Welcome back to the journal review. This is our walkthrough of Dermatologic Surgery for October 2026, and we've got four pieces worth your time this month — a SEER-based retrospective look at sentinel node biopsy in desmoplastic melanoma, a technique note on a color-coded inking protocol for specimen identification, a single-handed suturing technique for high-tension closures, and a case series on mini skin grafts after hidradenitis suppurativa surgery. Let's get into it.

First up is the retrospective cohort study on the role of sentinel lymph node biopsy in desmoplastic melanoma, using SEER data — that's Surveillance, Epidemiology, and End Results — covering over fifteen hundred cases. The background here is familiar territory for anyone managing these tumors: desmoplastic melanomas tend to present at deeper Breslow depths than superficial spreading melanoma, but they generally behave less aggressively, with lower rates of nodal metastasis and melanoma-specific death. That disconnect has led some authors to question whether sentinel node biopsy is even worthwhile in this histologic subtype. The problem is that prior SEER-based studies showing low positivity rates — under five percent — didn't stratify by Breslow depth or T-stage, which is exactly the kind of risk stratification you need before deciding this procedure doesn't add value. NCCN guidance generally reserves sentinel node biopsy for situations where positivity rates exceed five percent, so getting that stratified number right actually matters for your decision-making at the bedside.

Methodologically, the authors pulled histologically confirmed desmoplastic melanoma cases from SEER-17 using the appropriate ICD-O-3 and topography codes, restricted to patients who actually underwent sentinel node biopsy and had documented Breslow depth. Then they used a multivariate Cox proportional hazards model to compare melanoma-specific survival between sentinel-node-positive and sentinel-node-negative patients, adjusting for age, sex, and anatomic site. It's worth pausing on why Cox regression is the right tool here rather than, say, a simple survival comparison or a chi-square test on outcomes. Cox proportional hazards modeling compares the instantaneous risk of dying from melanoma at any given moment between the two groups, which matters enormously in a registry study like this because patients were diagnosed across a thirteen-year window and followed for variable lengths of time — some only a year or two, some considerably longer. Cox regression handles that unequal follow-up natively, and by adjusting for age, sex, and site, it tries to isolate the independent prognostic contribution of sentinel node status from other things that could plausibly confound the relationship. The output, a hazard ratio, tells you the relative risk of melanoma death at any point in follow-up — so a hazard ratio of six, for instance, means roughly a six-fold higher instantaneous risk of melanoma death in that group, adjusted for the covariates in the model.

Now the results. The cohort skewed male, about two-thirds, with an average age around sixty-eight and a median follow-up of a little over four years. Head and neck was the dominant site, consistent with what you'd expect for desmoplastic melanoma. Breaking it down by AJCC eighth edition T-stage, sentinel node positivity was under two percent for pT1b, right at five percent for pT2, just above five percent for pT3, and jumped to just over ten percent for pT4. Overall positivity across the whole cohort was about five percent. The pT1b group is the headline finding for practice: only two patients out of over a hundred had a positive node, and neither died of melanoma, so the positivity rate falls well below the five percent threshold that would justify routine biopsy. In contrast, pT2 and pT3 both cross that five percent line, and critically, in both groups a positive sentinel node was associated with significantly worse melanoma-specific survival — the hazard ratios were substantial, in the range of six to nine-fold increased risk, and tightly enough estimated to be clinically believable, not just statistically significant noise. pT4 showed the highest positivity rate, around ten percent, with a roughly five-fold increase in melanoma-specific mortality among node-positive patients.

The authors' takeaway is a more nuanced, stage-stratified view than prior guidance allows for. Current NCCN language suggests considering sentinel node biopsy even at pT1b, but this data argues against that — positivity is low and the two positive patients in this cohort had no mortality signal at all. Meanwhile pT2 and pT3 meet the positivity threshold and show a real prognostic signal when positive, and pT4 looks like the clearest candidate for the procedure. The limitations are honestly stated and important: SEER doesn't distinguish pure desmoplastic from mixed desmoplastic histology, and mixed tumors are thought to carry higher nodal positivity — though the authors reasonably note that this subclassification isn't something you're routinely getting from your pathology report anyway, so it's a limitation more of the data source than of real-world applicability. There's also selection bias baked in, since positivity rates only reflect patients who were selected to undergo the biopsy in the first place, not an unselected population, and the thirteen-year study window introduces potential confounding from stage migration and evolving treatment paradigms.

Practically, this is useful decision-support but I'd stop short of calling it practice-changing on its own — it's a single retrospective registry study, not a randomized comparison, so it can inform the conversation about who to offer sentinel node biopsy to but shouldn't be read as definitive proof that biopsy itself alters outcomes rather than simply identifying prognosis. That said, the pT1b data is reassuring if you've been on the fence about skipping biopsy in thinner desmoplastic tumors, and the pT2 through pT4 data supports continuing to offer the procedure in that range, consistent with how most of us are probably already practicing.

