm) was significantly less than both cut and coagulation mode electrosurgical incisions (456 +/- 35 microm and 615 +/- 22 microm, respectively). Histologic scoring for injury and wound strength was equivalent between the PlasmaBlade and scalpel incisions. By 6 weeks, the healed PlasmaBlade and scalpel incisions were approximately three times stronger, and scar cosmetic appearance was significantly better compared with electrosurgical incisions.The PlasmaBlade is a promising new surgical instrument that provides atraumatic, scalpel-like cutting precision and electrosurgical-like hemostasis, resulting in minimal bleeding, tissue injury, and scar formation.

View details for DOI 10.1097/PRS.0b013e3181bcee87

View details for Web of Science ID 000272615600015

View details for PubMedID 19952641
Human skin wounds: A major and snowballing threat to public health and the economy WOUND REPAIR AND REGENERATION Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Gottrup, F., Gurtner, G. C., Longaker, M. T. 2009; 17 (6): 763-771
Abstract

ABSTRACT In the United States, chronic wounds affect 6.5 million patients. An estimated excess of US$25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The annual wound care products market is projected to reach $15.3 billion by 2010. Chronic wounds are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from "highly branded" diseases such as diabetes and obesity. This seems to have overshadowed the significance of wounds per se as a major health problem. For example, NIH's Research Portfolio Online Reporting Tool (RePORT; http://report.nih.gov/), directed at providing access to estimates of funding for various disease conditions does list several rare diseases but does not list wounds. Forty million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. The need for post-surgical wound care is sharply on the rise. Emergency wound care in an acute setting has major significance not only in a war setting but also in homeland preparedness against natural disasters as well as against terrorism attacks. An additional burden of wound healing is the problem of skin scarring, a $12 billion annual market. The immense economic and social impact of wounds in our society calls for allocation of a higher level of attention and resources to understand biological mechanisms underlying cutaneous wound complications.

View details for DOI 10.1111/j.1524-475X.2009.00543.x

View details for Web of Science ID 000271314900001

View details for PubMedID 19903300
From Bedside to Bench and Back Again: Technology Innovation in Plastic Surgery PLASTIC AND RECONSTRUCTIVE SURGERY Gurtner, G. C., Rohrich, R. J., Longaker, M. T. 2009; 124 (4): 1355-1356
View details for DOI 10.1097/PRS.0b013e3181b8901a

View details for Web of Science ID 000270332300042

View details for PubMedID 19935323
The mechanisms of action of vacuum assisted closure: More to learn SURGERY Orgill, D. P., Manders, E. K., Sumpio, B. E., Lee, R. C., Attinger, C. E., Gurtner, G. C., Ehrlich, H. P. 2009; 146 (1): 40-51
View details for DOI 10.1016/j.surg.2009.02.002

View details for Web of Science ID 000267498600007

View details for PubMedID 19541009
Treating Chronic Wound Infections with Genetically Modified Free Flaps PLASTIC AND RECONSTRUCTIVE SURGERY Ghali, S., Bhatt, K. A., Dempsey, M. P., Jones, D. M., Singh, S., Arabi, S., Butler, P. E., Gallo, R. L., Gurtner, G. C. 2009; 123 (4): 1157-1168
Abstract

The success of antimicrobial therapy has been impaired by the emergence of resistant bacterial strains. Antimicrobial peptides are ubiquitous proteins that are part of the innate immune system and are successful against such antibiotic-resistant microorganisms. The authors have previously demonstrated the feasibility of protein delivery via microvascular free flap gene therapy and here they examine this approach for recalcitrant infections.The authors investigated the production of the human cathelicidin antimicrobial peptide-LL37, delivered by ex vivo transduction of the rodent superficial inferior epigastric free flap with Ad/CMV-LL37. The vascular permeabilizing agent vascular endothelial growth factor (VEGF) was co-administered during ex vivo transduction with adenoviral vectors in an attempt to augment transduction efficiency. A rodent model of chronic wound/foreign body infection seeded with bioluminescent Staphylococcus aureus was used to assess the biological efficacy of delivering therapeutic antimicrobial genes using this technology.The authors were successful in demonstrating significant LL37 expression, which persisted for 14 days after ex vivo transduction with Ad/CMV-LL37. Transduction efficiency was significantly improved with the co-administration of 5 micrograms of VEGF during transduction without significantly increasing systemic dissemination of adenovirus or systemic toxicity. They were able to demonstrate in the rodent model of chronic wound/foreign body infections a significant reduction in bacterial loads from infected catheters following transduction with Ad/CMV-LL37 and increased bacterial clearance.This study demonstrates for the first time that microbicidal gene therapy via microvascular free flaps is able to clear chronic infections such as occurs with osteomyelitis resulting from trauma or an infected foreign body [corrected]

View details for DOI 10.1097/PRS.0b013e31819f25a4

View details for Web of Science ID 000265669400003

View details for PubMedID 19337084
Osteoblasts Stimulated With Pulsed Electromagnetic Fields Increase HUVEC Proliferation Via a VEGF-A Independent Mechanism BIOELECTROMAGNETICS Hopper, R. A., VerHalen, J. P., Tepper, O., Mehrara, B. J., Detch, R., Chang, E. I., Baharestani, S., Simon, B. J., Gurtner, G. C. 2009; 30 (3): 189-197
Abstract

The clinically beneficial effect of low frequency pulsed electromagnetic fields (ELF-PEMF) on bone healing has been described, but the exact mechanism of action remains unclear. A recent study suggests that there is a direct autocrine mitogenic effect of ELF-PEMF on angiogenesis. The hypothesis of this study is that ELF-PEMF also has an indirect effect on angiogenesis by manipulation of vascular endothelial growth factor (VEGF)-A-based paracrine intercellular communication with neighboring osteoblasts. Conditioned media experiments measured fetal rat calvarial cell (FRC) and human umbilical vein endothelial cell (HUVEC) proliferation using tritiated thymidine uptake. We demonstrate that ELF-PEMF (15 Hz, 1.8 mT, for 8 h) has an indirect effect on the proliferation rate of both endothelial cells and osteoblasts in vitro by altering paracrine mediators. Conditioned media from osteoblast cells stimulated with ELF-PEMF increased endothelial proliferation 54-fold, whereas media from endothelial cells stimulated with ELF-PEMF did not affect osteoblast proliferation. We examined the role of the pro-angiogenic mediator VEGF-A in the mitogenic effect of ELF-PEMF-stimulated osteoblast media on endothelial cells. The production of VEGF-A by FRC as measured by ELISA was not changed by exposure to PEMF, and blocking experiments demonstrated that the ELF-PEMF-induced osteoblast-derived endothelial mitogen observed in these studies was not VEGF-A, but some other soluble angiogenic mediator.

View details for DOI 10.1002/bem.20459

View details for Web of Science ID 000264512900004

View details for PubMedID 19194859
Tissue engineering using autologous microcirculatory beds as vascularized bioscaffolds FASEB JOURNAL Chang, E. I., Bonillas, R. G., El-Ftesi, S., Chang, E. I., Ceradini, D. J., Vial, I. N., Chan, D. A., Michaels, J., Gurtner, G. C. 2009; 23 (3): 906-915
Abstract

Classic tissue engineering paradigms are limited by the incorporation of a functional vasculature and a reliable means for reimplantation into the host circulation. We have developed a novel approach to overcome these obstacles using autologous explanted microcirculatory beds (EMBs) as bioscaffolds for engineering complex three-dimensional constructs. In this study, EMBs consisting of an afferent artery, capillary beds, efferent vein, and surrounding parenchymal tissue are explanted and maintained for 24 h ex vivo in a bioreactor that preserves EMB viability and function. Given the rapidly advancing field of stem cell biology, EMBs were subsequently seeded with three distinct stem cell populations, multipotent adult progenitor cells (MAPCs), and bone marrow and adipose tissue-derived mesenchymal stem cells (MSCs). We demonstrate MAPCs, as well as MSCs, are able to egress from the microcirculation into the parenchymal space, forming proliferative clusters. Likewise, human adipose tissue-derived MSCs were also found to egress from the vasculature and seed into the EMBs, suggesting feasibility of this technology for clinical applications. We further demonstrate that MSCs can be transfected to express a luciferase protein and continue to remain viable and maintain luciferase expression in vivo. By using the vascular network of EMBs, EMBs can be perfused ex vivo and seeded with stem cells, which can potentially be directed to differentiate into neo-organs or transfected to replace failing organs and deficient proteins.

View details for DOI 10.1096/fj.08-114868

View details for Web of Science ID 000265506300026

View details for PubMedID 19001054

View details for PubMedCentralID PMC2653982
Mesenchymal Stem Cells Can Participate in Ischemic Neovascularization 52nd Annual Meeting of the Plastic-Surgery-Research-Council Hamou, C., Callaghan, M. J., Thangarajah, H., Chang, E., Chang, E. I., Grogan, R. H., Paterno, J., Vial, I. N., Jazayeri, L., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2009: 45S–55S
Abstract

Cells from the bone marrow contribute to ischemic neovascularization, but the identity of these cells remains unclear. The authors identify mesenchymal stem cells as a bone marrow-derived progenitor population that is able to engraft into peripheral tissue in response to ischemia.A murine model of skin ischemia was used. Bone marrow, blood, and skin were harvested at different time points and subjected to flow cytometric analysis for mesenchymal and hematopoietic markers (n = 3 to 7 per time point). Using a parabiotic model pairing donor green fluorescent protein (GFP)-positive with recipient wild-type mice, progenitor cell engraftment was examined in ischemic tissue by fluorescence microscopy, and engrafted cells were analyzed by flow cytometry for endothelial and mesenchymal markers. In vitro, the ability of both bone marrow- and adipose-derived mesenchymal stem cells to adopt endothelial characteristics was examined by analyzing (1) the ability of mesenchymal stem cells to take up DiI-acetylated low-density lipoprotein and Alexa Fluor lectin, and (2) phenotypic changes of mesenchymal stem cells co-cultured with GFP-labeled endothelial cells or under hypoxic/vascular endothelial growth factor stimulation.In vivo, the bone marrow mesenchymal stem cell population decreased significantly immediately after surgery, with subsequent engraftment of these cells in ischemic tissue. Engrafted cells lacked the panhematopoietic antigen CD45, consistent with a mesenchymal origin. In vitro, bone marrow- and adipose-derived mesenchymal stem cells took up DiI-acetylated low-density lipoprotein and Alexa Fluor lectin, and expressed endothelial markers under hypoxic conditions.The authors' data suggest that mesenchymal precursor cells can give rise to endothelial progenitors. Consequently, cell-based therapies augmenting the mesenchymal stem cell population could represent powerful alternatives to current therapies for ischemic vascular disease.

View details for DOI 10.1097/PRS.0b013e318191be4a

View details for Web of Science ID 000263721600007

View details for PubMedID 19182663
Intracranial Microvascular Free Flaps JOURNAL OF RECONSTRUCTIVE MICROSURGERY Levine, S., Garfein, E. S., Weiner, H., Yaremchuk, M. J., Saadeh, P. B., Gurtner, G., Levine, J. P., Warren, S. M. 2009; 25 (2): 89-95
Abstract

Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle (N=2), rectus abdominis muscle (N=2), or omentum (N=2). All patients had titanium (N=4) or Medpor (N=2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial.

View details for DOI 10.1055/s-0028-1090609

View details for Web of Science ID 000262933400002

View details for PubMedID 18925548
SDF-1 alpha Expression during Wound Healing in the Aged Is HIF Dependent 52nd Annual Meeting of the Plastic-Surgery-Research-Council Loh, S. A., Chang, E. I., Galvez, M. G., Thangarajah, H., El-Ftesi, S., Vial, I. N., Lin, D. A., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2009: 65S–75S
Abstract

Age-related impairments in wound healing are associated with decreased neovascularization, a process that is regulated by hypoxia-responsive cytokines, including stromal cell-derived factor (SDF)-1 alpha. Interleukin-1 beta is an important inflammatory cytokine involved in wound healing and is believed to regulate SDF-1 alpha expression independent of hypoxia signaling. Thus, the authors examined the relative importance of interleukin (IL)-1 beta and hypoxia-inducible factor (HIF)-1 alpha on SDF-1 alpha expression in aged wound healing.Young and aged mice (n = 4 per group) were examined for wound healing using a murine excisional wound model. Wounds were harvested at days 0, 1, 3, 5, and 7 for histologic analysis, immunohistochemistry, enzyme-linked immunosorbent assay, and Western blot. An engineered wild-type and mutated SDF luciferase reporter construct were used to determine HIF transactivation.Aged mice demonstrated significantly impaired wound healing, reduced granulation tissue, and increased epithelial gap compared with young controls. Real-time polymerase chain reaction demonstrated reduced SDF-1 alpha levels in aged wounds that correlated with reduced CD31+ neovessels. Western blots revealed decreased HIF-1 alpha protein in aged wounds. However, both IL-1 beta and macrophage infiltrate were unchanged between young and aged animals. Using the wild-type and mutated SDF luciferase reporter construct in which the hypoxia response element was deleted, only young fibroblasts were able to respond to IL-1 beta stimulation, and this response was abrogated by mutating the HIF-binding sites. This suggests that HIF binding is essential for SDF-1 transactivation in response to both inflammatory and hypoxic stimuli.SDF-1 alpha deficiency observed during aged wound healing is attributable predominantly to decreased HIF-1 alpha levels rather than impaired IL-1 beta expression.

