HBOT for Compromised Skin Grafts and Flaps: What the Evidence Supports

The short answer: HBOT for compromised skin grafts and flaps is one of the most firmly regulated uses in hyperbaric medicine: the FDA has cleared chambers for marketing in skin graft flap at risk of tissue death, the UHMS lists it as approved indication #12, and Medicare pays for it under NCD 20.29. In the largest early case series, 89% of threatened flaps and 91% of threatened grafts were salvaged with adjunctive HBOT. Published protocols run at 2.0–2.5 ATA, typically twice daily until the tissue stabilizes. This indication covers the acute rescue of failing tissue, not routine post-surgical recovery.

Plastic surgery clients ask about HBOT constantly, and the honest answer splits in two. Routine recovery after an uncomplicated facelift or abdominoplasty is a research question, covered in our guide to HBOT for post-surgical recovery. Chronic non-healing wounds are a separate, physician-supervised domain, covered in our HBOT for wound healing article. Between them sits a third scenario with a very different regulatory footing: a graft or flap that is actively failing. That scenario is the subject of this article, and it is the one post-surgical use of HBOT where the FDA, the UHMS, and Medicare all say yes. How those three lists work, and why “cleared” and “approved” are not the same word, is mapped in our hub guide to FDA-cleared HBOT indications.

Disclosure: Superhuman Chambers manufactures and sells hyperbaric chambers for wellness operators and home use. This article summarizes published clinical and regulatory information for education only and is not medical advice. Treatment decisions for a compromised graft or flap belong to the operating surgeon and treating physician, and operators are responsible for the claims, protocols, and compliance obligations in their own jurisdiction.

What “compromised” actually means

A graft and a flap are different constructions, and they fail differently. A skin graft is tissue fully detached from its blood supply; it survives by absorbing oxygen and nutrients from the wound bed beneath it until new vessels grow in, a process called revascularization. A flap keeps its own vascular pedicle, but that supply can be kinked, compressed, clotted, or simply inadequate for the tissue volume it feeds.

A graft or flap becomes compromised when oxygen delivery falls below what the tissue needs to survive: a questionable irradiated wound bed, venous congestion, arterial insufficiency, crush injury, ischemia-reperfusion damage after free tissue transfer, or a graft larger than its bed can support. The clinical picture is a flap turning dusky or a graft failing to take. The clock is measured in hours to days, and the alternative to salvage is usually debridement and a second operation.

This is the boundary that matters for operators. Compromised grafts and flaps are an acute salvage indication, managed by the surgical team, with HBOT as an adjunct. They are not routine swelling, not wellness recovery, and not a med-spa service line. The UHMS is blunt about the line: HBOT is “neither necessary nor recommended for the support of normal, uncompromised grafts or flaps.”

The regulatory position: all three lists agree

For this indication, the three US bodies that govern hyperbaric medicine land in the same place, which is rarer than you might expect.

• FDA cleared. The FDA’s list of 13 cleared conditions includes “skin graft flap at risk of tissue death.” As with all chamber clearances, this is a 510(k) device clearance: the agency cleared the equipment for marketing in this use, which is a different act from approving a drug.
• UHMS approved. The Undersea and Hyperbaric Medical Society lists compromised grafts and flaps as indication #12 in its Hyperbaric Medicine Indications Manual, now in its 15th edition (2023). The UHMS rationale states that in tissue compromised by irradiation, decreased perfusion, or hypoxia, HBOT “has been shown to be extremely useful in flap salvage” and can reduce the need for regrafting or repeat flap procedures.
• Medicare covered. NCD 20.29 covers “preparation and preservation of compromised skin grafts,” with an explicit parenthetical added by CMS in 2000: “not for primary management of wounds.” Medicare pays to save a failing graft, not to dress a wound.

That parenthetical is the single most useful sentence in this article for anyone writing marketing copy. The payer’s own language draws the same line the clinical literature draws: salvage of threatened tissue, yes; routine wound management, no.

