Compromised Grafts and Flaps and HBOT
Hyperbaric oxygen therapy improves the survival of skin grafts and surgical flaps at risk of failure by enhancing tissue oxygenation at the graft-wound interface during the critical period before durable neovascularisation establishes a permanent blood supply. It is used both to prepare compromised recipient sites before grafting (most commonly irradiated tissue) and to rescue grafts and flaps that show early signs of failure after surgery. Compromised grafts and flaps is on Ontario's OHIP-funded list for HBOT (Ontario Schedule of Benefits, as of April 1, 2026); in other provinces, check with the provincial hospital programme.
Quick Answer
Does HBOT help compromised grafts and flaps? Hyperbaric oxygen therapy improves the survival of skin grafts and surgical flaps at risk of failure by enhancing tissue oxygenation at the graft-wound interface during the critical period before durable neovascularisation establishes a permanent blood supply. It is used both to prepare compromised recipient sites before grafting (most commonly irradiated tissue) and to rescue grafts and flaps that show early signs of failure after surgery. Compromised grafts and flaps is on Ontario's OHIP-funded list for HBOT (Ontario Schedule of Benefits, as of April 1, 2026); in other provinces, check with the provincial hospital programme.
Authoritative references: Health Canada on hyperbaric oxygen therapy · UHMS clinical practice guidelines · Canadian regulatory framework
What Is Compromised Grafts and Flaps?
Skin grafts and surgical flaps fail when the new blood supply at the recipient site is inadequate to support tissue survival during the early post-operative period. The critical biological window is the first 24 to 72 hours after surgery, before plasmatic imbibition and capillary inosculation give way to durable neovascularisation from the recipient bed. Graft and flap failure rates rise with anything that compromises the vascular bed: prior radiation, diabetes mellitus, peripheral vascular disease, active or recent smoking, prior surgical scarring, infection, malnutrition, advanced age, and the use of non-vascularised grafts in problematic anatomic locations.
The recognised hyperbaric indication encompasses several distinct surgical scenarios: split-thickness and full-thickness skin grafts in compromised wound beds, pedicled and free vascularised flaps showing early signs of compromise (pallor, cyanosis, congestion, or capillary refill changes), composite grafts (skin and underlying tissue, including ear and nose reconstructions), nipple-areola complex grafts after breast reconstruction, and replantation of avulsed segments. The clinical pattern that prompts HBOT consultation is typically a graft or flap that was placed with adequate surgical technique but is showing early signs of inadequate perfusion, often within hours to a day or two of the index operation.
HBOT can also be used pre-operatively in patients whose recipient site is known to be compromised (most commonly previously irradiated tissue) to support angiogenesis before the planned reconstruction. The Marx 20-and-10 protocol applied to head-and-neck reconstruction in irradiated jaws is the canonical example: 20 HBOT sessions before the planned graft and 10 sessions afterward.
How HBOT Helps
Hyperbaric oxygen therapy supports compromised grafts and flaps through three convergent mechanisms.
First, oxygen delivery during the critical pre-vascularisation window. Inside the chamber at 2.0 to 2.5 ATA on 100 percent oxygen, plasma oxygen content rises 10- to 15-fold, raising tissue pO2 in the graft-wound interface from ischaemic levels to several hundred mmHg during each session. This intermittent hyperoxia keeps the graft and flap tissue alive long enough for plasmatic imbibition, capillary inosculation, and neovascularisation to establish a permanent blood supply.
Second, oedema reduction at the graft-bed interface. Hyperoxic vasoconstriction reduces capillary permeability and tissue oedema in well-oxygenated peri-graft tissue while preserving or improving oxygen delivery to the hypoxic graft itself. Reduced oedema lowers diffusion distance and supports earlier vascular ingrowth.
Third, support for angiogenesis and fibroblast activity. The same VEGF-mediated angiogenesis that underpins HBOT's benefit in chronic wounds and radiation injury contributes to definitive vascularisation of the graft or flap recipient bed. Fibroblast proliferation and collagen cross-linking, both oxygen-dependent, support the structural integration of the graft into surrounding tissue. In pre-operative use for irradiated recipient sites, repeated HBOT sessions substantially improve capillary density toward non-irradiated baseline before the planned surgery, improving the probability of graft take.
