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406
K. Johnson-Arbor
compromised by decreased tissue perfusion or
local hypoxia [29]. When affected by prolonged
ischemia, skin aps experience irreversible damage to the microcirculation [30]. The hyperoxygenation which occurs during application of
HBO may result in increased viability of compromised ap or graft tissue, reducing the need
for additional surgical procedures and increasing
the potential for limb salvage [31]. HBO has been
used for the treatment of compromised skin grafts
as well as ischemic random and free aps [32].
The mechanisms of action affecting the utility
of HBO in the treatment of compromised skin
grafts and aps include HBO-induced neovascularization, attenuation of inammatory mediators, and hyperoxygenation of ischemic tissue
[33]. Post-ischemic tissue reperfusion is associated with an increase in circulating neutrophils to
vascular cell walls; the administration of HBO
reduces this neutrophil adhesion and the
ischemia- reperfusion injury associated with it
[10]. The use of hyperbaric oxygenation may be
optimized when the treatment is initiated within a
short period of time (less than 1 week, and ideally
less than 48h) after identication of graft or ap
compromise [34]. Delays in recognition of ap
ischemia can result in irreversible tissue damage
that will not be ameliorated by use of HBO [35].
As rapid identication of ap or graft ischemia is
critical, use of intraoperative perfusion monitoring devices may be helpful in identifying early
ap compromise so that HBO can be initiated in
a timely fashion. Patients with acutely compromised skin grafts or aps may benet from twicedaily HBO sessions in order to optimize tissue
oxygenation.
Although HBO is most often recognized as a
treatment for arterial ischemia after skin ap or
graft surgery, it can also be utilized as an adjunctive treatment for skin aps complicated by
venous occlusion. In an animal study, axial epigastric skin aps were performed on rats; the
aps were then subjected to venous occlusion,
while arterial inow was left intact [36]. The animals were then randomized to receive HBO,
leeching, or leeching and HBO.While the use of
HBO alone was not effective in improving the
venous outow in this model, combined use of
HBO and leeching resulted in a signicant
increase in ap survival compared with use of
leeching as a sole treatment.
The use of HBO in the management of compromised grafts and aps is most commonly limited to the postoperative period, but HBO
preconditioning may also impact skin ap and
graft survival. HBO preconditioning involves the
initiation of HBO prior to a planned ischemic
insult in order to potentially reduce the sequelae
of subsequent hypoxia [37]. The mechanism of
action of HBO preconditioning may involve
induction of intracellular antioxidant enzyme
systems [13]. HBO preconditioning may play a
role in limiting the ischemic complications that
occur after reconstructive surgical procedures;
however, at this time, much of the evidence surrounding HBO preconditioning remains preclinical in nature [13].
To summarize, based on the available literature, HBO should be considered as an adjunctive
treatment for skin grafts and aps that exhibit
compromise due to arterial inow, venous occlusion, or both. When used to treat skin graft or ap
compromise, HBO appears to be most effective if
it is initiated soon after the ischemic insult.
Although many HBO facilities are located within
outpatient wound centers and do provide care to
inpatients, the initiation of inpatient HBO treatments should be considered for patients with
acutely compromised skin grafts or aps in order
to optimize the effectiveness of this treatment. If
HBO is indicated for an acutely compromised
skin graft or ap but only outpatient HBO care is
available, the treating physicians may consider
transfer of the patient to a facility that is able to
accommodate the patient for inpatient hyperbaric
treatments. Treatments may be administered
once or twice daily as indicated, and treatments
are discontinued when ap viability is achieved.
HBO inClinical Practice
Systemic HBO is administered while a patient is
enclosed within a hyperbaric chamber. These
chambers, composed of steel and acrylic components, are commonly located within outpatient
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407
wound centers in the United States and are utilized as an adjunctive wound healing modality.
There are approximately 1300 hospital-based
hyperbaric facilities present in the United States
as of 2021 [38]. There are two main types of
hyperbaric chambers: monoplace and multiplace.
Monoplace hyperbaric chambers (Fig.28.1) can
accommodate one patient; multiplace hyperbaric
chambers (Fig.28.2) can accommodate multiple
patients as well as caregivers, medical personnel,
and equipment.
In the United States, monoplace chambers are
the most commonly encountered hyperbaric
treatment vessels in hospital settings. In the
monoplace chamber, the patient remains enclosed
in the chamber for the duration of the hyperbaric
treatment; hands-on medical care is not possible
in the majority of monoplace chambers, and due
to this, patients must be clinically stable prior to
being treated in the monoplace chamber.
