SKIN GRAFTS AND FLAPS (COMPROMISED)

Reconstructing complex wounds is accomplished by shifting or transferring tissues to the wound from a different part of the body.  A “skin graft” is the transfer of a portion of the skin (without its blood supply) to a wound.  A “flap” consists of one or more tissue components including skin, deeper tissues, muscle and bone.  Flaps are transferred with either their own, original blood supply (pedicle flap) or with detached blood vessels which are attached at the site of the wound (free flap).

Skin grafts survive as oxygen and nutrients diffuse into them from the underlying wound bed.  Long-term survival depends on a new blood supply forming from the wound to the graft.  When the wound bed does not have enough oxygen supplied to it, the skin graft will at least partially fail.  Common causes for this are previous radiation to the wound area, diabetes mellitus, and certain infections.  In these situations, the availability of oxygen in the wound bed can be increased with hyperbaric oxygen therapy (HBO2) in preparation for skin grafting.  Additionally, HBO2 can be used after skin grafting to increase the amount of the graft that will survive in these compromised settings.

Flaps also require oxygen and nutrients to survive.  The outer, visible portion (usually skin) is furthest from the source of blood supply for the flap.  This is the area most likely to be compromised by inadequate oxygen.  Factors such as age, nutritional status, smoking, and previous radiation result in an unpredictable pattern of blood flow to the skin.  If a flap is found to have less than adequate oxygen after it has been transferred, HBO2 can help minimize the amount of tissue which does not survive and also reduce the need for repeat flap procedures.

Partial or complete failure of the wound reconstruction is very difficult for a patient and also very expensive.  HBO2 can help by assisting in the preparation and salvage of skin grafts and compromised flaps.

References 

  1. McFarlane RM, Wermuth RE.  The use of hyperbaric oxygen to prevent necrosis in experimental pedicle flaps and composite skin grafts.  Plast Reconstr Surg 1966;37:422-430.
  2. Greenwood TW, Gilchrist AG.  The effect of HBO on wound healing following ionizing radiation.  In: Trapp WC, ed. Proceedings of the Fifth International Congress on Hyperbaric Medicine, Vol 1.  Barnaby, Canada: Simon Frasier University, 1973:253-263. 
  3. Tan CM, Im MJ, Myers RA, Hoopes JE.  Effect of hyperbaric oxygen and hyperbaric air on survival of island skin flaps. Plast Reconstr Surg 1974;73:27-30.
  4. Zamboni WA.  Applications of hyperbaric oxygen therapy in plastic surgery.  In: Oriani G, Marroni A, Wattel F, eds.  Handbook on Hyperbaric Oxygen Therapy.  New York: Springer-Verlag, 1996.



Other references on Skin Grafts & Flaps (Compromised):

PREPARATION AND PRESERVATION OF COMPROMISED SKIN GRAFTS

Note

Problem wound healing frequently occurs in patients who are systemically or locally host compromised. Regardless of underlying etiology, tissue hypoxia is the most common denominator. When operative repair is necessary, surgeons turn to the Reconstructive Ladder, a series of graft and flap options of increasing complexity.

For skin grafts to be considered, the recipient bed must be of the health and quality to accept and nourish a graft. This is critical, as such grafts are immediately rendered ischemic/hypoxic upon harvest.

Availability of oxygen is critical to the success of any skin grafting procedure, and subsequent graft durability. The following papers chronicle the role of oxygen in the healing process, and conclude with the application of HBO therapy in wound healing and limb salvage. Such application is designed to either:

