Advancements in bioengineered and autologous skin grafting techniques for skin reconstruction: a comprehensive review

Abstract

The reconstruction of complex skin defects challenges clinical practice, with autologous skin grafts (ASGs) as the traditional choice due to their high graft take rate and patient compatibility. However, ASGs have limitations such as donor site morbidity, limited tissue availability, and the necessity for multiple surgeries in severe cases. Bioengineered skin grafts (BSGs) aim to address these drawbacks through advanced tissue engineering and biomaterial science. This study conducts a systematic review to describe the benefits and shortcomings of BSGs and ASGs across wound healing efficacy, tissue integration, immunogenicity, and functional outcomes focusing on wound re-epithelialization, graft survival, and overall aesthetic outcomes. Preliminary findings suggest ASGs show superior early results, while BSGs demonstrate comparable long-term outcomes with reduced donor site morbidity. This comparative analysis enhances understanding of bioengineered alternatives in skin reconstruction, potentially redefining best practices based on efficacy, safety, and patient-centric outcomes, highlighting the need for further innovation in bioengineered solutions.

Keywords: autologous skin grafting; bioengineered skin grafts; dermatologic surgery; human skin substitute; plastic surgery; skin deficits.

FIGURE 1

Types of skin grafting techniques. Three different types of skin grafting: (1) Autografting, where the graft is taken from the same individual; (2) Allografting, where the graft is from a non-identical donor of the same species; and (3) Xenografting, where the graft is from a different species. Figure created using BioRender, Toronto, ON, Canada.

FIGURE 2

Enzymatic digestion and cell isolation for bioengineered skin grafts. This diagram illustrates the process of enzymatic digestion and cell isolation from a skin biopsy, followed by cell culture and incorporation of biological factors such as VEGF, PDGF, FGF, cytokines, chemokines, MMPs, and TIMPs. The final product is a tissue-engineered cellular graft with an ECM-like scaffold, ready to be applied back to the patient. Figure created using BioRender, Toronto, ON, Canada.

FIGURE 3

Autologous skin grafting process. Steps involved in autologous skin grafting, starting from the donor site where a dermatome is used to harvest the skin graft. The harvested skin is then meshed using a skin graft meshing device before being applied to the site of the defect. Figure created using BioRender, Toronto, ON, Canada.

FIGURE 4

Anatomy of the skin and types of skin grafts. This diagram illustrates the detailed structure of the skin, including the epidermis, dermis, and hypodermis layers. Key components such as hair follicles, sebaceous glands, sweat glands, and various nerve fibers are labeled. The image also shows the distinction between full-thickness skin grafts (FTSG) and split-thickness skin grafts (STSG), highlighting the layers of skin each type includes. Figure created using BioRender, Toronto, ON, Canada.

FIGURE 5

Bioengineered skin graft composition. Different types of tissue-engineered skin substitutes including acellular and cellular constructs for dermal/epidermal, dermal, and epidermal tissue-engineered substitutes. Each construct comprises different components such as keratinocytes, polymer sheets, fibroblasts, and biomaterial scaffolds. Figure created using BioRender, Toronto, ON, Canada.

FIGURE 6

Immune response to skin grafts. Immune mechanisms involved in skin graft rejection and acceptance, including donor antigen presentation by donor APCs, direct recognition by T cells, and indirect recognition by recipient APCs, leading to the activation of effector T cells in the recipient. Figure created using BioRender, Toronto, ON, Canada.