Welcome back to the journal review. This is our walkthrough of the August 2026 issue of Dermatologic Surgery, and we've got four pieces on the docket today — a review on hormone replacement therapy and melasma, a reconstructive conundrum involving the helical rim, a comprehensive anatomy review for genital and inguinal surgery, and an original retrospective study on liposomal bupivacaine safety. Let's get into it.

First up is a review article asking whether hormone replacement therapy influences melasma development. This comes out of a Brisbane-based group, including Davin Lim, and it's tackling a question you've almost certainly fielded from a perimenopausal patient in clinic: does starting HRT put me at risk for melasma? The background here is that we have solid data linking pregnancy and oral contraceptives to melasma, but the HRT literature is thin, despite how commonly HRT is prescribed in peri- and postmenopausal women.

Methodologically, this is a straightforward narrative review — they searched PubMed, Embase, and Scopus, cast a wide net with no restrictions on study design, year, or geography, precisely because they anticipated a scarcity of evidence. That's worth noting as a methods point: when a field has essentially no controlled data, loosening your inclusion criteria isn't a flaw, it's a necessary adaptation. There's no meta-analysis or pooled statistic here, so no stats lesson to unpack this time — this is qualitative synthesis, graded by strength of evidence, not a quantitative pooling of effect sizes.

What did they find? Out of two hundred and three initial hits, only twenty-three papers made the cut, and the vast majority were case reports — five case reports total plus a single small randomized trial. No cohort studies, no case-control studies, nothing resembling a large observational dataset. The strongest signal, such as it is, comes from high-dose oral estrogen-only HRT, with case reports describing forearm melasma emerging after years of use — one case took eight years to develop, with partial fading after stopping the drug. Interestingly, the one randomized trial in the mix, using low-dose conjugated equine estrogen in Korean women with darker skin types, found no significant change in pigmentation over three months — though the authors reasonably point out the dose was low and follow-up short, so that's a fairly weak negative. Combined oral HRT and transdermal formulations each have only a handful of case reports, often confounded by concurrent oral HRT use, so causality is murky. Topical estrogen creams have exactly one reported case — a Fitzpatrick two patient who developed facial melasma after starting a topical estrogen for photoaging. And vaginal estrogen, given its minimal systemic absorption, has no reported cases at all. IVF is an interesting aside — no reported melasma cases despite the massive hormonal surges involved, though the authors note this hasn't really been looked for specifically.

The discussion nicely reviews melasma pathogenesis — genetic predisposition, with about a third of patients reporting a family history, hormone receptor-mediated melanogenesis through estrogen receptor alpha and beta, Wnt/beta-catenin pathway activation, and the increasingly recognized role of visible light and UVA1 penetrating into the dermis. The honest limitation here is that this entire evidence base is built on isolated case reports and expert opinion — there is essentially zero controlled prospective data, so any guidance is necessarily qualitative and cautious.

Practically, this is not practice-changing in the sense of new data — it's practice-organizing. The takeaway you can actually use tomorrow: counsel patients on oral estrogen-only HRT, especially higher Fitzpatrick types and higher doses, that there's a low but real risk, particularly on the forearms, and reinforce photoprotection. For transdermal, topical, and vaginal formulations, the risk is progressively lower, and for vaginal preparations specifically, no dermatologic precautions are really warranted unless there's concurrent systemic HRT. This is useful counseling language, but don't oversell certainty — the evidence strength is explicitly weak to very weak across the board.

Next, a reconstructive conundrum — these are case-based technique pieces, so we'll follow the actual shape: presentation, the repair performed, and the teaching points, no formal methods or limitations section here. An eighty-four-year-old man presented with a basosquamous carcinoma over the left mid-helical rim extending posteriorly to the eminence of scapha and antihelical fossa. Because Mohs wasn't available at their institution, they did a one-stage excision with frozen section margin control, trimming a thin layer of helical cartilage, and leaving a final defect of two and a half by just over two centimeters with exposed cartilage posteriorly.

The repair they chose was a superiorly based postauricular transposition flap, width-matched to the helical defect, with the flap length extended along the postauricular sulcus so it could roll over and resurface the helix, rotated slightly more than ninety degrees. They dissected at the subcutaneous plane without specifically hunting for perforators — relying on the rich random vascular supply of that retroauricular skin rather than an axial pedicle. The donor site closed primarily, a small standing cone was left unexcised, and no bolster was needed. Healing was good at one week, and at several months follow-up there was mild ear pinning and notching, but it remained cosmetically acceptable and functionally sound.

