Hyperbaric Oxygen Therapy for the Compromised Graft or Flap

Significance: Tissue grafts and flaps are used to reconstruct wounds fromtrauma, chronic disease, tumor extirpation, burns, and infection. Despitecareful surgical planning and execution, reconstructive failure can occur dueto poor wound beds, radiation, random flap necrosis, vascular insufficiency, orischemia–reperfusion (IR). Traumatic avulsions and amputated compositetissues—compromised tissue—may fail from crush injury and excessivelylarge sizes. While never intended, these complications result in tissue loss,additional surgery, accrued costs, and negative psychosocial patient effects.Recent Advances: Hyperbaric oxygen (HBO) has demonstrated utility in thesalvage of compromised grafts/flaps. It can increase the likelihood and effec tive size of composite graft survival, improve skin graft outcomes, and enhanceflap survival. Mechanisms underlying these beneficial effects include in creased oxygenation, improved fibroblast function, neovascularization, andamelioration of IR injury.Critical Issues: Common strategies for the compromised graft or flap includelocal wound care, surgical debridement, and repeated reconstruction. Thesemodalities are associated with added costs, time, need for reoperation, mor bidity, and psychosocial effects. Preservation of the amputated/avulsed tissuesminimizes morbidity and maximizes the reconstructive outcome by salvagingthe compromised tissue and obviating additional surgery. HBO is often over looked as a potential tool that can limit these issues.Future Directions: Animal studies demonstrate a benefit of HBO in thetreatment of compromised tissues. Clinical studies support these findings, butare limited to case reports and series. Further research is needed to providemulticenter prospective clinical studies and cost analyses comparing HBO toother adjunctive therapies in the treatment of compromised grafts/flaps.