Welcome back to the journal review. This is the October twenty twenty-six issue of Dermatologic Surgery, and we've got four pieces on the table today — a novel flap technique for the nasal dorsum, a database study probing demographic bias in melanoma surgery selection, a retrospective series on sclerotherapy for facial venous malformations, and a short case report on an underappreciated preanalytic pitfall in platelet-rich plasma. Let's get into it.

First up is an original article out of the Skin Cancer Institute in Tauranga, New Zealand, introducing what the authors call the bipedicled bridge flap, or BBF, for nasal dorsum reconstruction. This is framed squarely as a new-technique paper with a prospective case series behind it, so think of it as part innovation report, part outcomes study.

The background here will feel familiar to anyone who reconstructs noses for a living — the dorsum is thin, tightly adherent, low in laxity, and sits in the most visible cosmetic subunit on the face, so even small contour or color mismatches are conspicuous. The authors walk through the usual toolkit — full-thickness grafts with their atrophic, poorly matched texture; simple transpositions limited to small defects; bilobed flaps that often wander into the glabella; hatchet rotations that work for horizontal defects but can leave visible forehead scars, especially in younger patients; island pedicle flaps that risk pincushioning; the nasolabial Burow's advancement, which is better suited to sidewall-involving defects; and interpolated forehead or cheek flaps, which work but require two stages and added donor morbidity. Into that gap they insert the BBF — a bipedicled advancement concept, originally described for leg defects and then adapted by this group to the scalp and forehead, now brought to the nose. The idea is to recruit medial cheek laxity through a curvilinear releasing incision hidden along the naso-facial sulcus, giving you dual-pedicle vascular reliability plus a scar that sits right on a cosmetic unit boundary.

Methodologically, this was a prospective, single-center, single-surgeon case series of forty-five consecutive patients undergoing BBF reconstruction after Mohs micrographic surgery between twenty twenty-one and twenty twenty-five, depending on which date range you read in the manuscript — the abstract says one window, the methods section another, which is worth flagging as a minor internal inconsistency rather than a substantive issue. Patients were counseled on BBF versus alternatives and self-selected into the flap if they chose it, which is important: this is not a randomized or even a consecutive-unselected cohort, it's a cohort of patients and a surgeon who both opted into this particular closure. A prospective design here makes sense for what the authors wanted — standardized photographic documentation out to at least six months and a blinded, independent assessor scoring cosmesis with the Manchester Scar Scale, something you really can't reconstruct reliably from a retrospective chart review. There's no comparator arm and no inferential statistics in this paper — it's a descriptive case series — so there's no formal statistical technique to unpack here; the reported numbers are means, medians, and ranges.

On technique, briefly: after confirming tumor clearance and ruling out primary closure, standing cones are excised above and below the defect, and the releasing incision is placed at the sidewall-cheek junction, bowed laterally so the final scar lands exactly on that junction, no longer than three times the defect width. For larger or bilateral-mobility-limited defects, a second contralateral incision converts it to a bilateral BBF; for horizontally oriented defects, especially in older patients with tip ptosis, the flap is designed superiorly to recruit nasion and glabellar laxity instead. Undermining is in the superficial fat above the superficial musculoaponeurotic layer of the sidewall, and the authors describe preserving subcutaneous septa — a Type III variant — when vascularity is compromised by prior surgery, versus freely dividing septa for maximal mobility when it isn't. Nasal valve competence is protected with a resuspension suture between the lower lateral cartilage and the flap, mirroring maneuvers you'd already use with a laterally based bilobe or Rieger flap.

Results: forty-five patients, mean age sixty-six, defects averaging one-point-seven square centimeters, ranging up to about four square centimeters. Four were bilateral BBFs, four horizontal, and six incorporated M-plasties to manage standing cones. The headline finding is simply zero complications across the series — no infections, no necrosis, no dehiscence, no hematoma, no hypertrophic scarring, and no need for any scar revision, laser, or dermabrasion. Median follow-up was a respectable thirty-four months, and at the six-month mark an independent, blinded dermatologic surgeon scored cosmesis with the Manchester Scar Scale — remember, lower is better here — and the median score was four, which the authors characterize as excellent, with the large majority of scars falling into that top "excellent" tier and only one scoring as low as six.

The discussion is appropriately confident but also honestly limited in scope — the text available to us is clear that the authors see this as filling a genuine gap, since they note the original bipedicled bridge concept for the forehead goes back to a 1984 paper in this same journal, and even comprehensive flap references have no nasal dorsum iteration described. What you should weigh critically, even though the published discussion doesn't dwell on it: this is a single surgeon's experience, patients weren't randomized against alternative closures, the series skews toward smaller-to-medium defects under about four square centimeters, and outcome assessment, while blinded, was still a single rater using a single scar scale. There's also no long-term functional nasal valve data beyond the intraoperative resuspension maneuver, which matters given how central valve competence is to a happy nose years down the line.

