Welcome back to the journal review. This month we're working through the August twenty twenty-six issue of Dermatologic Surgery, and we've got four pieces on the docket — an original comparative study on facial nevus excision, a medicolegal communication on injectable topical cosmetics, a review on nail splinting to prevent dorsal pterygium, and a reconstructive conundrum on earlobe repair. Let's get into it.

First up is an original article out of the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences: a retrospective comparative analysis of a novel transcutaneous suturing technique with microsurgical assistance versus CO2 laser ablation for small facial nevi, specifically lesions two millimeters or less.

The background here is one you already know intuitively — sub-two-millimeter facial nevi, especially on the nose, sit in an awkward zone. Laser ablation is fast and essentially bloodless, but it's a blind vaporization process: you can't precisely control depth, so you risk incomplete removal and recurrence, plus thermal collateral damage giving you dyspigmentation or a scar that ends up bigger than the original lesion. Conventional excision with standard subcuticular closure, on the other hand, is nearly impossible to execute cleanly on something this small — you can't get good dead-space closure or eversion, so you're stuck with either widened scars or imprecise superficial sutures. The gap the authors are targeting is exactly that dead zone between "efficient but blind" and "precise but technically unworkable at this scale."

Their solution is a microscope-assisted transcutaneous suturing technique using fine six-oh or seven-oh PDS-two absorbable suture, with a specific three-pass needle trajectory under five-times magnification that achieves dermal apposition and edge eversion while explicitly avoiding burying epidermal tissue — which matters because buried epidermis is a known setup for inclusion cysts and poor healing.

Methodologically, this is a retrospective, nonrandomized, parallel-controlled study, sixty patients total, thirty getting the novel microsuture and thirty getting CO2 laser, assigned by whichever treatment the patient chose rather than by randomization. The authors don't spell out why they went retrospective rather than a prospective randomized design, but it's a reasonable inference that this reflects real-world practice patterns — patients self-selected their treatment, which is pragmatic for a single-center cohort like this but also means you have to worry about selection bias baked in from the start: patients who chose surgery over laser might have differed in lesion characteristics, risk tolerance, or aesthetic expectations in ways that could confound the outcome comparison.

Statistically, this is refreshingly simple — independent samples t-tests for continuous variables like operative time and Vancouver Scar Scale scores, and chi-square or Fisher's exact test for categorical variables like recurrence. Worth a quick word on why Fisher's exact shows up here: with a sample of thirty per arm and a recurrence event that's relatively rare in one group, cell counts in the two-by-two table can get small enough that the chi-square approximation becomes unreliable, so Fisher's exact computes the precise probability of the observed table arrangement rather than relying on an asymptotic approximation. That's the right choice for a study this size looking at a binary outcome like recurrence.

On results: the suture group took longer — about three and a half minutes versus roughly twenty-five seconds for the laser, and had a small amount of measurable bleeding versus essentially none for the laser, both statistically significant but clinically expected and trivial trade-offs for what you get in return. The real story is in the efficacy outcomes: Vancouver Scar Scale scores were substantially lower in the suture group, satisfaction scores were meaningfully higher, and recurrence was dramatically different — about three percent in the suture group versus thirty percent in the laser group. That recurrence gap is the number worth remembering, because a ten-fold difference in recurrence is not a subtle effect — that's a clinically decisive finding, assuming it holds up.

Now for the honest caveats, some of which the authors acknowledge and some worth adding yourself. This is a small, single-center, retrospective, nonrandomized cohort with patient self-selection into treatment arms — real risk of confounding. Follow-up is only six months, which is enough to catch early recurrence and initial scar maturation but not long enough to know if that three percent recurrence holds at one or two years, and not long enough to fully assess final scar appearance, since scars continue to remodel well past six months. There's also an obvious operator-dependency issue baked into any technique requiring a surgical microscope and fine suture handling at this scale — reproducibility outside a center with that specific equipment and experience is an open question they don't address.

Practical takeaway: this is interesting, not yet practice-changing. The underlying logic — that precise microscope-guided low-tension closure with eversion beats blind thermal ablation for a two-millimeter facial lesion — is mechanistically sound and consistent with everything you already know about tension and scar quality. But before you adopt a three-pass transcutaneous technique into your own small-nevus workflow, you'd want to see this replicated with randomization, longer follow-up, and ideally by surgeons outside the original center. File it as a technique worth watching, particularly for tiny nasal or facial nevi where you already default to excision over destruction for diagnostic reasons.

