> ## Content Index > Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt > Use this file to discover other available public pages before exploring further. # Local Grassroots Education, 5 Melanoma Decisions, & Staged Excision Guide - URL: https://www.theplasticsfella.com/february-8th/ - Published: 2026-02-07T14:40:27.000Z - Updated: 2026-02-08T11:52:42.000Z - Description: Also: Final round of the Sunday quiz, evidence on adjuvant therapy after melanoma excision, & 3 recommended melanoma articles. - Author: PlasticsFella - Tags: thePlasticsPaper #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/february-8th/#a-letter-from-pfella) Where good education actually starts. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-8th/#the-sunday-quiz) How well do you know *melanoma*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/february-8th/#image-of-the-week) Inguinal lymph node dissection - key anatomy. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-8th/#technique-tip) Staged excision for skin cancer in tissue-critical areas 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/february-8th/#what-does-the-evidence-say) Post melanoma excision adjuvant therapy: Does it reduce recurrence? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-8th/#articles-of-the-week) Adjuvant therapy in stage III melanoma, imaging vs clinical follow-up for high-risk melanoma, & malignant melanoma in the hand. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Where Good Education Actually Starts* 👋 Most surgical education is built top-down. Big centres. Big names. Big conferences. Then, eventually, it trickles down to the people who actually need it on a Tuesday afternoon. But if you think about how most of us really learned and the stuff that stuck, it usually didn’t come from a stage. It came from small groups, local teaching, someone deciding, “This would actually be useful for our lot.” That’s the kind of education that lasts. Over the past few weeks, we’ve been piloting something new that leans into exactly that idea. **The Grassroots Project: Malaysia Pilot** We’ve started a Grassroots initiative in Malaysia:a local team working with us to organise teaching that’s designed for their system, their patients, and their reality, instead of a carbon copy of someone else’s curriculum. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/WhatsApp-Image-2026-02-08-at-06.24.06-1.jpeg) Team for The Grassroots Project: Malaysia Pilot The premise is simple: Good surgical knowledge should travel, and it has to make sense when it gets there. We’re not trying to build a new national dataset or over-engineer the “perfect” programme. And we’re not pretending one country’s way of working should automatically apply everywhere else. The first session is currently in the works. Short teaching, case-based discussion, and hands-on elements where possible: The kind of session you’d want to attend yourself. If it works, we build on it, and if something doesn’t work, we change it. What I find most encouraging isn’t the content, it’s the model. When teaching is owned locally, it travels deeper. And when it fits the system people are working in, it actually gets used. That’s where the real impact is. And if we help local teams teach locally, the impact compounds. **A Quick Ask** If you’re part of a teaching group, society, student organisation, or departmental programme anywhere in the world, and you’d like to do something similar, tell us. This doesn’t need to be complicated. It starts with a small team (even one person) and a good teaching session. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Melanoma?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the final 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 **Inguinal Lymph Node Dissection - Key Anatomy* 🖼️ ****Image of the Week** This image demonstrates the anatomy encountered during inguinal lymph node dissection, a procedure most commonly performed for ****melanoma with regional nodal disease**. The ****femoral vessels and nerve** form the deep boundary of dissection, with the ****great saphenous vein stump**, ****sartorius**, and ****adductor longus** acting as critical landmarks. The ****femoral canal** is shown as the site of the ****node of Cloquet**, marking the proximal extent of superficial nodal clearance and its interface with the pelvis. For melanoma surgeons, this anatomy underpins two competing priorities 👉 Adequate oncological clearance while minimising morbidity, particularly vascular injury, lymphoedema, and wound complications. ****Source:** Lupinacci RM et al. **Inguinal lymph node dissection*. Surgical Technique. ![Inguinal Lymph Node