View details for DOI 10.1097/PRS.0b013e318191bdf4

View details for Web of Science ID 000263721600009

View details for PubMedID 19182665
Aging and Diabetes Impair the Neovascular Potential of Adipose-Derived Stromal Cells PLASTIC AND RECONSTRUCTIVE SURGERY El-Ftesi, S., Chang, E. I., Longaker, M. T., Gurtner, G. C. 2009; 123 (2): 475-485
Abstract

Aging and diabetes are major risk factors for poor wound healing and tissue regeneration that reflect an impaired ability to respond to ischemic insults. The authors explored the intrinsic neovascular potential of adipose-derived stromal cells in the setting of advanced age and in type 1 and type 2 diabetes.Adipose-derived stromal cells isolated from young, aged, streptozotocin-induced, and db/db diabetic mice were exposed to normoxia and hypoxia in vitro. Vascular endothelial growth factor (VEGF) expression, proliferation, and tubulization were measured. Conditioned media harvested from adipose-derived stromal cell cultures were assessed for their ability to stimulate human umbilical vein endothelial cell proliferation (n = 3 and n = 3).Young adipose-derived stromal cells demonstrated significantly higher levels of VEGF production, proliferation, and tubulogenesis than those derived from aged, streptozotocin-induced, and db/db mice in both normoxia and hypoxia. Although aged and diabetic adipose-derived stromal cells retained the ability to up-regulate VEGF secretion, proliferation, and tubulogenesis in response to hypoxia, the response was blunted compared with young controls. Conditioned media derived from these cells cultured in normoxia in vitro also had a significantly greater ability to increase human umbilical vein endothelial cell proliferation compared with media harvested from aged, streptozotocin-induced, and db/db adipose-derived stromal cells. This effect was magnified in conditioned media harvested from hypoxic adipose-derived stromal cell cultures.This study demonstrates that aging and type 1 and type 2 diabetes impair intrinsic adipose-derived stromal cell function; however, these cells may still be a suitable source of angiogenic cells that can potentially improve neovascularization of ischemic tissues.

View details for DOI 10.1097/PRS.0b013e3181954d08

View details for Web of Science ID 000265669200006

View details for PubMedID 19182604
Topical Lineage-Negative Progenitor-Cell Therapy for Diabetic Wounds (Invited Discussion) PLASTIC AND RECONSTRUCTIVE SURGERY Gurtner, G. C., Longaker, M. T. 2009; 123 (1): 421-423
View details for DOI 10.1097/PRS.0b013e318194d2b8

View details for Web of Science ID 000262317700054

View details for PubMedID 19116584
A Recommended Protocol for the Immediate Postoperative Care of Lower Extremity Free-Flap Reconstructions JOURNAL OF RECONSTRUCTIVE MICROSURGERY Rohde, C., Howell, B. W., Buncke, G. M., Gurtner, G. C., Levin, L. S., Pu, L. L., Levine, J. P. 2009; 25 (1): 15-19
Abstract

The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place.

View details for DOI 10.1055/s-0028-1090600

View details for Web of Science ID 000262164000003

View details for PubMedID 18979418
Taz is a transcriptional modulator of human adipose-derived stromal cell differentiation towards the osteogenic lineage 13th International Congress of the International-Society-of-Craniofacial-Surgery / Paris Distraction Symposium Gupta, D. M., Panetta, N. J., Vial, I. N., Lee, J. K., Wan, D. C., Gurtner, G. C., Longaker, M. T. MEDIMOND S R L. 2009: 87–89
View details for Web of Science ID 000303383400018
IFATS Collection: Adipose Stromal Cells Adopt a Proangiogenic Phenotype Under the Influence of Hypoxia STEM CELLS Thangarajah, H., Vial, I. N., Chang, E., El-Ftesi, S., Januszyk, M., Chang, E. I., Paterno, J., Neofytou, E., Longaker, M. T., Gurtner, G. C. 2009; 27 (1): 266-274
Abstract

Evolving evidence suggests a possible role for adipose stromal cells (ASCs) in adult neovascularization, although the specific cues that stimulate their angiogenic behavior are poorly understood. We evaluated the effect of hypoxia, a central mediator of new blood vessel development within ischemic tissue, on proneovascular ASC functions. Murine ASCs were exposed to normoxia (21% oxygen) or hypoxia (5%, 1% oxygen) for varying lengths of time. Vascular endothelial growth factor (VEGF) secretion by ASCs increased as an inverse function of oxygen tension, with progressively higher VEGF expression at 21%, 5%, and 1% oxygen, respectively. Greater VEGF levels were also associated with longer periods in culture. ASCs were able to migrate towards stromal cell-derived factor (SDF)-1, a chemokine expressed by ischemic tissue, with hypoxia augmenting ASC expression of the SDF-1 receptor (CXCR4) and potentiating ASC migration. In vivo, ASCs demonstrated the capacity to proliferate in response to a hypoxic insult remote from their resident niche, and this was supported by in vitro studies showing increasing ASC proliferation with greater degrees of hypoxia. Hypoxia did not significantly alter the expression of endothelial surface markers by ASCs. However, these cells did assume an endothelial phenotype as evidenced by their ability to tubularize when seeded with differentiated endothelial cells on Matrigel. Taken together, these data suggest that ASCs upregulate their proneovascular activity in response to hypoxia, and may harbor the capacity to home to ischemic tissue and function cooperatively with existing vasculature to promote angiogenesis.

View details for DOI 10.1634/stemcells.2008-0276

View details for Web of Science ID 000263032400030

View details for PubMedID 18974212
Hedgehog signaling is essential for normal wound healing WOUND REPAIR AND REGENERATION Le, H., Kleinerman, R., Lerman, O. Z., Brown, D., Galiano, R., Gurtner, G. C., Warren, S. M., Levine, J. P., Saadeh, P. B. 2008; 16 (6): 768-773
Abstract

The hedgehog family of morphogens (sonic [Shh], Indian, and desert hedgehog) are central regulators of embryologic growth and tissue patterning. Although recent work implicates Shh in postnatal tissue repair and development, conclusive evidence is lacking. Here, we demonstrated the importance of Shh in wound repair, by examining the effects of cyclopamine, a specific inhibitor of the Shh signaling cascade, on tissue repair. Using a murine-splinted excisional wound model, which attenuates wound contraction in this loose-skinned rodent, we established that, by all measures (wound closure, epithelialization, granulation formation, vascularity, and proliferation), wound healing was profoundly impaired when Shh signaling was disrupted. Because embryonic disruption of Shh is associated with distinct phenotypic defects, our findings invite investigation of the potential role of Shh signaling under postnatal conditions associated with disregulated wound healing.

View details for DOI 10.1111/j.1524-475X.2008.00430.x

View details for Web of Science ID 000260445200070

View details for PubMedID 19128247
Bisphosphonate-associated osteonecrosis of the jaw: Successful treatment at 2-year follow-up PLASTIC AND RECONSTRUCTIVE SURGERY Aarabi, S., Draper, L., Grayson, B., Gurtner, G. C. 2008; 122 (2): 57E-59E
View details for DOI 10.1097/PRS.0b013e31817d5fd7

View details for Web of Science ID 000258136900018

View details for PubMedID 18626318
"Priming" endothelial progenitor cells a new strategy to improve cell based therapeutics ARTERIOSCLEROSIS THROMBOSIS AND VASCULAR BIOLOGY Gurtner, G. C., Chang, E. 2008; 28 (6): 1034-1035
View details for DOI 10.1161/ATVBAHA.108.163246

View details for Web of Science ID 000256053400002

View details for PubMedID 18495972
Using genetically modified microvascular free flaps to deliver local cancer immunotherapy with minimal systemic toxicity 51st Annual Meeting of the Research-Council-of-Plastic-Surgery Dempsey, M. P., Hamou, C., Michaels, J., Ghali, S., Jazayeri, L., Grogan, R. H., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2008: 1541–53
Abstract

Clinical use of cancer gene therapy has been prevented by the inability to deliver high levels of local transgene expression with acceptable host toxicity. The authors' laboratory has developed an ex vivo technique to genetically modify free flaps to deliver immunotherapy locally without systemic toxicity.Superficial inferior epigastric flaps were dissected in Fischer rats, perfused with a viral vector expressing the antitumor interleukin-12 (IL-12) for 1 hour, and re-anastomosed. Beneath the flaps was a bolus of 1 x 10(6) beta-human chorionic gonadotropin-secreting MADB-106 tumor cells. Tumor growth was monitored using beta-human chorionic gonadotropin levels (secreted by the tumor) and size. IL-12 expression in tissue was assessed by enzyme-linked immunosorbent assay. Tumor inflammatory infiltrate was assessed using immunohistologic staining (CD8 and CD161) and enzyme-linked immunosorbent assay (interferon-gamma). Serum levels of liver enzymes and histologic analysis were used to assess systemic toxicity.IL-12 expression was confirmed in the flap and surrounding tissue. The rate of tumor growth in the IL-12-treated group was significantly suppressed compared with the control group (p < 0.001). Liver enzyme levels remained normal, and histological evaluation of the liver, lung, and spleen revealed no evidence of inflammation in the treated group.Using genetically modified free flaps, the authors were able to deliver IL-12 directly into the local environment of a tumor and suppress its growth without eliciting toxic systemic effects. This technique could provide valuable adjuvant treatment after oncologic surgery for soft-tissue cancers, with the transduced flap reconstructing the defect and supplying a therapeutic agent to the resected tumor bed.

View details for DOI 10.1097/PRS.0b013e31816ff6aa

View details for Web of Science ID 000255435200004

View details for PubMedID 18453976
Diabetes increases p53-mediated apoptosis following ischemia PLASTIC AND RECONSTRUCTIVE SURGERY Jazayeri, L., Callaghan, M. J., Grogan, R. H., Hamou, C. D., Thanik, V., Ingraham, C. R., Capell, B. C., Pelo, C. R., Gurtner, G. C. 2008; 121 (4): 1135-1143
Abstract

Diabetes impairs the ability of tissue to respond adequately to ischemia. The underlying mechanisms contributing to this impaired response remain unknown. Because increases in apoptosis have been linked to a spectrum of diabetic complications, the authors examined whether programmed cell death is involved in the pathogenesis of poor diabetic tissue responses to ischemia.Analysis for apoptosis and levels of proaptotic protein, p53, were performed on streptozocin-induced diabetic mice and wild-type controls in a murine model of soft-tissue ischemia (n = 6). In vitro, chronic hyperglycemic culture conditions were used to test inducibility and reversibility of the diabetic phenotype. Small interfering RNA was used to assess the role of p53.Ischemia-induced apoptosis and p53 levels were increased significantly in diabetic dermal fibroblasts both in vivo and in vitro. Chronic hyperglycemic culture was sufficient to induce the increased apoptotic phenotype, and this was not reversible with long-term normoglycemic conditions. Blocking p53 with small interfering RNA resulted in significant protection against ischemic apoptosis.These findings suggest that diabetes causes an increased apoptotic response to ischemia through a p53-mediated mechanism. This increase is not reversible by exposure to low-glucose conditions. This suggests that glycemic control alone will be unable to prevent tissue necrosis in diabetic patients and suggests novel therapeutic strategies for this condition.

View details for DOI 10.1097/01.prs.0000302499.18738.c2

View details for Web of Science ID 000254183600008

View details for PubMedID 18349630
Plastic surgical delivery systems for targeted gene therapy ANNALS OF PLASTIC SURGERY Ghali, S., Dempsey, M. P., Jones, D. M., Grogan, R. H., Butler, P. E., Gurtner, G. C. 2008; 60 (3): 323-332
Abstract

The expansion of gene therapy applications from inherited disorders to acquired conditions has been mirrored by an exponential rise in both experimental work and clinical trials. This review highlights current plastic surgical delivery systems and clinical applications for targeted gene therapy. We revisit some of the vectors used both experimentally and in clinical gene therapy trials, with an emphasis on developments in plastic surgical delivery systems resulting in improved targeting of therapeutic genes. In addition, we discuss a novel technique for the delivery of gene therapy using the ex vivo transduction of free flaps, developed in our laboratory. This delivery system achieves targeted high-level transgene expression with minimal demonstrable systemic toxicity. Advances in delivery systems are essential for translating basic research into clinical therapeutics.

View details for DOI 10.1097/SAP.0b013e31806917b0

View details for Web of Science ID 000253430300017

View details for PubMedID 18443515
Pulsed electromagnetic fields accelerate normal and diabetic wound healing by increasing endogenous FGF-2 release PLASTIC AND RECONSTRUCTIVE SURGERY Callaghan, M. J., Chang, E. I., Seiser, N., Aarabi, S., Ghali, S., Kinnucan, E. R., Simon, B. J., Gurtner, G. C. 2008; 121 (1): 130-141
Abstract

Chronic wounds, particularly in diabetics, result in significant morbidity and mortality and have a profound economic impact. The authors demonstrate that pulsed electromagnetic fields significantly improve both diabetic and normal wound healing in 66 mice through up-regulation of fibroblast growth factor (FGF)-2 and are able to prevent tissue necrosis in diabetic tissue after an ischemic insult.Db/db and C57BL6 mice were wounded and exposed to pulsed electromagnetic fields. Gross closure, cell proliferation, and vascularity were assessed. Cultured medium from human umbilical vein endothelial cells exposed to pulsed electromagnetic fields was analyzed for FGF-2 and applied topically to wounds. Skin flaps were created on streptozocin-induced diabetic mice and exposed to pulsed electromagnetic fields. Percentage necrosis, oxygen tension, and vascularity were determined.Pulsed electromagnetic fields accelerated wound closure in diabetic and normal mice. Cell proliferation and CD31 density were significantly increased in pulsed electromagnetic field-treated groups. Cultured medium from human umbilical vein endothelial cells in pulsed electromagnetic fields exhibited a three-fold increase in FGF-2, which facilitated healing when applied to wounds. Skin on diabetic mice exposed to pulsed electromagnetic fields did not exhibit tissue necrosis and demonstrated oxygen tensions and vascularity comparable to those in normal animals.This study demonstrates that pulsed electromagnetic fields are able to accelerate wound healing under diabetic and normal conditions by up-regulation of FGF-2-mediated angiogenesis. They also prevented tissue necrosis in response to a standardized ischemic insult, suggesting that noninvasive angiogenic stimulation by pulsed electromagnetic fields may be useful to prevent ulcer formation, necrosis, and amputation in diabetic patients.

