Compromised skin grafts and flaps
A skin graft or flap is compromised when it is not surviving as expected. The cause may be inadequate blood flow, poor drainage from a flap, infection, bleeding beneath a graft or movement. The surgical team must assess it promptly. Hyperbaric oxygen therapy (HBOT) is recognised by international hyperbaric bodies as an adjunct for selected compromised grafts and flaps; it is not routinely commissioned for this indication by NHS England.
This page is written for people whose skin graft or flap is not healing as expected, their families, and the surgical teams looking after them.
What grafts and flaps are, and why they fail
A skin graft is skin moved from one part of the body to cover a wound. It may be split-thickness or full-thickness. A graft has no blood supply of its own when transferred, so it must attach to a suitable wound bed and develop new blood vessels. Surgeons call this graft take.
A flap is skin and sometimes deeper tissue moved with its own blood vessels. A local flap remains connected at one end; a free flap is detached and its vessels are joined to vessels at the new site.
A flap may be compromised if blood cannot enter or drain adequately. That can be time critical and may need urgent surgical action.
Grafts can fail because of infection, blood or fluid collecting underneath, movement, or an unsuitable wound bed. Smoking, poor nutrition, diabetes and previous radiotherapy can increase the risk. Flaps can develop problems with blood inflow or venous drainage.
Your surgeon must determine the cause; the appearance of a graft or flap alone cannot identify it reliably.
When a graft or flap appears compromised, the first step is urgent surgical assessment and correction of a reversible cause where possible.
HBOT may then be considered as an adjunct when tissue viability remains threatened by poor perfusion or oxygenation. It must not delay surgical exploration or other treatment.
What the surgical team will normally do
Your surgical team leads this. Depending on the cause, treatment can include urgent examination or re-operation for a threatened flap, draining blood or fluid beneath a graft, treating infection, protecting the area from movement or pressure, and addressing smoking, nutrition or blood glucose.
If a graft does not survive, another operation may be needed. Where only part has failed, the wound can sometimes heal with dressings and follow-up. Your surgeon will decide which approach is appropriate.
HBOT does not remove a haematoma, restore a blocked flap vessel, secure a displaced graft or replace treatment for infection. Surgical and wound care come first.
Any HBOT plan would be made with the surgical team and monitored alongside its treatment.
What UK guidance says
We have not identified a NICE recommendation specifically supporting or opposing HBOT for compromised skin grafts or flaps. This should not be described as NICE approval, or as a NICE recommendation against it.
NHS England’s current national specialised HBOT service specification covers decompression illness and gas embolism. Compromised grafts and flaps are not a routinely commissioned indication under it. They are not named in the specification’s examples of other non-routinely commissioned conditions; that absence is not a separate clinical judgment on effectiveness.
The distinction is between no specific NICE recommendation and no routine NHS England commissioning under this service.
Heal & Go₂ considers international professional guidance and the published evidence while making that UK position clear.
What international guidance says
The European Committee for Hyperbaric Medicine (ECHM) suggests HBOT for a compromised graft or flap (type 2, level C evidence) and recommends it as soon as possible after compromise is diagnosed (type 1, level B).
Separately, it recommends considering HBOT before and after surgery when the graft or flap has a higher risk of failure, such as an irradiated wound bed (type 1, level C).
These are distinct situations: attempted salvage after compromise and planned support around surgery.
The Undersea and Hyperbaric Medical Society recognises compromised grafts and flaps as an accepted HBOT indication and says HBOT is not needed for normal, uncompromised grafts or flaps. Its professional indication is not a UK regulatory approval or proof of benefit for an individual patient.
Selection depends on the surgical diagnosis, how quickly a reversible problem can be corrected, whether tissue remains viable and whether HBOT is feasible without delaying essential care. A planned high-risk operation requires a separate discussion with the surgeon before surgery.
Where it is used routinely
In the United States, Medicare covers HBOT for the preparation and preservation of compromised skin grafts, and its wording excludes the primary management of wounds. This is a coverage decision in a different health system and does not alter UK guidance or commissioning.
Where the evidence shows possible benefit
A systematic review published in 2026 in Plastic and Reconstructive Surgery Global Open included 24 studies with 2,246 patients, 13 of them randomised trials, on HBOT before and after skin graft and flap surgery. Four randomised trials could be pooled, and together they reported higher graft and flap survival with HBOT. The authors rated the certainty of the evidence as very low to moderate, and recommended HBOT before and after surgery on the basis that a failed graft or flap can threaten a limb or a life.
A 2010 Cochrane review of HBOT for acute surgical and traumatic wounds included two small trials that suggested benefit for skin grafting. These results do not show how an individual graft or flap will respond.