Practically, I'd call this interesting and promising rather than immediately practice-changing for everyone, but if you reconstruct a lot of dorsal defects and have grown tired of the bilobed-into-the-glabella problem or the two-stage burden of forehead flaps, this gives you a genuinely novel single-stage option worth adding to your mental algorithm for small-to-medium dorsal defects, particularly when cheek laxity is favorable and the defect doesn't extend heavily onto the tip.

Second article is a research letter — a communication, not a full original study — out of Baylor, Johns Hopkins, and the University of Pennsylvania, using the Surveillance, Epidemiology, and End Results database, or SEER, to look at who actually gets Mohs micrographic surgery versus wide local excision for lentigo maligna melanoma. The clinical backdrop is one you already know cold: Mohs achieves recurrence rates under one percent for this subtype, meaningfully better than wide local excision, yet wide excision remains the more commonly used approach nationally. The gap here isn't about efficacy, it's about equity — why does utilization vary, and is it driven by tumor biology or by something else?

Methodologically, they pulled over eight thousand patients with lentigo maligna melanoma from SEER's seventeen-registry database between two thousand and twenty twenty-two, split about two-to-one toward wide local excision over Mohs, after excluding cases with missing stage, treatment timing, or anatomic site data. This is a great opportunity to talk about the statistical workhorse of this paper, logistic regression. When your outcome is binary — did this patient get Mohs or not — you can't use ordinary linear regression, because the model would happily predict probabilities below zero or above one. Logistic regression instead models the log-odds of the outcome as a linear combination of predictors, which keeps predicted probabilities bounded between zero and one, and the coefficients translate into odds ratios — how much the odds of receiving Mohs multiply for each unit change in a predictor. The authors ran both univariate models, looking at one factor at a time, and multivariable models, which hold all the other covariates constant so you can ask whether age, sex, or income still matter after accounting for tumor site, stage, Breslow depth, and ulceration. That multivariable step is the whole point of the paper — it's specifically designed to ask whether demographic disparities persist even after you've leveled the playing field on tumor biology. They also used a standardized mean difference, a way of comparing two groups' characteristics in units that don't depend on sample size, which is often preferred over p-values for simple descriptive balance checks because large cohorts can make trivial differences look statistically significant.

The results: after adjustment, patients under sixty, male patients, and patients with household income under seventy-five thousand dollars all had significantly lower odds of receiving Mohs surgery compared to wide local excision, and this persisted even controlling for tumor location, stage, Breslow depth, and ulceration — head and neck location and lower stage, as expected, strongly predicted Mohs use, which makes clinical sense given where Mohs is most valuable, but the demographic signal was independent of that.

The authors are appropriately cautious in their discussion — they can't fully explain the sex and income findings from SEER's variables alone, and they speculate about access to care, referral patterns, provider bias around perceived cosmetic stakes for women, and the well-documented rural scarcity of Mohs surgeons tracking with lower median incomes. They're honest that residual confounding is possible — multivariable regression adjusts for what you measure, not what you don't, and SEER simply doesn't capture comorbidities, insurance type, travel distance, or referral patterns. The retrospective, registry-based design is itself a limitation they acknowledge.

Practically, this isn't a paper that changes what you do in the operating room, but it is a paper that should make you pause on who is and isn't reaching your chair. If you're in a position to influence referral pathways, outreach, or trainee recruitment from underserved and rural backgrounds, this adds another data point to the argument that access — not biology — is driving a meaningful slice of treatment selection for a tumor where the surgical choice genuinely affects recurrence risk.

Third article is a retrospective original study out of Ankara, Turkey, looking at sclerotherapy outcomes for facial venous malformations — twenty-one patients treated with polidocanol between two thousand and twenty twenty-five. The background rationale is one most of you will recognize even outside strictly dermatologic-oncology practice: facial venous malformations sit in a dense neurovascular field where surgical excision risks permanent functional loss, so sclerotherapy has become the default for lesions that are diffuse, deep, or simply not resectable without unacceptable morbidity.

Design-wise, this is a retrospective chart review supplemented by patient satisfaction surveys conducted after the fact, drawn from an initial pool of thirty-nine treated patients narrowed to twenty-one who had adequate follow-up and could be reached for satisfaction scoring. A retrospective design is really the only practical option for a congenital vascular anomaly that's treated infrequently at a single center over two decades — you're not going to randomize facial venous malformations to different sclerosants in any reasonable timeframe, so a retrospective case series with structured outcome categories is a pragmatic way to accumulate signal. Polidocanol was given as liquid for small, localized lesions or as Tessari-technique foam for larger multicavernous ones, dosed conservatively under a two milligram per kilogram ceiling per session.