View details for DOI 10.1097/01.prs.0000293761.27219.84

View details for Web of Science ID 000252208700019

View details for PubMedID 18176216
Age decreases endothelial progenitor cell recruitment through decreases in hypoxia-inducible factor 1 alpha stabilization during ischemia CIRCULATION Chang, E. I., Loh, S. A., Ceradini, D. J., Chang, E. I., Lin, S., Bastidas, N., Aarabi, S., Chan, D. A., Freedman, M. L., Giaccia, A. J., Gurtner, G. C. 2007; 116 (24): 2818-2829
Abstract

Advanced age is known to impair neovascularization. Because endothelial progenitor cells (EPCs) participate in this process, we examined the effects of aging on EPC recruitment and vascular incorporation.Murine neovascularization was examined by use of an ischemic flap model, which demonstrated aged mice (19 to 24 months) had decreased EPC mobilization (percent mobilized 1.4+/-0.2% versus 0.4+/-0.1%, P<0.005) that resulted in impaired gross tissue survival compared with young mice (2 to 6 months). This decrease correlated with diminished tissue perfusion (P<0.005) and decreased CD31+ vascular density (P<0.005). Gender-mismatched bone marrow transplantation demonstrated significantly fewer chimeric vessels in aged mice (P<0.05), which confirmed a deficit in bone marrow-mediated vasculogenesis. Age had no effect on total EPC number in mice or humans. Reciprocal bone marrow transplantations confirmed that impaired neovascularization resulted from defects in the response of aged tissue to hypoxia and not from intrinsic defects in EPC function. We demonstrate that aging decreased hypoxia-inducible factor 1alpha stabilization in ischemic tissues because of increased prolyl hydroxylase-mediated hydroxylation (P<0.05) and proteasomal degradation. This resulted in a diminished hypoxia response, including decreased stromal cell-derived factor 1 (P<0.005) and vascular endothelial growth factor (P<0.0004). This effect can be reversed with the iron chelator deferoxamine, which results in hypoxia-inducible factor 1alpha stabilization and increased tissue survival.Aging impairs EPC trafficking to sites of ischemia through a failure of aged tissues to normally activate the hypoxia-inducible factor 1alpha-mediated hypoxia response.

View details for DOI 10.1161/CIRCULATIONAHA.107.715847

View details for Web of Science ID 000251542200009

View details for PubMedID 18040029
Hypoxia-induced mediators of stem/progenitor cell trafficking are increased in children with hemangioma ARTERIOSCLEROSIS THROMBOSIS AND VASCULAR BIOLOGY Kleinman, M. E., Greives, M. R., Churgin, S. S., Blechman, K. M., Chang, E. I., Ceradini, D. J., Tepper, O. M., Gurtner, G. C. 2007; 27 (12): 2664-2670
Abstract

The mechanism of neovascularization during the proliferative phase of infantile hemangioma is poorly understood. It is known that circulating bone marrow-derived endothelial progenitor cells (EPCs) form new blood vessels in ischemic tissues using mediators regulated by the transcription factor, HIF-1alpha. Mobilization of EPCs is enhanced by VEGF-A, matrix metalloproteinase (MMP)-9, and estrogen, whereas homing is secondary to localized expression of stromal cell-derived factor-1alpha (SDF-1alpha). We examined whether these mediators of EPC trafficking are upregulated during the proliferation of infantile hemangioma.Surgical specimens and blood samples were obtained from children with proliferating hemangioma and age-matched controls (n=10, each group). VEGF-A and MMP-9 levels were measured in blood, and tissue sections were analyzed for SDF-1alpha, MMP-9, VEGF-A, and HIF-1alpha. The role of estrogen as a modulator of hemangioma endothelial cell growth was also investigated. We found that all these mediators of EPC trafficking are elevated in blood and specimens from children with proliferating infantile hemangioma. In vitro, the combination of hypoxia and estrogen demonstrated a synergistic effect on hemangioma endothelial cell proliferation.These findings demonstrate that proliferating hemangiomas express known mediators of vasculogenesis and suggest that this process may play a role in the initiation or progression of this disease.

View details for DOI 10.1161/ATVBAHA.107.150284

View details for Web of Science ID 000251143300028

View details for PubMedID 17872454
Uniaxial mechanical strain: An in vitro correlate to distraction osteogenesis JOURNAL OF SURGICAL RESEARCH Bhatt, K. A., Chang, E. I., Warren, S. M., Lin, S., Bastidas, N., Ghali, S., Thibboneir, A., Capla, J. M., McCarthy, J. G., Gurtner, G. C. 2007; 143 (2): 329-336
Abstract

Distraction osteogenesis is a valuable clinical tool; however the molecular mechanisms governing successful distraction remain unknown. We have used a uniaxial in vitro strain device to simulate the uniaxial mechanical environment of the interfragmentary distraction gap.Using the Flexcell system, normal human osteoblasts were subjected to different levels of cyclical uniaxial mechanical strain. Cellular morphology, proliferation, migration, and the expression of angiogenic (vascular endothelial growth factor [VEGF] and fibroblast growth factor-2 [FGF-2]) and osteogenic (osteonectin, osteopontin, and osteocalcin) proteins and extracellular matrix molecules (collagen IalphaII) were analyzed in response to uniaxial cyclic strain.Osteoblasts exposed to strain assumed a fusiform spindle-shaped morphology aligning parallel to the axis of uniaxial strain and osteoblasts exposed to strain or conditioned media had a 3-fold increase in proliferation. Osteoblast migration was maximal (5-fold) in response to 9% strain. Angiogenic cytokine, VEGF, and FGF-2, increased 32-fold and 2.6-fold (P < 0.05), respectively. Osteoblasts expressed greater amounts of osteonectin, osteopontin, and osteocalcin (2.1-fold, 1.8-fold, 1.5-fold respectively, P < 0.01) at lower levels of strain (3%). Bone morphogenic protein-2 production increased maximally at 9% strain (1.6-fold, P < 0.01). Collagen I expression increased 13-, 66-, and 153-fold in response to 3, 6, and 9% strain, respectively.Uniaxial cyclic strain using the Flexcell device under appropriate strain parameters provides a novel in vitro model that induces osteoblast cellular and molecular expression patterns that simulate patterns observed in the in vivo distraction gap.

View details for DOI 10.1016/j.jss.2007.01.023

View details for Web of Science ID 000251281200021

View details for PubMedID 17950332
Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis FASEB JOURNAL Aarabi, S., Bhatt, K. A., Shi, Y., Paterno, J., Chang, E. I., Loh, S. A., Holmes, J. W., Longaker, M. T., Yee, H., Gurtner, G. C. 2007; 21 (12): 3250-3261
Abstract

Hypertrophic scars occur following cutaneous wounding and result in severe functional and esthetic defects. The pathophysiology of this process remains unknown. Here, we demonstrate for the first time that mechanical stress applied to a healing wound is sufficient to produce hypertrophic scars in mice. The resulting scars are histopathologically identical to human hypertrophic scars and persist for more than six months following a brief (one-week) period of augmented mechanical stress during the proliferative phase of wound healing. Resulting scars are structurally identical to human hypertrophic scars and showed dramatic increases in volume (20-fold) and cellular density (20-fold). The increased cellularity is accompanied by a four-fold decrease in cellular apoptosis and increased activation of the prosurvival marker Akt. To clarify the importance of apoptosis in hypertrophic scar formation, we examine the effects of mechanical loading on cutaneous wounds of animals with altered pathways of cellular apoptosis. In p53-null mice, with down-regulated cellular apoptosis, we observe significantly greater scar hypertrophy and cellular density. Conversely, scar hypertrophy and cellular density are significantly reduced in proapoptotic BclII-null mice. We conclude that mechanical loading early in the proliferative phase of wound healing produces hypertrophic scars by inhibiting cellular apoptosis through an Akt-dependent mechanism.

View details for DOI 10.1096/fj.07-8218com

View details for Web of Science ID 000249781600025

View details for PubMedID 17504973
Hypertrophic scar formation following burns and trauma: New approaches to treatment PLOS MEDICINE Aarabi, S., Longaker, M. T., Gurtner, G. C. 2007; 4 (9): 1464-1470
View details for DOI 10.1371/journal.pmed.0040234

View details for Web of Science ID 000249768100011

View details for PubMedID 17803351
Hypoxia up-regulates the angiogenic cytokine secretoneurin via an HIF-1 alpha- and basic FGF-dependent pathway in muscle cells FASEB JOURNAL Egger, M., Schgoer, W., Beer, A. G., Jeschke, J., Leierer, J., Theurl, M., Frauscher, S., Tepper, O. M., Niederwanger, A., Ritsch, A., Kearney, M., Wanschitz, J., Gurtner, G. C., Fischer-Colbrie, R., Weiss, G., Piza-Katzer, H., Losordo, D. W., Patsch, J. R., Schratzberger, P., Kirchmair, R. 2007; 21 (11): 2906-2917
Abstract

Expression of angiogenic cytokines like vascular endothelial growth factor is enhanced by hypoxia. We tested the hypothesis that decreased oxygen levels up-regulate the angiogenic factor secretoneurin. In vivo, muscle cells of mouse ischemic hind limbs showed increased secretoneurin expression, and inhibition of secretoneurin by a neutralizing antibody impaired the angiogenic response in this ischemia model. In a mouse soft tissue model of hypoxia, secretoneurin was increased in subcutaneous muscle fibers. In vitro, secretoneurin mRNA and protein were up-regulated in L6 myoblast cells after exposure to low oxygen levels. The hypoxia-dependent regulation of secretoneurin was tissue specific and was not observed in endothelial cells, vascular smooth muscle cells, or AtT20 pituitary tumor cells. The hypoxia-dependent induction of secretoneurin in L6 myoblasts is regulated by hypoxia-inducible factor-1alpha, since inhibition of this factor using si-RNA inhibited up-regulation of secretoneurin. Induction of secretoneurin by hypoxia was dependent on basic fibroblast growth factor in vivo and in vitro, and inhibition of this regulation by heparinase suggests an involvement of low-affinity basic fibroblast growth factor binding sites. In summary, our data show that the angiogenic cytokine secretoneurin is up-regulated by hypoxia in muscle cells by hypoxia-inducible factor-1alpha- and basic fibroblast growth factor-dependent mechanisms.

View details for DOI 10.1096/fj.06-7440com

View details for Web of Science ID 000249237500031

View details for PubMedID 17504977
db/db mice exhibit severe wound-healing impairments compared with other murine diabetic strains in a silicone-splinted excisional wound model WOUND REPAIR AND REGENERATION Michaels, J., Churgin, S. S., Blechman, K. M., Greives, M. R., Aarabi, S., Galiano, R. D., Gurtner, G. C. 2007; 15 (5): 665-670
Abstract

The pathophysiology of diabetic wound healing and the identification of new agents to improve clinical outcomes continue to be areas of intense research. There currently exist more than 10 different murine models of diabetes. The degree to which wound healing is impaired in these different mouse models has never been directly compared. We determined whether differences in wound impairment exist between diabetic models in order to elucidate which model would be the best to evaluate new treatment strategies. Three well-accepted mouse models of diabetes were used in this study: db/db, Akita, and streptozocin (STZ)-induced C57BL/6J. Using an excisional model of wound healing, we demonstrated that db/db mice exhibit severe impairments in wound healing compared with STZ and Akita mice. Excisional wounds in db/db mice show a statistically significant delay in wound closure, decreased granulation tissue formation, decreased wound bed vascularity, and markedly diminished proliferation compared with STZ, Akita, and control mice. There was no difference in the rate of epithelialization of the full-thickness wounds between the diabetic or control mice. Our results suggest that splinted db/db mice may be the most appropriate model for studying diabetic wound-healing interventions as they demonstrate the most significant impairment in wound healing. This study utilized a novel model of wound healing developed in our laboratory that stents wounds open using silicone splints to minimize the effects of wound contraction. As such, it was not possible to directly compare the results of this study with other studies that did not use this wound model.

View details for DOI 10.1111/j.1524-475X.2007.00273.x

View details for Web of Science ID 000249846800008

View details for PubMedID 17971012
Vascular delay revisited PLASTIC AND RECONSTRUCTIVE SURGERY Ghali, S., Butler, P. E., Tepper, O. M., Gurtner, G. C. 2007; 119 (6): 1735-1744
Abstract

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures.

View details for DOI 10.1097/01.prs.0000246384.14593.6e

View details for Web of Science ID 000246032200014

View details for PubMedID 17440348
Cyclic mechanical strain increases production of regulators of bone healing in cultured murine osteoblasts JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Singh, S. P., Chang, E. I., Gossain, A. K., Mehara, B. J., Galiano, R. D., Jensen, J., Longaker, M. T., Gurtner, G. C., Saadeh, P. B. 2007; 204 (3): 426-434
Abstract

The adaptive response of bone to mechanical strain, for which angiogenesis is required, is underscored during fracture healing. Vascular endothelial growth factor (VEGF) and transforming growth factor beta-1 (TGF-beta1) are critical regulators of angiogenesis. The purpose of this study was to examine the effect of strain on the production of VEGF and TGF-beta1.MC3T3-E1 mouse osteoblasts underwent cyclic strain (low, 0.1 Hz, or high, 0.2 Hz) for 24 or 48 hours. VEGF and TGF-beta1 protein levels were determined by ELISA, and Northern blot analysis was performed for VEGF mRNA. Alkaline phosphatase (an osteoblast differentiation marker) activity was determined by functional enzymatic assay. All measurements were standardized for cell number by crystal violet colorimetric assay. Statistical significance was determined by t-test, ANOVA, and the Tukey-Kramer test.Protein production of VEGF and TGF-beta1 was dose-dependently elevated by strain (p < 0.05); alkaline phosphatase did not rise significantly. Northern blot analysis of strained osteoblast cells demonstrated increased VEGF mRNA. Cyclic strain was found to be progressively destructive in a dose-dependent manner, causing 51% and 70% decreases in cell number under low and high strain, respectively (p < 0.01).We demonstrated simultaneous, dose-dependent increases in VEGF and TGF-beta1 protein production by osteoblastic cells in response to increasing strain. VEGF mRNA also increased in response to strain. This strain-induced increase in angiogenic cytokines suggests a potential mechanism by which injured bone may recruit a new blood supply. But we also found increasing strain to increase cellular toxicity, suggesting that cyclic mechanical strain may select for a subpopulation of osteoblasts.

