In this week's edition
- ✍️ Letter from P'Fella
When does a library become a curriculum? - 🤓 The Sunday Quiz
Week four is here! - 🖼️ Image of the Week
When breast lymphatics find another route - 🚑 Technique Tip
Axillary lymph node dissection - 📖 What Does the Evidence Say?
Does axillary radiotherapy increase lymphoedema risk? - 🔥 Articles of the Week
ICG fluorescence imaging, lymphatic drainage, & robots in lymphatic surgery. - 💕 Feedback
Suggest ideas & give feedback!
A Letter from P'Fella
When Does a Library Become a Curriculum?
That meant articles. Lots of them. Then came the Plastics Paper, Foundations, How I Operate, clinical illustrations, quizzes, interview guides, webinars, and all the other things we’ve added over time. Each one solved a different problem, and I’m proud of how much is now there.
But having a lot of useful material is not quite the same as having a curriculum.
A library can give you everything at once. It can answer a question when you already know what you’re looking for. What it doesn’t always do is tell you where to begin, what should come next, what you’re expected to know, or how the pieces fit together.
Take one area like hand surgery. You might have articles on anatomy, tendon repair, fractures, nerve injuries, local flaps, and complications. All useful, but if they sit as separate pages, the learner still has to work out the order, the gaps, and the level they should be aiming for. The same applies to every other part of the specialty.
A proper curriculum should do more than be a collection of articles. It should help someone move through it. It should make it easier to see the basics first, then the clinical decisions, the techniques, and finally the harder parts: complications, judgment, and when the standard approach no longer fits.
This is why we started building departments around each specialty, with their own curriculum, clinical leadership, and review process. It gives us a way to look at the subject as a whole rather than publishing isolated articles and making the reader gather them into something coherent for themselves.
This is also where the new platform update comes in. Our next version of Plastics Pro is being built around that idea: helping people follow a path, not just search a library.
Articles will always matter. So will the podcasts, visuals, quizzes, Foundations, and live teaching sessions we are planning. But there's also some very important work under the surface to connect them properly, so each part supports the next and guides the learner through a smooth flow.
Now we’re working towards not simply making good plastic surgery information easier to find, but along with it, a clearer way to learn.
P’Fella ❤️
The Sunday Quiz
Week Four Is Here!
Each week, we'll put your plastic surgery knowledge to the test with a new question designed to challenge you and keep you thinking. Join in every Sunday, keep your wits about you, and compete for the top spot. The winner at the end of eight rounds will receive 6 months of Plastics Pro, on us.
Image of the Week
When Breast Lymphatics Find Another Route
When normal lymphatic drainage is disrupted, the breast can develop collateral pathways that redirect lymph towards alternative drainage regions.
These ICG lymphography images compare normal and altered breast lymphatic drainage. In the control participant (A), lymph drains towards the ipsilateral axilla. In participants with breast lymphoedema (B and C), drainage is redirected towards the clavicular, parasternal, and even contralateral axillary regions, demonstrating how lymphatic pathways can adapt when normal drainage is compromised.
Technique Tip
Axillary Lymph Node Dissection (ALND)
Axillary lymph node dissection (ALND) involves the removal of axillary lymphatic tissue, with the extent of clearance determined by the oncological indication.
In this operative video, a mastectomy with Level III axillary clearance is demonstrated in a patient with node-positive invasive breast cancer.
What Does the Evidence Say?
Does Axillary Radiotherapy Increase Lymphoedema Risk?
The combination of treatments appears to produce the highest absolute risk. Prospective surveillance found 5-year lymphoedema rates of 8.0% after sentinel node biopsy alone, 10.7% after sentinel node biopsy plus regional nodal irradiation, 24.9% after axillary dissection alone, and 30.1% after axillary dissection plus irradiation. After adjustment, axillary dissection remained the dominant risk factor, and the additional effect of radiotherapy within each surgical group was not statistically significant. However, pooled evidence suggests that the radiotherapy-associated increase is clearest in patients who have already undergone axillary dissection.
The practical takeaway is that regional nodal irradiation adds some lymphoedema risk, but axillary dissection is usually the larger contributor. Axillary radiotherapy may reduce lymphoedema when it replaces dissection in suitable patients; when radiotherapy is added after dissection, patients enter the highest-risk group and should receive clear counselling, baseline measurements, and prospective surveillance.
(Whelan, 2015); (Bartels, 2022); (Naoum, 2020); (Shaitelman, 2016)
Articles of the Week
3 Interesting Articles with One-Sentence Summaries
ICG fluorescence imaging allows surgeons to visualise lymphatic drainage in real time, helping identify arm-draining lymph nodes during axillary surgery and map lymphatic vessels for reconstruction, with 80-88% of arm-draining nodes identified in patients undergoing axillary lymph node dissection.
Following breast cancer treatment, 90% of women with breast lymphoedema showed alternative lymphatic drainage pathways, redirecting fluid towards the opposite axilla, parasternal, intercostal, or clavicular regions, while only 40% retained drainage to the original axilla.
Robotic systems can help surgeons perform ultra-precise lymphatic connections in vessels smaller than 1 mm, filtering out hand tremors, but current evidence shows no clear improvement in patient outcomes compared with conventional microsurgery.
