Welcome back to the journal review. This is our walkthrough of the August 2026 issue of Dermatologic Surgery, and we've got four pieces to get through today — a technique communication on preventing ear canal stenosis, a case report on a basal cell carcinoning arising in a rare congenital hamartoma, a survey study on hyperbaric oxygen use among Mohs surgeons, and a technique paper with an accompanying case series on closing leg defects without flaps or grafts. Let's get into it.

First up is a communications piece — not a controlled study, but a practical, experience-and-literature-based recommendation — on acquired external auditory canal stenosis after Mohs surgery, and how to prevent it using an expandable ear wick. The clinical problem here is one every one of us who works on ears has bumped into: the external auditory canal is a narrow, curving structure with limited visualization, and when you take a defect there down through a meaningful chunk of the circumferential epidermis — the authors cite the fifty percent threshold — you're setting up conditions for granulation tissue, fibrosis, and eventual canal stenosis. That stenosis isn't just cosmetic; it traps cerumen and squamous debris, causes conductive hearing loss, otorrhea, and can make hearing aid use impossible, which matters enormously in the age group we're typically treating. The authors note this is well covered in the otolaryngology literature but barely addressed from the dermatologic surgery side, despite how often we're the ones creating these defects.

Their recommendation centers on the expandable ear wick — the same Merocel or Pope-type wick otolaryngology has used for decades, first described back in 1978. It's a hydroxylated polyvinyl acetate sponge that you insert dry, about two centimeters into the canal, extending medially past the defect or graft, and then it expands on contact with topical solution to stent the canal and hold pressure against the graft or wound bed. Compared to plain gauze packing, it holds fluid better and is gentler on removal, though the authors are honest that removal can still be uncomfortable and, if done carelessly, can disrupt an underlying graft. The other advantage is that it doubles as a delivery vehicle — you saturate it with a combined antibiotic and corticosteroid otic solution, typically a ciprofloxacin-dexamethasone combination, which both dampens inflammatory scarring and covers prophylactically against Pseudomonas, the classic pathogen you worry about in a moist canal environment. Their practical protocol is to have the patient redose the drops three to four times a day and to leave the wick in place for about seven to ten days — long enough to actually prevent stenosis, but not so long that you're courting infection or, at the extreme, toxic shock syndrome from prolonged intracanal packing.

There's no outcomes data here — no comparison group, no recurrence or stenosis rate — this is a "here's a tool you should know about" piece, and the authors say as much, explicitly calling for larger outcome-based studies on ear wick use in the Mohs setting. So the takeaway is practical and low-risk to adopt immediately: for any EAC defect involving half or more of the canal circumference, especially with a graft, keep an expandable ear wick with combination otic drops in your postoperative armamentarium, loop in otolaryngology if canal visualization is limited, and counsel patients to watch for otorrhea or hearing changes as early stenosis signals. It's not practice-changing in the sense of new data, but it is a genuinely useful, cheap, accessible adjunct that's probably underused by dermatologic surgeons simply because it lives in someone else's specialty literature.

Second is a case report: a basal cell carcinoma arising within a congenital apocrine nevus. This is a rarity worth knowing about mostly for the differential diagnosis and nomenclature lesson embedded in it. Apocrine nevi — sometimes conflated with apocrine hamartomas, though the authors point out these are technically distinct entities — are benign congenital overgrowths of mature apocrine glands in the dermis, exceedingly rare, classically presenting as a scalp nodule or plaque with associated alopecia, as opposed to apocrine hamartomas, which tend to show up at puberty on the face or trunk as papules. The case itself: a woman in her late thirties with a lifelong "birthmark" on the vertex scalp presented for Mohs surgery on a superficial basal cell carcinoma that had developed within it. The birthmark itself had never been biopsied and had been clinically stable since adolescence. Mohs clearance took two stages, and because the debulk specimen encompassed the entire birthmark, they got full histology on the underlying lesion — which showed benign mature apocrine glands with decapitation secretion sitting beneath the basal cell carcinoma, with clinicopathologic correlation to the alopecic patch from loss of follicles in that skin. Critically, they didn't see the sebaceous overgrowth or papillomatosis that would indicate nevus sebaceus, which is the more common organoid nevus context where secondary tumors like trichoblastoma or basal cell carcinoma are well documented. Here, this was a clean apocrine nevus — and by the authors' count, this is only the second reported case in the literature of a basal cell carcinoma arising within one, out of just eleven total reported apocrine nevus cases since the entity was first described in 1947.