View details for DOI 10.1016/j.jamcollsurg.2006.11.019

View details for Web of Science ID 000244825200012

View details for PubMedID 17324777
Progress and potential for regenerative medicine ANNUAL REVIEW OF MEDICINE Gurtner, G. C., Callaghan, M. J., Longaker, M. T. 2007; 58: 299-312
Abstract

Regenerative medicine focuses on new therapies to replace or restore lost, damaged, or aging cells in the human body to restore function. This goal is being realized by collaborative efforts in nonmammalian and human development, stem cell biology, genetics, materials science, bioengineering, and tissue engineering. At present, understanding existing reparative processes in humans and exploring the latent ability to regenerate tissue remains the focus in this field. This review covers recent work in limb regeneration, fetal wound healing, stem cell biology, somatic nuclear transfer, and tissue engineering as a foundation for developing new clinical therapies to augment and stimulate human regeneration.

View details for DOI 10.1146/annurev.med.58.085405.095329

View details for Web of Science ID 000244461500020

View details for PubMedID 17076602
Diabetes impairs endothelial progenitor cell-mediated blood vessel formation in response to hypoxia PLASTIC AND RECONSTRUCTIVE SURGERY Capla, J. M., Grogan, R. H., Callaghan, M. J., Galiano, R. D., Tepper, O. M., Ceradini, D. J., Gurtner, G. C. 2007; 119 (1): 59-70
Abstract

Diabetics suffer from vascular dysfunction with increased risks of coronary artery disease and peripheral vascular disease secondary to an impaired ability to respond to tissue ischemia. Because endothelial progenitor cells are known to home to sites of ischemia and participate in new blood vessel growth, the authors examined the effects of diabetes on human endothelial progenitor cell function and peripheral tissue signaling in hypoxia, and determined whether these cells might be a useful cell-based therapy for diabetic vascular complications.Circulating human endothelial progenitor cells from type 2 diabetic patients and controls were isolated and subjected to in vitro adhesion, migration, and proliferation assays (n = 5). Cell mobilization and recruitment were studied in vivo in diabetic and nondiabetic environments (n = 6). Exogenous human diabetic and normal cells were analyzed for therapeutic efficacy in a murine ischemia model (n = 6).Adhesion, migration, and proliferation of human diabetic endothelial progenitor cells in response to hypoxia was significantly reduced compared with controls. In diabetic mice, cell mobilization from the bone marrow and recruitment into ischemic tissue was significantly reduced compared with controls. Normal cells injected systemically as replacement therapy in a diabetic mouse increased but did not normalize ischemic tissue survival.These findings suggest that diabetes causes defects in both the endothelial progenitor cell and peripheral tissue responses to hypoxia. These changes in endothelial progenitor cell function and signaling offer a novel explanation for the poor clinical outcome of type 2 diabetics following ischemic events. Based on these findings, it is unlikely that endothelial progenitor cell-based cellular therapies will be able to prevent diabetic complications.

View details for DOI 10.1097/01.prs.0000244830.16906.3f

View details for Web of Science ID 000243094700010

View details for PubMedID 17255657
Hypoxia, hormones, and endothelial progenitor cells in hemangioma. Lymphatic research and biology Chang, E. I., Chang, E. I., Thangarajah, H., Hamou, C., Gurtner, G. C. 2007; 5 (4): 237-243
Abstract

Hemangiomas are the most common tumor of infancy, and although the natural history of these lesions is well described, their etiology remains unknown. One current theory attributes the development of hemangiomas to placentally-derived cells; however, conclusive evidence to support a placental origin is lacking. While placental tissue and hemangiomas do share molecular similarities, it is possible that these parallels are the result of analogous responses of endothelial cells and vascular progenitors to similar environmental cues. Specifically, both tissue types consist of actively proliferating cells that exist within a low oxygen, high estrogen environment. The hypoxic environment leads to an upregulation of hypoxia inducible factor-1alpha (HIF-1alpha) responsive chemokines such as stromal cell derived factor-1alpha (SDF-1alpha) and vascular endothelial growth factor (VEGF), both of which are known to promote the recruitment and proliferation of endothelial progenitor cells. Increased hormone levels in the postpartum period further potentiate the growth of these lesions. In this model, increased stabilization of HIF-1 in concert with increased levels of estrogen create a milieu that promotes new blood vessel development, ultimately contributing to the pathogenesis of infantile hemangiomas.

View details for DOI 10.1089/lrb.2007.1014

View details for PubMedID 18370914
Inventing our future: training the next generation of surgeon innovators. Seminars in pediatric surgery Krummel, T. M., Gertner, M., Makower, J., Milroy, C., Gurtner, G., Woo, R., Riskin, D. J., Binyamin, G., Connor, J. A., Mery, C. M., Shafi, B. M., Yock, P. G. 2006; 15 (4): 309-318
Abstract

Current surgical care and technology has evolved over the centuries from the interplay between creative surgeons and new technologies. As both fields become more specialized, that interplay is threatened. A 2-year educational fellowship is described which teaches both the process and the discipline of medical/surgical device innovation. Multi-disciplinary teams (surgeons, engineers, business grads) are assembled to educate a generation of translators, who can bridge the gap between scientific and technologic advances and the needs of the physician and the patient.

View details for PubMedID 17055962
No evidence for maternal-fetal microchimerism in infantile hemangioma: A molecular genetic investigation JOURNAL OF INVESTIGATIVE DERMATOLOGY Pittman, K. M., Losken, H. W., Kleinman, M. E., Marcus, J. R., Blei, F., Gurtner, G. C., Marchuk, D. A. 2006; 126 (11): 2533-2538
Abstract

In this study, using the placental origin theory as a basis, we set out to explore whether hemangioma endothelial cells (HEC) were maternal in origin. We rigorously addressed this hypothesis using several molecular genetic techniques. Fluorescent in situ hybridization on surgical specimens of proliferating hemangiomas (n=8) demonstrated no XX-labeled HEC from resected tumors of male infants. This analysis was followed by PCR genotyping of HEC (n=11) using microsatellite markers where cellular components were genotyped and compared to genomic DNA of corresponding mother-child pairs. In the seven informative mother-child pairs, HEC matched the genotype of the child and not the maternal genotype. Concerned that HEC represented a mixed population of cells, we subsequently enriched for cells using the placental-specific endothelial cell (EC) marker, Fc gammaRII. Three informative mother-child pairs exhibited only the genotype of the child in our enriched cell population. Using sequence analysis, we identified an informative single nucleotide polymorphism in an exon of the placental-EC-specific protein, GLUT1. When comparing GLUT1 complementary DNA (cDNA) with mother-child DNA, the genotype of the cDNA matched the constitutional DNA of the child. Our results indicate that hemangiomas are not microchimeric in origin. This study provides further insight into the origin of a tumor whose pathogenesis remains elusive.

View details for DOI 10.1038/sj.jid.5700516

View details for Web of Science ID 000241359600023

View details for PubMedID 16902414
Early-gestation fetal scarless wounds have less lysyl oxidase expression - Discussion PLASTIC AND RECONSTRUCTIVE SURGERY Aarabi, S., Gurtner, G. C. 2006; 118 (5): 1130-1131
View details for DOI 10.1097/01.prs.0000221057.26183.a0

View details for Web of Science ID 000241327600009
Overview of the role for calreticulin in the enhancement of wound healing through multiple biological effects 54th Annual Montagna Symposium on Biology of Skin Gold, L. I., Rahman, M., Blechman, K. M., Greives, M. R., Churgin, S., Michaels, J., Callaghan, M. J., Cardwell, N. L., Pollins, A. C., Michalak, M., Siebert, J. W., Levine, J. P., Gurtner, G. C., Nanney, L. B., Galiano, R. D., Cadacio, C. L. NATURE PUBLISHING GROUP. 2006: 57–65
Abstract

Calreticulin (CRT), an intracellular chaperone protein crucial for the proper folding and transport of proteins through the endoplasmic reticulum, has more recent acclaim as a critical regulator of extracellular functions, particularly in mediating cellular migration and as a requirement for phagocytosis of apoptotic cells. Consistent with these functions, we show that the topical application of CRT has profound effects on the process of wound healing by causing a dose-dependent increase in epithelial migration and granulation tissue formation in both murine and porcine normal and impaired animal models of skin injury. These effects of CRTare substantiated, in vitro, as we show that CRT strongly induces cell migration/wound closure of human keratinocytes and fibroblasts, using a wound/scratch plate assay, and stimulates cellular proliferation of human keratinocytes, fibroblasts, and vascular endothelial cells, providing mechanistic insight into how CRT functions in repair. Similarly, in both animal models, the histology of the wounds show marked proliferation of basal keratinocytes and dermal fibroblasts, dense cellularity of the dermis with notably increased numbers of macrophages and well-organized collagen fibril deposition. Thus, CRT profoundly affects the wound healing process by recruiting cells essential for repair into the wound, stimulating cell growth, and increasing extracellular matrix production.

View details for DOI 10.1038/sj.jidsymp.5650011

View details for Web of Science ID 000253355800008

View details for PubMedID 17069011
Biologic brachytherapy: Ex vivo transduction of microvascular beds for efficient, targeted gene therapy PLASTIC AND RECONSTRUCTIVE SURGERY Michaels, J., Levine, J. P., Hazen, A., Ceradini, D. J., Galiano, R. D., Soltanian, H., Gurtner, G. C. 2006; 118 (1): 54-65
Abstract

Gene therapy for cancer holds enormous therapeutic promise, but its clinical application has been limited by the inability to achieve targeted, high-level transgene expression with limited systemic toxicity. The authors have developed a novel method for delivering genes to microvascular free flaps (commonly used during reconstructive surgery) to avoid these problems.During the finite period in which a free flap is separated from the host (ex vivo), it can be perfused with extremely high titers of genetic material through the afferent artery, resulting in efficient transduction of the tissue. Before reanastomosis, unincorporated genetic material is flushed from the flap, minimizing systemic toxicity.In a rodent model using an adenoviral vector containing the lacZ reporter gene, high regional expression of beta-galactosidase was achieved in all the different cells in a microvascular free flap. Moreover, no beta-galactosidase staining was observed outside of the transduced flap, and viral sequence was undetectable by polymerase chain reaction analysis in other tissues. Further analysis confirmed that high-level transgene expression was precisely localized to the explanted tissue, with no collateral transduction.Targeting gene delivery with minimal systemic toxicity is essential for successful gene therapy. This form of "biological brachytherapy" provides a new opportunity to deliver targeted therapeutic transgenes to patients undergoing reconstructive surgery and allows microvascular free flaps to perform therapeutic and reconstructive functions.

View details for DOI 10.1097/01.prs.0000220466.27521.22

View details for Web of Science ID 000239048700009

View details for PubMedID 16816674
Skin graft vascularization involves precisely regulated regression and replacement of endothelial cells through both angiogenesis and vasculogenesis PLASTIC AND RECONSTRUCTIVE SURGERY Capla, J. M., Ceradini, D., Tepper, O. M., Callaghan, M. J., Bhatt, K. A., Galiano, R. D., Levine, J. P., Gurtner, G. C. 2006; 117 (3): 836-844
Abstract

Long-term survival of a skin graft is dependent on eventual revascularization. The authors' aim in the present study was to determine whether skin graft vascularization occurs by (1) simple reconnection of vessels, (2) ingrowth of recipient vasculature, (3) outgrowth of donor-derived vessels, and/or (4) recruitment of bone marrow-derived endothelial progenitor cells.Full-thickness skin grafts (1 x 1 cm) were transferred between wild-type FVB/N mice (n = 20) and transgenic tie2/lacZ mice (n = 20), where lacZ expression is controlled by the endothelial specific tie2 promoter, allowing differentiation of recipient and donor endothelial cells. The contribution of endothelial progenitor cells to skin graft neovascularization was determined using a bone marrow transplant model where tie2/lacZ bone marrow was transplanted into wild-type mice (n = 20).Vascular regression in the graft was observed at the periphery starting on day 3 and moving centrally through day 21, sparing graft vessels in the absolute center of the graft. At the same time, vascular ingrowth occurred from the wound bed to replace the regressing vessels. Furthermore, bone marrow-derived endothelial progenitor cells contributed to these new vessels starting as early as day 7. Surprisingly, the contribution of bone marrow-derived vessels to the overall process was approximately 15 to 20 percent of new endothelial cells.Replacement of the donor graft vasculature by endothelial and endothelial progenitor cells from the recipient along preexisting channels is the predominant mechanism for skin graft revascularization. This mechanism is likely similar for all nonvascularized free grafts and suggests novel strategies for optimizing the vascularization of tissue constructs engineered in vitro.

View details for DOI 10.1097/01.prs.0000201459.91559.7f

View details for Web of Science ID 000235942500019

View details for PubMedID 16525274
Hyperglycemia-induced reactive oxygen species and impaired endothelial progenitor cell function ANTIOXIDANTS & REDOX SIGNALING Callaghan, M. J., Ceradini, D. J., Gurtner, G. C. 2005; 7 (11-12): 1476-1482
Abstract

Vascular complications in diabetes are a significant source of human morbidity and mortality, affecting multiple organ systems and persisting despite tight glucose control. Many of these complications can be linked to impairments in vasculogenesis, the process by which circulating and bone marrow-derived endothelial progenitor cells (EPCs) contribute to new vessel formation. Recent evidence suggests that hyperglycemia alone, through the mitochondrial overproduction of reactive oxygen species (ROS), can induce changes in gene expression and cellular behavior in diabetes. In this review, we examine how hyperglycemia-induced overproduction of ROS could explain EPC impairments observed in diabetes. Experimentally, impairments in EPC function prevent new blood vessel growth and are potentially reversible by manipulations to decrease ROS. Novel strategies aimed at reducing hyperglycemia-induced ROS may be a useful adjuvant to antihyperglycemic therapies in the restoration of vasculogenesis and the prevention of diabetic complications.