Next is a communication — not a study, more of a medicolegal alert — on the injectable use of topical cosmetics.

The core issue: platelet-derived growth factor products and various stem-cell, human, or plant-derived exosome preparations, all marketed as topical cosmetics, are increasingly being injected off-license in aesthetic practice. The authors walk through why this is legally precarious rather than clinically debatable. Under the Federal Food, Drug, and Cosmetic Act, a cosmetic is by definition something applied to the body's surface — rubbed, poured, sprinkled, sprayed. The moment you inject a product percutaneously, you've bypassed the cutaneous barrier and altered tissue structure, which disqualifies it from cosmetic status entirely and reclassifies it as either a drug or a device.

Here's the sharper point: off-label use — which is standard, legal practice for physicians using approved drugs or cleared devices outside their labeled indication — only applies to products that have at least one FDA-approved or cleared use to begin with. Exosome products currently have zero FDA-approved indications, and unlabeled PDGF products used this way don't have an approved injectable indication either. So injecting them isn't "off-label use" in the legally protected sense — it's the use of an unapproved new drug or biologic, or an unauthorized device, full stop. That distinction matters enormously, because it strips away the usual legal safe harbor physicians rely on when they use something outside its label, and it opens the door to FDA sanctions, criminal penalties, malpractice exposure, and medical board discipline.

The authors also flag a genuine gray zone worth knowing about: transepidermal delivery via microneedling or ablative laser channels. They suggest applying a topical cosmetic after microneedling or before ultrasound-assisted delivery likely doesn't constitute "injection" in the same sense, and that purely intraepidermal disruption is probably less legally fraught than something that reaches the dermis. But they're explicit this is their own reasoned suggestion, not settled law.

No methods, no results here — this is a legal-risk communication, and the practical takeaway is direct: if you or your practice is injecting an exosome product or an unlabeled PDGF preparation, marketing language like "not for injection" printed on the product does not protect you, and intent can be inferred from how the product is promoted or used regardless of label disclaimers. Worth actually reviewing what's being injected in your own cosmetic or hybrid practice with this framework in mind.

Third, a review article on nail splints to prevent dorsal pterygium after nail surgery, from a group including Adam Rubin.

The clinical problem is one you manage directly: when nail matrix or proximal nail fold epithelium is disrupted — whether from trauma or from surgery like matrix biopsy or tumor extirpation — exposed dermis on the ventral proximal nail fold can fuse with exposed dermis of the matrix or bed. That fusion creates fibrosis that blocks nail plate production, splitting the nail into two progressively narrowing segments as the pterygium widens, and in severe cases causes total nail loss. It's often permanent, since correction is technically difficult and recurrence after repair is common given how delicate the matrix is. So prevention is everything, and the barrier of choice is a splint placed between those exposed tissues during the healing window.

This is a literature review, not original data — a PubMed and Ovid Medline search from 1950 through September twenty twenty-five, screened down to forty-two included sources, excluding non-English articles and anything about splints for ingrown nails specifically, since that's a different clinical question.

The review organizes around two practical questions: when do you need a splint, and what do you splint with. On indications, the risk stratification is genuinely useful to have systematized: simple or partial nail avulsions without matrix trauma, and lateral longitudinal biopsies, are low risk and often don't need splinting — though subtle superficial ulceration during an aggressive avulsion can still occasionally cause a pterygium, so it's surgeon judgment. Small nonmidline distal matrix biopsies under three millimeters are also lower risk. But midline biopsies, especially proximal matrix biopsies, tumor extirpation involving the matrix, Seymour fracture repairs, and periosteal flap procedures for pincer nail or micronychia correction all carry real risk and the review recommends splinting in every one of these scenarios.