Dissection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/Screenshot-2026-02-07-at-13.37.10.png) Inguinal Lymph Node Dissection ## Technique Tip **Staged Excision for Skin Cancer in Tissue-Critical Areas* 🚑 ****Technique Tip of the Week** This video outlines the principles of ****staged excision** for skin cancer, a technique used when lesions arise on the face or other anatomically and **cosmetically sensitive sites** where tissue preservation is important. Unlike standard wide local excision where margins are excised and reconstruction proceeds in a single sitting, staged excision involves ****stepwise removal** of peripheral margins with delayed reconstruction, allowing full histological assessment before closure. This approach is particularly valuable for ****lentigo maligna and melanoma in situ**, where subclinical lateral spread is common and predefined margins may either be inadequate or excessively morbid. The key technical decision is ****timing**. Margins are cleared first, often over multiple procedures, and definitive reconstruction is only undertaken once oncologic clearance is confirmed. This technique emphasises that melanoma surgery is not just about excision margins, but about planning reconstruction around **oncologic certainty**, optimising both tumour control and aesthetic outcome. ## What Does the Evidence Say? **Post Melanoma Excision Adjuvant Therapy: Does It Reduce Recurrence?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. High-risk resected melanoma is one of the clearest areas where systemic adjuvant therapy **does* move the needle, primarily by lowering recurrence risk, at the cost of treatment-related toxicity. Across large adjuvant trials in ****resected stage III/IV melanoma**, PD-1 blockade consistently improves recurrence-free survival versus older standards or placebo. For example, nivolumab improved 12-month recurrence-free survival (70.5% vs 60.8%; HR 0.65) with markedly fewer grade 3-4 toxicities than ipilimumab (14.4% vs 45.9%). ([Weber](https://pubmed.ncbi.nlm.nih.gov/28891423/?ref=theplasticsfella.com) et al., 2017). Pembrolizumab versus placebo similarly improved 1-year recurrence-free survival (75.4% vs 61.0%; HR 0.57), with grade 3-5 treatment-related events reported in 14.7% (vs 3.4% with placebo). ([Eggermont](https://pubmed.ncbi.nlm.nih.gov/29658430/?ref=theplasticsfella.com) et al., 2018). For ****BRAF V600-mutated stage III melanoma**, targeted therapy is another high-quality option. Dabrafenib + trametinib improved 3-year relapse-free survival (58% vs 39%; HR 0.47). Overall survival was numerically higher at 3 years (86% vs 77%; HR 0.57), though that interim analysis didn’t meet the prespecified boundary for statistical significance. ([Long](https://pubmed.ncbi.nlm.nih.gov/28891408/?ref=theplasticsfella.com) et al., 2017). Even in ****resected stage IIB/IIC melanoma**, adjuvant PD-1 therapy reduces recurrence risk. In KEYNOTE-716, pembrolizumab lowered recurrence/death versus placebo at interim analyses (HR 0.61 at the second interim), with grade 3–4 treatment-related adverse events reported in 16% (vs 4% with placebo). ([Luke](https://pubmed.ncbi.nlm.nih.gov/35367007/?ref=theplasticsfella.com) et al., 2022). ****Bottom line:** Adjuvant systemic therapy meaningfully reduces recurrence risk in resected high-risk melanoma. The practical decision is less “does it work?” and more which pathway (PD-1 vs BRAF/MEK), and is the recurrence-risk reduction worth the toxicity trade-off for this patient? ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Changing Role of Adjuvant Therapy in Stage III Melanoma**](https://www.nejm.org/doi/abs/10.1056/NEJMe2514054?ref=theplasticsfella.com) Effective immunotherapy has shifted stage III melanoma management away from traditional “clean-up” adjuvant treatment toward earlier, more biologically powerful systemic therapy that alters long-term outcomes. ✅ [****TRIM Trial: Imaging vs Clinical Follow-Up After Surgery for High-Risk Melanoma**](https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2825%2900487-5/abstract?ref=theplasticsfella.com) This interim phase 3 trial suggests that routine whole-body imaging during follow-up after surgery for stage IIB-III melanoma does not improve survival compared with careful physical examination alone. ✅ [****Malignant Melanoma in the Hand: Current Evidence and Recommendations**](https://pubmed.ncbi.nlm.nih.gov/38663875/?ref=theplasticsfella.com) Melanoma of the hand often presents later and carries a worse prognosis than elsewhere, so any pigmented lesion of the hand or nail unit should be treated as malignant until proven otherwise. ## Feedback ### I hope you enjoyed it 😄 ---