View details for Web of Science ID 000233962500008

View details for PubMedID 16356110
Stem cells and distraction osteogenesis: Endothelial progenitor cells home to the ischemic generate in activation and consolidation 48th Annual Meeting of the Plastic-Surgery-Research-Council Cetrulo, C. L., Knox, K. R., Brown, D. J., Ashinoff, R. L., Dobryansky, M., Ceradini, D. J., Capla, J. A., Chang, E. I., Bhatt, K. A., McCarthy, J. G., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2005: 1053–64
Abstract

Ischemia is a limiting factor during distraction osteogenesis. The authors sought to determine the extent of ischemia in the distraction zone and whether endothelial progenitor cells home to the distraction zone and participate in local vasculogenesis.Laser Doppler imaging was used to assess the extent of blood flow in the distraction zone in gradually distracted, immediately distracted, and osteotomized rat mandibles during activation and consolidation. Animals (n = 50; 25 rats with unilateral gradual distraction and contralateral osteotomy as an internal control, and 25 rats with unilateral immediate distraction) were examined on postoperative days 4, 6, and 8 of activation, and after 1 and 2 weeks of consolidation. Endothelial progenitor cells isolated from human peripheral blood were labeled with fluorescent DiI dye, and 0.5 x 10 cells were injected intra-arterially under direct vision into each carotid artery at the start of activation in nude rats (n = 18) that then underwent the distraction protocol outlined above.Doppler flow analysis demonstrated relative ischemia during the activation period in the distraction osteogenesis group and increased blood flow in the osteotomized control group as compared with flow in a normal hemimandible [normal, 1 (standardized); distraction osteogenesis, 0.58 +/- 0.05; control, 2.58 +/- 0.21; p < 0.05 for both results]. We observed a significantly increased endothelial progenitor cell population at the generate site versus controls at midactivation and at 1 and 2 weeks of consolidation [25 +/- 1.9 versus 1 +/- 0.3 DiI-positive cells per high-power field (p < 0.05), 124 +/- 21 versus 8 +/- 4 DiI-positive cells per high-power field (p < 0.05), and 106 +/- 18 versus 9 +/- 3 DiI-positive cells per high-power field (p < 0.05), respectively].These data suggest that the distraction zone becomes relatively ischemic during activation and that endothelial progenitor cells home to the ischemic generate site during the activation phase and remain during the consolidation phase. Selective expansion of these stem cells may be useful in overcoming ischemic limitations of distraction osteogenesis. Moreover, their homing capability may be used to effect site-specific transgene delivery to the generate.

View details for DOI 10.1097/01.prs.0000178403.79051.70

View details for Web of Science ID 000232114400021

View details for PubMedID 16163094
Topical vascular endothelial growth factor reverses delayed wound healing secondary to angiogenesis inhibitor administration WOUND REPAIR AND REGENERATION Michaels, J., Dobryansky, M., Galiano, R. D., Bhatt, K. A., Ashinoff, R., Ceradini, D. J., Gurtner, G. C. 2005; 13 (5): 506-512
Abstract

The prevention of new blood vessel growth is an increasingly attractive strategy to limit tumor growth. However, it remains unclear whether anti-angiogenesis approaches will impair wound healing, a process thought to be angiogenesis dependent. Results of previous studies differ as to whether angiogenesis inhibitors delay wound healing. We evaluated whether endostatin at tumor-inhibiting doses delayed excisional wound closure. C57/BL6J mice were treated with endostatin or phosphate-buffered solution 3 days prior to the creation of two full-thickness wounds on the dorsum. Endostatin was administered daily until wound closure was complete. A third group received endostatin, but also had daily topical vascular endothelial growth factor applied locally to the wound. Wound area was measured daily and the wounds were analyzed for granulation tissue formation, epithelial gap, and wound vascularity. Endostatin-treated mice showed a significant delay in wound healing. Granulation tissue formation and wound vascularity were significantly decreased, but reepithelialization was not effected. Topical vascular endothelial growth factor application to wounds in endostatin-treated mice resulted in increased granulation tissue formation, increased wound vascularity, and wound closure approaching that of control mice. This study shows that the angiogenesis inhibitor endostatin delays wound healing and that topical vascular endothelial growth factor is effective in counteracting this effect.

View details for Web of Science ID 000231910600008

View details for PubMedID 16176459
Mechanical strain alters gene expression in an in vitro model of hypertrophic scarring 21st Annual Meeting of the Northeastern-Society-of-Plastic-Surgeons Derderian, C. A., Bastidas, N., Lerman, O. Z., Bhatt, K. A., Lin, S. E., Voss, J., Holmes, J. W., Levine, J. P., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2005: 69–75
Abstract

Fibroblasts represent a highly mechanoresponsive cell type known to play key roles in normal and pathologic processes such as wound healing, joint contracture, and hypertrophic scarring. In this study, we used a novel fibroblast-populated collagen lattice (FPCL) isometric tension model, allowing us to apply graded biaxial loads to dermal fibroblasts in a 3-dimensional matrix. Cell morphology demonstrated dose-dependent transition from round cells lacking stress fibers in nonloaded lattices to a broad, elongated morphology with prominent actin stress fibers in 800-mg-loaded lattices. Using quantitative real-time RT-PCR, a dose dependent induction of both collagen-1 and collagen-3 mRNA up to 2.8- and 3-fold, respectively, as well as a 2.5-fold induction of MMP-1 (collagenase) over unloaded FPCLs was observed. Quantitative expression of the proapoptotic gene Bax was down-regulated over 4-fold in mechanically strained FPCLs. These results suggest that mechanical strain up-regulates matrix remodeling genes and down-regulates normal cellular apoptosis, resulting in more cells, each of which produces more matrix. This "double burden" may underlie the pathophysiology of hypertrophic scars and other fibrotic processes in vivo.

View details for DOI 10.1097/01.sap.0000168160.86221.e9

View details for Web of Science ID 000230322100024

View details for PubMedID 15985794
Sonographically guided percutaneous carpal tunnel release - An anatomic and cadaveric study 21st Annual Meeting of the Northeastern-Society-of-Plastic-Surgeons Rowe, N. M., Michaels, J., Soltanian, H., Dobryansky, M., Peimer, C. A., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2005: 52–56
Abstract

Minimally invasive techniques have become the standard of care for multiple procedures. This paper demonstrates both the surgeons' capacity to perform an accurate anatomic evaluation of the hand and forearm (n=10) and the use of this anatomic information to accurately perform sonographically guided, percutaneous carpal tunnel release using a single-portal endoscope without direct or indirect visualization in a cadaver model (n=6). Open dissection was then performed to confirm complete ligament transection and to evaluate the surrounding structures for injury. In all 6 cadavers, the transverse carpal ligament was transected completely without injury to any surrounding structures. With further investigation, this novel technique may offer a less invasive, office-based method for the surgical treatment of carpal tunnel syndrome that may offer patients an expedited recovery.

View details for DOI 10.1097/01.sap.0000168281.77528.02

View details for Web of Science ID 000230322100018

View details for PubMedID 15985791
Adult vasculogenesis occurs through in situ recruitment, proliferation, and tubulization of circulating bone marrow-derived cells BLOOD Tepper, O. M., Capla, J. M., Galiano, R. D., Ceradini, D. J., Callaghan, M. J., Kleinman, M. E., Gurtner, G. C. 2005; 105 (3): 1068-1077
Abstract

Ischemia is a known stimulus for vascular growth. Bone marrow (BM)-derived endothelial progenitor cells (EPCs) are believed to contribute to new blood vessel growth, but the mechanism for this contribution is unknown. To elucidate how BM cells are able to form new blood vessels, a novel murine model of soft tissue ischemia was developed in lethally irradiated mice with BM reconstituted from either tie2/lacZ or ROSA/green fluorescent protein (GFP) mice (n = 24). BM-derived EPCs were recruited to ischemic tissue within 72 hours, and the extent of recruitment was directly proportional to the degree of tissue ischemia. At 7 days, there were persistently elevated levels of vascular endothelial growth factor (VEGF) (2.5-fold) and circulating VEGF receptor-2/CD11(-) (flk-1(+)/CD11(-)) cells (18-fold) which correlated with increased numbers of BM-derived EPCs within ischemic tissue. The cells were initially located extravascularly as proliferative clusters. By day 14, these clusters coalesced into vascular cords, which became functional vessels by day 21. In vitro examination of human EPCs from healthy volunteers (n = 10) confirmed that EPC proliferation, adhesion, and chemotaxis were all significantly stimulated in hypoxic conditions. We conclude that BM-derived cells produce new blood vessels via localized recruitment, proliferation, and differentiation of circulating cells in a sequence of events markedly different from existing paradigms of angiogenesis.

View details for DOI 10.1182/blood-2004-03-1051

View details for Web of Science ID 000226596700033

View details for PubMedID 15388583
Homing to hypoxia: HIF-1 as a mediator of progenitor cell recruitment to injured tissue TRENDS IN CARDIOVASCULAR MEDICINE Ceradini, D. J., Gurtner, G. C. 2005; 15 (2): 57-63
Abstract

The identification of bone marrow-derived endothelial progenitor cells has altered our understanding of new blood vessel growth and tissue regeneration. Previously, new blood vessel growth in the adult was thought to only occur through angiogenesis, the sprouting of new vessels from existing structures. However, it has become clear that circulating bone marrow-derived cells can form new blood vessels through a process of postnatal vasculogenesis, with endothelial progenitor cells selectively recruited to injured or ischemic tissue. How this process occurs has remained unclear. One common element in the different environments where vasculogenesis is believed to occur is the presence of a hypoxic stimulus. We have identified the chemokine stromal cell-derived factor-1 (SDF-1) and its receptor CXCR4 as critical mediators for the ischemia-specific recruitment of circulating progenitor cells. We have found that the endothelial expression of SDF-1 acts as a signal indicating the presence of tissue ischemia, and that its expression is directly regulated by hypoxia-inducible factor-1. Stromal cell-derived factor 1 is the only chemokine family member known to be regulated in this manner. Later events, including proliferation, patterning, and assembly of recruited progenitors into functional blood vessels, are also influenced by tissue oxygen tension and hypoxia. Interestingly, both SDF-1 and hypoxia are present in the bone marrow niche, suggesting that hypoxia may be a fundamental requirement for progenitor cell trafficking and function. As such, ischemic tissue may represent a conditional stem cell niche, with recruitment and retention of circulating progenitors regulated by hypoxia through differential expression of SDF-1.

View details for Web of Science ID 000229468900003

View details for PubMedID 15885571
Circulating endothelial progenitor cells and vascular anomalies. Lymphatic research and biology Kleinman, M. E., Blei, F., Gurtner, G. C. 2005; 3 (4): 234-239
Abstract

Recent findings regarding pathways of stem/progenitor cell involvement in adult blood vessel growth (postnatal vasculogenesis) suggest new theories for the pathogenesis of vascular anomalies. The somatic growth of vascular malformations and the mysterious pattern of proliferation and involution in infantile hemangioma can no longer be purely understood through the paradigm of angiogenesis. Molecular signals for postnatal vasculogenesis are being discovered in numerous animal models of cancer and ischemia, yet little research has addressed the importance of vasculogenesis in the growth of vascular anomalies. In this review, we discuss early studies that have investigated stem/progenitor cell involvement in the pathophysiology of infantile hemangioma and other congenital vascular anomalies.

View details for PubMedID 16379593
Progenitor cell trafficking is regulated by hypoxic gradients through HIF-1 induction of SDF-1 NATURE MEDICINE Ceradini, D. J., Kulkarni, A. R., Callaghan, M. J., Tepper, O. M., Bastidas, N., Kleinman, M. E., Capla, J. M., Galiano, R. D., Levine, J. P., Gurtner, G. C. 2004; 10 (8): 858-864
Abstract

The trafficking of circulating stem and progenitor cells to areas of tissue damage is poorly understood. The chemokine stromal cell-derived factor-1 (SDF-1 or CXCL12) mediates homing of stem cells to bone marrow by binding to CXCR4 on circulating cells. SDF-1 and CXCR4 are expressed in complementary patterns during embryonic organogenesis and guide primordial stem cells to sites of rapid vascular expansion. However, the regulation of SDF-1 and its physiological role in peripheral tissue repair remain incompletely understood. Here we show that SDF-1 gene expression is regulated by the transcription factor hypoxia-inducible factor-1 (HIF-1) in endothelial cells, resulting in selective in vivo expression of SDF-1 in ischemic tissue in direct proportion to reduced oxygen tension. HIF-1-induced SDF-1 expression increases the adhesion, migration and homing of circulating CXCR4-positive progenitor cells to ischemic tissue. Blockade of SDF-1 in ischemic tissue or CXCR4 on circulating cells prevents progenitor cell recruitment to sites of injury. Discrete regions of hypoxia in the bone marrow compartment also show increased SDF-1 expression and progenitor cell tropism. These data show that the recruitment of CXCR4-positive progenitor cells to regenerating tissues is mediated by hypoxic gradients via HIF-1-induced expression of SDF-1.

View details for DOI 10.1038/nm1075

View details for Web of Science ID 000223055700041

View details for PubMedID 15235597
Electromagnetic fields increase in vitro and in vivo angiogenesis through endothelial release of FGF-2. FASEB journal Tepper, O. M., Callaghan, M. J., Chang, E. I., Galiano, R. D., Bhatt, K. A., Baharestani, S., Gan, J., Simon, B., Hopper, R. A., Levine, J. P., Gurtner, G. C. 2004; 18 (11): 1231-1233
Abstract

Pulsed electromagnetic fields (PEMF) have been shown to be clinically beneficial, but their mechanism of action remains unclear. The present study examined the impact of PEMF on angiogenesis, a process critical for successful healing of various tissues. PEMF increased the degree of endothelial cell tubulization (sevenfold) and proliferation (threefold) in vitro. Media from PEMF cultures had a similar stimulatory effect, but heat denaturation ablated this activity. In addition, conditioned media was able to induce proliferative and chemotactic changes in both human umbilical vein endothelial cells and fibroblasts, but had no effect on osteoblasts. Angiogenic protein screening demonstrated a fivefold increase in fibroblast growth factor beta-2 (FGF-2), as well as smaller increases in other angiogenic growth factors (angiopoietin-2, thrombopoietin, and epidermal growth factor). Northern blot analysis demonstrated an increase in FGF-2 transcription, and FGF-2 neutralizing antibody inhibited the effects of PEMF. In vivo, PEMF exposure increased angiogenesis more than twofold. We conclude that PEMF augments angiogenesis primarily by stimulating endothelial release of FGF-2, inducing paracrine and autocrine changes in the surrounding tissue. These findings suggest a potential role for PEMF in therapeutic angiogenesis.

