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# Low Volume Surgeons = Hobbyists, Skin Cancer Guidelines & Episode 1.
- URL: https://www.theplasticsfella.com/may-26th/
- Published: 2024-05-26T14:29:49.000Z
- Updated: 2024-05-26T16:36:31.000Z
- Description: Also: New Sunday Quiz & new feature on scientific evidence.
- Author: PlasticsFella
- Tags: thePlasticsPaper

#### In this week's edition

1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-26th/#a-letter-from-pfella)  
Low-volume surgeons are hobbyists?
2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-26th/#the-sunday-quiz) **\+ Leaderboard**  
Start of a new season: Merkel cell carcinoma
3. ****🎙️** [****Behind the 'Fella Episode 1**](https://www.theplasticsfella.com/may-26th/#behind-the-fella)  
Listen to our first podcast episode!
4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/may-26th/#the-fellows-corner)  
What's new with the team?
5. 📖 [****What does the evidence say?** ](https://www.theplasticsfella.com/may-26th/#what-does-the-evidence-say)  
What does the evidence say about burying K-wires?
6. ****🔥** [****Skin Cancer Articles of the Week**](https://www.theplasticsfella.com/may-26th/#articles-of-the-week)  
Merkel cell carcinoma, melanoma controversies, & basal cell carcinoma; with 1 sentence summaries.
7. 💕 [****Feedback**](https://www.theplasticsfella.com/may-26th/#feedback)  
Suggest ideas & give feedback!

## A Letter from P'Fella

**Low-Volume Surgeons are Hobbyists?*

👋

****Hey Team!**  
  
I've come across the argument that low-volume surgeons are hobbyists, but I disagree, especially in the context of plastic surgery. Let's dive into the details.   
  
👇

### 

### 

**Defining "low volume" is tricky**. The "Take the Volume Pledge" campaign sets minimum annual procedure thresholds, like 10 per hospital and 5 per surgeon for carotid stenting, and 50 per hospital and 25 per surgeon for hip and knee replacements. However, these numbers can be arbitrary and not always evidence-based.

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Screenshot-2024-05-26-at-15.16.12.png)

[NEJM Publication](https://www.nejm.org/doi/abs/10.1056/NEJMp1508472?ref=theplasticsfella.com)

### But the Evidence is Clear?

Higher-volume surgeons do generally have better outcomes. A systematic review by Chowdhury et al. found that high-volume hospitals had significantly better outcomes in 74% of studies, though the benefit was less pronounced in prospective studies (40%). Similarly, high-volume surgeons had better outcomes in 74% of studies.

### A Different Perspective

In plastic surgery, many conditions are inherently low volume, making certain surgeries rare. Procedures like thumb pollicization or Gustilo-Anderson 3C fractures are seldom encountered, even by subspecialists. As plastic surgeons, we handle a wide range of complex cases, similar to general surgeons but without the focus on visceral organs. The "Take the Volume Pledge" doesn't address managing low-volume procedures in these specialties, which are critical for patient care.

### Potential Solutions

High standards must be maintained across all types of surgeries, whether common or rare. 

- **Subspecialize Further:** Encourage focused subspecialization to develop deep expertise in specific areas.
- **Travel to Other Departments:** Gain exposure to rare procedures by collaborating with high-volume centers.
- **Centralize Surgeries:** Centralize low-volume surgeries in specialized centers to ensure patients receive care from experienced surgeons.

I'm eager to hear your thoughts. What methods should we explore to maintain our low-volume skills? Just reply to this email and share your insights!

P'Fella ❤️

  
****tl;dr**  
  
👉 I disagree with the idea that low-volume surgeons are hobbyists, especially in plastic surgery.  
👉 Defining low volume is complex and often arbitrary.  
👉 Many conditions in plastic surgery are already low volume, making surgeries even rarer.  
👉 Let's discuss how to adapt our training to ensure optimal patient care.  

## The Sunday Quiz

**New Season is Starting!* 

****Are you ready for a new round of The Weekly Quiz?**  
  
Welcome to ****the first round** of The Weekly Quiz.  
  
Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher.   
  
PS: Our top scorers from the last season are joining us for a playoff, live on our upcoming podcast episode! 

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--13--3.png)

Presentation of Merkel Cell Carcinoma

## Behind the ‘Fella

**Episode One is Now Live!*

Have you checked out the first episode of our podcast yet? "Behind the Fella," is now live on[**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **or** [**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)**.**   
  
Join us for exclusive insights from our team meetings and engaging discussions on plastic surgery with our fellows. Get a unique, behind-the-scenes look at our practice! 