What the evidence shows

The mechanism is the strongest part of the case

The physiology behind flap salvage is unusually well characterized for an HBOT indication. Breathing 100% oxygen at pressure dissolves enough oxygen in plasma to keep marginally perfused tissue alive while circulation catches up. Francis and Baynosa’s 2017 review in Advances in Wound Care summarizes the documented effects: increased tissue oxygenation, improved fibroblast function, neovascularization, and mitigation of ischemia-reperfusion injury.

The ischemia-reperfusion piece deserves a sentence of its own. When blood flow returns to a starved flap, the reperfusion itself triggers neutrophil adhesion and microvascular damage that can kill tissue the initial ischemia spared. Zamboni’s microcirculation studies in Plastic and Reconstructive Surgery showed that hyperbaric oxygen interrupts this cascade, which is why HBOT is used prophylactically around free-flap surgery at some centers, not only after a flap turns dusky.

Clinical studies point the same direction, with thin trial depth

The human evidence base is consistent but old and mostly uncontrolled. The classic series, Bowersox and colleagues reviewing 105 patients with ischemic flaps or grafts, reported salvage of 89% of threatened flaps and 91% of threatened grafts, most of which carried poor prognostic factors to begin with. Controlled trials exist but are small, and the randomized literature dates back to a 1967 Lancet study of split skin grafts.

Two systematic appraisals frame the current consensus. Dauwe and colleagues’ 2014 systematic review in Plastic and Reconstructive Surgery found eight studies of level III evidence or better on HBOT in complicated acute wounds, flaps, and grafts, concluding that HBOT can augment healing in complicated acute wounds when combined with standard wound management, that it is not indicated in normal wound management, and that more investigation is needed before it becomes a mainstay. Friedman’s 2006 evidence-based appraisal in the same journal reached the matching verdict: substantial animal data, clinical evidence largely limited to case reports and series, and a clear need for multicenter prospective trials.

The aesthetic-surgery corner of the literature is catching up. A 2025 systematic review and meta-analysis of HBOT as an adjunct in aesthetic surgery pooled 11 studies and 734 patients, reporting a pooled mean healing time of 11.3 days in HBOT groups and early patient satisfaction up to 88.2%, while stressing that protocol variability demands proper randomized trials. Note that this review covers elective aesthetic recovery broadly, a weaker-evidence setting than the salvage indication this article is about.

Evidence snapshot

The protocols the literature actually used

Salvage protocols are intensive, front-loaded, and physician-directed. Across the plastic surgery literature, treatments for a compromised graft or flap run at 2.0–2.4 ATA, 90–120 minutes per session on 100% oxygen, twice daily for the first two to three days, then once daily as the tissue stabilizes, for a typical total of 20–30 treatments, with free flaps under total arterial or venous occlusion treated three times on day one (Bhutani and Vishwanath, Indian Journal of Plastic Surgery). The consistent finding on timing is that early initiation matters: HBOT started while the tissue is still salvageable outperforms HBOT started after necrosis sets in.

Two practical facts sit inside those numbers. First, every one of these protocols lives at 2.0 ATA and above, which is hard-shell clinical pressure territory; the full dosing picture is in our guide to hyperbaric chamber pressure levels. Second, sessions at twice-daily frequency with 100% oxygen are hospital or dedicated-clinic workflows, run under a hyperbaric physician’s orders alongside the surgical team, not drop-in wellness appointments.

For operators reading this as an equipment question, the buyer dimension is straightforward: clinical-grade salvage and wound protocols were all produced on hard-shell chambers in the 2.0–2.5 ATA class, which is precisely the class the Superhuman L1 is built to. The engineering difference between that class and mild 1.3 ATA equipment is covered in our hard-shell versus soft-shell comparison.

Limitations of the evidence

The honest summary leads with what is solid. The mechanism is well characterized, the regulatory triad is aligned (FDA cleared, UHMS approved, Medicare covered), and decades of clinical series point in the same direction: used early, as an adjunct, HBOT salvages tissue that was trending toward loss.