The teaching point is straightforward: apocrine nevi are basically always benign and a cosmetic non-issue, but if one shows any clinical evolution, that's your cue to biopsy, because rare malignant transformation — or, as here, a coincidental second malignancy arising within the lesion — does happen. And when it does, surgical excision or Mohs surgery, depending on location, is the treatment of choice. Nothing here is practice-changing on its own, but it's a useful pattern-recognition entry to file away: a stable congenital scalp plaque with alopecia that starts changing warrants tissue sampling, not just observation.

Third, and the one with actual inferential statistics, is a survey study: hyperbaric oxygen therapy as a treatment for postoperative complications after Mohs surgery, surveying members of the American College of Mohs Surgery. The background gap is clean — hyperbaric oxygen therapy is FDA-approved for exactly the kinds of complications we occasionally see, air or gas embolism, compromised flaps or grafts, delayed radiation injury, nonhealing wounds — but nobody had ever actually measured how much Mohs surgeons know about it, or what's keeping them from using it. So the authors built an anonymous REDCap survey, sent it to roughly fifteen hundred ACMS members, and got sixty-three completed responses, a response rate a little over four percent, which they're upfront is a real limitation. Methodologically, most of the analysis is descriptive — proportions of respondents who knew this or that — but they did run one actual statistical test, a Wilcoxon rank-sum test, to see whether having previously attended a lecture on hyperbaric oxygen therapy was associated with better knowledge of its indications. It's worth pausing on why that test specifically: the outcome here — number of indications a surgeon could correctly name — is an ordinal count, not a nicely bell-shaped continuous measurement, and with a small sample you can't safely assume it's normally distributed. The Wilcoxon rank-sum, sometimes called the Mann-Whitney U test, sidesteps that by ranking all the responses across both groups — lecture-attenders versus not — and comparing whether one group's ranks systematically sit higher than the other's, rather than comparing raw means. It's the nonparametric workhorse you reach for exactly in this situation: two independent groups, an ordinal or non-normal outcome, and a small sample where a t-test's assumptions would be shaky. And it found a statistically significant association — surgeons who'd attended a hyperbaric oxygen lecture knew meaningfully more about its indications than those who hadn't.

Beyond that, the numbers paint a fairly stark knowledge gap. Close to half of respondents couldn't name a single indication for hyperbaric oxygen therapy, and only one person could name more than four. About two-thirds recognized its potential role in postoperative care in general terms, but only around a third felt confident actually explaining it to a patient. The vast majority were unaware of chamber-to-chamber variability or how insurance coverage works for it. Referral barriers stacked up predictably: lack of knowledge topped the list, followed closely by cost and coverage concerns, unfamiliarity with local treatment centers, and unclear referral pathways. Only nine surgeons — about fourteen percent — had ever actually referred a patient, but among those nine, most referred within one to three days of the complication, and seven of the nine felt it improved outcomes; the two who were uncertain had both referred more than a week out, well past the window where hyperbaric oxygen is thought to be most effective. Only one adverse event was reported across all those referrals, a case of barotrauma. Encouragingly, more than seventy percent of the whole cohort said they wanted more education on the topic.

