Welcome back to the journal review. This is our walkthrough of Dermatologic Surgery for September twenty twenty-six, volume fifty-two, number nine. We've got four pieces on deck this time — a "How We Do It" on simulation training for nail surgery, a case report on a nail bed complication, a short communication on regenerative scar treatment, and a reconstructive conundrum on a digital defect repair. Let's get into it.

First up is a "How We Do It" piece on silicone-based nail models for resident training. This is a technique and educational-intervention article, not a comparative trial, so we'll walk it through as it's built — problem, technique, and what they observed.

The setup here is a familiar frustration for anyone who trains residents: nail surgery is chronically under-taught. The authors cite a survey showing that well over half of third-year residents had done ten or fewer nail procedures, a quarter had only watched, and a third of graduates didn't feel competent doing nail surgery at all. And they tie this directly to something we all care about — nail matrix melanoma in situ is only correctly diagnosed clinically about half the time, which the authors frame as partly a confidence-and-competence problem with nail biopsy itself. Cadaveric training is accurate but expensive and non-reusable, so their answer was a low-cost silicone simulation model.

The model itself is nicely thought through. Silicone hands with flexible acrylic nails glued on with cyanoacrylate to mimic the nail plate, and silicone fingers with adhesive foam underneath standing in for the matrix and bed. The clever design touch is the foam layer — when a trainee does a shave biopsy that's too deep, they punch through to bare silicone, giving immediate tactile and visual feedback on specimen depth, which is exactly the kind of judgment call that's hard to teach without real tissue. The acrylic nail's bond strength was also tuned to approximate the resistance of an actual nail plate avulsion. Residents ran through a full curriculum in one session — didactic review of anatomy and indications, then hands-on practice of wing blocks, tourniquet application, elevator separation, hemostat avulsion, and matrix shave biopsy.

On outcomes, this is really just a pre/post survey with univariate comparisons, not a randomized or controlled design — worth naming plainly rather than dressing it up. They measured self-reported confidence across six nail-procedure skills on a Likert scale, collapsed into confident versus not confident. The finding: workshop participation was significantly associated with improved confidence across all six skills. More interesting is what happened to the baseline gap — before the workshop, higher training year and more prior procedural experience predicted higher confidence, which is exactly what you'd expect. After the workshop, that gap disappeared. In other words, the intervention seemed to level the playing field, bringing less-experienced residents up rather than just reinforcing existing confidence in those who already had it. They also note that residents with more than six prior biopsies were already confident going in, which is a nice internal consistency check.

The honest limitation here, which the authors don't belabor but is worth naming for you: this is self-reported confidence, single-session, single-institution, no assessment of actual procedural competence or downstream patient outcomes. Confidence and competence are related but not the same thing. Still, as a low-cost, reproducible curricular tool — materials sourced from Amazon, essentially — the practical takeaway is genuinely actionable if you're involved in resident education: this is an easy, cheap addition to a nail surgery curriculum, particularly for programs with limited cadaver access. It's not practice-changing for your own surgical technique, but it's a very exportable teaching tool.

Riding along on that same page is a short letter responding to a prior AIR-P article on ultrasound-guided intraoral removal of PMMA — polymethylmethacrylate — filler nodules. The letter writers, from a Brazilian teaching hospital, essentially make the point that while real-time ultrasound guidance is a nice advance, it isn't necessary — they've been doing intraoral PMMA nodule removal successfully for over two decades using careful history, exam, and palpation alone, in both immunocompromised and immunocompetent patients, without ultrasound. It's a brief clinical rejoinder rather than a study, so there's no methods or results to walk through — just worth flagging that ultrasound guidance, however elegant, may not be a prerequisite for this technique if you don't have access to it or trained interpreters.

Second article: a case report on nail bed pyogenic granuloma as a late postoperative complication after nail biopsy, successfully managed conservatively. Straightforward case-report shape — presentation, management, teaching point.

A thirty-two-year-old man with a nail-biting history had a tangential nail bed biopsy of an onychopapilloma via a lateral trapdoor approach, with the nail plate replaced and sutured back down, standard practice. Fine post-op course initially. Then, on day fifty-two — about seven and a half weeks out, well past when re-epithelialization should be complete — he developed pain and was found four days later to have an onycholytic nail plate. When they clipped back the loose nail, they uncovered a small friable exophytic papule on the nail bed, clinically consistent with pyogenic granuloma. This resolved completely with conservative management alone: serial in-office silver nitrate, plus at-home timolol drops and table salt under occlusion, with a good cosmetic result.

The teaching points are twofold. First, the timing is unusual and instructive — pyogenic granulomas after trauma or surgery typically show up within days to weeks, and this one appeared at nearly two months, well after the epithelium should have sealed. That argues the trigger wasn't just the initial surgical trauma but possibly the retained, replaced nail plate itself acting as a low-grade foreign body stimulus, especially combined with this patient's nail-biting and his recent liquid nitrogen treatments as additional irritant exposures. Second, and this is the practical pearl: the authors note that the granulation tissue may not even be visible unless you actively clip back the onycholytic nail — so if a patient reports pain and you see nail lifting after a nail bed procedure, don't just reassure and wait, trim back and look underneath.