Typical Treatment Protocol
Standard adjunctive protocol is 2.0 to 2.5 ATA on 100 percent oxygen for 90 minutes per session. Total course depends on the clinical scenario. For compromised post-operative grafts and flaps showing early signs of failure, treatment begins as soon as the diagnosis is recognised, typically within hours to a day or two of the index operation. Twice-daily sessions for the first 24 to 48 hours are followed by once-daily sessions for the remainder of the course. Course length is set by the treating team, guided by clinical response, capillary refill, colour, and (for flaps with monitoring) Doppler signal. For pre-operative preparation of compromised recipient sites (most commonly irradiated tissue), the Marx 20-and-10 protocol applies: 20 HBOT sessions before the planned graft or flap, 10 sessions afterward, total 30 sessions. The pre-operative phase stimulates angiogenesis in the recipient bed; the post-operative phase supports the graft during the critical pre-vascularisation window. HBOT is delivered as an adjunct to standard reconstructive-surgery management, never as a substitute for surgical re-exploration when revision is indicated. The decision to add HBOT, and whether to combine it with surgical revision, is made jointly by the plastic-surgery team and hyperbaric medicine.
Evidence Summary
Level B - Moderate Evidence
Supported by controlled studies and clinical evidence
Key Research Findings
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Multiple case series and observational cohorts (Friedman 2006 and other published series) demonstrate that adjunctive HBOT can rescue compromised grafts and flaps that show early signs of failure, with high reported salvage rates in published series. The signal is strongest when treatment is started within hours to a day or two of the index operation.
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A Cochrane Review of HBOT for acute surgical and traumatic wounds (Eskes 2013) found four small, clinically heterogeneous trials with some evidence of benefit for graft and flap survival, but judged the trials at risk of bias and concluded that high-quality randomised trials are still needed.
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Pre-operative HBOT in irradiated tissue (Marx 20-and-10 protocol) substantially improves capillary density toward non-irradiated baseline, improving the probability of graft take in the planned reconstruction.
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The biological window for post-operative HBOT in compromised grafts and flaps is approximately 24 to 72 hours after the index operation, the period before durable neovascularisation establishes a permanent blood supply. Earlier intervention produces better salvage rates.
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Standard adjunctive protocol is 2.0 to 2.5 ATA, 90 minutes per session, twice daily for the first 24 to 48 hours then once daily, with course length set by the treating team. Pre-operative use follows the Marx 20-and-10 schedule.
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HBOT is an adjunct to plastic-surgery management, not a substitute for surgical re-exploration when revision is indicated. The decision to add HBOT and whether to combine it with surgical revision is made jointly by the plastic-surgery team and hyperbaric medicine.
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Key supporting studies in the Canada Hyperbarics research database: PMID 28116225, PMID 40215364, PMID 41649920.
Top studies in our database
Highest-evidence-tier studies tagged to this condition in the Canada Hyperbarics research database, ranked by evidence tier (1 = meta-analysis or RCT, 2 = cohort, 3 = case series), most recent first.
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Tier 1Hyperbaric oxygen therapy for skin flap transplantation: a meta-analysis
J Wound Care · 2026 · Meta-Analysis
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Tier 1Systematic Review of Comparative Studies Evaluating Hyperbaric Oxygen Therapy on Skin Flap and Graft Surgical Indications
Plast Reconstr Surg Glob Open · 2026 · Systematic Review
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Tier 1Hyperbaric oxygen therapy for the compromised graft or flap
Adv Wound Care · 2017 · Review
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Tier 2
What to Expect from Treatment
For post-operative compromised grafts and flaps, the plastic-surgery team typically recognises the early signs of failure (pallor, cyanosis, congestion, capillary refill changes) within hours to a day or two of the index operation and contacts the hospital hyperbaric programme directly. The decision to add HBOT, and whether to combine it with surgical re-exploration of the flap pedicle or graft bed, is made jointly. The first chamber session is typically delivered the same day as the consultation.
You change into cotton scrubs (no synthetic fabrics, no skin lotions, no jewellery), enter the chamber, and lie down (in a monoplace) or sit in a recliner (in a multiplace with multiple patients). Pressurisation takes five to ten minutes, the 90-minute treatment phase is on 100 percent oxygen at 2.0 to 2.5 ATA, and decompression takes another five to ten minutes. For critically ill patients, multiplace chambers accommodate ventilator-dependent and infusion-dependent support with a hyperbaric-trained nurse and physician inside the chamber.
Twice-daily sessions for the first 24 to 48 hours are followed by once-daily sessions through the remainder of the course. Course length is set by the treating team. The plastic-surgery team monitors the graft or flap clinically (colour, capillary refill, temperature, Doppler signal where applicable) at each visit. Pre-operative Marx 20-and-10 cases are scheduled around the planned reconstructive surgery date.
