Welcome back to the Dermatologic Surgery journal review. This is the September twenty twenty-six issue, and we've got four pieces to walk through today — an invited commentary on a nasal splinting technique, a pilot immunohistochemistry study on lentigo maligna margin assessment, a single-center case series on punch debridement for hidradenitis suppurativa, and a reconstructive conundrum case on repairing a nasal ala defect. Let's get into it.

First up is a commentary — specifically, an invited response piece reacting to a technique article by Luke and colleagues describing something called the "Bazooka nasal splint," used to support the external nasal valve after Mohs micrographic surgery. This isn't an original study with its own methods and results; it's one experienced Mohs surgeon, Stanislav Tolkachjov, giving his expert take on someone else's technique, so I'll walk you through what the technique is, what he likes about it, where he pushes back, and what he does instead.

The underlying clinical problem is one you know well even if it's underappreciated: nasal valve insufficiency after Mohs reconstruction on the ala. It's not just cosmetic asymmetry we worry about — patients can develop real inspiratory obstruction or a "stuffy" sensation postoperatively, driven by flap bulk, contracted grafts, scarring, muscle disruption, or simply dead space from lidocaine volume, hematoma, or serosanguinous fluid pushing against internal nasal structures. The Bazooka splint approach constructs a silicone tube splint and sutures it through the cartilaginous septum to the contralateral ala, essentially using the septum as an anchor point for structural support, and it's removed a week later with a suture pull.

Tolkachjov's take is measured. He agrees the concept has merit — using multipoint suturing or splinting to prevent nasal valve collapse is well established, and he credits the original authors for a nicely documented technique with video and photographic support. But he flags real risks specific to suturing through the septum: the septum is vascular, many Mohs patients are anticoagulated, and difficult-to-control bleeding or hematoma is a legitimate concern. There's also the possibility of iatrogenic septal perforation, particularly in patients who have unrecognized septal thinning already — which, as any of us doing nasal reconstruction know, is not rare. He also raises a practical point about suture removal logistics — staff unfamiliar with the technique, or patients traveling long distances for a return visit — and the rare but real risk of a confused or sundowning patient pulling at a sutured splint overnight and tearing tissue.

What he offers instead is worth banking as practical technique pearls, even though this is his personal practice rather than validated comparative data. He prepurchases inexpensive silicone cone-shaped nasal dilators — the kind marketed for snoring — in a range of diameters, sized intraoperatively and left in place for one to two weeks, removable and replaceable by the patient without any suture burden. Intraoperatively, his core tenets are avoiding structural collapse and minimizing dead space: he takes a full-thickness bite through the defect floor at the internal or external valve and sews it to the underside of the flap to pull the valve open and eliminate dead space, accepting some early alar asymmetry that typically relaxes over time. For multi-subunit reconstructions — say a crescentic advancement flap on the sidewall combined with a graft for the ala — he anchors a suspension suture from the defect floor to the advancing flap's dermal edge before placing the graft. And for suture material, he favors absorbable plain gut, arguing it lasts long enough to prevent flap push and internal scar bulging without requiring a removal visit — and he even suggests using dissolving suture within the Bazooka technique itself would solve his main practical objection to it.

There's no results section here, no data to round for you — this is expert opinion layered onto a technique description. The practical takeaway is a menu, not a mandate: if you're doing ala or sidewall reconstruction where nasal valve collapse is a realistic risk, you now have at least three complementary strategies in your pocket — a septal-anchored splint for definitive structural support when needed, off-the-shelf dilator devices for a lower-risk postoperative bridge, and intraoperative suspension suturing to close dead space at the time of flap inset. None of this is practice-changing in the sense of altering your fundamental approach, but it is a useful expansion of your toolkit, and the septal bleeding and perforation risks are worth internalizing before you adopt the Bazooka splint specifically in an anticoagulated patient.

Next, a pilot study out of Rotterdam: evaluation of lentigo maligna with additional immunohistochemical staining on frozen sections using PRAME, Melan-A, and SOX10. This one is a genuine original study, though a small feasibility one, so let's treat it as such.

The clinical gap here is familiar to anyone managing lentigo maligna on the head and neck. Staged excision gives you complete peripheral margin assessment and low recurrence rates, but the tradeoff is a one-to-three-week wait between stages while permanent sections process. True Mohs frozen-section technique is the mainstay for keratinocyte carcinoma, but for melanoma it's historically been considered less reliable on frozen tissue, and this is especially true in Europe, where immunohistochemistry on frozen sections for melanocytic lesions isn't standard practice the way it is in some American modified-Mohs protocols. PRAME specifically — a marker increasingly used in clinical practice to distinguish lentigo maligna from reactive melanocytic hyperplasia — had, per the authors, never been reported on frozen sections at all. So the question was simple: can you get diagnostic-quality PRAME, Melan-A, and SOX10 staining on frozen tissue, in a standardized lab, well enough to trust it for real-time margin calls?

