Welcome to this October 2026 journal review, covering four articles from Dermatologic Surgery. We've got a review on circulating tumor DNA in melanoma, a sustainability review for Mohs practice, a systematic review of Mohs for penile squamous cell carcinoma, and a reconstructive conundrum involving a combined cheek, nasal sidewall, and alar defect. Let's get into it.

First up is a review article: circulating tumor DNA, or ctDNA, as a predictor of recurrence and survival in cutaneous melanoma treated with dermatologic surgery, from Abukhadra and Eisen out of UC Davis.

The background here is straightforward and relevant to anyone doing melanoma surgery. ctDNA is tumor-derived genetic material shed into the bloodstream, typically picked up by PCR-based assays. It's already got traction in colorectal, breast, lung, and pancreatic cancer as a way to detect molecular residual disease after treatment and to flag recurrence before it's visible on imaging or exam. The translation to cutaneous melanoma is intuitive but biologically harder, because skin tumors have comparatively low volume, and detectability tracks with tumor burden — the authors note detection rates around nine in ten for stage four disease at baseline, dropping to roughly half for stage three, and down to a minority of patients with stage two disease. The gap the authors identify is that nobody has aggregated what we know about ctDNA specifically in melanoma patients who underwent surgical treatment, as opposed to purely medical or mixed cohorts.

Methodologically, this is a structured literature review, not a formal systematic review with meta-analysis — they ran an OVID Medline search, pulled 33 initial hits, and whittled it down to six studies that actually paired ctDNA measurement with a recurrence or survival endpoint in surgically treated cutaneous melanoma. Given how heterogeneous the underlying assays and endpoints are here, pooling the data quantitatively wouldn't have been defensible anyway, so narrative synthesis is really the only honest option — the authors don't say this explicitly, but it's the obvious methodological reasoning. There's no statistical modeling in this piece to unpack, so we'll move straight to results.

Two broad detection strategies showed up across the six studies. One approach uses individual tumor-specific assays — essentially whole-exome sequencing of the patient's own tumor to build a personalized multiplex PCR panel, as used by commercial tests like Signatera. This captures tumor heterogeneity well but is logistically heavy. The other approach tests for known recurrent mutations — BRAF V600E, NRAS, TERT, TP53, KIT, and so on — which is simpler but blind to the roughly one-fifth of melanomas that don't carry any of these known alterations.

On the clinical question that matters most to you: postoperative ctDNA was the more informative time point. Four of the six studies found a significant association between postoperative ctDNA detection and recurrence or survival. One study specifically reported a postoperative sensitivity for recurrence of about sixty percent, with specificity in the mid-nineties. That pattern — modest sensitivity, high specificity — showed up again in a second study. The clinical read on that is important: a positive postoperative ctDNA result is fairly trustworthy as a rule-in test, but a negative result doesn't reliably exclude recurrence, so this isn't ready to function as a standalone surveillance tool. Preoperative ctDNA was less consistently predictive — only one of the six studies linked preoperative detection to recurrence-free and distant metastasis-free survival, though detection rates preoperatively, roughly a third to half of patients, did at least track with known stage-based detection rates, which is a reassuring internal consistency check even if it doesn't move the needle clinically.

Stage representation skewed toward stage two and three disease, which the authors flag as a real confounder — since detectability itself depends on tumor volume, you can't cleanly compare studies with different stage mixes. And there was no standardization of postoperative measurement timing across studies, ranging from two to three weeks out to three to six months out, which limits any pooled interpretation of how sensitivity evolves over the surveillance window.

Practical takeaway: this is interesting but not yet actionable for your practice. There's no FDA approval for ctDNA as a melanoma detection or screening tool, testing access and reimbursement remain inconsistent, and the evidence base is six heterogeneous studies with non-standardized timing. What it does tell you is where this is heading — postoperative ctDNA positivity, especially with a commercial personalized assay, is looking like a legitimate high-specificity adjunct for detecting molecular residual disease earlier than imaging, particularly in stage two and three patients where adjuvant systemic therapy decisions are already being made by your medical oncology colleagues. Keep this on your radar for multidisciplinary discussions, but don't expect to be ordering this yourself just yet.

Next, a review article on environmental sustainability in Mohs micrographic surgery, from Abdelwahab, Abdelwahab, and Vidal at Mayo Clinic.

This is a scoping review following PRISMA-ScR methodology — the authors searched five databases across a ten-year window and screened over five thousand articles down to nine that actually addressed sustainability specifically within Mohs surgery. That funnel size itself is a finding: this is a thin evidence base, and the authors are upfront that consolidated recommendations simply haven't existed before this.