The discussion runs through the differential of reconstructive options for this location and is genuinely useful to have systematized: wedge excision works for helix or antihelix defects up to about one to one and a half centimeters but risks webbing or cupping deformity; full-thickness skin grafts are an option but exposed cartilage — as in this case — jeopardizes graft take; the Antia-Buch advancement flap is excellent for helical rim defects up to about two centimeters but can sacrifice significant auricular height or width in larger defects; and a staged retroauricular interpolation flap is a solid alternative but requires a second procedure. The authors also note that in cases with substantial cartilage loss, a cartilage graft can be incorporated into a local flap for structural support — something to file away for larger composite defects than this one.

The practical takeaway: this is a nice single-stage solution for combined helical rim and posterior auricular defects with exposed cartilage, leveraging the robust retroauricular blood supply from the posterior auricular and superficial temporal arterial arcade. It's not a new technique conceptually, but it's a clean demonstration worth keeping in your back pocket for exactly this defect geometry — rim plus posterior scapha or antihelical fossa involvement — when you want to avoid a graft on exposed cartilage or a staged interpolation flap.

Third, we have a substantial review article on surgical anatomy of the genital and inguinal region for the dermatologic surgeon — this is a practical, non-comparative anatomy and technique review, so again, no statistics and no results-limitations scaffolding in the traditional sense, just a systematic walkthrough of landmarks and danger zones.

The background rationale is straightforward: genital and inguinal cutaneous malignancies are rare, on the order of a fraction to a few cases per hundred thousand person-years, but they present late and aggressively — penile squamous cell carcinoma has regional nodal involvement in roughly a quarter of cases at presentation, vulvar squamous cell carcinoma behaves similarly, and extramammary Paget disease is notorious for diagnostic delay, often around two years, allowing substantial subclinical spread. Despite this, the region is underrepresented in training and textbooks, which is the gap this review fills.

Methodologically, they did a structured literature search through July of last year, screening over a thousand records down to thirty core studies plus four more from reference mining — essentially a scoping review methodology, appropriate here because the goal is synthesis of anatomic and technique knowledge rather than pooling an effect size.

The content itself is the real value. On general perioperative setup: lithotomy positioning for vulvar or perineal work improves exposure and reduces wound tension; chlorhexidine-alcohol for keratinized skin, but a combined chlorhexidine-for-skin, povidone-iodine-for-mucosa approach for the vestibule, meatus, and frenulum. They emphasize meticulous specimen orientation given the irregular topography — flattening tissue and placing orienting sutures before inking to preserve Mohs mapping accuracy — and note that in the inguinal fold specifically, moisture and friction predispose to epidermal overlap and dehiscence, so the authors favor a somewhat longer suture retention time there.

For the male genitalia, penile squamous cell carcinoma accounts for the vast majority of penile cancers, with meaningful metastatic potential, and Mohs has shown favorable margin control and recurrence outcomes compared to the roughly one-in-five recurrence rates and near one-in-five margin positivity reported with traditional organ-sparing excision or partial penectomy. Anatomically, the key teaching point is the tissue plane hierarchy: superficial subcutaneous tissue, then dartos fascia — your safe, easily-developed undermining plane, continuous with Scarpa's fascia of the abdomen and Colles' fascia of the perineum — and then Buck's fascia, the denser investing layer over the corpora, which for early-stage shaft squamous cell carcinoma is generally your appropriate depth of excision. Staying superficial to Buck's fascia protects the dorsal neurovascular bundles sitting at roughly the ten and two o'clock positions, and the deep dorsal vein at twelve o'clock. The ventral urethra is most at risk at the frenulum and penoscrotal junction, demanding extra caution there. They also flag lidocaine-with-epinephrine dosing limits — the standard seven milligrams per kilogram, translating to roughly five hundred milligrams for a seventy-kilogram adult — and the practical point that dorsal penile blocks, like their facial analogues sparing the columella or philtrum, don't anesthetize the frenulum, which needs direct infiltration.

There's much more in the full text on female genital anatomy, the femoral triangle, and reconstruction — the danger zones worth committing to memory are the dorsal penile and clitoral neurovascular bundles, the ventral urethra, the Bartholin glands at the posterior vestibule, and the femoral neurovasculature within the femoral triangle. This is a reference-style article — the practical takeaway is less about one actionable change and more that this is a genuinely useful anatomic refresher to have on hand before your next genital Mohs case, particularly if these cases aren't a high-volume part of your practice.

