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Hi, I have been trying to find any research related to the post-op healing duration of a compromised flap or graft regarding an appropriate window to refer to HBOT. Looking to provide education to our referring physicians (recently had a patient referred for "failing flap" done 2 years prior, as well as other similar situations).

The closest I found is something from a Plastics Journal in 2004:
Two distinct phases of graft adherence occur. Phase 1 begins immediately after grafting and lasts about 72 hours. During this time the graft remains adherent to the bed through the bond formed by the fibrin layer. Phase 2 coincides with the onset of fibrovascular ingrowth and vascular anastomoses between the graft and the host.

Otherwise, the guideline seems to be “acutely compromised”. How long is it appropriate to accept patients after the procedure?

Thank you!
Nov 8, 2023 by Sarah Karson, RN, BSN
1 replies
Elaine Horibe Song
MD, PhD, MBA

Hi Sarah,

Thanks for your question - below is an excerpt of the topic Compromised Skin Grafts and Flaps, with information on HBOT Criteria and Treatment protocol.

The HBOT Knowledge Base > Outreach tab also has a flyer that can be shared with referring providers, with information on HBOT criteria and treatment that will be useful for determining timing.

HBOT Criteria:

  • Surgical referral with current diagnosis and documentation of skin graft or flap compromise (e.g., random pattern ischemia, pain, coolness or a bluish/purple hue of the cutaneous portion of flap)
  • Absence of surgically correctable cause of decreased perfusion to flap or skin graft (e.g. skin flaps created by trauma with inadequate perfusion due to crush injury, large random flaps that do not follow the classic 3:1 length-to-width ratio, ischemia-reperfusion injuries, etc)
  • Initiation of first HBO session within 24 hours of the initial limb/ digit replantation/ revascularization. This is generally considered a hyperbaric emergency and due consideration for urgent (within one to a few hours) initial treatment in a hyperbaric chamber.
  • Postoperative edema and congestion, in the absence of obvious surgically correctable causes of ischemia or congestion
  • Postoperative concerns regarding viability of the replanted part. A reference to a verbal conversation with the surgeon is adequate documentation.

Of note:

  • Hyperbaric Oxygen therapy should be started as soon as signs of flap or graft compromise appear.
  • In an acutely failing flap, up to 3 treatments in the first 24 hours is recommended.
  • After the first 24 hours, twice daily treatments are recommended.

Topics:

Hope this helps!
Nov 8, 2023
* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
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