On material selection, the native nail plate is unequivocally the ideal splint — it matches the exact shape, curvature, and rigidity you're trying to recreate, and it's free. If it's fragmented, tissue adhesive can reconstruct it before reinsertion. But when the nail is unavailable — most commonly because it's gone to pathology — you're choosing a synthetic substitute, and the review lays out a genuinely practical comparison table. Soft options like nonadherent petrolatum gauze, silicone sheeting, or surgical glove are cheap and available but flimsy, prone to falling out of the nail pocket, and provide poor mechanical protection. Semi-rigid options — aspiration tubing, nasogastric tubing, suture packet foil, polypropylene from infusion set reservoirs — hit a better balance: inexpensive, often transparent for postoperative visualization, and enough rigidity to actually function as a barrier against external force, though foil packets need to go in shiny-side down to avoid staining the nail bed. There's also a commercial proprietary splint option, sterile and individually packaged with pre-made drainage holes, but it's not widely available and costs roughly fifty dollars against options that run a dollar or two.

Since this is a pure review with no comparative outcome data of its own, there's no statistics lesson here and no results-versus-limitations arc to walk through — it's a synthesis and a practical guide. Takeaway for your practice: this is genuinely useful as a quick-reference framework, particularly the risk-stratified indication table. If you're doing proximal matrix biopsies or matrix-involving tumor extirpations and not routinely splinting, this is worth changing tomorrow. And if you don't already have a go-to synthetic splint stocked when the native nail isn't available, aspiration or nasogastric tubing is a cheap, practical default worth keeping on hand.

Last up is a reconstructive conundrum — a case-based technique discussion — on repair of an earlobe defect.

The setup: a seventy-eight-year-old man with an eleven-millimeter squamous cell carcinoma of the right earlobe, cleared in a single Mohs stage, leaving a defect just over a centimeter and a half by just over a centimeter. The piece walks through the standard menu for earlobe defects and why each falls short here. Full and split-thickness skin grafts are the traditional workhorses but carry real risk of partial or complete graft failure, contour irregularity, and color mismatch, plus bolster dressings and wetting restrictions for one to two weeks. Two-stage interpolation flaps — postauricular or preauricular cheek — give excellent color match and robust tissue but require a second procedure for pedicle division and prolonged wound care. Second intention risks contraction and earlobe deformity. And given this specific defect's location, a preauricular transposition flap would have blunted the preauricular sulcus — an aesthetically important landmark you don't want to sacrifice.

Their resolution was a single-staged tunneled island pedicle flap from the preauricular cheek. Technique-wise: an elliptical flap slightly larger than the defect is raised from the preauricular cheek, undermined vertically with minimal undermining at the inferior aspect to protect the pedicle, the superior aspect freed to allow a ninety-degree turn, the leading edge released and the distal half undermined, then the flap is tunneled subcutaneously at the ear-to-cheek junction and sutured over the defect. No true de-epithelialization needed provided the undermining is adequate for full mobility, and a basting stitch secures contact with the wound base. Donor site closes primarily, concealed within the preauricular sulcus.

The stated advantages are substantial: patients can shower within forty-eight hours rather than avoiding wetting for one to two weeks, no bolster dressing, no second procedure for pedicle division, lower graft-failure risk since the flap carries its own blood supply, and a single bandage covering both defect and donor site. The one real limitation they flag explicitly is relevant to your consent conversations — the tunneling can disrupt an existing earlobe piercing tract, so that needs to be discussed upfront with any pierced patient. Their patient had an excellent cosmetic outcome at six months, with preserved natural ear-to-cheek contour and no pixie-ear deformity.

As a reconstructive conundrum, there's no statistical analysis and no cohort — it's a single case demonstrating a technique, so the takeaway is straightforwardly practical rather than evidence-graded: for earlobe defects in this size range where a preauricular transposition would blunt the sulcus and you want to avoid graft-related wound care burden or a two-stage interpolation flap, the tunneled island pedicle flap from the preauricular cheek is a reasonable single-stage option to have in your reconstructive repertoire — with the piercing-tract conversation as a mandatory part of consent.

That wraps the August issue. To summarize the through-line: a promising but early-stage technique for tiny facial nevi worth watching rather than adopting outright, a legal reminder to scrutinize anything you or your staff might be injecting that started life as a topical cosmetic, a genuinely practical risk-stratified framework for nail splinting you can apply this week, and a clean single-stage flap option for earlobe defects that spares your patients the graft-care burden. Thanks for listening, and I'll see you next month.