Exosome therapy for flap and skin graft survival: A systematic review and meta-analysis of preclinical evidence

Flap necrosis and graft failure remain significant sources of morbidity in reconstructive and aesthetic surgery, yet no cell-free biological adjunct has been established to improve tissue survival after transfer. Exosomes are nano-sized extracellular vesicles capable of simultaneously modulating angiogenesis, inflammation, apoptosis, and oxidative stress, and have been investigated as candidate regenerative adjuncts in plastic surgery. This PROSPERO-registered systematic review and meta-analysis (CRD420251146650), conducted per PRISMA 2020, searched PubMed, OVID, Scopus, Web of Science, and Google Scholar through September 2025 and included 24 animal studies (19 flap; 5 skin graft). Flap and graft studies were analysed as separate populations. Random-effects meta-analysis suggested increased flap survival (k=19; MD 35.54%; 95% CI 25.11–45.97; p