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Noh et al. Plast Aesthet Res 2020;7:50 I http://dx.doi.org/10.20517/2347-9264.2020.49 Page 7 of 10

teaching. They concluded that centralization alone would not be effective but that other factors required to
be addressed.

[2]
An interesting finding in the Cho et al. study was that patients with private insurance were twice as likely
to receive replantation in comparison to patients with Medicare or Medicaid. As payer status directly
influences reimbursement, they suggested that financial incentive may play a role. This is further supported
by a recent analysis of reimbursement information for 51,716 patients by Hooper and colleagues, who
determined that replantation reimburses at $78/wRVU, which is significantly lower compared to revision
amputation ($108) or common procedures such as carpal tunnel release ($101), trigger finger release ($116),
[47]
and extensor tendon repair ($122) . Physician work relative value units (wRVU) is a direct measure of
physician reimbursement in the United States and, in this case, an indirect indicator of the perceived value
of a procedure. For both surgeons and payers, a common misconception is that there is minimal value in
replantations. This is in stark contrast to the literature, which shows good functional outcomes and high
patient satisfaction [15,48] .

It has been proposed that surgeon experience with microsurgery and anastomoses of fine veins is more
[11]
important to successful replantation than surgical technique . A conclusion of the above evidence is
that the stagnant or even decreasing survival rates result from a lack of experience. In the US, this has
unfortunately led to a self-perpetuating cycle: lack of experience leads to decreasing success rates, which
leads to decreased confidence and incentive, fewer attempts, and thus further lack of experience.

CONCLUSION
The current literature reveals two problems. First, there is a stagnation of the techniques and knowledge
associated with replantation in the literature. There are few conclusive statements that can be made of the
intricacies of the surgery. Second, and more discouraging, there is a regression of the field in the Western
hemisphere, most notably in the US. The rates of replantation and survival are both decreasing - this is
evidence of regression of medical care in the US. These two problems paint a concerning picture for the
current state of replantation surgery.

In 21st century medicine, we expect a continual and forward march in our knowledge, innovation,
treatments, and solutions. The current state of replantation surgery is unfortunately not consistent with
this. Can or should we expect any better in the future? If so, there are very important changes that need to
take place. Below are four important points that, if appropriately implemented, can allow for progression in
replantation surgery.

(1) Further research is urgently needed to better understand the barriers of successful replantation,
specifically in the United States. The current literature on replantation varies widely. Length of follow
up, how function is determined, and patient-reported outcomes vary from study to study. A coordinated
effort with consistent measures of function and patient-reported outcomes, similar to the 1981 report by
Dr. Zhong-Wei and other leaders in replantation, would be immensely valuable. Since injury patterns and
techniques are heterogenous, well designed and large prospective multi-center studies are a necessary part
of the solution.

(2) The evidence clearly supports the importance of technical skill, frequency of replantation, and clinical
experience as critical for improved survival rates. It is no secret that there are centers with much higher
success rates. Centralizing replantation surgery, especially in the United States, is an essential component
of this and naturally fosters the formation for centers of excellence. The knowledge and skill gained at these
centers of excellence must be shared and taught to younger replantation surgeons allowing for elevation of
the entire field.