The results break into pre-operative, intraoperative, and postoperative buckets. On waste quantification, two UK-based studies found Mohs generates roughly one to one-and-a-half kilograms of waste per case, and interestingly, more non-sharp waste than wide local excision at the same sites. Recycling rates across twelve UK sites averaged only fourteen percent, with wide site-to-site variation, and most procedure rooms simply didn't have recycling bins available. In the US, soft plastics were flagged as the single largest waste stream.

On the pre-operative side, transportation-related emissions were identified as the largest overall environmental category tied to Mohs care, which makes virtual pre-operative visits an appealing lever — though the authors note insurance reimbursement limitations remain a real-world barrier to adoption.

The intraoperative section has a few points worth flagging for your own practice. Three separate studies found no significant difference in infection rates between sterile and non-sterile glove use — consistent with existing literature questioning whether extensive PPE, gowns, foot covers, and full draping actually reduce surgical site risk at all, despite their waste and cost burden. There's also a nice practical pearl here: hyfrecator setups using a cautery tip and Penrose drain produced roughly eleven-fold less waste than standard electrosurgical setups with a grounding pen and hemostatic pencil, and were more cost-effective, though the authors caution hyfrecators aren't suited for deeper or more complex cases. Other suggestions include microtubules for storing chromacoding dye to cut down on spillage and desiccation waste from larger dye bottles, standardized surgical sets limited to essential instruments, and sterile covers to reduce the number of trays opened across multiple Mohs stages.

The Mayo authors also share their own institutional experience as a kind of informal case study — reusable cloth gowns for inpatient dermatology, a wet scrub only for the first case of the day followed by waterless scrubs thereafter, and ongoing internal debate about disposable versus reusable instrument sets that's been tabled over waste concerns.

There's no results-versus-limitations statistical structure here since this is a scoping review of heterogeneous practices rather than a quantitative synthesis — the authors are explicit that this is meant to consolidate scattered observations, not to prove effect sizes. The honest caveat is that most of this evidence comes from UK-based single-institution waste audits, so the external validity to US Mohs practice, with different disposables culture and insurance structures, is uncertain.

Practical takeaway: a few things here are genuinely low-cost, zero-downside changes you could implement tomorrow — non-sterile gloves where appropriate, microtubules for chromacoding dye, trimming surgical sets to essentials, and advocating for recycling bins directly in your procedure rooms. The hyfrecator-versus-electrosurgery waste difference is a nice data point if you're optimizing workflow. Virtual pre-op visits and broader systemic recycling partnerships are directionally right but still rate-limited by reimbursement and infrastructure, so file those under aspirational rather than immediately actionable.

Third is a systematic review: Mohs micrographic surgery for penile squamous cell carcinoma, from Greenzaid and colleagues across Wake Forest and Ohio State.

The clinical problem is one you've likely encountered rarely but with high stakes — penile SCC has traditionally been managed with partial or total penectomy, which controls disease well but comes with major psychosocial and functional cost. NCCN guidelines currently restrict MMS consideration to penile intraepithelial neoplasia grade three and pathologic T1 tumors in select cases, but the evidence underlying that restriction has never been systematically pulled together, especially for higher-stage, deeper-invasion tumors.

Methodologically, this is a proper PRISMA-guided systematic review across five databases through October of 2024, with two independent reviewers and formal risk-of-bias assessment — ROBINS-I for the cohort studies, the JBI tool for case reports and series. That rigor matters here because, as the authors acknowledge upfront, the underlying literature is almost entirely low-level evidence: of nineteen included studies covering 329 tumors, only six were retrospective cohorts, and the other thirteen were case reports or small case series. Given that landscape, a systematic review with descriptive pooling rather than meta-analysis is the right call — the authors note explicitly that small sample sizes and heterogeneity across studies precluded meta-analysis, so rather than inappropriately pooling incompatible data into a single effect estimate, they aggregated raw counts and reported proportions, which is the honest approach when study quality and reporting are this variable.

The findings are quite favorable for MMS as a tissue-sparing option. Tumors were mostly in situ, about six in ten, with the remainder spread across T1 through T3. Mohs achieved clear histologic margins in about nine in ten cases. Local recurrence occurred in just five percent overall, nodal metastasis in three percent, distant metastasis under one percent, and disease-specific death in about one percent — genuinely low numbers for a penis-sparing approach. Complications were also uncommon, around nine percent total, split fairly evenly between poor wound healing, urethral stricture, wound infection, and bleeding. The stage-stratified data is clinically the most useful piece: advanced-stage tumors, T2 and T3, had an eight percent local recurrence rate compared to just one percent for in situ and T1 tumors, while nodal and distant metastasis rates were similar regardless of stage. Urologic surgery was involved in about a quarter of cases, mostly for reconstruction, with urethrectomy and meatotomy rounding out the rest. Quality of life data were sparse, but the one study using validated measures found most patients retained urinary and sexual function.