Advantages of monoplace chambers include
enhanced patient privacy and reduced stafng
requirements compared with multiplace chambers; in addition, monoplace chambers have a
smaller physical footprint than many multiplace
facilities, and some monoplace chambers are portable. The monoplace hyperbaric chamber is
compressed with 100% oxygen; patients may be
intermittently administered compressed air to
breathe via face mask to reduce the risk of oxygen toxicity. The use of 100% oxygen enhances
the risk of re in the monoplace chamber; this
risk is mitigated by careful patient preparation
and meticulous oversight by the chamber
operator.
In contrast, multiplace hyperbaric chambers
are compressed with air. The use of compressed
air instead of oxygen reduces, but does not completely eliminate, the risk of re in the multiplace
chamber. Patients treated in multiplace hyperbaric chambers receive 100% oxygen via the use
of vinyl hoods that are attached to a silicon neck
Fig. 28.1 Monoplace hyperbaric chamber
408
K. Johnson-Arbor
Fig. 28.2 Multiplace hyperbaric chamber. (Photo credit: Wikipedia.com)
ring to make an airtight seal. The larger, more
spacious nature of multiplace chambers is benecial for many claustrophobic patients, as the risk
of connement anxiety is reduced in this setting.
Additional advantages of multiplace chambers
include the ability to treat multiple patients during each treatment session and the ability to perform hands-on patient care during the treatment.
Critical care, including use of mechanical ventilatory support, can also be accomplished more
easily in a multiplace chamber than in a monoplace chamber. Patients who are critically ill or
hemodynamically unstable, including those with
necrotizing soft tissue infections, crush injuries,
and compartment syndromes, are best treated in a
multiplace environment, as medical providers
can accompany these patients into the chamber
for the duration of the hyperbaric treatment to
provide necessary care. Due to the increased
costs associated with the stafng and operation
of these chambers as well as the larger physical
space requirements and increased relative complexity associated with their use, multiplace
chambers are less frequently found than mono-
place chambers in hospitals across the United
States.
During hyperbaric treatments, patients sit or
lie supine in the hyperbaric chamber and breathe
100% oxygen for the duration of the treatment.
Due to re safety standards, patients treated in
the monoplace environment cannot bring books,
magazines, cell phones, or other personal belongings into the chamber with them. Monoplace
hyperbaric chambers commonly have a television
monitor attached to the outside of the chamber;
this allows the patient to watch television or a
movie during each treatment, with sound available inside the chamber through a built-in
speaker. Patients may be allowed to bring personal material into a multiplace chamber with
them, but certain items (including many batteryoperated devices, matches, and other highly combustible material) are never permitted in any
hyperbaric environment due to the risk of re. In
the United States, the National Fire Protection
Association (NFPA) sets re safety codes for
hyperbaric facilities that are adhered to by
hospital- based hyperbaric programs [39]. The
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409
NFPA code provides specic recommendations
for hyperbaric facility construction as well as
standards for patient safety and re prevention.
With proper adherence to the NFPA code and
knowledge and application of the basic techniques used to reduce the risk of re in the hyperbaric environment, the potential for re in the
hyperbaric environment is signicantly reduced.
Despite this, not all hyperbaric facilities follow
NFPA regulations, and there have been fatal res
in the United States and abroad involving hyperbaric chambers.
The use of traditional medical equipment and
implanted devices in the hyperbaric environment
poses unique challenges related to the inability of
many modern medical devices (including
intravenous pumps and ventilators) to withstand
the typical pressurization encountered in the
hyperbaric chamber. Most monoplace chambers
are unable to accommodate patients who are
undergoing treatment with mechanical ventilation or continuous intravenous infusions. Some
implanted medical devices are unsuitable for use
in the hyperbaric environment, due to re or other
safety concerns; many newer medical devices
have not been tested under pressure and may
malfunction or experience structural failure when
exposed to hyperbaric pressurization. Many
pacemaker manufacturers have tested their
devices under pressure, and thus permanent pacemakers are often not regarded as a contraindication to hyperbaric compression. Other medical
devices, including insulin pumps and continuous
glucose monitoring devices, have not been extensively tested under hyperbaric conditions; these
devices are frequently not compatible for use in
the hyperbaric environment.
Hyperbaric treatments are generally scheduled on a daily basis; most hyperbaric chambers
in the United States operate during weekday
business hours only, but some facilities may offer
weekend or after-hours treatments for emergent
conditions such as acute skin graft or ap compromise or necrotizing soft tissue infection.
