Etiology of unsuccessful covering of non-healing areas in compromised tissues is related to pre-existing hypoxia, predisposing the negative outcome of transferred tissues in case a flap or graft is required.
HBO should be considered as an adjunct therapy, both preventive and supportive, for the attachment of transferred grafts or flaps in hypoxic tissues where the diminished local oxygen delivery is inadequate to satisfy the high-energy demands.
Acute injuries like thermal burns and necrotic lesions or chronic ones like irradiated tissues and diabetic wounds may benefit from HBO, applied in parallel to the primary treatment to optimize the conditions for restoration of the local metabolic balance and promotion of healing.
In acute injuries the presence of edema, hypoxia, microcirculation impairment, enlargement of the damaged area and high risk for infection are usual predisposing for HBO application, to improve outcome of transferred tissues.
Ketchum et al.120 in an experimental study on rats, regarding the HBO effect on small burns (1st, 2nd, 3rd degree), reported an improvement in microvascular growth. Author through micro-angiographic studies supported the hypothesis that HBO had an ameliorating effect on the revascularisation of the injured area.
In a clinical series of 20 patients with severe burns (20-80% surface area) Hanquet et al.121 demonstrated that HBO use resulted in acceleration of wound healing and better integration of grafts versus a control group.
Waisbrein et al.122, performing a clinical retrospective study on 36 patients with burns, reported an important reduction in grafted skin area in the HBO group equal to XA of the relevant in the control group.
Necrotizing lesions (crushes syndromes, complicated open traumas) or infections (anaerobes, mixed) are often accompanied by aggressive surgical debridements requiring a tissue transfer for healing. Bouachour et al123 in a controlled series of severe limb injuries reported among other results that skin grafting was reduced in the HBO group.
Chronic injuries like irradiated tissues and diabetic wounds have been demonstrated clinically and experimentally to be favored by HBO application.
After radiation therapy, tissue hypoxia is installed through induced capillary endarteritis. This secondary ischemia was shown to be restored through the HBO promotion of neovascularity. An enlarged microvascular net in the irradiated receptor bed is mandatory for an uncomplicated tissue transfer process, as Davis and Heckman124 have shown in a series of myocutaneous flaps. In a clinical series of soft tissues radiation injuries Hart and Strauss125 reported successful skin grafting after HBO use.
Diabetic ulcers, the most favored wounds treated with HBO, may benefit further when a tissue transfer is required to cover a defective area. A multidisciplinary approach in this kind of wound is obligatory (diabetic balance, regular debridements, use of proper antibiotics, HBO use) in order to establish a sufficient granulation and support the attachment of a graft or flap.
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