When should HBOT start for a skin graft?

For high-risk patients, HBOT is often started before graft surgery to prepare the wound bed — typically 20 sessions pre-op and 10 sessions post-op. For grafts already showing signs of compromise, HBOT should start as quickly as possible after the problem is identified.

Does every skin graft patient need HBOT?

No. HBOT for skin grafts is used for compromised or high-risk cases — patients with radiation-damaged tissue, diabetes, vascular disease, or prior graft failure. Routine skin grafts in otherwise healthy patients typically heal without HBOT.

Is HBOT for skin grafts covered by insurance?

Compromised skin grafts and flaps are an FDA-approved indication for HBOT. Insurance may cover it when clinical criteria are documented. Coverage varies by plan. Verify with your facility's billing team.

HBOT for Failed or Compromised Skin Grafts and Flaps

Skin graft failure comes down to oxygen. A graft survives only if it receives enough oxygen from the wound bed below it while new blood vessels grow in from the edges. In patients with poor vascularity, HBOT addresses this oxygen deficit directly.

Why Grafts Fail

A skin graft is a piece of skin transferred to cover a wound. Unlike local flaps that carry their own blood supply through a pedicle, split-thickness and full-thickness skin grafts are initially avascular — they have no blood supply of their own. The graft survives on oxygen and nutrients diffusing from the wound bed below it (plasmatic imbibition) until new blood vessels grow in.

This process, called inoculation and revascularization, takes 3-5 days. During that window, the wound bed’s oxygen-carrying capacity is everything.

In patients with radiation-damaged tissue, diabetes, peripheral vascular disease, or other conditions that reduce local blood flow, the wound bed is hypoxic. The graft can’t get enough oxygen during those critical early days. It fails.

Types of Grafts and Flaps

Split-thickness skin grafts (STSG) take only part of the dermis. They’re used for large wounds and donor sites heal on their own. These are the most common type in wound care settings.

Full-thickness skin grafts (FTSG) include the full dermis. Better cosmetic and functional outcomes, but require more oxygen from the recipient bed.

Local and regional flaps carry their own blood supply through an attached pedicle. They’re more resilient than free grafts but still vulnerable to hypoxia if the pedicle is compromised.

Free flaps are the most complex. A section of tissue with its own blood vessels is moved to a distant site and the vessels are reconnected microsurgically (microvascular anastomosis). Free flap compromise — where the anastomosis is at risk — can be a surgical emergency.

The Evidence for HBOT

Thom (2011) reviewed the literature on HBOT for compromised grafts and estimated approximately 29% improvement in graft take rates with adjunctive HBOT in patients with compromised vascularity. PMID: 21200260.

Marx’s foundational work on radiation-damaged tissue established the physiological basis: HBOT increases oxygen tension in hypoxic tissue, promotes angiogenesis (new blood vessel formation), and collagen synthesis — all of which the recipient bed needs to support a graft.

For free flap compromise, evidence is observational rather than from controlled trials, but the mechanism is sound and HBOT is used at many centers as an adjunct when flap viability is in question.

When HBOT Is Started

For planned procedures in high-risk patients — diabetic patients, previously irradiated wound beds, patients with vascular disease — HBOT is often started before surgery to improve the wound bed first.

A common protocol for complex cases:

20 HBOT sessions before graft surgery (to oxygenate and prepare the wound bed)
10 HBOT sessions after graft placement (to support revascularization)

Sessions run at 2.0-2.4 ATA, 90 minutes each.

For grafts that have already been placed and are showing signs of poor take — pale color, slow capillary refill, failure to incorporate — HBOT can be started post-procedure to salvage the graft. Earlier intervention gives better results.

Who Is a Candidate

HBOT for skin grafts isn’t used routinely for uncomplicated procedures. Most skin grafts in otherwise healthy patients heal without it.

The candidates are patients with:

Radiation-damaged recipient beds
Diabetic lower-extremity wounds receiving grafts
Peripheral vascular disease limiting wound bed perfusion
Prior graft failure in the same area
Large, complex wounds where graft take is clinically uncertain

TcPO2 (transcutaneous oxygen) testing of the wound bed before grafting can help predict who needs adjunctive HBOT. A wound bed with TcPO2 below 40 mmHg is unlikely to support a graft without intervention.

Insurance Coverage

Compromised skin grafts and flaps are an FDA-approved indication for HBOT. Insurance may cover HBOT when clinical criteria are documented. The patient must have a compromised wound bed — not just a standard graft on a healthy wound. Verify coverage with your facility’s billing team.

FAQ

Q: Can HBOT save a failing skin graft? Yes, in compromised cases. Studies estimate about 29% improvement in graft take rates when HBOT is added in patients with poor vascularity (Thom 2011, PMID: 21200260).

Q: When should HBOT start? Before surgery for high-risk patients (20 sessions pre-op, 10 post-op). As soon as possible if graft compromise is already showing.

Q: Does every graft patient need HBOT? No. Only compromised or high-risk cases. Routine grafts in healthy patients don’t need it.

Q: Is it covered by insurance? It’s FDA-approved for compromised grafts. Coverage varies. Verify with your facility.

Medical Disclaimer: This content is for informational purposes only and does not constitute medical advice. Skin graft management requires evaluation and treatment planning by a licensed physician. Always consult your care team about your specific situation. This site does not establish a doctor-patient relationship.