Statistically, the paper leans on two classic nonparametric tools. Chi-square testing was used to check whether categorical outcomes, like treatment response grouped into categories, differed by sex — chi-square essentially asks whether the observed distribution across categories deviates from what you'd expect if there were no real association, and it's the right tool here because you're comparing frequencies in a contingency table, not continuous means. Spearman correlation was used for the ordinal relationships, like number of procedures versus degree of response — Spearman is just the correlation coefficient you get when you rank-order your data first, which is appropriate here because treatment response is an ordered category, mild versus significant versus excellent, rather than a true continuous measurement, and Spearman doesn't assume the kind of linear, normally distributed relationship that a standard Pearson correlation would require.

Results: about one in four patients achieved an excellent response, greater than ninety percent lesion reduction; just over half had a significant response in the fifty-to-ninety percent range; and about one in five had only a mild response under fifty percent. Mean satisfaction was high, two-point-eight out of three, with roughly four in five patients reporting full satisfaction. Complications were common but uniformly transient — pain in roughly half, swelling in about a quarter, blister formation in about one in four — all managed conservatively with nothing like necrosis or permanent injury reported. The statistically meaningful finding was a negative correlation between number of procedures and treatment response — patients who needed more sessions tended to have done worse overall, which is intuitive since harder-to-treat lesions presumably needed repeat treatment in the first place, so this is more plausibly a marker of lesion difficulty than a sign that repeated sclerotherapy itself blunts response. Lesion size showed a similar trend toward worse response with larger lesions, but this one did not reach statistical significance, likely simply due to the small sample — twenty-one patients is not a lot of power to detect a moderate correlation, and the authors are upfront that this is a trend, not a proven effect. Satisfaction correlated strongly with treatment response, which is reassuring face validity more than a novel insight. Complications didn't significantly affect either response or satisfaction, consistent with their transient nature.

Limitations the authors don't belabor but that are worth naming clearly for your own interpretation: this is a twenty-one patient single-center series spanning a twenty-five-year treatment window, which raises real questions about whether practice patterns, polidocanol concentrations, and injection technique were consistent across that much time; satisfaction was collected retrospectively by phone or in person, introducing recall and social-desirability bias; and eighteen of the original thirty-nine treated patients were simply unreachable or excluded, which could bias the cohort toward patients with better outcomes who were more willing to engage.

Practically, nothing here is practice-changing if sclerotherapy for facial venous malformations is already part of your practice or your referral network — the headline numbers essentially confirm what's already assumed, that it's effective, well tolerated, and complication-light, with the useful added nuance that lesions requiring many sessions are a signal to counsel patients early that complete resolution may not be realistic and that satisfaction tracks closely with objective response, which is a useful framing for setting expectations before you start.

Last up is a short case report — a communication rather than a study — from Columbia and Weill Cornell, on postprandial lipemia causing suboptimal platelet-rich plasma preparation. No methods section, no statistics, just a clinical vignette and a teaching point, so I'll treat it exactly as it's written.

A thirty-seven-year-old man with androgenetic alopecia and a documented normal lipid panel came in for platelet-rich plasma, and on two separate draws the processed plasma came out pink-white and cloudy instead of the expected amber-gold. The team initially suspected a collection or processing error, but on further questioning the patient disclosed a large fatty meal the night before and a substantial amount of cheese shortly before his appointment — classic acute postprandial hypertriglyceridemia, despite a normal baseline lipid panel. The plasma was discarded rather than injected. The following week, after an overnight fast and avoidance of fatty foods before the draw, the preparation returned to its normal golden appearance and was used.

The teaching point is straightforward but genuinely easy to miss in a busy practice: platelet-rich plasma protocols typically don't include routine bloodwork beyond a general history screening for inflammatory disease, blood dyscrasias, or interfering drugs like non-steroidal anti-inflammatories or anticoagulants, so acute dietary lipemia is an invisible variable unless you're specifically looking at the tube. The authors cite in-vitro evidence that elevated triglycerides can blunt platelet activation and responsiveness to collagen signaling, which matters because the entire therapeutic premise of platelet-rich plasma depends on robust growth factor release from activated platelets — so a lipemic-looking sample isn't just cosmetically odd, it may be biologically subtherapeutic. Their practical recommendation is to visually screen every preparation, decline to inject anything that looks lipemic or discolored, and when that happens, counsel an eight-to-twelve-hour fast before redrawing rather than assuming a processing error. They flag that persistent lipemia despite fasting should prompt a formal fasting lipid panel, with particular suspicion in older patients, those with a family history of dyslipidemia, or those on medications known to raise triglycerides, like isotretinoin, systemic corticosteroids, or certain antipsychotics.

This one is squarely practice-changing in the sense of a simple, zero-cost habit: look at your plasma before you inject it, and if it's cloudy or pink-white rather than golden, don't assume it's fine just because the patient's last lipid panel was normal — ask about last night's dinner first.

That wraps the October issue. A clever new single-stage option for a notoriously unforgiving part of the face, a sobering look at who does and doesn't get offered the better oncologic operation, solid reassurance on sclerotherapy for a difficult vascular anomaly, and a reminder that even something as routine as platelet-rich plasma has a preanalytic blind spot worth watching for. Thanks for listening, and I'll see you next month.