Accessing HBOT for Compromised Grafts and Flaps in Canada
Compromised grafts and flaps is on Ontario's OHIP-funded list for HBOT (Ontario Schedule of Benefits, as of April 1, 2026). Treatment is delivered at hospital-based hyperbaric programmes; each province sets which indications its plan funds.
In Ontario, OHIP covers treatment at the three hospital programmes (Toronto General / UHN, Hamilton General Hospital, The Ottawa Hospital). Toronto General has particularly close working relationships with the major reconstructive plastic-surgery teams in the GTA. Select eligible clinics may also bill OHIP for approved indications. In Alberta, Misericordia Edmonton (Covenant Health) treats conditions listed by the Undersea and Hyperbaric Medical Society, on referral from a doctor. The Alberta Health Services hyperbaric service at AJECCC Calgary treats a specified list of conditions approved by Alberta Health and the College of Physicians and Surgeons of Alberta. British Columbia: check with Vancouver General Hospital. Quebec has two hospital hyperbaric centres, Hôpital du Sacré-Cœur de Montréal and Hôtel-Dieu de Lévis; for coverage, check with your provincial hospital programme.
For patients in provinces or territories without an in-province hospital programme (Manitoba, New Brunswick, Prince Edward Island, Yukon, Northwest Territories, Nunavut), inter-provincial referral is arranged through the receiving province's transfer service. The most common scenarios are post-operative graft compromise after reconstructive surgery in a referring province and pre-operative Marx-protocol preparation before planned reconstruction at a hospital with both plastic-surgery and hyperbaric capabilities.
Provincial Access for Compromised Grafts and Flaps
Health Canada has licensed hyperbaric chambers to treat 14 conditions (the list the UHMS recognised in 2011); this condition falls under one of them: skin grafts and flaps that are not healing well. In Ontario, OHIP insures hyperbaric oxygen therapy for skin grafts and flaps (compromised), an indication on its funded list (Ontario Schedule of Benefits for Physician Services, as of April 1, 2026). Other provinces set their own lists; check with your provincial hospital programme. Use the links below for province-specific coverage, referral pathway, and emergency routing details.
Hospital + Private
OHIP (Ontario Health Insurance Plan)
Hospital-Based
MSP (Medical Services Plan)
Hospital + Private
Alberta Health / AHCIP
Hospital-Based
RAMQ
Open for Outpatient Care
Saskatchewan Health Authority
CUHMA Lists No Unit
Manitoba Health
Hospital-Based
MSI (Medical Services Insurance)
CUHMA Lists No Unit
Medicare NB
Hospital-Based
MCP (Medical Care Plan)
CUHMA Lists No Unit
PEI Medicare
CUHMA Lists No Unit
Yukon Health and Social Services
CUHMA Lists No Unit
NWT Health and Social Services
CUHMA Lists No Unit
Nunavut Department of Health
For acute or emergency presentations of Compromised Grafts and Flaps, call 911 first (in Nunavut, which has no 9-1-1 service, dial the first three digits of your local RCMP phone line followed by 1111, or 1-867-979-1111). In Ontario, hospital-based physicians can reach CritiCall Ontario at 1-800-668-4357. For a dive accident or injury, call 911 first (in Nunavut, which has no 9-1-1 service, your community RCMP line), then the Divers Alert Network (DAN) at +1 (919) 684-9111.
Risks and Contraindications
The only absolute contraindication to HBOT is untreated pneumothorax (because trapped intrathoracic air expands on decompression and can cause tension pneumothorax). Concurrent bleomycin chemotherapy (because hyperbaric oxygen can trigger or accelerate oxygen-induced pulmonary fibrosis) and concurrent disulfiram (because it inhibits superoxide dismutase, the enzyme that neutralises hyperbaric-oxygen-generated free radicals) are relative contraindications, weighed case by case. Prior bleomycin exposure with documented pulmonary clearance is a relative contraindication that requires individualised pulmonary-function review before HBOT. Relative contraindications include severe chronic obstructive pulmonary disease with bullous lung disease, uncontrolled seizure disorder, claustrophobia (manageable in monoplace chambers), recent middle-ear or sinus surgery, and uncontrolled hypertension. None of these typically override the hyperbaric decision in a patient with a failing graft or flap that would otherwise require complete revision and a second major operation.
