Welcome back to the journal review. This is our walkthrough of the October 2026 issue of Dermatologic Surgery, and we've got four pieces to get through today — a commentary, a how-we-do-it technique piece, a reconstructive conundrum case, and an original database study out of SEER looking at Mohs utilization trends in melanoma. Let's get into it.

First up is a commentary — so no methods, no results, just an invited reflection — responding to an article on environmental sustainability in Mohs micrographic surgery. Doctor William Coleman uses the sustainability discussion as a jumping-off point to revisit a question that's been quietly simmering in our field for decades: do we actually need full sterile technique, sterile gloves, hat, mask, and gown, for what is fundamentally a surface surgical procedure? He recalls training-era experience watching a renowned reconstructive surgeon who operated entirely bare-handed after a single scrub, rarely saw infections, and valued the tactile feedback enough to forgo gloves altogether. Coleman contrasts that with his own general surgery background, which drilled in extensive scrubbing and double-gloving for everything. There's no data presented here, no trial, just an experienced clinician voicing a long-standing open question and explicitly leaving it to the reader to decide. The honest takeaway is that this is food for thought rather than a call to change your glove practices tomorrow — it's really an invitation to think critically about which elements of our sterile ritual are evidence-based infection prevention versus inherited habit, especially as environmental cost becomes part of that calculus.

Next, a how-we-do-it piece on selecting hidradenitis suppurativa lesions for deroofing based on surface contour. This is a technique article, so we're following steps and rationale rather than a results-and-limitations structure. The clinical problem is familiar to anyone managing HS surgically — deroofing is tissue-sparing and has a gentler recovery profile than excision, but it only works when the underlying cavity architecture actually permits structural correction, and until now that's been assessed mainly by intraoperative probing, after you're already committed. These authors propose a preoperative heuristic they call the contour sign. The idea is elegantly simple — classify the lesion's surface as convex or concave relative to the surrounding skin. A convex lesion, they argue, almost has to be sitting on an intact or densely fibrotic dermal base, because you need a firm deep surface providing counterpressure to produce a convex roof in the first place — tubular subcutaneous tunnels can't generate that counterpressure. So convex lesions correspond to intradermal cavities that are ideal deroofing candidates. Concave or depressed lesions, by contrast, tend to signal a cavity that has broken through into the subcutis, often with lateral extension well beyond what the surface suggests — their intraoperative photos show one tunnel extending five centimeters laterally from a concave lesion. Deroofing those anyway means sacrificing a lot of healthy overlying tissue, risks edge splaying from loss of dermal tension, and in their experience incompletely deroofed concave lesions kept draining and granulating because the underlying disease architecture was never actually corrected. They do flag one morphologic exception worth remembering — small domed nodules where a deep tunnel fistulizes to the surface, as you see in pilonidal disease, which look convex and soft but behave differently and shouldn't be lumped in with typical convex HS lesions. Practically, the message for anyone doing deroofing is this: before you ever pick up a probe, look at contour. Convex lesions are your reliable yes. Concave lesions demand careful peripheral palpation for lateral extension before you commit, and if you feel that extension, strongly consider steering away from deroofing rather than converting intraoperatively to a bigger excision than planned. This is a simple, low-cost addition to preoperative counseling and consent conversations, and it's reasonable to start incorporating now, while recognizing it's based on this group's accumulated experience rather than a formal validation study.

Third is a reconstructive conundrum — a case-based teaching format working through a single challenging defect and the flap logic used to close it. The patient is a 61-year-old man with an infiltrative basal cell carcinoma of the right upper cutaneous lip, cleared after three stages of Mohs, leaving a deep three-and-a-half by three centimeter defect that crossed the nasolabial fold into the medial cheek and took out nearly the entire lateral alar base. The challenge here is the convergence of three cosmetic subunits at once — lip, cheek, and ala — where even small distortions cascade into alar asymmetry, nasolabial fold blunting, or lip malalignment, and where the depth of the defect raises a real functional concern about contracture pulling on the ala and compromising the airway. The authors walk through why the simpler options fail: primary closure or a single cheek advancement flap would distort the lip or displace the ala laterally; a full-thickness skin graft would mismatch in texture and color and likely depress; second intention risks contracture; and single rotation or transposition flaps or a large perforator-based V-to-Y each carried their own risk of trapdoor deformity or asymmetry. Their resolution was a multi-flap, single-stage strategy that's worth remembering as a template. First, a medial cheek advancement closed the cheek portion only up to the nasolabial fold — deliberately not pulled further, to avoid displacing the ala. Second, a V-to-Y advancement flap recruited jowl tissue to close the lip portion, with meticulous preservation of the apical triangle of the cutaneous lip to avoid that telltale blunting. And third — the clever part — the redundant tissue generated at the nasofacial sulcus by the cheek advancement wasn't discarded, it was rotated nearly a hundred and eighty degrees as a small pedicled flap to actually rebuild structural support for the lateral alar base. So one flap's leftover tissue became the raw material for repairing an entirely separate subunit. The patient healed without complications and had a good functional and cosmetic result with facial symmetry preserved at five months. The teaching points here are reusable beyond this specific defect: think of advancement flap redundancy as a resource for an adjacent subunit rather than something to simply excise as a dog-ear, use local tissue over distant flaps when preserving hair-bearing skin and facial symmetry matters — particularly relevant in male patients with beard involvement — and recognize that consolidating a complex multi-subunit defect into a single stage can be achievable with layered, deliberately conservative flap advancement at each step rather than one large heroic flap.