View details for PubMedID 15208265
Quantitative and reproducible murine model of excisional wound healing WOUND REPAIR AND REGENERATION Galiano, R. D., Michaels, J., Dobryansky, M., Levine, J. P., Gurtner, G. C. 2004; 12 (4): 485-492
Abstract

The goal of animal wound healing models is to replicate human physiology and predict therapeutic outcomes. There is currently no model of wound healing in rodents that closely parallels human wound healing. Rodents are attractive candidates for wound healing studies because of their availability, low cost, and ease of handling. However, rodent models have been criticized because the major mechanism of wound closure is contraction, whereas in humans reepithelialization and granulation tissue formation are the major mechanisms involved. This article describes a novel model of wound healing in mice utilizing wound splinting that is accurate, reproducible, minimizes wound contraction, and allows wound healing to occur through the processes of granulation and reepithelialization. Our results show that splinted wounds have an increased amount of granulation tissue deposition as compared to controls, but the rate of reepithelialization is not affected. Thus, this model eliminates wound contraction and allows rodents' wounds to heal by epithelialization and granulation tissue formation. Given these analogies to human wound healing, we believe that this technique is a useful model for the study of wound healing mechanisms and for the evaluation of new therapeutic modalities.

View details for Web of Science ID 000222725900012

View details for PubMedID 15260814
Ex vivo transduction of microvascular free flaps for localized peptide delivery 20th Annual Meeting of the Northeastern-Society-of-Plastic-Surgeons Michaels, J., Dobryansky, M., Galiano, R. D., Ceradini, D. J., Bonillas, R., Jones, D., Seiser, N., Levine, J. P., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2004: 581–84
Abstract

Gene therapy is a promising modality for the treatment of soft tissue malignancies. Our laboratory has developed a novel technique of gene transfer using microvascular free flaps that addresses many of the current barriers preventing gene therapy from achieving widespread clinical use. Our previous work has demonstrated our ability to transduce free flaps with an adenovirus encoding the reporter gene lacZ. In this current study, we show that microvascular free flaps can be transduced with an adenovirus encoding the angiogenesis inhibitor endostatin with high levels of local flap expression. These transduced free flaps were able to serve as "biologic pumps" and were able to secrete endostatin into the serum as demonstrated by enzyme-linked immunosorbent assay. This form of "biologic brachytherapy" could provide a novel approach for the continuous delivery of therapeutic genes to a localized area while avoiding many of the practical obstacles currently limiting gene therapy.

View details for DOI 10.1097/01.sap.0000122652.81844.37

View details for Web of Science ID 000221715400010

View details for PubMedID 15166989
Electromagnetic fields increase in vitro and in vivo angiogenesis through endothelial release of FGF-2 FASEB JOURNAL Tepper, O. M., Callaghan, M. J., Chang, E. I., Galiano, R. D., Bhatt, K. A., Baharestani, S., Gan, J., Simon, B., Hopper, R. A., Levine, J. P., Gurtner, G. C. 2004; 18 (9): 1231-?
View details for DOI 10.1096/fj.03-0847fje

View details for Web of Science ID 000222327500023
Bone morphogenic protein-2 gene therapy for mandibular distraction osteogenesis 20th Annual Meeting of the Northeastern-Society-of-Plastic-Surgeons Ashinoff, R. L., Cetrulo, C. L., Galiano, R. D., Dobryansky, M., Bhatt, K. A., Ceradini, D. J., Michaels, J., McCarthy, J. G., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2004: 585–91
Abstract

Distraction osteogenesis (DO) requires a long consolidation period and has a low but real failure rate. Bone morphogenic proteins (BMPs) accelerate bone deposition in fractures and critical-sized bone defects, but their effects on mandibular DO are unknown. We investigated the effect of local delivery of adenovirus containing the gene for BMP-2 (Adbmp-2) on mandibular DO in a rat model. Rats (n = 54) were distracted to 3 mm over 6 days. At the start of consolidation (POD 10), Adbmp-2 or adenovirus containing the lacZgene (AdlacZ) was injected directly into the distraction zone. After 1, 2, and 4 weeks of consolidation, mandibles were evaluated for amount of bone deposition. Adbmp-2-treated specimens demonstrated an increased amount of new bone formation by radiographic, histologic, and histomorphometric analysis. This study demonstrates that local, adenovirally-mediated delivery of BMP-2 can increase bone deposition during DO, potentially shortening consolidation and enhancing DO in poorly healing mandibles, such as occurs postirradiation.

View details for DOI 10.1097/01.sap.0000123.23.28874.1e

View details for Web of Science ID 000221715400011

View details for PubMedID 15166991
Topical vascular endothelial growth factor accelerates diabetic wound healing through increased angiogenesis and by mobilizing and recruiting bone marrow-derived cells AMERICAN JOURNAL OF PATHOLOGY Galiano, R. D., Tepper, O. M., Pelo, C. R., Bhatt, K. A., Callaghan, M., Bastidas, N., Bunting, S., Steinmetz, H. G., Gurtner, G. C. 2004; 164 (6): 1935-1947
Abstract

Diminished production of vascular endothelial growth factor (VEGF) and decreased angiogenesis are thought to contribute to impaired tissue repair in diabetic patients. We examined whether recombinant human VEGF(165) protein would reverse the impaired wound healing phenotype in genetically diabetic mice. Paired full-thickness skin wounds on the dorsum of db/db mice received 20 microg of VEGF every other day for five doses to one wound and vehicle (phosphate-buffered saline) to the other. We demonstrate significantly accelerated repair in VEGF-treated wounds with an average time to resurfacing of 12 days versus 25 days in untreated mice. VEGF-treated wounds were characterized by an early leaky, malformed vasculature followed by abundant granulation tissue deposition. The VEGF-treated wounds demonstrated increased epithelialization, increased matrix deposition, and enhanced cellular proliferation, as assessed by uptake of 5-bromodeoxyuridine. Analysis of gene expression by real-time reverse transcriptase-polymerase chain reaction demonstrates a significant up-regulation of platelet-derived growth factor-B and fibroblast growth factor-2 in VEGF-treated wounds, which corresponds with the increased granulation tissue in these wounds. These experiments also demonstrated an increase in the rate of repair of the contralateral phosphate-buffered saline-treated wound when compared to wounds in diabetic mice never exposed to VEGF (18 days versus 25 days), suggesting that topical VEGF had a systemic effect. We observed increased numbers of circulating VEGFR2(+)/CD11b(-) cells in the VEGF-treated mice by fluorescence-activated cell sorting analysis, which likely represent an endothelial precursor population. In diabetic mice with bone marrow replaced by that of tie2/lacZ mice we demonstrate that the local recruitment of bone marrow-derived endothelial lineage lacZ+ cells was augmented by topical VEGF. We conclude that topical VEGF is able to improve wound healing by locally up-regulating growth factors important for tissue repair and by systemically mobilizing bone marrow-derived cells, including a population that contributes to blood vessel formation, and recruiting these cells to the local wound environment where they are able to accelerate repair. Thus, VEGF therapy may be useful in the treatment of diabetic complications characterized by impaired neovascularization.

View details for Web of Science ID 000221601000008

View details for PubMedID 15161630
Endostatin inhibits ischemia-induced neovascularization and increases ischemic tissue loss 20th Annual Meeting of the Northeastern-Society-of-Plastic-Surgeons Dobryansky, M., Galiano, R. D., Cetrulo, C. L., Bhatt, K. A., Michaels, J., Ashinoff, R., Levine, J. P., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2004: 512–18
Abstract

The impact of inhibitors of tumor angiogenesis (endostatin, angiostatin) on the neovascularization required for the healing of transferred tissue has not been examined. We investigated the effect of endostatin on the functional neovascularization of random pattern flaps. C57BL6 mice were pretreated with endostatin beginning 3 days prior to surgery (n = 10), and daily injections continued throughout the study. Dorsal random cutaneous flaps were raised in both treatment and control (saline-treated) groups. The remaining cranial attachment was divided on day 9. Oxygen tension (PO2) was measured using a microprobe on days 1, 3, 5 and 16. Flaps were harvested and the vasculature was stained with CD31 on day 16. We found that endostatin significantly decreased flap survival. Mice that were treated with endostatin had fewer CD31+ blood vessels, worse flap perfusion at all time points, and lower oxygen tensions throughout the length of the flap. These findings have potential implications for the patients undergoing antiangiogenesis therapy who require surgical reconstruction.

View details for DOI 10.1097/01.sap.0000123022.98361.c5

View details for Web of Science ID 000221283600014

View details for PubMedID 15096942
Selective recruitment of endothelial progenitor cells to ischemic tissues with increased neovascularization 47th Annual Meeting of the Plastic-Surgery-Research-Council Park, S., Tepper, O. M., Galiano, R. D., Capla, J. M., Baharestani, S., Kleinman, M. E., Pelo, C. R., Levine, J. P., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2004: 284–93
Abstract

Tissue ischemia remains a common problem in plastic surgery and one for which proangiogenic approaches have been investigated. Given the recent discovery of circulating endothelial stem or progenitor cells that are able to form new blood vessels, the authors sought to determine whether these cells might selectively traffic to regions of tissue ischemia and induce neovascularization. Endothelial progenitor cells were isolated from the peripheral blood of healthy human volunteers and expanded ex vivo for 7 days. Elevation of a cranially based random-pattern skin flap was performed in nude mice, after which they were injected with fluorescent-labeled endothelial progenitor cells (5 x 10(5); n = 15), fluorescent-labeled human microvascular endothelial cells (5 x 10(5); n = 15), or media alone (n = 15). Histologic examination demonstrated that endothelial progenitor cells were recruited to ischemic tissue and first appeared by postoperative day 3. Subsequently, endothelial progenitor cell numbers increased exponentially over time for the remainder of the study [0 cells/mm2 at day 0 (n = 3), 9.6 +/- 0.9 cells/mm2 at day 3 (n = 3), 24.6 +/- 1.5 cells/mm2 at day 7 (n = 3), and 196.3 +/- 9.6 cells/mm2 at day 14 (n = 9)]. At all time points, endothelial progenitor cells localized preferentially to ischemic tissue and healing wound edges, and were not observed in normal, uninjured tissues. Endothelial progenitor cell transplantation led to a statistically significant increase in vascular density in ischemic tissues by postoperative day 14 [28.7 +/- 1.2 in the endothelial progenitor cell group (n = 9) versus 18 +/- 1.1 in the control media group (n = 9) and 17.7 +/- 1.0 in the human microvascular endothelial cell group (n = 9; p < 0.01)]. Endothelial progenitor cell transplantation also showed trends toward increased flap survival [171.2 +/- 18 mm2 in the endothelial progenitor cell group (n = 12) versus 134.2 +/- 10 mm2 in the media group (n = 12) and 145.0 +/- 13 mm2 in the human microvascular endothelial cell group (n = 12)], but this did not reach statistical significance. These findings indicate that local tissue ischemia is a potent stimulus for the recruitment of circulating endothelial progenitor cells. Systemic delivery of endothelial progenitor cells increased neovascularization and suggests that autologous endothelial progenitor cell transplantation may have a role in the salvage of ischemic tissue.

View details for DOI 10.1097/01.PRS.0000091169.51035.A5

View details for Web of Science ID 000220063200040

View details for PubMedID 14707648
Reconstruction of a large mandibular defect utilizing temporary zygomatic-ramal fixation and bilateral Risdon incisions JOURNAL OF CRANIOFACIAL SURGERY Derderian, C. A., Gurtner, G. C., McCarthy, J. G. 2004; 15 (1): 16-19
Abstract

Ameloblastoma is a benign, invasive, odontogenic tumor of the jaws that predominantly affects the mandible. Despite the benign nature of these lesions, there is a high rate of local recurrence after curettage, which usually requires resection. The traditional surgical approach for resection of ameloblastomas, via either mandibulotomy or mandibulectomy, has been through lower lip-splitting incisions, which are associated with significant functional and esthetic sequelae. A case is presented here in which less invasive Risdon and intraoral degloving incisions were used in combination with temporary zygomatic-ramal fixation to maintain occlusion after resection of a large mandibular ameloblastoma. The bilateral Risdon approach provided wide access to the mandible, allowing an angle-to-angle resection to be performed. This approach also provided adequate exposure for an osteocutaneous fibula free flap reconstruction to be performed, with 100% flap survival. At 1 year of follow-up, there were minimal functional and esthetic defects. This approach represents a less invasive alternative that provides access to the mandible for curative resection of benign tumors with minimal postoperative sequelae.

View details for Web of Science ID 000225848500006

View details for PubMedID 14704555
Microvascular free-tissue transfer for traumatic defects of the upper extremity: A 25-year experience 80th Annual Meeting of the American-Association-of-Plastic-Surgeons Derderian, C. A., Olivier, W. A., Baux, G., Levine, J., Gurtner, G. C. THIEME MEDICAL PUBL INC. 2003: 455–61
Abstract

Microvascular free-tissue transfer has been a major advance in the treatment of complex traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue transfers were performed in 133 patients with complex traumatic upper extremity defects at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent), and functional deficit (8 percent). The parascapular region was the most common donor site used (26 percent). Microvascular free-tissue transfer was performed either emergently at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent), during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap failure rate was 9 percent. A decreased incidence of flap failure was observed in patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed in 14 percent of patients overall. A decreased incidence of recipient-site infection was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent, respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and now preferentially microvascular free flaps are performed 6 to 21 days post injury. The treatment algorithm has been simplified and now only four different flaps are used in the majority of patients (70 percent). With this, the authors have witnessed a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent to 4 percent. The preferred timing for microvascular free-tissue transfers to the upper extremity is concluded to be 6 to 21 days post injury.