For context, the authors note that other penis-sparing techniques — wide local excision, laser, glansectomy — carry recurrence rates over twenty percent in comparative literature, dramatically higher than the five percent seen here with MMS, while full penectomy sits around five percent recurrence but at a much higher functional cost. That comparison is really the crux of the paper's argument for MMS as a middle path.

The limitations are significant and the authors are candid about them: this is overwhelmingly case report and case series level evidence, individual study sample sizes ranged from just one patient up to eighty-five, there's substantial reporting heterogeneity, and meta-analysis wasn't possible. Publication bias toward favorable outcomes in case report literature is also a real concern that isn't explicitly stated but is worth you keeping in mind given the format mix.

Practical takeaway: this supports what's probably already your practice pattern — MMS is a reasonable and effective option for in situ and T1 penile SCC, with recurrence rates meaningfully better than other organ-sparing alternatives and comparable to penectomy, while preserving function. The T2/T3 data, while still favorable relative to historical penile-preserving therapy, comes with a real jump in local recurrence to eight percent, so for these more advanced or urethral-involving tumors, this review reinforces early multidisciplinary involvement with urology, not solo Mohs management. This is useful confirmatory evidence rather than something that should change current NCCN-guided selection, but it does give you solid numbers to quote patients during consent conversations.

Last up is a reconstructive conundrum — a single-stage repair of a combined cheek, nasal sidewall, and alar defect, from Downey, Arreola, and Yu.

This is a case-based technique piece, so no methods or statistics to walk through — just presentation, decision-making, and the technical execution. An eighty-three-year-old woman had a three-by-three centimeter lentigo maligna melanoma on the medial malar cheek, requiring six stages of Mohs with Melan-A immunostaining to clear, leaving a substantial six-by-five centimeter defect spanning the medial cheek, right ala, lateral nasal sidewall, and nasofacial sulcus out to the medial canthus — a genuinely difficult multi-subunit defect crossing the boundary between cheek and nose.

The reconstructive reasoning is the heart of this piece, and it's worth following closely. For the cheek and medial canthus component, the authors considered three standard options and talk through why each fell short: a cervicofacial advancement flap is the classic choice for medial cheek defects, but this patient had prominent malar soft tissue projection, and a cervicofacial advancement risks flattening that volume and creating visible asymmetry. A V-Y advancement preserves upper cheek volume nicely, but the defect here was longer than it was wide, and a V-Y wouldn't have had the reach to extend up to the medial canthus. A paramedian forehead interpolation flap could have supplied both coverage and volume, but it requires a second stage, which the patient didn't want, and her forehead was also on the smaller side, limiting donor tissue.

Their solution was a rotated V-Y island pedicle flap for the cheek and eyelid portion, paired with two separate Burow's full-thickness skin grafts for the nasal sidewall and ala. The island pedicle flap was rotated a full 180 degrees into the defect, with the flap tip tacked to the medial canthal ligament to suspend the cheek and prevent downward traction on the eyelid margin — guarding against ectropion, which is always the top concern in this anatomic zone. The flap was also thinned and tacked to the periosteum at the nasofacial sulcus to recreate that natural concavity separating cheek from nose. The skin graft for the nasal sidewall and ala was harvested from the standing cutaneous cone of the rotated flap itself — efficient use of discarded tissue — and deliberately split into two separate pieces rather than placed as one continuous graft, with the epidermal edges secured to deep tissue and the pyriform aperture rather than to each other, specifically to preserve the alar groove and apical triangle rather than letting those subunit boundaries blur.

The outcome was clean: no complications, full function preserved, no ectropion at five-month follow-up.

The teaching points here translate directly to your own reconstructive decision-making: a rotated V-Y island pedicle flap is a volume-preserving option for medial cheek defects, particularly useful when a defect's length outstrips its width and a standard V-Y lacks reach; combining a pedicle flap with adjacent grafts can achieve a single-stage repair across multiple cosmetic subunits when the patient needs or prefers to avoid a staged interpolation flap; and tacking flap or graft edges down to deep tissue or periosteum, rather than suturing skin edge to skin edge across a subunit boundary, is a reliable way to recreate natural grooves and sulci and keep multi-subunit repairs looking anatomic rather than patched together.

That wraps our four articles for this October 2026 issue — a biomarker still finding its clinical footing, some genuinely actionable sustainability wins for your procedure room, reassuring systematic review data supporting penis-sparing Mohs in appropriately selected tumors, and a nice piece of reconstructive problem-solving for a defect that crosses cheek and nasal subunits. Thanks for listening.