    • prepare the recipient bed for definitive coverage (grafts or flaps)
    • it is recognized that, in some cases, the therapeutic effect of HBO will be such that skin grafting may be unnecessary.
    • support skin graft or skin flap procedures, in the immediate post-operative setting.
  • Sheffield PJ: Tissue oxygen measurements with respect to soft-tissue wound healing with normobaric and hyperbaric oxygen. HBO Review 1985;6(1):18-43.
    Evidence that hyperbaric doses of oxygen increase tissue oxygen levels in otherwise hypoxic and ischemic wounds. This work represents a fundamental rationale for the application of HBO therapy in the setting of non-healing lesions, where an underlying hypoxia is demonstrated.
  • Padberg FT, Back TL, Thompson PN, et al: Transcutaneous oxygen (TcP02) estimates probability of healing in the ischemic extremity. J Surg Res 1996;60(2):365-369.
    A more recent evaluation of the relationship between availability of oxygen and probability of healing in the ischemic extremity. Transcutaneous oximetry "alone" is sufficient for objective risk stratification of arterial ischemia in the lower extremity.
  • Bunt TJ, Holloway GA: TcP02 as an accurate predictor of therapy in limb salvage. Ann Vasc Surg 1996;10(3):224-227.
    Further evidence of both the role of oxygen in limb salvage, and the ability of transcutaneous oximetry to identify tissue beds at risk.
  • LaVan FB, Hunt TK: Oxygen and wound healing. Clinics in Plast Surg 1990;17(3):463-472.
    This paper summarizes the extensive amount of basic research (much of which came from these authors’ laboratory at the     University of California, San Francisco). The authors emphasize the role of HBO therapy as a "strong stimulus" for angiogenesis. They further note that HBO is not effective "if blood supply is insufficient". Hence, the important role of transcutaneous oxygen in the case management of hyperbarically-referred patients under the Preparation or Preservation of Compromised Graft protocol.
  • Clarke D: An evidence-based approach to hyperbaric wound healing. Blood Gas News 1998;7(2):14-20.
    One example of an algorithmic approach to hyperbaric wound healing. The goal is to identify those who possess the physiologic capability to respond locally (the wound) to centrally-delivered (HBO) hyperoxia. In those patients, determination of therapeutic endpoint (when a critical mass of angiogenesis is presumed to be present) ensures a cost-effective application of this therapeutic resource.
  • Tompach PC, Lew D, Stoll JL: Cell response to hyperbaric oxygen treatment. Int J Oral Maxillofac Surg 1997;26:82-86.
    More advanced thinking, and confirmatory study, regarding the effect of HBO on wound healing. Here, in an in-vitro cell model, HBO positively influences healing responses at the cellular level.
  • Hehenberger K, Brismar K, Lind F, et al: Dose-dependent hyperbaric oxygen stimulation of human fibroblast proliferation. Wound Rep Reg 1997;5(2):147-150.
    Further cellular research that demonstrates the dose dependent nature of oxygen on an important component of the wound healing module.
  • Siddiqui A, Davidson JD, Mustoe TA: Ischemic tissue oxygen capacitance after hyperbaric oxygen therapy: A new physiologic concept. Plast Reconstr Surg 1997;99(1):148-155.
    A new concept is proposed, one that incorporates previous evidence of HBO’s benefit in ischemic wound healing, and is supported by the research presented herein. This work further demonstrates the superiority of hyperbaric vs. normobaric oxygen.
  • Gibson JJ, Hunt TK: Hyperbaric oxygen potentiates wound healing. Diving and Hyperbaric Medicine Proc. 23rd EUBS Congress, Bled. Slovenia 1997:153-160.
    This paper demonstrates a beneficial effect of HBO therapy, in a dose-dependent manner, on angiogenesis. This effect is highly significant when compared to "controls"; air breathing at sea level pressure.
  • Boykin JV: Hyperbaric oxygen therapy: A physiological approach to selected problem wound healing. Wounds 1996;8(6):183-198.
    A recent summary article of the role of HBO therapy in problem wound healing. This paper captures much of the historic and recent science, and molds it into a clinical algorithm in order to maximize medical and surgical management.
  • Hammarlund C, Sundberg T: Hyperbaric oxygen reduced size of chronic leg ulcers: A randomized double-blind study. Pjlast Reconstr Surg 1994;93(4):829-833.