Finally, an original article — a retrospective study on the safety of perioperative liposomal bupivacaine, or LB, in dermatologic surgery patients, from the Mayo Clinic group. The background problem: liposomal bupivacaine, brand name Exparel, is an appealing long-acting nonopioid option, giving sustained analgesia out to about seventy-two hours, but it's used off-label in dermatology and there's a theoretical concern about Local Anesthetic Systemic Toxicity, or LAST, especially given that it's typically layered on top of other local anesthetics already in the field, raising a theoretical risk of displacing free bupivacaine off the liposomes.

For methods, this was a single-institution retrospective chart review, querying the electronic record for "Exparel" or "liposomal bupivacaine" over roughly a nine-year window. A retrospective design makes sense here — the authors aren't testing an intervention against a comparator, they're characterizing the real-world safety profile of a drug already in use, and LAST is rare enough that you'd need a large accumulated denominator, which a retrospective pull naturally provides. The one inferential statistic they ran was a Wilcoxon rank-sum test, comparing case characteristics between patients with and without documented postoperative pain. Worth a quick note on what that test actually does: it's the nonparametric alternative to a t-test, used when you're comparing two groups on a continuous or ordinal variable but can't assume that variable is normally distributed — which fits perfectly here, since things like wound area or dosage are typically skewed rather than bell-shaped, with a handful of very large or very small outliers. Rather than comparing means directly, it ranks all the observations across both groups and asks whether one group tends to have systematically higher or lower ranks — essentially testing whether the two distributions differ in typical value without needing the normality assumption a t-test requires.

Onto results. They captured a hundred and thirty-six administrations across a hundred and twenty-seven patients — the abstract cites slightly different rounding of a hundred and forty administrations and a hundred and twenty-nine patients, but the body text settles on a hundred and thirty-six and a hundred and twenty-seven, essentially the same dataset. LB was used most often for excisions, at about six in ten cases, and Mohs surgery, at about a third. Hidradenitis suppurativa was actually the leading diagnosis, at just over half of cases, ahead of cutaneous neoplasms at around four in ten, with squamous cell carcinoma the most common tumor type. The axilla and groin were the leading anatomic sites — which tracks with the hidradenitis predominance. Median dose was twenty milliliters, working out to about two hundred sixty-six milligrams, and notably, no case exceeded that two hundred sixty-six milligram ceiling — the FDA's maximum recommended local infiltration dose — even in patients undergoing large, multisite procedures with postoperative wound areas up to nearly nine hundred square centimeters in the biggest outliers.

The headline safety finding: no adverse events in ninety-eight and a half percent of administrations. There were exactly two reports of nausea, both on postoperative day one, both in patients also taking opioids — so arguably attributable to the opioid rather than the LB itself. Critically, there were zero cases of LAST — no central nervous system symptoms like seizures or perioral numbness, no cardiovascular toxicity like arrhythmia or hypotension — across this entire cohort, including patients with quite large and multisite wounds.

In their discussion, the authors contextualize this against the broader surgical literature, where LB-associated nausea rates run around three percent and LAST incidence, pulled from FDA adverse event reporting data across all specialties, is already low, well under one percent by any of several analytic definitions. They reasonably argue that dermatologic local infiltration is a lower-risk context than regional nerve blocks — where the maximum recommended LB dose is lower, at one hundred thirty-three milligrams, and where higher vascularity and prolonged systemic absorption around neural structures raise theoretical LAST risk further. The honest limitations here are the ones inherent to any retrospective chart review: adverse event capture depends entirely on documentation, so a mild transient symptom a patient didn't mention or a physician didn't chart could be missed, and the absence of LAST is inferred from absence of documentation rather than systematic active monitoring. It's also a single-institution, single-practice-pattern cohort, and dosing here was conservative and never exceeded established maximums, so this doesn't tell you what happens if that threshold is pushed.

Practically, this is a meaningful, if incremental, addition — it doesn't change dosing guidelines, since the authors stayed within FDA-recommended maximums throughout, but it does add real-world reassurance that LB is well tolerated in dermatologic local infiltration, including in the large, multisite hidradenitis excisions and complex Mohs closures where postoperative pain is a genuine concern. I'd call this supportive-but-not-paradigm-shifting: if you're already using or considering LB for axillary or groin cases, this data backs continuing that practice within standard dosing; it does not license using it in place of, or in excess of, the two hundred sixty-six milligram infiltration ceiling.

That wraps our four articles for this August issue — a cautious counseling framework for HRT and melasma, an elegant single-stage flap solution for a combined helical rim and posterior auricular defect, a genuinely useful anatomic field guide for genital and inguinal oncologic surgery, and reassuring real-world safety data on liposomal bupivacaine in our specialty. Thanks for listening, and we'll see you next issue.