Methodologically, this is a small prospective feasibility study — eight patients with biopsy-proven lentigo maligna undergoing staged excision, with additional research biopsies taken from the lesion margins. Each frozen biopsy got hematoxylin and eosin plus all three immunostains, scored for slide quality by a blinded pathologist. Those same biopsies were then processed as permanent paraffin sections and re-stained, serving as the gold standard for accuracy comparison, with the evaluator blinded to which frozen result corresponded to which paraffin result. That blinding is the methodological backbone here — it's what lets you trust that the quality scoring wasn't unconsciously influenced by already knowing the answer. There's no formal statistical test in this paper, and that's the right call for an eight-patient, eleven-biopsy pilot — the goal isn't to establish an effect size or claim significance, it's simply to demonstrate feasibility as a first step before a larger validation study.

The results are genuinely interesting. Frozen Melan-A hit "good" quality in almost all biopsies, frozen SOX10 in the large majority, frozen H&E in about three-quarters. Frozen PRAME lagged behind on raw slide quality — only about a third scored "good," with most of the rest landing in "moderate" rather than poor. But here's the clinically important finding: frozen H&E alone was never sufficient to render a confident diagnosis of lentigo maligna in any of the eleven biopsies. Zero. Add any one of the three immunostains to that H&E, though, and a diagnosis became achievable in every single case. When compared back against the paraffin gold standard in the cases with adequate tissue, the frozen-plus-immunostain diagnosis was accurate in essentially all evaluable specimens.

So the headline message is that frozen section H&E is not enough for confident lentigo maligna margin calls, but pairing it with any single immunostain — PRAME, Melan-A, or SOX10 — closes that gap, even though PRAME's raw staining quality on frozen tissue trails the other two markers. The authors frame this explicitly as a pilot to test laboratory workflow and staining protocol, with an eye toward eventually implementing a modified Mohs approach for lentigo maligna that would shorten the current staged-excision waiting period.

The limitations are exactly what you'd expect from a study this size: eight patients, single center, a single blinded evaluator, and three biopsies excluded from the paraffin comparison for insufficient tissue. There's no assessment here of turnaround time, cost, or how this would perform in the hands of a lab without the ISO-certified standardization these authors used — and no comparison of interobserver reliability across multiple pathologists or surgeons reading these stains in real time. This is hypothesis-generating, not yet validating.

Practically, this is interesting but not remotely practice-changing yet. It doesn't give you a new tool to use Monday morning. What it does is lay early groundwork for frozen-section immunostain-augmented staged excision of lentigo maligna, and if you're in a practice that already does modified Mohs for melanoma in situ with intraoperative immunostains, this adds PRAME to the panel with reasonable — if not perfect — technical feasibility. Worth watching for a larger, prospective, multi-reader follow-up before it changes anything you're doing.

Third, a single-center case series from Gazi University in Turkey: punch debridement as a minimally invasive technique for hidradenitis suppurativa. This is a small original study, descriptive in nature, so I'll flag upfront that there's no comparator arm and no formal statistical testing — which is itself worth pausing on as a methodology point.

The clinical backdrop is the persistent gap in hidradenitis suppurativa surgery between minimally invasive options like incision and drainage, which have high recurrence, and definitive but morbid options like wide excision or STEEP surgery, which often need general anesthesia and carry real complication burden. Punch debridement — sometimes called mini-deroofing — sits in between: using a punch biopsy tool to create circular openings along abscesses and sinus tracts under local anesthesia, evacuating contents, and healing by secondary intention. It's been described before, but mostly in earlier-stage disease. This group specifically wanted to look at its performance in late-stage, treatment-resistant hidradenitis suppurativa, alongside ongoing systemic therapy.

The design is a straightforward retrospective-style single-center series: fourteen patients, average age around thirty-five, with roughly two-thirds having Hurley stage two disease and the remainder stage three, all continuing their existing systemic regimens — biologics for the stage three group, systemic antibiotics for most of the stage two group. Response was assessed with a fairly rigorous composite definition of complete response requiring absence of drainage, resolution of erythema and induration, a pain score of one or less, and sonographic confirmation of tract closure. That's a reasonably objective endpoint, which is a methodological strength even in a small series — but with only fourteen patients, there's no statistical model to build here; the authors report plain proportions, and that's appropriate given the sample size. It's worth flagging as a teaching point: a descriptive case series like this can tell you a technique is feasible and can generate a hypothesis about who benefits most, but with no control group — no arm getting incision and drainage alone, or systemic therapy alone — you cannot cleanly attribute the response to the punch debridement itself versus the concurrent biologic or antibiotic thery. That's confounding by co-intervention, and it's the central limitation of this whole paper.

The results: complete response was seen in half of treated lesions, achieved after an average of under two sessions per patient. Notably, the complete response rate was actually higher in the more advanced Hurley stage three group — about three in five lesions — compared with stage two, at just under half. Partial response, by contrast, occurred exclusively in the stage two group, in about four in nine lesions. By anatomic site, the inguinal region had the highest complete response rate at three-quarters, the gluteal region landed around half, and the axillary region had the lowest complete response at one in four, though three-quarters of axillary lesions showed at least a meaningful partial response.