View details for Web of Science ID 000185905200003

View details for PubMedID 14634908
Reliable assessment of skin flap viability using orthogonal polarization imaging 87th Annual Clinical Congress of the American-College-of-Surgeons Olivier, W. M., Hazen, A., Levine, J. P., Soltanian, H., Chung, S., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2003: 547–55
Abstract

Intraoperative evaluation of skin flap viability has primarily been dependent on clinical judgment. The purpose of this study was to determine whether an orthogonal polarization spectral imaging device could be used to accurately predict viability of random-pattern skin flaps. Orthogonal polarization spectral imaging is a newly developed technique that visualizes the microcirculation using reflected light without the use of fluorescent dyes and allows for noninvasive real-time observation of functional microvascular networks. In Sprague-Dawley rats (n = 24), three types of random skin flaps were designed with unknown zones of viability (n = 8 per group). After flap elevation, the skin flaps were evaluated by both clinical examination and orthogonal polarization spectral imaging. Areas of the flap determined to be nonviable by clinical examination were measured and marked. Orthogonal polarization spectral imaging was subsequently performed, and areas of the skin flap with stasis (i.e., cessation of red blood cell movement) in the dermal microcirculation on orthogonal polarization spectral imaging were measured and marked. The skin flaps were then secured in place. Flaps were evaluated on a daily basis for clinical signs of ischemia and necrosis. On postoperative day 7, the total amount of random skin flap necrosis was measured and recorded. Clinical examination of the random skin flaps significantly underestimated the actual amount of eventual flap necrosis, and as result was a very poor predictor of flap necrosis. By contrast, assessment of microcirculatory stasis using the orthogonal polarization spectral imaging device correlated well with the subsequent development of necrosis in all groups. In the three groups, the average amount of flap necrosis predicted by clinical examination deviated from actual necrosis by approximately 2 to 4 cm. However, the amount that orthogonal polarization spectral imaging differed from actual necrosis was 0.1 to 0.3 cm. Therefore, orthogonal polarization spectral imaging was an excellent predictor of eventual flap necrosis and much more accurate than clinical observation (p < 0.001). Intraoperative evaluation of axial and random pattern flap viability has traditionally been based on clinical examination as no other reliable, convenient test currently exists. The authors demonstrated that an orthogonal polarization spectral imaging device accurately predicts zones of necrosis in random pattern flaps by directly visualizing cessation of microcirculatory flow. Intraoperative stasis in the dermal microcirculation correlated precisely with subsequent flap necrosis. Orthogonal polarization spectral imaging was significantly more accurate than clinical examination, which consistently underestimated flap necrosis. The orthogonal polarization spectral imaging technique may have value in the intraoperative assessment of skin flap perfusion such as that required after skin-sparing mastectomy.

View details for DOI 10.1097/01.PRS.0000070968.42857.43

View details for Web of Science ID 000184532700022

View details for PubMedID 12900613
Endothelial progenitor cells: The promise of vascular stem cells for plastic surgery PLASTIC AND RECONSTRUCTIVE SURGERY Tepper, O. M., Galiano, R. D., Kalka, C., Gurtner, G. C. 2003; 111 (2): 846-854
View details for DOI 10.1097/01.PRS.0000039576.63523.08

View details for Web of Science ID 000180798600058

View details for PubMedID 12560713
Vascularized acellular dermal matrix island flaps for the repair of abdominal muscle defects 46th Annual Meeting of Plastic-Surgery-Research-Council Chung, S., Hazen, A., Levine, J. P., Baux, G., Olivier, W. A., Yee, H. T., Margiotta, M. S., Karp, N. S., Gurtner, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2003: 225–32
Abstract

The potential widespread use of tissue-engineered matrices in soft-tissue reconstruction has been limited by the difficulty in fabricating and confirming a functional microcirculation. Acellular dermal matrix placed in a soft-tissue pocket acts as a scaffold to be incorporated by the host's fibrovascular tissue. A new method for noninvasive real-time observation of functional microvascular networks using orthogonal polarization spectral (OPS) imaging has recently been reported. Arterioles, venules, and capillaries can be directly visualized, and the movement of individual blood cells through them can be observed. The present study was performed to investigate the use of prefabricated acellular dermal matrix with an arteriovenous unit for the repair of abdominal muscle defects. OPS imaging was used to determine the presence of a functional microcirculation in the neovascularized matrix. In Sprague-Dawley rats, vascularized matrix was prefabricated by placing the superficial epigastric artery and vein on a 2-cm x 2-cm implant-type acellular dermal matrix in the thigh. Three weeks after implantation, the matrix-arteriovenous unit was elevated as an axial-type flap and a 2-cm x 2-cm full-thickness block of abdominal muscle immediately superior to the inguinal ligament was resected. Additional procedures were performed according to group: no repair (group 1, n = 20); repair with nonvascularized acellular dermal matrix (group 2, n = 20); repair with devascularized acellular dermal matrix (group 3, = 20); and repair with vascularized acellular dermal matrix (group 4, n = 20). OPS imaging (field of view, 1 mm in diameter; scan depth range, 0.2 mm) was performed on both sides of each flap on a total of 10 random distal regions before and after pedicle transection in group 3 and with the pedicle preserved in group 4. Hernia rate and duration of survival were compared for 21 days. OPS imaging showed directional blood cell movement through the capillary network in all areas scanned in group 4. No microvascular perfusion was observed after pedicle transection in group 3. Hernia rates of 100, 80, 90, and 0 percent were seen in groups 1, 2, 3, and 4, respectively. Median survival times of 9, 11.5, 9, and 21 postoperative days were noted in groups 1, 2, 3, and 4, respectively. Histopathologic analysis with factor VIII revealed full-thickness infiltration of the matrix by endothelial cells, signifying newly formed blood vessels. Repair of abdominal muscle defects using vascularized acellular dermal matrix resulted in no hernia and survival of all animals for the duration of study. However, repairs using avascular or devascularized matrix resulted in significant rates of hernia and decreased survival. Acellular dermal matrix can be prefabricated into vascularized tissue using an arteriovenous unit and used successfully to repair abdominal muscle defects. OPS imaging allowed for high-contrast direct visualization of microcirculation in previously acellular tissue following prefabrication with an arteriovenous unit.

View details for DOI 10.1097/01.PRS.0000034934.05304.ED

View details for Web of Science ID 000180191700039

View details for PubMedID 12496583
Endothelial progenitor cell trafficking in distraction osteogenesis in the activation and consolidation phases 10th International Congress of the International-Society-of-Craniofacial-Surgery Cetrulo, C. L., Ashinoff, R. L., Ceradini, D. J., Dobryanski, M., Capla, J. M., Bhatt, K. A., Galiano, R. D., Jensen, J. N., Levine, J. P., Gurtner, G. C., McCarthy, J. G. MEDIMOND PUBLISHING CO. 2003: 113–113
View details for Web of Science ID 000227470500020
Mesenchymal stem cell homing in distraction osteogenesis: Promise for ex vivo expansion therapy and gene-delivery vehicles 10th International Congress of the International-Society-of-Craniofacial-Surgery Cetrulo, C. L., Ceradini, D. J., Ashinoff, R. L., Dobryanski, M., Bhatt, K. A., Michaels, V. J., Jensen, J. N., Galiano, R. D., Levine, J. P., Gurtner, G. C., McCarthy, J. G. MEDIMOND PUBLISHING CO. 2003: 385–385
View details for Web of Science ID 000227470500070
Increased circulating AC133+ CD34+ endothelial progenitor cells in children with hemangioma. Lymphatic research and biology Kleinman, M. E., Tepper, O. M., Capla, J. M., Bhatt, K. A., Ceradini, D. J., Galiano, R. D., Blei, F., Levine, J. P., Gurtner, G. C. 2003; 1 (4): 301-307
Abstract

Hemangioma is the most common soft-tissue tumor of infancy. Despite the frequency of these vascular tumors, the origin of hemangioma-endothelial cells is unknown. Circulating endothelial progenitor cells (EPCs) have recently been identified as vascular stem cells with the capacity to contribute to postnatal vascular development. We have attempted to determine whether circulating EPCs are increased in hemangioma patients and thereby provide insight into the role of EPCs in hemangioma growth.Peripheral blood mononuclear cells (PBMCs) were isolated from hemangioma patients undergoing surgical resection (N = 5) and from age-matched controls (N = 5) undergoing strabismus correction surgery. PBMCs were stained with fluorescent-labeled antibodies for AC133, CD34, and VEGFR2/KDR. Fluorescent-labeled isotype antibodies served as negative controls. Histologic sections of surgical specimens were stained with the specific hemangioma markers Glut1, CD32, and merosin, to confirm the diagnosis of common hemangioma of infancy. EPCs harvested from healthy adult volunteers were stained with Glut1, CD32, and merosin, to assess whether cultured EPCs express known hemangioma markers. Hemangioma patients had a 15-fold increase in the number of circulating CD34 AC133 dual-staining cells relative to controls (0.78+/-0.14% vs.0.052+/-0.017%, respectively). Similarly, the number of PBMCs that stained positively for both CD34 and KDR was also increased in hemangioma patients (0.49+/-0.074% vs. 0.19+/-0.041% in controls). Cultured EPCs stained positively for the known hemangioma markers Glut1, CD32, merosin.This is the first study to suggest a role for EPCs in the pathogenesis of hemangioma. Our results imply that increased levels of circulating EPCs may contribute to the formation of this vascular tumor.

View details for PubMedID 15624558
Gene therapy with bone morphogenic protein-2 in mandibular distraction osteogaiesis 10th International Congress of the International-Society-of-Craniofacial-Surgery Ashinoff, R. L., Galiano, R. D., Cetrulo, C. L., Dobryansky, M., Bhatt, K. A., Michaels, J., Ceradini, D., Levine, J. P., Gurtner, G. C., McCarthy, J. G. MEDIMOND PUBLISHING CO. 2003: 115–115
View details for Web of Science ID 000227470500021
Cellular dysfunction in the diabetic fibroblast - Impairment in migration, vascular endothelial growth factor production, and response to hypoxia AMERICAN JOURNAL OF PATHOLOGY Lerman, O. Z., Galiano, R. D., Armour, M., Levine, J. P., Gurtner, G. C. 2003; 162 (1): 303-312
Abstract

Although it is known that systemic diseases such as diabetes result in impaired wound healing, the mechanism for this impairment is not understood. Because fibroblasts are essential for wound repair, we compared the in vitro behavior of fibroblasts cultured from diabetic, leptin receptor-deficient (db/db) mice with wild-type fibroblasts from mice of the same genetic background in processes important during tissue repair. Adult diabetic mouse fibroblast migration exhibited a 75% reduction in migration compared to normal fibroblasts (P < 0.001) and was not significantly stimulated by hypoxia (1% O(2)), whereas wild-type fibroblast migration was up-regulated nearly twofold in hypoxic conditions (P < 0.05). Diabetic fibroblasts produced twice the amount of pro-matrix metalloproteinase-9 as normal fibroblasts, as measured by both gelatin zymography and enzyme-linked immunosorbent assay (P < 0.05). Adult diabetic fibroblasts exhibited a sevenfold impairment in vascular endothelial growth factor (VEGF) production (4.5 +/- 1.3 pg/ml versus 34.8 +/- 3.3 pg/ml, P < 0.001) compared to wild-type fibroblasts. Moreover, wild-type fibroblast production of VEGF increased threefold in response to hypoxia, whereas diabetic fibroblast production of VEGF was not up-regulated in hypoxic conditions (P < 0.001). To address the question whether these differences resulted from chronic hyperglycemia or absence of the leptin receptor, fibroblasts were harvested from newborn db/db mice before the onset of diabetes (4 to 5 weeks old). These fibroblasts showed no impairments in VEGF production under basal or hypoxic conditions, confirming that the results from db/db fibroblasts in mature mice resulted from the diabetic state and were not because of alterations in the leptin-leptin receptor axis. Markers of cellular viability including proliferation and senescence were not significantly different between diabetic and wild-type fibroblasts. We conclude that, in vitro, diabetic fibroblasts show selective impairments in discrete cellular processes critical for tissue repair including cellular migration, VEGF production, and the response to hypoxia. The VEGF abnormalities developed concurrently with the onset of hyperglycemia and were not seen in normoglycemic, leptin receptor-deficient db/db mice. These observations support a role for fibroblast dysfunction in the impaired wound healing observed in human diabetics, and also suggest a mechanism for the poor clinical outcomes that occur after ischemic injury in diabetic patients.

View details for Web of Science ID 000180009800031

View details for PubMedID 12507913
Human endothelial progenitor cells from type II diabetics exhibit impaired proliferation, adhesion, and incorporation into vascular structures. Circulation Tepper, O. M., Galiano, R. D., Capla, J. M., Kalka, C., Gagne, P. J., Jacobowitz, G. R., Levine, J. P., Gurtner, G. C. 2002; 106 (22): 2781-2786
Abstract

The recent discovery of circulating endothelial progenitor cells (EPCs) has altered our understanding of new blood vessel growth such as occurs during collateral formation. Because diabetic complications occur in conditions in which EPC contributions have been demonstrated, EPC dysfunction may be important in their pathophysiology.EPCs were isolated from human type II diabetics (n=20) and age-matched control subjects (n=20). Proliferation of diabetic EPCs relative to control subjects was decreased by 48% (P<0.01) and inversely correlated with patient levels of hemoglobin A1C (P<0.05). Diabetic EPCs had normal adhesion to fibronectin, collagen, and quiescent endothelial cells but a decreased adherence to human umbilical vein endothelial cells activated by tumor necrosis factor-alpha (TNF-alpha) (P<0.05). In a Matrigel assay, diabetic EPCs were 2.5 times less likely to participate in tubule formation compared with controls (P<0.05).These findings suggest that type II diabetes may alter EPC biology in processes critical for new blood vessel growth and may identify a population at high risk for morbidity and mortality after vascular occlusive events.

