Clinical Indications for Hyperbaric Oxygen Therapy

Early hyperbaric consultation may be appropriate when a graft or flap demonstrates evidence of compromise despite appropriate surgical assessment and management.

Situations may include:

• Threatened skin graft
• Arterial or venous flap compromise after correctable causes have been addressed
• Ischemic flap tissue
• Grafts placed onto poorly vascularized tissue
• Reconstruction within previously irradiated tissue
• Traumatic graft or flap compromise
• Progressive tissue hypoxia following reconstruction
• Persistent concern for partial or complete tissue loss

When HBOT is appropriate, early treatment is generally preferred because the objective is to preserve tissue before irreversible necrosis develops.

HBOT as Part of Reconstructive Care

The first priority in a compromised graft or flap is determining why the tissue is failing.

Management may include:

• Surgical exploration
• Correction of vascular obstruction
• Revision of anastomoses
• Relief of pressure or tension
• Treatment of hematoma
• Management of venous congestion
• Debridement when appropriate
• Infection management
• Optimization of perfusion and oxygenation

HBOT should never delay surgical correction of a reversible cause of graft or flap compromise.

When mechanical causes have been corrected or no additional surgical intervention is available, HBOT may be incorporated to support threatened tissue and reduce the extent of tissue loss.

Clinical Evidence and Guidelines

Compromised grafts and flaps are recognized by the Undersea & Hyperbaric Medical Society as an accepted indication for HBOT.

Experimental and clinical evidence demonstrates several mechanisms through which HBOT may improve graft and flap viability, including increased tissue oxygenation, enhanced fibroblast function and collagen synthesis, stimulation of angiogenesis, and reduction of ischemia-reperfusion injury.

The clinical literature includes experimental studies, case series, observational studies, reviews, and studies involving multiple types of reconstructive grafts and flaps.

A 2025 UHMS review concluded that adjunctive HBOT can improve survival of compromised grafts and flaps and emphasized that treatment should begin as soon as compromise is recognized to maximize the opportunity for tissue salvage.

HBOT remains an adjunct to appropriate reconstructive and surgical management and is not recommended for uncomplicated grafts or flaps.

Medicare Coverage

The Centers for Medicare & Medicaid Services National Coverage Determination for Hyperbaric Oxygen Therapy (NCD 20.29) specifically covers:

Preparation and preservation of compromised skin grafts—not for the primary management of wounds.

This distinction is important. Medicare does not cover HBOT simply to support routine wound healing or an uncomplicated graft.

Coverage for individual reconstructive situations, including compromised flaps, may depend on the specific clinical circumstances and applicable payer policy.

Documentation should clearly establish evidence of tissue compromise, conventional treatment provided, and the medical necessity for adjunctive HBOT.

When to Refer

Consider hyperbaric medicine consultation when a graft or flap demonstrates:

• Progressive ischemia
• Venous congestion
• Significant tissue hypoxia
• Threatened graft adherence or survival
• Progressive discoloration or tissue deterioration
• Compromise within an irradiated or poorly vascularized wound bed
• Continued tissue threat after surgical causes have been corrected

HBOT is intended for compromised tissue and should not be used routinely to support healthy grafts or flaps.

Early communication between the reconstructive surgeon and hyperbaric medicine team can help determine whether threatened tissue may be salvageable.