The caveats are about trial architecture, not direction. Controlled human trials are few, small, and partly decades old; both major systematic appraisals call for multicenter randomized studies, and the strongest single-number results come from uncontrolled series. Salvage rates in the literature reflect physician-selected patients treated early at 2.0 ATA or above on hard-shell equipment, so results do not transfer to lower pressures, late referrals, or standalone use without surgical management. That pressure point is worth keeping: the evidence base was built exactly where clinical-grade hard-shell chambers operate.

What this means for wellness operators

For med spas and aesthetic-adjacent operators, this indication is a positioning asset only if the language stays exact.

Talk about salvage, not recovery. “HBOT helps your facelift heal faster” is a wellness claim with thin evidence. “Medicare has covered HBOT for compromised skin grafts since before most of your clients were born, and the UHMS approves it for failing flaps” is a verifiable fact that demonstrates how seriously medicine takes this technology. The second sentence builds more trust than the first and carries none of the compliance risk.

Build referral pathways, not service menus. The client whose flap is failing needs their surgeon and a hyperbaric physician, fast. Operators who know the local wound care and hyperbaric programs, and who can explain to clients why that case belongs there, position themselves as the credible end of the market. Equipment safety and certification discipline are part of that credibility, covered in our hyperbaric chamber safety guide.

Let the regulatory vocabulary do the work. Clients comparing providers notice when one facility can explain the difference between a cleared indication, an approved indication, and a covered one, and can name the pressure class behind published protocols. Precision reads as authority in this category because so much of the market speaks in vague recovery language.

References

1. Undersea and Hyperbaric Medical Society. Compromised Grafts and Flaps. Indication 12, UHMS Hyperbaric Medicine Indications Manual, 15th ed. North Palm Beach, FL: Best Publishing Company; 2023. uhms.org/12-compromised-grafts-and-flaps.html.
2. Centers for Medicare & Medicaid Services. National Coverage Determination 20.29: Hyperbaric Oxygen Therapy. Medicare NCD Manual Pub. 100-03, Ch. 1 Part 1. Version 4, effective 3 April 2017.
3. Dauwe PB, Pulikkottil BJ, Lavery L, Stuzin JM, Rohrich RJ. Does hyperbaric oxygen therapy work in facilitating acute wound healing: a systematic review. Plast Reconstr Surg. 2014;133(2):208e-215e. PMID: 24469192.
4. Francis A, Baynosa RC. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017;6(1):23-32. PMID: 28116225; PMCID: PMC5220535.
5. Friedman HI, Fitzmaurice M, Lefaivre JF, Vecchiolla T, Clarke D. An evidence-based appraisal of the use of hyperbaric oxygen on flaps and grafts. Plast Reconstr Surg. 2006;117(7 Suppl):175S-190S. PMID: 16799386.
6. Zamboni WA, Roth AC, Russell RC, Graham B, Suchy H, Kucan JO. Morphological analysis of the microcirculation during reperfusion of ischemic skeletal muscle and the effect of hyperbaric oxygen. Plast Reconstr Surg. 1993;91(6):1110-1123. PMID: 8479978.
7. Bowersox JC, Strauss MB, Hart GB. Clinical experience with hyperbaric oxygen therapy in the salvage of ischemic skin flaps and grafts. J Hyperbaric Med. 1986;1(3):141-149.
8. Mortada H, González JE, Husseiny YM, et al. Efficacy of hyperbaric oxygen therapy as an adjunct in aesthetic surgery: a systematic review and meta-analysis of postoperative outcomes and complications. Aesthetic Plast Surg. 2025;49(9):2498-2512. PMID: 40011247.
9. Bhutani S, Vishwanath G. Hyperbaric oxygen and wound healing. Indian J Plast Surg. 2012;45(2):316-324. PMID: 23162231.