The authors also use this case to needle at a bit of dogma — the routine practice of replacing the nail plate after nail bed biopsy. They cite a pediatric retrospective study linking nail plate replacement to higher infection rates and foreign body reactions, and a randomized trial in children showing no difference in cosmesis, pain, or satisfaction between replacing the nail versus not. But they're appropriately cautious about extrapolating pediatric data to adults, given adults have thicker, slower-growing, more adherent nails, which changes the risk-benefit calculus around things like disappearing nail bed. This is a single case, so no one is telling you to abandon nail plate replacement tomorrow — but it's a reasonable prompt to keep pyogenic granuloma on your differential for a painful, onycholytic nail well beyond the immediate post-op window, and to know that conservative management can spare the patient a second trip to the OR.

Third, a short communication on regenerative treatment of burn scars using autologous nanofat grafting, evaluated with the POSAS scale — that's the Patient and Observer Scar Assessment Scale. This is a single pediatric case report, not a controlled study, so again we're following presentation and outcome rather than a full methods-results-limitations arc.

An eleven-year-old boy sustained deep second- and third-degree burns over a fifth of his body surface area from a domestic fire, affecting his arms, neck, face, ears, and airway, requiring debridement, skin grafting, and two tracheal dilations for subglottic stenosis. Despite over a year of conventional multimodal scar therapy — pressure garments, silicone sheeting, triamcinolone injections, dye laser — he still had symptomatic hypertrophic and keloid scarring with itching, stiffness, and disfigurement. At twelve months post-injury, he underwent three staged sessions of autologous nanofat grafting under general anesthesia, roughly a year apart, with fat harvested by tumescent liposuction, mechanically emulsified between syringes, and filtered down to sub-tenth-millimeter particle size, then injected across multiple dermal planes, combined with microneedling to enhance graft integration and local angiogenesis.

The outcome was tracked with POSAS 2.0 at baseline and three months after each session. The mean composite score improved substantially — from about eight at baseline down to under two by the final assessment, with consistent gains across observer domains like thickness, vascularity, pliability, and texture, and patient-reported drops in pain, itch, and stiffness. Vascularity improved only modestly, which the authors attribute partly to the patient not tolerating additional laser sessions.

Worth being clear-eyed about what this is: an n-of-one case, unblinded, with the patient serving as his own before-and-after comparator across a treatment that also included concurrent microneedling and surgical debridement, so attributing the improvement cleanly to nanofat alone isn't really possible from this design. The authors acknowledge this is consistent with, not proof beyond, the existing small pediatric nanofat literature, and they explicitly call for larger cohorts and long-term durability data. For your practice, this lands as interesting-but-not-actionable — a nice biological rationale, a compelling single case, but nothing here that should change how you counsel patients on refractory hypertrophic burn scarring today.

Last piece is a Reconstructive Conundrum — one of the format's case-based reconstructive teaching columns, walking through defect and repair choice with the reasoning made explicit, so we'll follow the logic rather than a results-and-limitations structure.

An eighty-three-year-old woman had squamous cell carcinoma in situ on the dorsal right third finger, and after two stages of Mohs, was left with a sizeable defect — about four centimeters by just under four centimeters. The reasoning walkthrough here is the real value. Primary linear closure was ruled out because the defect's size and orientation meant closing it under tension would have distorted the interdigital web space. A full-thickness skin graft was considered viable from a vascular-bed standpoint since tendon and bone weren't exposed, but the authors avoided it to sidestep graft failure, trap-door deformity, tissue color and texture mismatch, and functional contracture or webbing — plus the added burden of a second wound-care site. More complex regional options like a tunneled island flap or a reverse dorsal metacarpal artery flap were considered too technically demanding relative to what was needed here.

Their solution was a bilobed transposition flap — a technique most of us reflexively associate with the nose, being repurposed for a finger. The logic: it recruits adjacent tissue with matched color, thickness, and texture; it carries its own blood supply so it resists contraction better than a graft; and critically, the lobe geometry let them design around the interdigital space to avoid webbing, which is the functional failure point you're most worried about on a dorsal digit. They do flag the obvious caveat — the digit doesn't have the vascular abundance or tissue laxity of the face, so this is a modification of a facial workhorse flap adapted to a much less forgiving donor site.

Procedurally, the first lobe reservoir closed the primary defect, the second lobe closed the secondary defect from the first lobe's transposition, and a standard Burow's triangle handled the redundant tissue cone, closed in layers with buried absorbable sutures and a running everting closure on the surface. At nine months, the scar was described as nearly imperceptible with full hand function preserved.

The practical takeaway for a Mohs-and-reconstruction audience: this is a genuinely useful conceptual reminder rather than a landmark change — the bilobed flap is worth keeping in your mental toolkit for select dorsal digital defects where primary closure would cause web-space distortion and a graft carries too much functional risk, provided the defect geometry and available adjacent laxity actually support it. It's a single favorable case, so it's a "consider this option" pearl rather than a first-line mandate.

That wraps this month's four pieces — a low-cost simulation tool worth adopting in your own training programs, a reminder to look under the nail plate when a post-biopsy patient hurts, an interesting but preliminary regenerative case in pediatric burn scarring, and a clever flap adaptation for a tricky digital defect. Thanks for listening, and we'll see you next issue.