Low Volume Surgeons = Hobbyists, Skin Cancer Guidelines & Episode 1.

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.

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 ❤️

Have you checked out the first episode of our podcast yet? "Behind the Fella," is now live on Spotify or Apple.

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!

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

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.

Merkel Cell Carcinoma

Definition
Merkel cell carcinoma is a malignant skin lesion arising from neuroendocrine cells.

Risk Factors
Include sun exposure, older age, immunosuppression, being Caucasian, and being male.

Pathogenesis
Merkel cell polyomavirus (MCPyV) is a recently discovered polyomavirus in MCC tumour tissue.

Clinical Features
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
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
MCC is classified and staged from the AJCC 8th edition of 2017.

Treatment
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

On top of that, we've also curated a clinical case of Merkel cell carcinoma – you can read it here.

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 lower 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)".