Now the main original research piece — a retrospective database analysis using SEER data to look at trends in Mohs micrographic surgery utilization for melanoma from 2003 to 2022. The background gap is pretty clear: we know MMS use in melanoma has been rising overall, and we know there have been historical disparities in uptake by income and geography, but nobody had actually traced whether those disparities are narrowing, widening, or staying flat as utilization grows — is this a rising tide lifting all boats, or is growth concentrated in groups that already had better access?

Methodologically, this is a classic population-level trends analysis using SEER-21, which captures a bit under half the US population, identifying just over three-quarters of a million melanoma patients and excluding those with distant metastatic disease at diagnosis. The core statistical tool here is annual percent change, derived from what's called joinpoint regression, layered on top of logistic regression. It's worth pausing on this because it's a technique you'll see constantly in these utilization-trend papers. Logistic regression first models the probability of receiving MMS versus conventional excision as a function of year and other covariates — it's the natural choice here because the outcome is binary, MMS or not, rather than continuous. Joinpoint regression then takes that yearly trend and asks a more specific question: is the rate of change actually constant across the entire twenty-year window, or is there a point where the slope meaningfully shifts? Instead of forcing one straight trend line onto the whole period, it tests for breakpoints and fits separate linear segments on either side, reporting an annual percent change, essentially the compounded yearly growth rate, for each segment. This matters because a single flat trend line would have completely obscured what they actually found.

And what they found was a clear inflection. Overall, MMS utilization for melanoma climbed about 6 percent of cases by the end of the study from a starting point that was much lower, with an average annual increase of about 4 percent per year across the full two decades. But joinpoint analysis found a breakpoint around 2007 — before that, uptake was accelerating fast, with an annual increase of nearly 11 percent, and after 2007 it settled into a steadier climb of about 3 percent per year. That's a meaningful pattern: a rapid early-adoption phase followed by more measured, sustained integration into practice, which is exactly the shape you'd expect as a technique moves from early adopters into mainstream guideline-concordant use.

The disparity findings are the more clinically important part. Utilization rose significantly across every single age bracket, both sexes, all anatomic sites, all melanoma subtypes, and both in situ and invasive disease — so this was a broad, non-selective increase. Head and neck melanomas showed the steepest climb, which tracks sensibly with guideline recognition of these as specialty sites at higher risk for positive margins and recurrence after conventional excision. Acral lentiginous and superficial spreading subtypes also showed particularly strong growth. But here's the key equity finding: when they compared growth rates between nonmetropolitan versus metropolitan counties, lower-income versus higher-income counties, and Commission on Cancer accredited versus non-accredited facilities, there was no statistically significant difference in the rate of increase between any of those paired groups. In plain terms, everybody's growth curve was climbing at a similar pace — rural and underserved areas weren't being left behind as MMS adoption expanded; they were keeping pace with urban, higher-resourced, academic settings.

For limitations, the authors are upfront that SEER's anatomic coding can't separate out hand, foot, and pretibial leg melanomas from the broader extremity category, which matters because those specific locations are themselves considered specialty sites warranting MMS consideration, so the extremity-site analysis is a bit blunter than ideal. As with any SEER analysis, there's no information on surgeon specialty, individual case complexity, or the specific clinical reasoning behind treatment selection — this is population-level association, not patient-level causal inference.

Where does this land practically? This isn't a practice-changing paper in the sense of altering what you do at the bedside tomorrow, but it is a genuinely reassuring health-services finding — it's evidence that the growth of Mohs for melanoma over the past two decades has been broadly equitable in its pace of adoption rather than concentrating further advantage in already-resourced populations, even though baseline gaps presumably still exist in absolute utilization rates. It's useful ammunition if you're involved in advocacy, program building, or justifying expanded MMS access in community or rural settings, and it's a good data point for conversations about guideline-concordant care reaching beyond academic centers.

That wraps the October issue. A thought-provoking commentary on sterile technique and sustainability, a practical new heuristic for selecting hidradenitis lesions for deroofing, an instructive multi-flap solution for a tough central-face defect, and reassuring population-level data on equitable growth in Mohs for melanoma. Thanks for listening, and we'll see you next month.