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# The Time Index, 3 Keys in Melanoma Care, & Evidence on SLNB
- URL: https://www.theplasticsfella.com/december-7th/
- Published: 2025-12-07T10:14:00.000Z
- Updated: 2025-12-07T10:14:00.000Z
- Description: Also: ABCDEs of melanoma detection, Glabellar flap, & the Sunday quiz.
- Author: PlasticsFella
- Tags: thePlasticsPaper

#### In this week's edition

1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/december-7th/#a-letter-from-pfella)  
Introducing the time index.
2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-7th/#the-sunday-quiz)  
How well do you know **melanomas*?
3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/december-7th/#image-of-the-week)  
The ABCDEs of melanoma detection.
4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-7th/#technique-tip)  
Glabellar flap for melanoma reconstruction.
5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/december-7th/#what-does-the-evidence-say)  
Does SLNB improve survival?
6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-7th/#articles-of-the-week)  
NCCN guidelines: cutaneous melanoma, neoadjuvant immunotherapy for stage III melanoma, & sentinel node-positive melanoma management.
7. 💕 [****Feedback**](https://www.theplasticsfella.com/december-7th/#feedback)  
Suggest ideas & give feedback!

## A Letter from P'Fella

**Introducing the Time Index*

👋

The metrics publishers celebrate in medical education are mostly useless. Submission counts, acceptance rates, pageviews — they make for nice annual reports, but they tell us nothing about whether anyone actually learns. If we really cared about education, our scoreboard would look completely different.

**The Metric We *Should* Care About**

The ideal metric is *Retrieval-to-Bedside Time*:  
  
**How long does it take for someone to learn something and then use it safely, in real clinical practice, more than once?**  
  
That’s the real proof of understanding. And right now, we can’t measure it — not accurately. Realistically, not until 2027.

So until then, we can work with the next best proxy: time. Retention measures comprehension. Recurrence measures adoption.

**Introducing the Time Index**

This is why surgical education needs a new cultural metric: the **Time Index**.

**How long does a trainee stay with a single idea?**  
Not how many visited.  
Not how many clicked.  
But how long they stayed — voluntarily, repeatedly, because the concept mattered.

A crucial caveat: more time doesn’t automatically mean more learning. Ten hours trapped in an ISCP portfolio is a design failure, not a victory.

But consistent, repeated time spent with a concept? That’s behaviour change. Commitment changes behaviour — and behaviour is the closest proxy we have to genuine learning.  
  
And that’s the beginning of a real metric.

We are currently rebuilding thePlasticsFella to enable us to personalise these metrics to you. Stay tuned! 

With love,  
**P’Fella ❤️**

## The Sunday Quiz

**How Well Do You Know Melanomas?*

****Ready to climb the leaderboard?**  
  
Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the second round of seven rounds!  
  
The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount!

## Image of the Week

**The ABCDEs of Melanoma Detection*

🖼️

****Image of the Week**   
  
This week’s image highlights the ABCDE criteria: a simple and effective tool for distinguishing benign moles from suspicious lesions.  
  
A - ****Asymmetry**: Melanomas often lack symmetry.  
B - ****Border**: Irregular, notched, or uneven edges raise concern.  
C - ****Color**: Multiple or uneven colors can indicate malignancy.  
D - ****Diameter**: Lesions larger than 6 mm warrant closer assessment.  
E - ****Evolving**: Any change in size, shape, or colour is a key red flag.

![The ABCDEs of Melanoma Detection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/Illustration-of-ABCDE-criteria-for-skin-cancer-detection.png)

The ABCDEs of Melanoma Detection - [Source](https://www.researchgate.net/figure/Illustration-of-ABCDE-criteria-for-skin-cancer-detection%5Ffig2%5F359338536?ref=theplasticsfella.com)

## Technique Tip

**Glabellar Flap for Melanoma Reconstruction*

🚑

****Technique Tip of the Week**  
  
This week’s technique tip focuses on reconstruction after wide excision of a melanoma on the nasal dorsum — an area where tissue match is important but ****oncologic safety must guide every decision**.  
  