0:00 

/3:50 

1× 

Click here for [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****.**

**The first episode is out! 🌟**   
  
Have a listen to our discussion on:

- Meet the team!
- Seymour fractures
- K-wire tips and tricks
- Surgical video brainstorming debut on the platform

[Subscribe on Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)

[Subscribe on Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com)

## the Fellows' Corner

**What have the fellows been up to?*

  
Our team has been hard at work creating fantastic new content for our community, including fresh **articles**, clinical **cases**, and surgical **techniques** focused on tumors. Don't miss our article on **Merkel cell carcinomas.**

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--14--1.png) 

#### Merkel Cell Carcinoma

[****Definition**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#definition-of-merkel-cell-carcinoma)  
Merkel cell carcinoma is a malignant skin lesion arising from neuroendocrine cells.

[****Risk Factors** ](https://www.theplasticsfella.com/merkel-cell-carcinoma/#risk-factors-of-merkel-cell-carcinoma)Include sun exposure, older age, immunosuppression, being Caucasian, and being male.

[****Pathogenesis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#pathogenesis-of-merkel-cell-carcinoma)  
Merkel cell polyomavirus (MCPyV) is a recently discovered polyomavirus in MCC tumour tissue.

[****Clinical Features**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-features-of-merkel-cell-carcinoma)  
A fast-growing, painless, firm, non-tender cutaneous nodule. It is reddish-purple with a shiny surface, most commonly in the head and neck region.

[****Diagnosis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#diagnosis-of-merkel-cell-carcinoma)  
Definitive diagnosis of MCC consists of histopathology with an immunohistochemistry panel. An SNLB should be performed on all patients who are diagnosed with MCC.

[****Clinical Staging**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma)  
MCC is classified and staged from the AJCC 8th edition of 2017.

[****Treatment**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma)  
Treatment of MCC involves wide local excision +/- radiotherapy as MCC is very radiosensitive. Chemotherapy is rarely used, except occasionally for palliative care.

[Read the Article](https://www.theplasticsfella.com/seymour-fracture/) 

On top of that, we've also curated a clinical case of Merkel cell carcinoma – you can read it [here](https://www.theplasticsfella.com/merkel-cell-carcinoma-clinical-scenario/). 

## **What does the Evidence say?*

**A new section!*

In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For our first debate topic, we have ****Buried vs Non-Buried K-Wires in Hand Surgery!**

### Buried vs Non-Buried K-Wires in Hand Surgery 

"The decision to bury or leave Kirschner wires (K-wires) exposed in hand surgery is influenced by various factors, including ease of removal, perceived risk of infection, and patient preferences (Gardiner 2018). While some studies have found **no significant difference** in infection rates between buried and non-buried K-wires (Koç 2012), others have reported a **lower risk of pin site infection** with buried K-wires (Hidajat 2023). However, non-buried K-wires have been associated with a l**ower risk of adverse events** and may be more **cost-effective** (Wormald 2017). Similarly, percutaneous K-wires have been found to have a significantly greater infection rate than buried wires in treating hand fractures (Rafique 2006)".

## Articles of the Week

**3 interesting articles with 1 sentence summaries.* 

1️⃣

***NCCN guidelines for Merkel cell carcinoma** ([Chrysalyne](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2024)  
  
The NCCN Guidelines for Merkel Cell Carcinoma highlight the importance of early detection through comprehensive skin exams and biopsy, with immunohistochemistry staining confirming the diagnosis.

2️⃣

***What are some controversies in melanoma treatment?** ([Temple-Oberle](https://journals.lww.com/plasreconsurg/abstract/2023/03000/current%5Fcontroversies%5Fin%5Fmelanoma%5Ftreatment.42.aspx?ref=theplasticsfella.com), 2023)  
  
Controversies in melanoma treatment: Optimal margins for in situ and invasive disease, reconstructive options like the keystone flap for excision defects, and advancements in managing sentinel node biopsies.

3️⃣

***NCCN guidelines on basal cell carcinoma** ([Chrysalyne](https://jnccn.org/configurable/content/journals$002fjnccn$002f21$002f11$002farticle-p1181.xml?t%3Aac=journals%24002fjnccn%24002f21%24002f11%24002farticle-p1181.xml&ArticleBodyColorStyles=full%20html&ref=theplasticsfella.com), 2024)  
  
Explore the latest NCCN guidelines on Basal Cell Skin Cancer, detailing diagnostic, treatment, and follow-up practices for this prevalent skin cancer. 

## Feedback

### I hope you enjoyed it 😄

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