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Compromised Skin Grafts of Flaps and Enhancement of Healing in Selected Problem Wounds


Cases accepted for adjunctive hyperbaric oxygen must be judged to be refractory to adequate surgical and specific parenteral antibiotic treatment. While hyperbaric oxygen should improve results in acute osteomyelitis, it is considered too expensive except in critical sites such as skull, vertebra, hand, elbow, or other life-or-function threatening acute cases which have not responded at once to surgery and antibiotics. Judgment in declaring a given case refractory or critical must be jointly made by the surgeon and hyperbaric medicine specialists.


Hyperbaric Oxygen is not indicated for normal skin grafts or flaps. It can be used for preparing a granulating base for skin grafting where viability of graft or flap is compromised or uncertain or where previous grafts have failed. Pre-operative hyperbaric oxygen is effective by promoting capillary proliferating to prepare for grafting in poorly granulating wounds. Regarding specific, partially ischemic wounds of soft tissue, current experience from centers of UMS committee members that is being prepared for publication yields some important recommendations:

  1. Diabetic Wounds: The major question is that of the status of perfusion in the wound area. There exists an infinite variety of states ranging from those with nearly total large vessel occlusion with little wound perfusion to those with small vessel involvement and adequate perfusion for the wound to heal slowly but without hyperbaric oxygen. Obviously, in both states, hyperbaric oxygen is not recommended. Between these extremes are marginal wounds which may respond well to hyperbaric oxygen. Regular active, daily debridement is required as hyperbaric oxygen progresses.
  2. Venous Stasis Ulcers: In general, hyperbaric oxygen is not approved for such wounds because venous surgery, local wound care, leg elevation, and counterpressure support and skin grafting as indicated, will achieve success. Only occasionally, with failure of these procedures, is hyperbaric oxygen warranted.
  3. Decubitus Ulcers: In general, hyperbaric oxygen is not not approved because good nursing care and skin flaps as indicated are successful. Hyperbaric oxygen is warranted in a case with underlying osteomylitis, or in the case of a compromised skin flap or an infected wound; HBO can help control infection and promote capillary angiogenesis to prepare for reconstructive surgery.
  4. Arterial Insufficiency Ulcers: In general, hyperbaric oxygen is not approved because most cases which can be resolved need surgical revascularization. In occasional cases, the skin wound persists after bypass surgery has restored large vessel function and a short course of hyperbaric oxygen will achieve healing or prepare a healthy vascular bed for skin grafting.

Peer review after 20 treatments when preparing a site for grafting. Peer review after 10 treatment post grafting.

Cost Impact

If hyperbaric oxygenation is used very judiciously in selected cases, these is a savings in rehospitalization and reoperation.

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