Kyle Y. Xu’s research while affiliated with University of Miami and other places

Background: Microsurgery is a core component of United States (US) plastic surgery residency curriculum. This study compares publicly available information on microsurgery curricula and training among US plastic surgery residency programs, while evaluating the background and experience of microsurgeon faculty at these institutions. Methods: The authors performed a cross-sectional web-search search on 103 accredited US plastic surgery residency programs in March 2023. Publicly available information evaluated for each program included non-clinical microsurgery education, clinical microsurgical exposure, and the number of microsurgeon faculty. The perceived gender and race, professorship title, previous training, academic productivity, and scope of practice were determined for each individual faculty member. Results: While approximately one-half of programs had evidence of microsurgical skill labs with anastomosis models (n=56; 54%), fewer had a formal microsurgery curriculum (n=36; 35%) or benchmark examinations (n=25; 24%). Significantly more home institutions provided clinical exposure to breast, trauma or cancer, head and neck, and hand-related microsurgery than gender (p<0.001) and lymphedema microsurgery (p<0.001). Of the 724 faculty microsurgeons, most were male (n=543), Caucasian (n=488), and Assistant Professors (n=316). Faculty underrepresented in plastic surgery were most often Assistant Professors with significantly fewer years of experience than their male (p<0.001) and Caucasian counterparts (p<0.023). Conclusion: Great variability exists in clinical and non-clinical microsurgery training among US plastic surgery residency programs. As the demand for microsurgery continues to rise, we can expect microsurgery education to become more uniform. Most microsurgeon faculty underrepresented in plastic surgery were earlier in their career, suggesting a potential shift in diversity as these individuals ascend the academic ladder.

Background: The work relative value unit (wRVU) system quantifies surgeons' effort and resources for procedures. Studies have shown its inaccuracy in capturing the complexity of certain plastic and upper extremity surgeries. Analysis for peripheral nerve surgery (PNS), a growing niche within hand and plastic surgery, has not been performed. The authors aim to evaluate the PNS wRVUs by correlation to their operative time. Methods: A retrospective analysis with current procedure terminology (CPT) codes for PNS (2005-2021) from the American College of Surgeons National Surgical Quality Improvement Program database was performed. Efficiency was determined by wRVU per operative time. Correlation was performed between operative time with wRVU and wRVU/minute. Results: A total of 2402 procedures across 21 CPT Codes were included and categorized into neuroplasty, nerve repair, and nerve grafting/transfers with the median operative time being 63.75, 100, and 153.78 minutes respectively. Nerve graft/transfer generated the maximum wRVU (mean 16.35). Neuroplasty generated the minimum wRVU (mean 7.24). Nerve grafts/transfers generated the least wRVUs per minute (0.09). Longer operative times were associated with higher wRVUs. Neuroplasty (R = .86) and nerve repairs (R = .84) had a strong correlation to the operative time. Nerve grafts/transfer had a positive but moderate correlation with the operative time (R = .67). All procedures had a negative correlation between operative time and wRVU/minute. Conclusions: Nerve grafts/transfers had reduced compensation compared to neuroplasty or nerve repairs. Compensation did not reflect the procedure efficiency. This disparity in wRVU allocation for complex PNS underscores the need for remuneration reform.

Background Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures. Methods A retrospective study was done using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0–5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories. Results Of 2,305 patients, the mean age and body mass index (BMI) were 53.13 years and 28.53 kg/m2, respectively. The 5-mFI ≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant. Conclusion 5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI ≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions.

Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients’ lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.

Neuroma management has gained significant attention in the peripheral nerve literature in the past decade. Alongside techniques such as targeted muscle reinnervation and regenerative peripheral nerve interface, another technique known as the “allograft to nowhere” has emerged. This approach involves the placement of an extended allograft at the end of a nerve, creating a regrowth zone in cases where muscle or nerve targets are not available. Although technique and outcomes research has been performed regarding the above techniques, there is a lack of imaging studies to examine postoperative outcomes. The authors present a case of recurrent neuroma management using a combined nerve allograft to nowhere + muscle target, supported by postoperative imaging.

Background Mastectomy, axillary lymph node dissection, and irradiation for breast cancer commonly result in perivascular and axillary scarring. This scarring is thought to cause functional venous stenosis that leads to downstream venous hypertension in the affected extremity. Standard surgical practice is to decompress perivascular scarring at the time of physiologic lymphedema surgery in patients with breast cancer-related lymphedema (BCRL). However, it is unknown whether this scar release influences surgical outcomes. The purpose of this study was to evaluate the prevalence of functional venous stenosis in patients with BCRL and determine whether scar decompression is a necessary step in physiologic lymphedema surgery. Methods The authors conducted a retrospective review of 64 patients with unilateral BCRL that presented to our lymphedema center between January 2020 and October 2022. Radiologist reports of venous duplex ultrasound for the bilateral upper extremities identified any disturbances in venous flow or indications of venous stenosis. Results Of the 64 patients with BCRL, 78% (n = 50) had prior axillary lymph node dissection. Forty-seven (73%) patients completed ultrasound imaging, of which, one patient (2%) had venous stenosis in the affected lymphedematous extremity identified on duplex ultrasound that may have suggested functional scarring. Vascularized lymph node transfer (VLNT) without scar decompression was performed in six patients (9%). Average preoperative Lymphedema Life Impact Scale and Lymphedema Index scores were 35 and 19 units, with a mean decrease of 23 (67%) and 6 (30%) units postoperatively. Conclusion Most patients with BCRL did not have identifiable functional venous stenosis on duplex ultrasound, apart from one patient with suspected postthrombotic changes. All six patients that received VLNT without scar decompression had a successful outcome with decreased measures of lymphedema postoperatively. Scar decompression may therefore be unnecessary in physiologic lymphedema surgery, reducing operative times and avoiding risk of injury to neurovascular structures of the axilla.

Demand for hand rejuvenation is on the rise. Hands are one of the foremost herald to aging (secondary only to the face). Two of the most prominent markers of an aged hand are prominent deep structures (such as veins and tendons) and areas of discoloration on the dorsum of the hand. These can all be effectively addressed with hand rejuvenation procedures; these include topical agents, chemical peels, laser therapy, dermal fillers, fat grafting, and a combination of modalities.

Finger entrapment with rings or ring-like objects is an uncommon possible hand emergency. In cases in which noncutting removal is ineffective, ring cutters or dental drills with carbide or diamond burs have been successfully used. However, objects composed of hard metallic alloys, such as lug nuts or wrenches, are often resistant to such equipment. In these instances, larger diameter metal cutting burrs or rasps may be more advantageous. Due to their increased size and cutting power, these tools are better suited to handle the toughness of hard metals. In this case report, we present the effective and efficient removal of a stainless steel wrench from an entrapped digit using a helicoidal rasp. Availability of this instrument within orthopedic departments may prevent the delays often described in the treatment of finger entrapment when traditional cutting equipment fails.