Methods for serial cultivation of human keratinocytes can provide large quantities of epidermal cells, which have the potential of restoring the vital barrier function of the epidermis in extensive skin defects such as burns. To investigate the value of combining an epidermis with a dermal component, fibroblasts originated from the superficial dermis were used to seed a collagen lattice as described by E. Bell (dermal equivalent). Beginning in 1981, we grafted 18 patients (burns and giant nevi) using 35 grafts 10 x 10 cm in size. In the course of this work, the original technique was modified and improved as experience was gained. We began by using small skin biopsy samples as a source of keratinocytes cultured on a dermal equivalent before grafting in a one-step procedure, but this gave poor cosmetic results, because of a nonhomogeneous epidermalization. We then chose to cover the graft bed using a two-step procedure. The first step consisted of grafting a dermal equivalent to provide a dermal fibroblast-seeded substrate for subsequent in vivo epidermalization by cultured epidermal sheets. Whatever the epidermalization technique used, a living dermal equivalent applied to the graft bed was found to reduce pain, to provide good hemostasis, and to improve the mechanical and cosmetic properties of the graft. A normal undulating dermal-epidermal junction reappeared by 3 to 4 months after grafting and elastic fibers were detectable 6 to 9 months after grafting. As a result of the biosynthesis of these products, the suppleness (e.g., elasticity) of the grafts was closer to that of normal skin than the cicatricial skin usually obtained with epidermal sheets grafted without the presence of living dermal cells. This rapid improvement of the mechanical properties of the graft could be attributed to the presence of fibroblasts cultured from the dermis and seeded into the collagen matrix.

Using a model of pure epidermal wounds in normal human volunteers, we have studied the effects of Biafme® emulsion firstly on inflammatory cell migration, vascular permeability and cytokine release during the first 24 h, and secondly on epidermal wound healing by measuring transepidermal water loss from day 1 to day 7. Under these conditions, Biafme does not improve epidermal healing, in contrast to what is observed with bleeding dermoepidermal wounds. Our results suggest that the effects of Biafine are essentially at the dermis level. The analysis of epidermal wound exudates leads to the same conclusion. As a matter of fact, we demonstrated that Biafine is chemotactic for macrophages and increases the IL-l/IL-6 ratio, chiefly by reducing the secretion of IL-6. This study permits to progressively clarify the mode of action of Biafine, that seems to be located at the level of granulation tissue formation and not at the epidermal level.