****Image sequence:**  
(a) Melanoma marked for wide local excision  
(b) Defect after excision with a glabellar flap elevated  
(c) Flap inset restoring nasal contour  
(d) Three-week healing with good colour match  
  
⚠️ Caution:   
  
While the ****glabellar flap** offers excellent tissue match, ****flaps in melanoma are risky** because they can bury residual disease and make re-excision difficult. For melanoma and MIS, ****skin grafts are generally preferred** until margins are confirmed, and flaps should only be used when oncologic safety is certain.

![Glabellar Flap for Melanoma Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/fig5.png)

Glabellar Flap for Melanoma Reconstruction - [Source](https://www.intechopen.com/chapters/47760?ref=theplasticsfella.com)

## What Does the Evidence Say?

**Does SLNB Improve Survival?*

In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. 

****Major Trials**  
  
****MSLT-I** showed that SLNB improves staging accuracy and disease-free survival, and provides therapeutic benefit mainly in patients with intermediate-thickness melanoma and positive nodes compared with observation and delayed lymphadenectomy.  
  
****MSLT-II** and ****DeCOG-SLT** then showed that ****completion lymph node dissection (CLND) after positive SLNB does not improve melanoma-specific survival**, but increases morbidity (especially lymphedema).  
  
****Take-Home**  
  
SLNB is a ****prognostic and staging tool** that identifies patients for adjuvant systemic therapy and guides the intensity of follow-up.  
  
CLND is now rarely indicated; nodal basins with metastatic disease are managed with ****systemic therapy + ultrasound surveillance** in many centres.  
  
****Key Trials and Summaries**  
\- Morton DL, et al. [Sentinel-node biopsy or nodal observation in melanoma (MSLT-I)](https://pubmed.ncbi.nlm.nih.gov/24521106/?ref=theplasticsfella.com). **N Engl J Med*. 2014;370:599–609\.   
\- Faries MB, et al. [Completion dissection or observation for sentinel-node metastasis in melanoma (MSLT-II)](https://pubmed.ncbi.nlm.nih.gov/28591523/?ref=theplasticsfella.com). **N Engl J Med*. 2017;376:2211–22\.   
\- Leiter U, et al. [DeCOG-SLT trial – CLND vs observation](https://pubmed.ncbi.nlm.nih.gov/27161539/?ref=theplasticsfella.com). **Lancet Oncol*. 2016;17(6):757–67\. 

## Articles of the Week

**3 Interesting Articles with One-Sentence Summaries*

✅

****Neoadjuvant Immunotherapy Outperforms Adjuvant-Only Approach in Resectable Stage III Melanoma** ([Chen](https://pubmed.ncbi.nlm.nih.gov/40305630/?ref=theplasticsfella.com), 2025)  
  
The NADINA trial established neoadjuvant immunotherapy as superior to surgery-first followed by adjuvant therapy for resectable stage III melanoma, demonstrating improved long-term outcomes and changing the standard treatment paradigm. 

✅

****Do Patients with a Positive Sentinel Node Still Need Completion Lymph-Node Dissection?** ([Faries](https://pubmed.ncbi.nlm.nih.gov/28591523/?ref=theplasticsfella.com), 2017)  
  
MSLT-II showed that in sentinel node-positive melanoma, routine completion lymph-node dissection improves regional nodal control and prognostic information but does not improve melanoma-specific survival, so ultrasound nodal surveillance is now preferred and dissection is reserved for therapeutic indications.

✅

****NCCN Guidelines: Cutaneous Melanoma - Key Clinical Principles** ([NCCN Guidelines: Cutaneous Melanoma - Key Clinical Principles](https://www.nccn.org/professionals/physician%5Fgls/pdf/cutaneous%5Fmelanoma.pdf?ref=theplasticsfella.com), 2025)  
  
These guidelines recommend complete excisional biopsy for accurate staging, stratify wide excision and sentinel-node biopsy by Breslow depth, endorse neoadjuvant immunotherapy for resectable stage III disease, prioritize modern systemic therapy for advanced melanoma, and outline risk-based follow-up to detect recurrence early.

## Feedback

### I hope you enjoyed it 😄

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