The authors' interpretation is that this reflects a "dual-hit" synergy — systemic biologic control of inflammation in the stage three patients combined with local mechanical debulking from the punch technique — but they're appropriately careful to call this a hypothesis rather than a proven mechanism, and you should hold it the same way. Limitations are the ones you'd expect: small sample, single center, no control arm, no long-term recurrence data beyond twenty-four weeks, and the inherent selection bias of using this technique preferentially in patients already responding to systemic therapy.

Practically, I'd file this under interesting but not practice-changing. It's a reasonable option to keep in your back pocket as a low-morbidity, office-based bridging maneuver for hidradenitis suppurativa patients with tunnels or abscesses who aren't ready for — or don't want — a definitive excisional procedure, particularly as a way to potentially reduce the extent of tissue that eventually needs radical excision. But the lack of a comparator arm means you shouldn't oversell this to patients as validated definitive therapy; it's an adjunct, not a replacement for excisional surgery in appropriate candidates.

Last is a reconstructive conundrum — a case-based technique presentation, so no formal methods or statistics here, just the clinical problem, the chosen solution, and the reasoning.

The setup: a seventy-five-year-old man with a nodulo-infiltrative basal cell carcinoma of the right nasal ala, cleared after three stages of Mohs, leaving a defect just under two centimeters involving the ala and the lateral crus of the lower lateral cartilage, with the mucosal lining of the nasal vestibule fortunately preserved. That's a classic full-thickness structural defect without a lining problem — cartilage support needed, internal lining already intact.

The authors talk through the standard options before landing on their choice. Secondary intention is dismissed for a defect this size because of prolonged healing, contracture risk, and the real threat of alar retraction and airway compromise. Interpolated flaps — paramedian forehead or melolabial — get credit for robust tissue and good color match but come with the multi-stage burden and a visible pedicle for weeks, plus melolabial flaps specifically risk blunting the nasolabial fold. Spiral flaps are ruled out for defects over about a centimeter and a half, and for anything requiring real structural support. Skin grafting alone is inadequate here because cartilage support is needed. Composite grafts — cartilage with attached or separately harvested overlying skin — are mentioned as viable alternatives with a track record, but historically carry higher failure rates than flap-based reconstruction and can mismatch color or texture.

Their chosen approach was a single-stage lateral nasal sidewall inverted island flap combined with an auricular cartilage graft for structural support. The technique itself is worth walking through because the pedicle handling is the clever part. Cartilage was harvested from the contralateral conchal bowl, shaped, and secured medially to the residual lower lateral cartilage and laterally to the alar-facial groove tissue for rim support. The island skin flap was then designed on the nasal sidewall, with a dissection plane that shifts from deep subcutaneous superiorly to sub-nasalis inferiorly, and — critically — kept broad-based inferolaterally to preserve a soft tissue cuff protecting the facial artery's contributing branches. The pedicle itself was deliberately never formally dissected out, specifically to avoid injuring the venous plexus, relying instead on that broad soft-tissue base for both arterial inflow and venous outflow. Once mobile, the island was rotated ninety degrees medially into the defect and trimmed to fit. The secondary defect on the sidewall was closed with a medial cheek advancement flap, excising a crescentic bit of peri-alar skin to manage a standing cutaneous deformity along the nasolabial fold — which conveniently hides the secondary scar in a natural crease.

The discussion frames this as a versatile, reliable single-stage option with excellent color and thickness match, and the authors note an important extension: the same flap can be rotated a full one hundred eighty degrees instead of ninety, folding the distal end onto itself, to reconstruct alar rim defects requiring internal lining reconstruction — which wasn't needed here since the mucosal lining was preserved, but broadens the flap's applicability. Postoperative photos at six months show good color and textural blending.

The practical takeaway is genuinely useful for anyone doing high-volume nasal reconstruction: for full-thickness ala defects with intact mucosal lining and a need for structural support, the nasal sidewall island inversion flap with a conchal cartilage graft is a legitimate single-stage alternative to the interpolated flap workhorses, sparing the patient a multi-stage pedicle at the cost of a technically demanding pedicle-preservation dissection. It's not going to replace the paramedian forehead flap for your largest or most complex ala defects, but for a defect in this size range, with lining intact, it's a technique worth having ready — particularly the pearl about deliberately not dissecting out the pedicle to protect venous outflow, and the rotational flexibility to convert it into a lining flap when the rim itself is involved.

That wraps our four articles for this September issue — a cautionary but practical commentary on nasal valve splinting, an early but promising look at frozen-section immunostaining for lentigo maligna margins, a hypothesis-generating case series on punch debridement in advanced hidradenitis suppurativa, and a technically elegant single-stage solution for a full-thickness ala defect. Thanks for listening, and we'll see you next month.