The authors are appropriately modest in their conclusions — this is descriptive, hypothesis-generating survey work, not an efficacy trial, and they flag the small sample and the inability to confirm each respondent was a unique, non-duplicate participant as real limitations. There's also the standard survey caveat of nonresponse bias — the surgeons motivated enough to answer an anonymous survey about a therapy they barely use may not represent the full ACMS membership. But the clinically useful signal is this: hyperbaric oxygen therapy is an underutilized, evidence-supported option sitting right there in your complication-management toolkit for compromised flaps, grafts, and nonhealing wounds, and if you're going to use it, timing matters — refer early, within the first few days, not after the window has likely closed. This isn't practice-changing in the sense of new efficacy data, but it's a legitimate nudge to know your local hyperbaric center, understand roughly what your patients' insurance will and won't cover, and lower your threshold for referral rather than defaulting to watchful waiting on a struggling flap.

Fourth and last is a technique article with an accompanying small retrospective case series: percutaneous mesh expansion for closing surgical defects on the legs. The clinical problem is one every Mohs surgeon doing lower extremity work knows well — thin, inelastic, often edematous or venously insufficient skin that doesn't advance easily, where flaps and grafts carry their own burden of necrosis risk and demanding aftercare, particularly in older patients. The technique itself is a modification of percutaneous aponeurotomy, borrowed conceptually from the Dupuytren's contracture literature, and previously described by Khouri and colleagues for scalp defects back in 2018 — this paper is, per the authors, the first application of it specifically to the leg. After standard tumor-appropriate excision, they test closure with a single approximating suture; if that's under too much tension, they make multiple small stab incisions — using either a fine needle or a number eleven blade — spaced about two millimeters apart around the defect, down to the subcutaneous plane, meshing roughly half the defect's width on each side. That meshing releases tension mechanically, similar in spirit to how a fasciotomy or a skin-graft meshing pattern spreads tissue, allowing the wound edges to come together with epidermal sutures alone — no deep sutures, no flap, no graft. Oral antibiotics are routine given the anatomic site, compression dressing goes on for five to seven days, and sutures typically come out around two weeks.

This was a single-center retrospective review of eighteen patients and twenty-two surgical defects between June and November of 2024, with a mean age of seventy-six — so, appropriately, the population where flap and graft physiology is often working against you. Tumor types were a real-world mix, mostly basal cell and squamous cell carcinomas with a few melanomas in situ and other diagnoses. Mean defect size was about twenty-six millimeters, pretibial skin being the most common site — arguably the hardest location on the body to close primarily. Complications were minimal: one hematoma that resolved on its own, one wound infection treated with an extra course of oral antibiotic, and one partial dehiscence — no major flap-type complications like frank necrosis. Sutures came out at a mean of about two weeks. At the one-month mark, blinded aesthetic and functional scoring by an uninvolved dermatologic surgeon averaged four and a half out of five, and patient satisfaction averaged four point eight out of five, with every single patient saying they'd choose the procedure again.

The authors are appropriately restrained about what this means — this is a small, uncontrolled, single-arm case series with a study-specific, non-validated rating scale and a fairly short mean follow-up of about eight weeks, so durability of the cosmetic result and any late complications like widened scar or recurrent laxity aren't really answered here. There's also no comparison arm against grafting or flap reconstruction, so we don't know how it stacks up head-to-head. But as a technique, the appeal is obvious: it's fast, cheap, avoids the vascular-supply problem that undermines flaps and grafts on the leg, and requires nothing beyond local anesthesia and instruments already on your tray. For a practicing Mohs surgeon, I'd call this interesting and promising rather than fully practice-changing yet — worth trying as an option for small-to-moderate leg defects where primary closure is borderline and you're hesitant about flap vascularity, particularly in elderly or vasculopathic patients, but it needs larger, comparative, longer-follow-up data before it displaces your standard reconstructive ladder for lower extremity defects.

That wraps our four articles from this August issue — a low-tech prevention tool for ear canal stenosis, a rare case linking a congenital apocrine nevus to basal cell carcinoma, a sobering look at how little Mohs surgeons know about hyperbaric oxygen therapy despite its relevance to our own complications, and a promising minimally invasive closure technique for one of the more frustrating anatomic sites we work on. Thanks for listening, and we'll see you next month.