    An exacting clinical study. The wounds in question had failed to heal over more than one year. The healing effect of HBO on these ulcers was highly significant (p<0.001).
  • Baroni G, Porro T, Faglia E, et al: Hyperbaric oxygen in diabetic gangrene treatment. Diabetes Care 1987;10(1):81-86.
    One of the "early" case controlled studies, in which HBO was evaluated in diabetic foot gangrene. It was not uncommon for these patients to undergo subsequent grafts or flap repair, in one form or another, when major limb salvage is averted. HBO therapy markedly reduced the rate of such amputations.
  • Oriani G, Michael M. Meazza D, et al: Diabetic foot and hyperbaric oxygen therapy: A ten-year experience. J Hyperbaric Med 1992;7(4):213-221.
    A similar study, and findings, to the previous paper. Diabetic foot ulcers benefited from HBO pre-operatively.
  • Faglia E, Favales F, Aldeghi A, et al: Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. Diabetes Care 1996;19(12):1338-1343.
    A randomized controlled clinical trial; the findings of which mirror those of the two previous, and less well controlled, reports. Note that transcutaneous oxygen data was able to discriminate between the healed and non-healed groups.
  • Wheen L: The effectiveness and cost of oxygen therapy for diabetic foot wounds. SPUMS Journal 1994;24(4):182-190.
    A paper that evaluates the clinical and cost-effectiveness of HBO therapy in diabetic foot wounds. "…the financial costs are lessened when hyperbaric oxygen therapy is used in combination with conventional management of the problem diabetic foot".
  • Bowersox JC, Strauss MB, Hart GB: Hyperbaric oxygen treatment in the management of threatened skin flaps and grafts. Handout: VIII International Congress on HBO, Long Beach, California 1984:149-152.
    A report of the application of HBO therapy in threatened skin flaps/skin grafts. "…90% of the patients with grafts had risk factors that were considered poor prognostic signs". Almost all of these risks involved resulted in an underlying hypoxic component (    PVD, radiation therapy to the recipient bed, diabetes mellitus). Presumably, if transcutaneous oximetry had been afforded these patients, many graft or flap procedures would have been deferred pending a pre-operative course of HBO therapy! Here is evidence of the high failure rate of graft/flap procedures in tissue beds previously rendered hypoxic.
  • Perrins, DJF: Influence of hyperbaric oxygen on the survival of split skin grafts. The Lancet 1967:868-871.
    The first controlled study of HBO therapy in skin graft support. HBO therapy resulted in twice as many graft "takes" than the control group.
  • Zamboni WA, Roth AC, Russell RC, et al: The effect of acute hyperbaric oxygen therapy on axial pattern skin flap survival when administered during and after total ischemia. J Reconst Microsurg 1989;5(4):343-347.
    HBO therapy is observed to increase axial pattern skin flap survival when administered during or immediately after total flap ischemia. The administration of HBO during ischemia with resulting improved outcome was surprising at the time of this publication. These authors have since demonstrated a "constitutional" effect of HBO, influencing the ischemia-reperfusion syndrome in a way that minimizes/negates I-R injury.
  • Kaelin CM, Im MJ, Myers RA, et al: The effects of hyperbaric oxygen on free flaps in rats. Arch Surg 1990;125:607-609.
    The "pre-operative" benefits of HBO therapy in flap reconstruction.
  • Stevens DM, Weiss DD, Koller WA, et al: Survival of normothermic microvascular flaps after prolonged secondary ischemia: Effects of hyperbaric oxygen. Otolaryngol Head Neck Surg 1996;115(4):360-364.
    A study that closely equates to the clinical setting; i.e., flap repair (including a "primary" ischemic period), flap ischemic compromise with resulting secondary ischemia, then correction of secondary ischemia with resulting reperfusion. HBO, but not normobaric oxygen, therapy enhanced flap tolerance, and survival. "… the additional expense and technology of a hyperbaric chamber system is necessary to achieve this effect."
  • Ciaravino ME, Friedell ML, Kammerlocher TC: Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds? Ann Vasc Surg 1996;10(6):558-562.