While a majority of hyperbaric patients receive
daily treatments, patients with acute or emergent
hyperbaric indications may benet from twice
daily treatment delivery, although availability
may be limited due to logistical issues including
facility stafng limitations. Each wound healing
hyperbaric treatment is approximately 2 h in
duration. Pressurization is maintained at a treatment depth ranging from 2.0 atmospheres absolute (ATA) to 2.5 ATA; the treatment regimens
are derived from the United States Navy recompression tables and are generally not able to be
signicantly modied due to the potential for
adverse events including systemic breathing gas
toxicity. The HBO treatment course is typically
tailored to each individual patient. The number of
hyperbaric treatments required per patient varies
based on the indication for treatment. Patients
with acute or emergent treatment indications,
such as necrotizing soft tissue infection or acute
skin graft or ap compromise, may require ten or
fewer HBO treatments to achieve clinical
improvement. Patients who are treated with HBO
for chronic conditions, such as DFU, may require
40–60 daily HBO treatments for maximum clinical effect. Some patients may end their treatment
course earlier than expected based on a more
rapid course of healing or symptom resolution.
Interestingly, despite the lengthy time commitment and need to present to the hospital for daily
treatments, HBO has not been associated with
decrements in patient quality of life [40].
Adverse Eects ofHBO
When administered by trained professionals with
clinical oversight by a physician who specializes
in Undersea and Hyperbaric Medicine, adverse
effects of HBO are rarely encountered. Most
adverse effects associated with HBO can be
avoided or mitigated with careful patient preparation and attention to detail.
Middle ear barotrauma (MEBT) is the most
common complication of HBO; MEBT occurs
due to inadequate ear pressure equalization, often
due to eustachian tube dysfunction. Preventive
measures such as educating the patient on autoinsufation techniques such as the Valsalva
maneuver, are often used to reduce the risk of
MEBT.Patients who are unable to equalize ear
pressures despite adequate education may require
410
K. Johnson-Arbor
use of topical or systemic decongestant medications. In some cases, tympanostomy tube placement may be necessary.
Systemic oxygenation can also induce hyperactivity of the central nervous system (CNS)
resulting in oxygen toxicity; the exact mechanism of this is not well understood, but may be
related to the presence of ROS that result in alterations in enzyme inhibition or brain metabolism
[41]. The risk of CNS oxygen toxicity is related
to both the partial pressure of oxygen inspired
and the exposure time; the clinical presentation
involves tonic-clonic seizure activity that can
occur with or without prodromal signs [42].
Seizures associated with CNS oxygen toxicity
are rarely encountered in clinical practice; in a
retrospective analysis of 2334 patients who
received HBO, the incidence of seizures was
0.011% [42]. The risk of central nervous system
oxygen toxicity may be reduced by the use of
intermittent air breathing periods during each
hyperbaric treatment.
In diabetic patients, HBO is associated with a
signicant decrease in blood sugar concentrations. The cause of this is not fully known; possible mechanisms include increased systemic
glucose consumption or insulin production as
well as increased tissue insulin sensitivity [43].
Pre-treatment glucose values may correlate with
the presence of hypoglycemia during or after
hyperbaric treatment; in one study, a pretreatment blood glucose concentration of 150mg/
dL was predictive of subsequent hypoglycemia
[44]. Due to the risk of hypoglycemia, diabetic
patients who receive HBO are required to have
blood glucose levels checked prior to each treatment, and treatments are generally withheld if the
blood glucose value is below the hyperbaric facility’s pre-dened threshold level.
Changes in visual acuity, most often affecting
distance vision, may occur as a side effect of
HBO.A myopic shift can be detected in almost
90% of patients who receive a standard course of
40 HBO treatments [45]. Patients may describe
having difculties with distance vision and nighttime driving. Fortunately, these visual changes
are almost always temporary, and they resolve
over the ensuing weeks to months after the treat-
ment course is nished [46]. Due to the temporary nature of these visual changes, patients who
experience myopia as a consequence of hyperbaric oxygenation are often counseled to not purchase new corrective lenses, as their vision will
revert back to baseline after the treatments are
completed. Nuclear cataract formation after HBO
has rarely been reported to occur as a consequence of HBO, almost always in association
with a prolonged course of treatment (greater
than 150 HBO treatments) [47, 48].
