The purpose to improve the results of surgical treatment of patients with defects of integumentary tissues by optimizing the preoperative planning of the area of formation of perforating flaps.
The study is based on examination and treatment of 129 patients who underwent reconstructive surgery using different types of perforating flaps and 35 healthy volunteers to establish normative indicators of the effects of negative pressure on the skin of the thigh - a total of 164 people.
The comparison group consisted of 60 patients who received traditional preoperative preparation. Control group - 35 healthy volunteers. The study involved patients aged 18 to 70 years, mean age of 34.70 years. The majority of the examined 10 patients, both in general (60.37%) and in the comparison groups were men, the rest (39.63%) - women. The lesions were mostly wounds. Preoperative preparation consisted in creating a local vacuum (VAC-action) in the donor area with a pressure of P = (- 130 mm Hg) for 30 minutes, followed by dynamic infrared thermography (DIT) to visualize perforating vessels with perforasomes.
The largest proportion of transplanted flaps in both study groups was occupied by the ALT flap of the thigh. In the main group in 18 (26.09%) cases, in the comparison group - in 15 (25.0%) cases (p = 0.529). The second place, both in the main and in the comparison group, was occupied by Keystone flaps (24.64% and 20.0%, respectively), the third position in the comparison group – propeller and sural flaps (16.67% each) and in the main group – V-Y flaps (17.39%), (p = 0.567).
Based on the ROC-analysis, it was found that the greatest, close to the maximum specificity is observed when using dynamic infrared thermography, the diagnostic capabilities of which have excellent operational characteristics for the detection of perforating vessels - sensitivity 95.16%, specificity 97.0%, area under ROC curve 0.906; p <0.001, which allows you to make more focused decisions in the preoperative period.
It is proved that the action of negative pressure enhances local microcirculation in tissues, as evidenced by the data of dynamic infrared thermography - an increase in local skin temperature, increased temperature with a temperature gradient ∆T2,1 2,13 (95% 1,72 - 2,54) °C . The optimal mode of action of negative pressure is 30 minutes at P = (- 130 mm Hg), which allows to increase blood flow by 2.42 times (p <0.001), which is confirmed by laser Doppler flowmetry.
The lack of statistically significant relationships (p> 0.05) of the flap size with the type of preoperative preparation, significant differences between the main group and the comparison group by flap size, suggests that the effectiveness of the approach as for "training" of donor skin with perforation by means of negative pressure is not determined by the type and size of the applied flap, but is associated primarily with VAC-action.
According to the correlation analysis, this approach ultimately significantly affected the development of complications: Spearman's correlation coefficient rs = 0.41 (p <0.001). Changes in flap perfusion were feedback-correlated with the incidence of complications (rs = −0.27; p = 0.027), so the more perfusion at the flap projection in the preoperative period, the fewer complications can be expected in the future. The analysis of survival of transplanted flaps proved the effectiveness of the proposed algorithm of preoperative planning of perforating flaps, the use of which significantly increased the survival of the flap during a month in hospital stay using thermography (81.82%) compared to cases when the method was not used (53.61%). Nagelker's coefficient of determination R2 showed the proportion of variance of the dependent variable, which was explained by the independent factors included in the model. Obtained by the results of logistic regression analysis R2 = 0.290 meant that the part of influence of the applied approach to the preparation of the donor site for plastic surgery by the influence of negative pressure on the development of complications is 29.0%.
The developed algorithm of actions at planning of a perforating flap taking into account a type of a flap and a condition of a blood flow in donor sites allowed to essentially increase a survival of the transplanted flap during a month of hospital stay