View details for PubMedID 12451003
Human endothelial progenitor exhibit impaired proliferation, cells from type II diabetics adhesion, and incorporation into vascular structures CIRCULATION Tepper, O. M., Galiano, R. D., Capla, J. M., Kalka, C., Gagne, P. J., Jacobowitz, G. R., Levine, J. P., Gurtner, G. C. 2002; 106 (22): 2781-2786
View details for DOI 10.1161/01.CIR.0000039526.42991.93

View details for Web of Science ID 000179581700016
Muristerone A-induced nerve growth factor release from genetically engineered human dermal fibroblasts for peripheral nerve tissue engineering TISSUE ENGINEERING Patrick, C. W., Zheng, B., Wu, X. M., Gurtner, G., Barlow, M., Koutz, C., Chang, D., Schmidt, M., Evans, G. R. 2001; 7 (3): 303-311
Abstract

In this study, human dermal fibroblasts (hDFBs) were genetically modified to release human nerve growth factor (NGF) using an ecdysone-inducible system. NGF cDNA was inserted into the pIND vector and then hDFBs were cotransfected with pIND-NGF and pVgRXR. Muristerone A, an analog of ecdysone, was used as the inducing agent. NGF release from transfected hDFBs was assessed in vitro and in vivo. Transfected hDFBs in the presence of Muristerone A possessed a maximal in vitro release of 8.5 +/- 0.4 pg of NGF/mL per 10(3) cells, demonstrating significantly higher NGF levels compared to control hDFBs. The in vitro release rate curve for transfected hDFBs in the presence of Muristerone A exhibited a maximum of 5.1 +/- 0.2 ng NGF/10(6) cells/day. A PC-12 bioassay demonstrated that the in vitro NGF released is bioactive. When transfected hDFBs in the presence of Muristerone A were placed in vivo in nude rats, NGF levels reach 2074 +/- 257 pg/mL and 1620 +/- 132 pg/mL at 24 and 48 h, respectively. These levels were significantly higher than negative control and wound fluid levels. Results support further in vivo investigation of this molecular "on" switch for peripheral nerve regeneration.

View details for Web of Science ID 000169407700005

View details for PubMedID 11429150
Reduction mammoplasty improves breast conservation therapy in patients with macromastia AMERICAN JOURNAL OF SURGERY Newman, L. A., Kuerer, H. M., McNeese, M. D., Hunt, K. K., Gurtner, G. C., Vlastos, G. S., Robb, G., Singletary, S. E. 2001; 181 (3): 215-220
Abstract

Macromastia has been considered a contraindication to breast conservation therapy because of difficulties with radiation therapy. This study evaluates the feasibility of bilateral reduction mammoplasty as a component of breast conservation therapy for breast cancer patients with pendulous breasts.Of 153 patients undergoing reduction mammoplasty at the University of Texas M. D. Anderson Cancer Center, 28 were identified as breast cancer patients with macromastia receiving breast conservation therapy. Median follow-up was 23.8 months.Median patient age was 55 years. Nearly all patients were described as obese. Median weight of the reduction mammoplasty specimen on the cancerous side was 766 g. One patient (4%) required completion mastectomy for inadequate margin control. Major postoperative complications occurred in 2 patients (7%). There were no major postradiation complications. Patient survey revealed a satisfaction rate of 86%.Bilateral reduction mammoplasty is a reasonable and safe option for breast cancer patients with macromastia who desire breast conservation therapy.

View details for Web of Science ID 000168869400006

View details for PubMedID 11376574
Advances in head and neck reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Gurtner, G. C., Evans, G. R. 2000; 106 (3): 672-682
Abstract

Head and neck deformities, which can be caused by trauma, congenital defects, infections, or neoplasms, produce a stereotypical constellation of functional and aesthetic deficits, depending on the specific anatomic region. These deformities can be classified into six major anatomic categories: intraoral, mandibular, midfacial, cranial base, cutaneous, and scalp. This article presents a reliable approach to the reconstruction of these six areas that is used at the University of Texas M. D. Anderson Cancer Center. The emphasis is on an analysis of the unique functional and aesthetic problems presented by each of these specific anatomic lesions, and the reconstructive options are selected to maximize outcomes. The problems and limitations of current methods are discussed, and areas of potential development are explored.

View details for Web of Science ID 000088925700025

View details for PubMedID 10987478
Immunotargeting of liposomes to activated vascular endothelial cells: A strategy for site-selective delivery in the cardiovascular system PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Spragg, D. D., Alford, D. R., Greferath, R., Larsen, C. E., Lee, K. D., Gurtner, G. C., Cybulsky, M. I., Tosi, P. F., Nicolau, C., Gimbrone, M. A. 1997; 94 (16): 8795-8800
Abstract

Endothelial-selective delivery of therapeutic agents, such as drugs or genes, would provide a useful tool for modifying vascular function in various disease states. A potential molecular target for such delivery is E-selectin, an endothelial-specific cell surface molecule expressed at sites of activation in vivo and inducible in cultured human umbilical vein endothelial cells (HUVEC) by treatment with cytokines such as recombinant human interleukin 1beta (IL-1beta). Liposomes of various types (classical, sterically stabilized, cationic, pH-sensitive), each conjugated with mAb H18/7, a murine monoclonal antibody that recognizes the extracellular domain of E-selectin, bound selectively and specifically to IL-1beta-activated HUVEC at levels up to 275-fold higher than to unactivated HUVEC. E-selectin-targeted immunoliposomes appeared in acidic, perinuclear vesicles 2-4 hr after binding to the cell surface, consistent with internalization via the endosome/lysosome pathway. Activated HUVEC incubated with E-selectin-targeted immunoliposomes, loaded with the cytotoxic agent doxorubicin, exhibited significantly decreased cell survival, whereas unactivated HUVEC were unaffected by such treatment. These results demonstrate the feasibility of exploiting cell surface activation markers for the endothelial-selective delivery of biologically active agents via immunoliposomes. Application of this targeting approach in vivo may lead to novel therapeutic strategies in the treatment of cardiovascular disease.

View details for Web of Science ID A1997XQ12400090

View details for PubMedID 9238057
EFFECT OF CARBON-DIOXIDE PNEUMOPERITONEUM ON BACTEREMIA AND ENDOTOXEMIA IN AN ANIMAL-MODEL OF PERITONITIS BRITISH JOURNAL OF SURGERY Gurtner, G. C., Robertson, C. S., Chung, S. C., Ling, T. K., Ip, S. M., Li, A. K. 1995; 82 (6): 844-848
Abstract

Laparoscopy is increasingly used in conditions complicated by peritonitis. A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteraemia. This study examines the effect of carbon dioxide pneumoperitoneum on bacteraemia, endotoxaemia and physiological correlates of sepsis in an animal model of peritonitis. New Zealand white rabbits were assigned to three groups of six animals. Group 1 received an intraperitoneal inoculation of 10(9) colony-forming units of Escherichia coli followed by a 10-cm midline laparotomy. Group 2 received an identical bacterial inoculum followed by a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Group 3 received no bacteria but had a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Groups 1 and 2 had significantly higher levels of bacteraemia (P < 0.01) and endotoxaemia (P < 0.01) accompanied by significantly lower mean arterial pressures (P < 0.05) and higher heart rates (P < 0.05) compared with group 3. After 6 h groups 1 and 2 were significantly hypocarbic (P < 0.01), leucopenic (P < 0.01) and thrombocytopenic (P < 0.01). There was no difference between group 1 and group 2. A carbon dioxide pneumoperitoneum of 12 mmHg does not increase bacteraemia or endotoxaemia, nor does it adversely affect physiological or laboratory correlates of sepsis compared with laparotomy in this animal model of peritonitis.

View details for Web of Science ID A1995RC64400034

View details for PubMedID 7627528
TARGETED DISRUPTION OF THE MURINE VCAM1 GENE - ESSENTIAL ROLE OF VCAM-1 IN CHORIOALLANTOIC FUSION AND PLACENTATION GENES & DEVELOPMENT Gurtner, G. C., Davis, V., Li, H. M., McCoy, M. J., Sharpe, A., Cybulsky, M. I. 1995; 9 (1): 1-14
Abstract

Vascular cell adhesion molecule-1 (VCAM-1) is expressed on vascular endothelium in a variety of inflammatory conditions and mediates leukocyte recruitment from blood into tissues. In this study we report a novel role for VCAM-1 in the formation of the umbilical cord and placenta during development. The murine VCAM1 gene was disrupted by targeted homologous recombination, and a distinct phenotype was found in VCAM-1-deficient embryos. At 8.5 days of gestation, the allantois failed to fuse to the chorion, resulting in abnormal placental development and embryonic death within 1-3 days. In addition, a role for VCAM-1 in early placental formation after chorioallantoic fusion was observed. In a minority of VCAM-1-deficient embryos, the allantois was able to fuse with the chorion, but the allantoic mesoderm was abnormally distributed over the chorionic surface. A small number of VCAM-1-deficient embryos survived, presumably by circumventing the placentation defects. They became viable and fertile adult mice with lack of VCAM-1 expression, normal organs, and an elevated number of circulating blood mononuclear leukocytes.

View details for Web of Science ID A1995QB81000001

View details for PubMedID 7530222
2-TEAM SYNCHRONOUS ESOPHAGECTOMY BRITISH JOURNAL OF SURGERY Gurtner, G. C., Robertson, C. S., Chung, S. C., Li, A. K. 1994; 81 (11): 1620-1622
Abstract

Between 1984 and 1992, 131 patients underwent two-team synchronous oesophagectomy for carcinoma. Some 95 per cent of tumours were successfully resected by this technique. In 5 per cent of patients the tumour was found to be irresectable at operation and gastric bypass was performed. The overall operative mortality rate was 8 per cent and the pulmonary complication rate 10 per cent. The actuarial survival rate was 55 per cent at 1 year, 22 per cent at 3 years and 16 per cent at 5 years. When compared with the traditional two-stage Lewis approach, two-team synchronous oesophagectomy was significantly faster (mean 222 versus 282 min), but was not significantly different with respect to blood loss, transfusion requirement, pulmonary complications or operative mortality rate. Patients undergoing two-team oesophagectomy had a significantly shorter hospital stay than those receiving the two-stage procedure (mean 16 versus 24 days).

View details for Web of Science ID A1994PQ50000015

View details for PubMedID 7827888
LOW-DENSITY LIPOPROTEIN UNDERGOES OXIDATIVE MODIFICATION INVIVO PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Palinski, W., Rosenfeld, M. E., YLAHERTTUALA, S., Gurtner, G. C., SOCHER, S. S., Butler, S. W., Parthasarathy, S., CAREW, T. E., STEINBERG, D., WITZTUM, J. L. 1989; 86 (4): 1372-1376
Abstract

It has been proposed that low density lipoprotein (LDL) must undergo oxidative modification before it can give rise to foam cells, the key component of the fatty streak lesion of atherosclerosis. Oxidation of LDL probably generates a broad spectrum of conjugates between fragments of oxidized fatty acids and apolipoprotein B. We now present three mutually supportive lines of evidence for oxidation of LDL in vivo: (i) Antibodies against oxidized LDL, malondialdehyde-lysine, or 4-hydroxynonenal-lysine recognize materials in the atherosclerotic lesions of LDL receptor-deficient rabbits; (ii) LDL gently extracted from lesions of these rabbits is recognized by an antiserum against malondialdehyde-conjugated LDL; (iii) autoantibodies against malondialdehyde-LDL (titers from 512 to greater than 4096) can be demonstrated in rabbit and human sera.

View details for Web of Science ID A1989T274500059

View details for PubMedID 2465552
IMPROVED STATIC LUNG PRESERVATION WITH CORTICOSTEROIDS AND HYPOTHERMIA JOURNAL OF HEART TRANSPLANTATION Hall, T. S., Borkon, M., Gurtner, G. C., Brawn, J., Hutchins, G. M., Reitz, B. A., Baumgartner, W. A. 1988; 7 (5): 348-352
Abstract

With methylprednisolone as a chemical inhibitor of leukocytes, extended preservation was conducted with an isolated rabbit lung model. The heart-lung blocks of 39 New Zealand white rabbits were flushed in situ with 100 ml of Euro-Collins' solution, harvested, inflated (70%), and preserved at 4 degrees C. Lungs immediately reperfused with whole blood (control lungs, group 1) were compared with lungs preserved without methylprednisolone for 5, 12, and 24 hours (groups 2 to 4) and those preserved with methylprednisolone for 12 and 24 hours (groups 5 and 6, respectively). Methylprednisolone (30 mg/kg) was administered before harvest and was used as an additive to the flush and in the blood reperfusate. Hypothermia and Euro-Collins' flush alone provided adequate preservation for up to 5 hours; however, lung edema was evident by 12 hours of cold ischemia and became severe by 24 hours. By all measured parameters, the lungs in group 5 (treated with methylprednisolone) demonstrated values equal to or better than control lungs. By 24 hours of preservation the beneficial effects of the steroid treatment were no longer evident. Histologic evaluation revealed mild to moderate injury after 5 hours of cold ischemia; progressive edema and hemorrhage were found after 12 and 24 hours of preservation. This injury was significantly ameliorated by methylprednisolone treatment at 12 hours but not at 24 hours. This study suggests that static preservation for up to 5 hours is possible with hypothermia and a Euro-Collins' flush and that extended preservation to 12 hours is possible with pharmacologic dosages of methylprednisolone.(ABSTRACT TRUNCATED AT 250 WORDS)

View details for Web of Science ID A1988Q554200005

View details for PubMedID 3199247

Johnson & Johnson Professor of Surgery and Professor, by courtesy, of Bioengineering and of Materials Science and Engineering

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