Not all patients are acceptable candidates for
treatment with HBO. Patients with underlying
COPD or bullous lung disease are at increased
risk for pulmonary barotrauma, including pneumothorax, which represents a potentially fatal
complication of HBO. Fatal pulmonary edema
has been reported to occur in patients with
impaired cardiac function (ejection fraction less
than 40%), as HBO administration results in an
increase in pulmonary capillary wedge pressure
[49]. As previously discussed, patients with
implanted medical devices may be unable to
safely receive HBO.The toxicities of some pharmacologic therapies may be exacerbated by
exposure to hyperbaric oxygenation. Patients
with severe anxiety, claustrophobia, or impaired
cognitive function may benet from treatment in
a multiplace chamber instead of a monoplace, as
medical personnel can accompany them into the
former type of hyperbaric environment to provide assistance during the treatment process.
Prior to starting a course of HBO, patients should
be evaluated by a trained and experienced hyperbaric medicine physician and nurse in order to
assess for these and other characteristics that
could preclude them from safely receiving treatment in the hyperbaric environment.
Topical Oxygen Therapy
Discussions of oxygen therapy for wound care
often include a mention of topical oxygenation.
Topical oxygen therapy involves administration
of oxygen via a bag, boot, or other device to a
specic area of the body. This form of oxygen
therapy involves regional application of oxygen
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411
to an extremity and does not involve systemic
oxygenation. The mechanism of action of topical
oxygen therapy involves the direct application of
oxygen to a wound; topical oxygen therapy does
not share the same physiologic mechanisms as
HBO. Topical oxygen therapy may be advantageous for certain patients, as its use does not
require the patient to make daily visits to a hospital or outpatient treatment center; patients can
receive topical oxygen therapy in out-of-hospital
settings such as a private residence or nursing
facility [19]. It is also associated with a lower
treatment cost than traditional HBO. Although
topical oxygen therapy is relatively simple and
easy to use, it does require the patient to remain
immobilized and attached to the external oxygen
source during each treatment [50]. Unlike HBO,
topical oxygen therapy is not associated with the
potential for systemic oxygen toxicity. However,
topical oxygen delivery systems generally do not
achieve the high pressures found in hyperbaric
chamber environments, and at this time there is
not sufcient high-quality evidence to support
the use of topical oxygen therapy as a medical
treatment for wound healing and limb salvage
[19, 20].
Conclusions
HBO is a valuable adjunctive treatment modality
for patients with complicated wounds and represents a useful pillar of the comprehensive limb
salvage process. The administration of hyperbaric oxygenation results in neovascularization,
an improved inammatory response, and
enhancement of infection control; these clinical
effects can have a favorable impact on patients
with challenging wounds who are at risk for limb
loss. When administered by trained professionals, HBO is a safe treatment modality that is associated with a limited number of adverse events.
Systemic hyperbaric oxygenation should be considered as an integral adjunctive treatment for
patients with complex wounds, especially DFU
and compromised skin grafts or aps, who are
referred for attempts at limb salvage.
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Skin Grafting
IN: Functional Limb Salvage: The
Multidisciplinary Team Approach
AdaahSayyed, PaigeK.Dekker, CaitlinS.Zarick,
andKarenK.Evans
29
Introduction
Skin grafting is a surgical technique in which
skin from one region of the body is harvested
from its local blood supply and transplanted to
another location. As a result of being separated
from its vascular bed, the viability of a skin graft
relies on the development of new blood supply
from the regional bed in which it is placed [1].
This technique is thousands of years old, originating in 2500–3000 B.C. by surgeons of the
Hindu Tilemaker Caste who used gluteal skin to
recreate noses for those who suffered traumatic
facial wounds. The focus of this chapter is split-
thickness skin grafting (STSG), a technique rst
A. Sayyed
Georgetown University School of Medicine,
Washington, DC, USA
e-mail: as4425@georgetown.edu
P. K. Dekker
Department of Plastic and Reconstructive Surgery,
MedStar Georgetown University Hospital,
Washington, DC, USA
e-mail: pkd15@georgetown.edu
C. S. Zarick (*) · K. K. Evans
Department of Plastic and Reconstructive Surgery,
MedStar Georgetown University Hospital,
Washington, DC, USA
Center for Wound Healing and Hyperbaric Medicine,
Washington, DC, USA
e-mail: caitlin.s.zarick@medstar.net;
karen.k.evans@medstar.net
described in 1872 by Ollier and Thiersch [1].