Frequently Asked Questions
HBOT is indicated when a graft or flap shows early signs of compromise (pallor, cyanosis, congestion, capillary refill changes) in the first 24 to 72 hours after surgery, or when a planned reconstruction is to be performed in a compromised recipient site (most commonly previously irradiated tissue). It is an adjunct to surgical management, not a substitute for surgical revision when indicated.
As soon as the diagnosis is recognised, ideally within hours of the appearance of compromise. Twice-daily sessions for the first 24 to 48 hours are standard. Earlier intervention produces better salvage rates. The decision to add HBOT, and whether to combine it with surgical re-exploration of the flap pedicle, is made jointly by the plastic-surgery team and hyperbaric medicine.
Published case series report high salvage rates for compromised grafts and flaps treated with adjunctive HBOT, with the strongest signal in patients treated within hours to a day or two of the index operation. The Cochrane Review concludes HBOT may improve the survival of compromised grafts and flaps, particularly in irradiated tissue.
In Ontario, OHIP funds HBOT for skin grafts and flaps (compromised) (Ontario Schedule of Benefits, as of April 1, 2026); in another province, check with your provincial hospital programme. Select eligible clinics in Ontario may also bill OHIP for approved indications.
The Marx 20-and-10 protocol is a pre-operative HBOT regimen designed to support reconstructive surgery in previously irradiated tissue. It delivers 20 HBOT sessions before the planned graft or flap and 10 sessions afterward, each at 2.0 to 2.4 ATA for 90 minutes. The pre-operative phase stimulates angiogenesis in the irradiated recipient bed, raising capillary density to approximately 80 percent of non-irradiated baseline before the surgery. The post-operative phase supports the graft during the critical pre-vascularisation window. The protocol was established by Marx in the 1980s and remains the canonical regimen for head-and-neck reconstruction in irradiated jaws.
No. HBOT is an adjunct to plastic-surgery management. When surgical revision (release of a constricting suture, re-anastomosis of a thrombosed pedicle, drainage of a hematoma compromising perfusion) is indicated, surgery is performed first; HBOT is added afterward to support the revised flap. The decision is made jointly by the plastic-surgery team and hyperbaric medicine.
Post-operative rescue course length is set by the treating team: twice-daily for the first 24 to 48 hours, then once-daily for the remainder. Pre-operative Marx 20-and-10 protocol totals 30 sessions over approximately six weeks (20 before surgery, 10 after).
Yes. Replantation of an avulsed segment is one of the recognised acute traumatic ischaemia indications, and HBOT supports tissue survival in the marginally perfused replanted segment during the critical period before robust microvascular recovery. Standard adjunctive protocol applies; total course depends on segment size, vascular repair quality, and clinical course.
You change into cotton scrubs, enter the chamber, and lie down (in a monoplace) or sit in a recliner (in a multiplace with multiple patients). Pressurisation takes five to ten minutes and feels like the descent in an aircraft. Most people clear their ears with the same technique used in flying. During the 90-minute treatment phase you breathe pure oxygen, often through a hood or mask. Decompression takes another five to ten minutes. The most common sensation during a session is a feeling of warmth.
Ask the nearest hospital hyperbaric programme whether it treats compromised grafts and flaps. The Canada Hyperbarics directory at canadahyperbarics.ca/facilities/ lists hospital programmes with phone numbers, addresses, and current operational status. Toronto General Hospital has particularly close working relationships with the GTA reconstructive plastic-surgery teams.
Compromised grafts and flaps is on Ontario's OHIP-funded list for HBOT (Ontario Schedule of Benefits, as of April 1, 2026); for coverage and referral in Ontario or another province, check with the hospital hyperbaric programme. The only absolute contraindication to HBOT is untreated pneumothorax (trapped intrathoracic air expands on decompression); concurrent bleomycin chemotherapy (oxygen-induced pulmonary fibrosis risk) and concurrent disulfiram (interferes with superoxide dismutase, the enzyme that neutralises hyperbaric-oxygen-generated free radicals) are relative contraindications, weighed case by case. Other relative contraindications include severe haemodynamic instability requiring continuous high-dose vasopressor titration, uncontrolled seizure disorder, severe COPD with bullous lung disease, and uncontrolled claustrophobia. In pregnancy, HBOT is indicated for carbon monoxide poisoning; for other conditions the evidence is limited (a 2023 review suggests stabilising the mother may take priority in a life-threatening emergency), and elective treatment during pregnancy has no established indication or safety data.
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