Lower flap necrosis vs. controls
Comparative study
3×
Graft loss reduction with HBOT
Controlled trial
52%→23%
Optimal treatment window
UHMS recommendation
48 hrs
Salvage rate for failing grafts/flaps
Retrospective review
75%+
Oversized Grafts
Grafts/flaps in traumatic wounds with significant edema and tissue compromise.
Crush Injury / Ischemia-Reperfusion
Grafts/flaps in traumatic wounds with significant edema and tissue compromise.
Arterial Insufficiency
Pale, cool flaps with poor or absent cap refill indicating inadequate arterial inflow.
Venous Congestion
Distal flap necrosis from inadequate random blood supply, pedicle tension, or torsion.
Random Pattern Flap Ischemia
Distal flap necrosis from inadequate random blood supply, pedicle tension, or torsion.
Grafts/flaps placed on previously irradiated tissue with compromised vascularity and impaired healing capacity.
Irradiated Wound Beds
Indications for HBOT
HBOT is not for routine grafts or flaps with normal healing. It's a salvage tool for compromised tissue — when something has gone wrong and the graft or flap is at risk of failure without intervention.
— Undersea and Hyperbaric Medical Society (UHMS)
"Hyperbaric oxygen therapy is neither necessary nor recommended for the support of normal, uncompromised grafts or flaps. However, in tissue compromised by irradiation or in other cases where there is decreased perfusion or hypoxia, HBO₂T has been shown to be extremely useful in flap salvage."
When Is HBOT Indicated?
Enhances collagen synthesis and tissue remodeling for graft take
Fibroblast Function
Stimulates new capillary growth for permanent vascular improvement
Neovascularization
Vasoconstriction reduces tissue swelling while maintaining oxygen delivery
Edema Reduction
Plasma oxygen increased 10-15×, reaching tissue RBCs cannot access
Hyperoxygenation
How HBOT Works
Dark or bloody Doppler signal
Progressive demarcation at margins
Increasing tissue edema
Cool tissue temperature
Rapid cap refill (venous congestion)
Delayed or absent capillary refill
Pale, white, or waxy appearance
Dusky, mottled, or cyanotic color
Clinical Signs Requiring Urgent Evaluation
Early recognition is critical. The sooner HBOT begins after identifying compromise, the better the chance of salvage.
Recognizing Graft/Flap Compromise
HBOT should be initiated within 48-72 hours of recognizing compromise. Studies show significantly better outcomes with earlier intervention. For acute cases (crush injury, replantation), treatment within 4-6 hours of injury is ideal when possible.
Critical Timing
Total sessions (typical)
20-30
Acute phase (first 48-72 hrs)
BID-TID
Session duration
90 min
Treatment pressure
2.0-2.4 ATA
HBOT Protocol for Graft/Flap Salvage
Treatment Protocol
Sources: Undersea Hyperb Med 2020; Laryngoscope 2022; PMC 2016; Bouachour et al. RCT
Time to granulation: 25% shorter with HBOT, enabling earlier reconstruction
Mastectomy flaps: 9/10 patients achieved successful flap healing with early HBOT
Salvage rate: 75.7% successful salvage of failed grafts/flaps (30 treatments avg.)
Crush injuries: 94% complete healing with HBOT vs. 56% sham (RCT)
Flap necrosis: 3× less likely with adjuvant HBOT (15% vs. 51%)
Graft loss: Reduced from 52% to 23% in HBOT-treated group
Flap survival: 62-97% with HBOT vs. 35-78% in controls across multiple studies
Key Clinical Findings
Clinical Evidence for Surgeons
The evidence base for HBOT in compromised grafts and flaps includes controlled trials, retrospective reviews, and extensive animal data demonstrating improved outcomes.
Compromised grafts and flaps is an FDA-approved indication. Coverage varies by plan, but most insurers cover it when there's documented evidence of compromise. We verify benefits and can expedite authorization for urgent cases.
Is HBOT covered by insurance for graft/flap salvage?
HBOT helps both arterial insufficiency and venous congestion. The edema-reducing effect of hyperoxygenation can improve venous outflow, while the direct oxygen delivery supports tissue survival regardless of the mechanism of compromise.
What if the flap is congested rather than ischemic?
Yes. For high-risk wound beds (radiation-damaged tissue, diabetic wounds, chronic wounds), preoperative HBOT can improve vascularity and tissue oxygenation before reconstruction. This is a separate indication from acute graft/flap salvage.
Can HBOT help prepare a wound bed before grafting?
For urgent surgical cases, we can often begin treatment the same day. Time is critical — call us as soon as you identify compromise. We'll coordinate with your team to initiate therapy as rapidly as possible.
How quickly can you start treatment?
No. HBOT is not indicated for normal, uncompromised grafts or flaps. It's a salvage therapy for tissue that is failing or at high risk of failure — such as grafts on irradiated beds, ischemic flaps, or tissue affected by crush injury.