Despite its initial use in facial reconstruction,
skin grafting is commonly employed in soft tissue reconstruction of defects such as deep burns,
sores, large wounds, cancer resections, and
chronic ulcerations that are commonly encountered in diabetic populations. This chapter will
discuss the techniques and outcomes of skin
grafting, specically STSG, in lower extremity
wounds resulting from diabetes and peripheral
artery disease. Timely closure and healing are
critical in reducing the morbidity and cost associated with chronic lower extremity wounds.
Categories ofSkin Grafting
The two major classications of skin grafts are
autogenous and tissue-engineered skin grafts.
Autogenous skin grafts are those transplanted
from a donor site and grafted onto a different site
on the same individual. Autogenous skin grafts
can be further divided into split-thickness and
full-thickness skin grafts. Tissue-engineered skin
grafts are biologic cell-based dressings composed of live-cell constructs containing at minimum one layer of live allogeneic cells [2]. These
are commonly used when traditional autogenous
dressings have failed or are deemed inappropriate, such as in patients unable to undergo anesthesia for donor site harvesting. The take rate and
healing rate of such grafts, however, are much
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A. Sayyed et al.
lower than of autologous STSGs [3]. Most tissueengineered skin grafts do not provide complete
denitive skin coverage after one usage, and they
can also be more costly. A more complete discussion is presented in other chapters.
Split-Thickness Skin Grafts
Split-thickness skin grafts involve harvesting the
epidermis and varying portions of the underlying
dermis, allowing the donor site to heal from epidermal elements left behind. STSGs can be further divided into thin (0.008–0.012 in.),
intermediate (0.012–0.018 in.), and thick (0.018–
0.030 in.) [4]. Advantages of STSGs include the
large surface area coverage they provide while
using minimal donor skin that can be expanded
via meshing techniques. Donor sites have the
ability to heal completely in 10–15days and can
be reharvested at that time if necessary.
Disadvantages of this technique include the limited pliability and elasticity afforded by STSGs,
resulting in increased contracture upon healing.
Additionally, STSGs are fragile, lack hair, heal
with abnormal pigmentation, and lack a smooth
texture.
STSGs are used in a variety of reconstructive
procedures. Indications for STSG use include
cases when simpler methods of wound closure
such as healing by primary closure, secondary
intention, or negative pressure wound therapy do
not sufce or are not possible. In patients with
large skin defects extending over the trunk or
extremities (not including joints), the increased
contractility of STSGs results in smaller areas of
scarring. In addition, compared to large wounds
treated with standard local wound care dressings,
STSG provides more stable coverage than the
scar created by secondary closure. STSG can also
provide denitive coverage for wounds that
closed partially in response to other therapies, or
to improve healing of donor sites formed by other
surgical procedures [4].
STSGs are also indicated in cases of acute
skin loss (burns, infection, traumatic wounds)
and chronic skin loss (leg ulcers). Utilization of
thinner grafts is particularly benecial in these
cases as they have decreased metabolic needs.
Intermediate-thickness STSGs provide the ideal
graft for diabetic foot wounds, providing good
quality repair and resultant skin with sufcient
elasticity and reduced retraction [4]. The most
common thickness used by the authors is
0.0012in. The conservative approach to treating
chronic wounds entails frequent debridement and
dressing changes, along with topical solutions
such as collagenase ointments, antimicrobial
absorbent ber sheets, saline, or iodine. The benet of STSG, however, is the signicantly shortened healing time achieved when compared to
conservative treatment. One study reported an
average healing time of 28days with STSG versus 122days in conservatively treated patients, as
well as a decreased hospital length of stay and
overall reduced cost of care [3, 5].
Full-Thickness Skin Grafts
Full-thickness skin grafts (FTSGs) require harvesting the entire layer of skin, including both the
epidermis, dermis, and underlying adnexal structures such as sweat glands, hair follicles, and
nerves [1]. Because FTSGs require full-thickness
harvesting, the donor skin takes longer to revascularize relative to STSGs, and often requires
closure by local advancement of the skin or by
secondary local ap placement.
Benets of FTSGs include their minimal
wound contraction and ability to provide good
color, texture, elasticity, and thickness to match
the surrounding skin [1]. The aesthetic advantages provided by FTSGs make them a prime
choice in the repair of hand and facial wounds,
such as facial defects resulting from skin cancer
resections. Patients have reported increased satisfaction with the matching of texture and color
provided by FTSGs [6]. Their minimal contraction, pliable reconstructability, and improved
capacity to provide sensation and temperature
discrimination postoperatively also make FTSGs
the preferred option in cases requiring grafting
over mobile areas such as joints, palms, and ngertips [3]. They are used less frequently in complex lower extremity wounds due to the poor host
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