Journal of Plastic, Reconstructive & Aesthetic Surgery 84 (2023) 237–240

Correspondence and Communications

Effects of cutaneous negative pressure

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application on skin microcirculation and

state of anastomoses between perforators:
A preliminary study
⁎,1
Pavlo O. Badiul a, , Sergii V. Sliesarenko b, Oleh I. Rudenko b

a
Dnipro State Medical University, Dnipro, Ukraine
b
Burn and Plastic Surgery Center, Municipal Hospital #8, Dnipro, Ukraine

Received 21 August 2022; Accepted 14 May 2023

KEYWORDS
Negative pressure
application;
Perforator flaps;
Anastomoses between
perforators;
Thermography

At present perforator flaps are popular technique in re­
constructive surgery. However, in spite of the fact that it
provide good esthetic results, but often the use of those
is related to complications in the form of flaps perfusion
disorders.
In 2011 Taylor et al. Published their studies of perfora­
somes,1 and in 2013 the findings of the study of true and
choke anastomoses between perforator angiosomes in var­
ious regions of body and their role in flap survival2 were
⁎ interaction with adjacent perforators via subdermal plexus
Correspondence to: Municipal Hospital #8, 19, Kosmichna str.,
Dnipro 49000, Ukraine.
E-mail address: badyul@gmail.com (P.O. Badiul).
1
ORCID: 0000-0001-8656-3143.
published. They indicated in their studies that as a rule true
anastomoses between perforators are located parallel
nerves and veins. Caliber of the blood vessels, which form
true anastomoses, does not change, while the vessels,
which form “choke” anastomoses, reduce their caliber de­
pending on physiological state. Functional ability of sub­
dermal vascular anastomoses between individual
perforasomes specifically defines survival probability for
flap distal part, which contains perforasomes of the second
and third order. Thus theoretical data on the perforator flap
type and its anatomic features, axial blood current, and
are critically relevant in perforator flap design.
Our team began searching for ways to improve micro­
circulation in perforator flaps by means of opening the “choke”

https://doi.org/10.1016/j.bjps.2023.05.059
1748-6815/© 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd.
 P.O. Badiul, S.V. Sliesarenko and O.I. Rudenko

anastomoses. We bring the negative pressure application (NPA)
method of acting upon the estimated donor area.
Patients and methods
The study was pursued between 2018 and 2020. The study
arm consisted of 20 people at the ages from 25 to 70 (5
women and 15 men), who had suffered full-thickness burns,
injuries, or had surgeries resulting in deep defects to be
covered with flaps.
Study methodology consisted in dynamic thermography
of the anticipated donor area after its preliminary cooling.
Two warm points of the perforator (Point 1, Point 2) and
a point in the cool area between perforators (Point 3 – Cold
Point) were selected, and the temperature in those points
was evaluated. Upon that the NPA system was placed in the
cool area for 5 days. Upon taking off the NPA system and
skin temperature measurements were taken once a day,
under the same conditions during 5 days, at that the NPA
system was placed back again after each measurement. The
NPA pressure setting was − 125 mm Hg continuous.
Results
Temperature measurement results in the two selected
warm perforator points (Point 1, Point 2) and the point in
the cool area between perforators (Point 3) before using
NPA system show steady temperature downward trend
(р < 0,1) in the cool area by a mean of − 1,89 °С as com­
pared to Point 1, and by − 2,12 °С as compared to Point 2.
Trend analysis of skin temperature under the influence of
local negative pressure showed significant decrease of dif­
ferences between values in the cool area and warm areas
already after the first day of NPA system use. At that "le­
velling" (reduction of differences) of temperature curves
was associated with temperature rise both in the cool area,
and in the perforator exit points (Figures 1 and 2).
The rate of skin temperature increase in Point 1 and
Point 2 ranged from 1,78 °С and 1,40 °С on the second day
after NPA system was placed to 2,82 °С and 2,52 °С as
compared to the basic value after 5 days of treatment. In
the cool area between perforators the rate of skin tem­
perature increase was almost twice higher – from 3,09 °С
within 24 h to 4,46 °С after 5 days of NPA.
Thus, mean skin temperature in the cool area after ap­
plying NPA system during 5 days in 20 patients included in
the study increased by an average from 30,85 °С to
33,64 °С, i.e. by 2,79 °С.
After NPA all patients had reconstructive surgeries to cover
defects using free or regional flaps. After reconstruction all
flaps survived and only in one case we had a non-critical com­
plication in the form of partial necrosis of the flap (5%).
In similar inclusion criteria patient groups in the studies
conducted in our department earlier where patients had no
NPA сomplications in the form of ischemia, venous conges­
tion resulting in partial necrosis of flaps was observed in the
range from 13% to 40% of cases.3,4

Figure 1 Thermal Images Analysis Report before NPA.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 84 (2023) 237–240

Figure 2 Thermal Images Analysis Report after 3 days NPA.

Discussion study, ethical approval was not required. Treatment of the

patient was not related to any of the Clinical trial.
In all cases after NPA program we saw temperature rise in
cool areas. Already in 24 h after usage of NPA system,
temperature difference between perforator exit points and
the area between perforators decreased.
CRediT authorship contribution statement
This fact evidences improved microcirculation in the skin
between perforators that implies function improvement of Pavlo O. Badiul: the idea of the research, thermal images
anastomoses between perforators and possible opening of analysis, surgery, writing the manuscript, research the
“choke” anastomoses. scientific literature. Sergii V. Sliesarenko: the idea of
the research, surgery, writing the manuscript, adminis­
trative and material support. Oleh I. Rudenko: per-
Conclusion forming the practical part of the study, thermal images
analysis, writing the manuscript, research the scientific
The results, based on thermography analysis, showed a ten­ literature.
dency to optimize the blood circulation of the intended donor
area under influence of NPA. That's why we may speak re­
garding the possibility of improvement microcirculation in the
skin and positive influence of local negative pressure applica­ Declaration of Competing Interest
tion on the state of anastomoses between perforators.
None of the authors has a financial interest in any of the
products, devices, or drugs mentioned in this manuscript.
Funding

None.
Ethical approval
Treatment of the patient was conducted fully in accordance
with the Helsinki Declaration. Due to the nature of this
References
1. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical
(angiosome) and clinical territories of cutaneous perforating
arteries: development of the concept and designing safe flaps.
Plast Reconstr Surg 2011;127(4):1447–59.

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 P.O. Badiul, S.V. Sliesarenko and O.I. Rudenko

2. Taylor GI, Chubb DP, Ashton MW. True and 'choke' anastomoses
between perforator angiosomes: part I. Anatomical location.
Plast Reconstr Surg 2013;132(6):1447–56.
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Efficiency assessment of multidetector-row computed
tomographic angiography using reconstruction with locoregional
perforator flaps. Plast Surg 2023;31(1):36–43.
4. Badiul PO, Sliesarenko SV. Multidetector-row computed tomo­
graphic angiography in the planning of the local perforator flaps.
Plast Reconstr Surg Glob Open 2015;3(9):e516.

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