Systematic Review of Comparative Studies Evaluating Hyperbaric Oxygen Therapy on Skin Flap and Graft Surgical Indications

Background: This systematic review aims to determine whether pre- and postoperative hyperbaric oxygen therapy (HBOT) incurs any benefits or harms in soft tissue injuries (STIs) considered for skin flap or graft surgery. Methods: We included adequately powered clinical trials that enrolled patients with STIs serious enough for skin flaps or grafts; evaluated HBOT (≥1.5 ATA) versus control, placebo, or sham procedures; and analyzed survival/healing and complication rates. MEDLINE, Google Scholar, and Embase were searched for relevant literature through June 30, 2024. The Cochrane risk of bias (RoB 2) and the ROBINS-I tools assessed RoB. Meta-analysis and random effects models analyzed randomized controlled trial (RCTs) evaluating flap/graft survival rates within 4 weeks of HBOT (2-2.5 ATA). The GRADE approach determined the evidence recommendations. Results: Among 743 records screened, 45 were assessed; 25 reports from 24 studies (13 RCTs; 11 non-RCTs; 2246 patients) were included. RCT RoB ranged from low RoB (1 trial) to high (2 trials). Nonrandomized trials had moderate RoB (n = 5, 45%), whereas 6 had serious RoB. Four RCTs showed a large, horizontal overall effect size (log odds ratio, 1.045; standard error, 0.3104; z , 3.3.67; P < 0.001; 95% confidence interval, 0.44–1.65). Evidence levels were very low to moderate, with 11 strong and 13 conditional recommendations, including a strong recommendation to use HBOT to heal flaps/grafts in STI/trauma wounds. Conclusions: A strong recommendation for pre- and postoperative HBOT is warranted to mitigate the need for flap/graft surgery and heal flaps and grafts, given the potentially life- and/or limb-threatening harms that could otherwise occur.