Where the evidence does not support use
The 2010 Cochrane review found a lack of high quality evidence on the effects of HBOT on wound healing, judged the skin grafting trials to be at risk of bias, and called for further high quality randomised trials. It predates most of the studies in the 2026 review, which still graded much of the evidence as very low or low certainty.
For a graft or flap that is healing normally, there is no evidence of benefit, and the Undersea and Hyperbaric Medical Society states that HBOT is not recommended.
HBOT does not treat graft or flap failure caused by bleeding or fluid underneath, infection or movement. Those need surgical care.
No UK trial has tested HBOT for compromised grafts or flaps, and we have not identified a UK guideline on it. HBOT can cause adverse effects, and individual risks and contraindications require assessment before treatment. We cannot infer a reliable benefit for an individual patient from an international indication list alone.
How we assess whether treatment is appropriate
HBOT is not offered for grafts or flaps in general. It may be considered as an adjunct for a compromised skin graft or flap where the surgical team has identified reduced blood supply or oxygen to the tissue as the problem, including tissue previously treated with radiotherapy, and where any bleeding, infection or movement is already being managed surgically. Those are the selection criteria set out by the European and American hyperbaric bodies.
Standard care comes first. Your surgical team stays in charge. Nothing on this page is a reason to change, pause or delay anything they have recommended. If HBOT is considered, we work alongside them and share our assessment and treatment plan.
Not everyone can have HBOT safely. It has risks and contraindications, including ear pressure injury and temporary visual changes, and recent surgery needs particular assessment. We review relevant medicines, medical conditions and chamber safety before making a recommendation. Our safety page provides more detail; an individual clinical assessment determines whether treatment is suitable.
How the assessment works. We normally require a referral and relevant information from the surgical team, including the operation, its date, the current state of the graft or flap, and what has been done for any bleeding, infection or movement. A compromised graft or flap can deteriorate quickly, and our assessment must never delay urgent surgical care. The Medical Director reviews the diagnosis, the cause of the compromise, treatment so far, evidence and safety within our clinical governance process, then explains whether HBOT has any plausible adjunctive role. We discuss uncertainties, risks, alternatives and costs before any decision. An assessment is not a promise of treatment or benefit.
HBOT is not appropriate for every patient or every graft. A graft that is healing normally does not need it. If we do not think HBOT is appropriate or likely to help, we will say so.
Common questions
My skin graft is not taking. What should I do first?
Contact the surgical team that did the operation. The commonest reasons a graft fails, according to NHS patient information, are infection, blood or fluid collecting underneath it, movement, an unhealthy wound surface and smoking. Those need the surgical team, not us, and quickly.
Is hyperbaric oxygen available on the NHS for a failing graft or flap?
No. NHS England commissions hyperbaric oxygen for decompression illness and gas embolism only. Compromised grafts and flaps are not funded, and no UK body has published guidance on hyperbaric oxygen for them either way.
Does it work?
A 2026 systematic review pooling four randomised trials found a large improvement in graft and flap survival with hyperbaric oxygen, on evidence it rated very low to moderate certainty. A 2010 Cochrane review found the evidence lacking in quality. It is a recognised indication internationally, for compromised grafts and flaps only.
Can it be used before surgery in tissue damaged by radiotherapy?
European guidance recommends hyperbaric oxygen before and after surgery where a graft or flap is at increased risk, giving irradiated wound beds as an example. That is a decision for your surgical team, with the timing planned around the operation, and we would work with them on it.
Is it safe?
It is generally well tolerated but not without risk. The full list of side effects and contraindications is on our safety page, which is the Medical Director's screening list. Recent surgery is one of the things that needs assessing, which is another reason we speak to your surgical team first.
- Clinical and advertising approval
- Approved 30 September 2026 · Dr Anil Dasineni (own revision)
- Reviewed by
- Dr Anil Dasineni, MBBS, DNB (Emergency Medicine), MRCEM. Registered with the General Medical Council with a licence to practise.
- Last reviewed
- 30 September 2026
- Next review due
- 30 September 2027
- Clinical tier
- Tier 1
Sources (9)
www.uhsussex.nhs.uk/resources/looking-after-your-split-thickness-skin-graft-and-donor-site/, www.uhsussex.nhs.uk/resources/skin-grafts-and-skin-flaps-2/, www.england.nhs.uk/wp-content/uploads/2018/11/Hyperbaric-oxygen-therapy-services-all-ages-Service-specification-January-2025.pdf, www.england.nhs.uk/commissioning/spec-services/npc-crg/group-d/hyperbaric-oxygen-therapy/, www.echm.org/documents/DHM%202017-Mathieu%20D-Tenth%20European%20Consensus%20Conference%20on%20Hyperbaric%20Medicine.pdf, uhms.org/resources/featured-resources/hbo-indications.html, www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008059.pub2/full, pmc.ncbi.nlm.nih.gov/articles/PMC13200958/, www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=12
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