Next, two technique pieces worth a quick walkthrough together, starting with the standardized color-coded inking protocol for reducing specimen misidentification. This is a "how we do it" piece, not a study, so there's no results or limitations section to speak of — it's presenting a workflow innovation and its rationale. The clinical problem is one every Mohs surgeon has lived with: specimen mix-ups, most likely to occur at removal, labeling, or handoff to pathology, with real medicolegal stakes if they happen. The authors build on the fact that inking is already universal in dermatopathology for margin orientation, and propose extending that same ink to serve double duty as a patient-specific identity code. For biopsies, each specimen gets a single ink color from a palette of seven standard tissue dyes, documented on both the specimen bottle and the pathology requisition, with different colors used when multiple biopsies come from the same patient. For Mohs layers, they use quadrant-specific inking — for example blue at twelve o'clock, yellow at three, green at six, black at nine — and assign each patient a unique color combination that isn't repeated among other patients that same day. With four ink colors you get two dozen possible quadrant combinations, and with the full seven-color palette, as many as several hundred. The practical case they make is that this costs essentially nothing — no new equipment, minimal training — while adding redundancy at exactly the failure points that matter, and it has the side benefit of letting multiple tissue sections from one patient be mounted on a single slide without confusion, which saves processing time and lab costs. The honest caveat, implicit rather than stated as a limitation, is that this is a workflow proposal based on the authors' experience rather than a validated study with error-rate data — there's no comparison of mix-up rates before and after implementation. Practical takeaway: this is low-cost, low-friction, and worth considering adopting tomorrow, particularly if you're running a high-volume practice with concurrent cases — it's not "practice-changing" in the evidentiary sense, but it's a sensible safety habit with essentially no downside.

The other technique piece is the single-handed additional supportive approximation technique, abbreviated SHASA, for closing high-tension wounds with a surgeon's knot when you don't have an assistant. This builds directly on a previously published technique using a buried vertical mattress suture with a three-throw surgeon's knot, locked after repeated back-and-forth tugging of the tail and needle ends. The modification here is mechanical: instead of relying purely on repetitive tugging, the surgeon hooks the suture tail with the right middle finger against the needle holder, manually approximates the wound edges with the thumb and index finger of that same hand, and then pulls both the needle end and the tail end simultaneously — effectively generating four directions of closing force using two hands instead of needing a four-handed, assisted setup. Fine adjustments to tension and tail length are made by incorporating the ring finger or twirling the middle finger to gather suture. This is purely a technique description — a video walkthrough accompanies it — with no outcomes data, no comparison group, nothing to analyze statistically. The stated rationale is logical and self-evident: unassisted closure reduces reliance on assistant availability, which the author argues improves efficiency and reduces back-and-forth trauma to the wound edges from repeated tugging, and may help achieve better dermal eversion. Takeaway for your own practice: this is a nice-to-have pearl for solo high-tension closures, worth trying next time you're working without an assistant on a tight closure, but it's anecdotal and technique-only — there's no data here suggesting it changes outcomes versus existing assisted or unassisted methods, so file it as interesting and worth experimenting with rather than anything resembling a new standard.

Last, a case series from a single center in Turkey on using mini skin grafts after hidradenitis suppurativa surgery. This is a small, uncontrolled case series — nineteen patients and thirty-six lesions — so think of it as hypothesis-generating rather than practice-defining. The clinical rationale is straightforward: after wide excision for hidradenitis, you need to cover the defect, and while split-thickness, full-thickness, and recycled partial-thickness grafts have all been used, there's limited published experience specifically with mini skin grafts harvested from the adjacent perilesional margin. The procedure itself: ultrasound was used both preoperatively to map disease extent and intraoperatively to confirm clear margins after electrosurgical excision, after which small grafts were harvested from the immediately adjacent normal skin, de-haired, and placed at intervals across the defect under a pressure dressing, with follow-up checks on day three and then weekly.

On results, most patients were Hurley stage two, the axilla was overwhelmingly the treated site at about three-quarters of cases, and nearly four in five patients were smokers, current or former — worth noting as a population characteristic given smoking's known impact on wound healing. Average excision size was around eleven square centimeters, healing took about three and a half weeks on average, and recurrence in the treated area over three months of follow-up occurred in about one in nine lesions — all of which were nodular and managed with intralesional steroid rather than repeat surgery. The authors frame this favorably against prior reports using similar graft strategies, pointing to advantages of simplicity, affordability, no need for hospitalization, and quick return to daily activity, since the graft is autologous and harvested locally rather than requiring a separate donor site.

The limitations are plainly stated by the authors themselves: small sample size and no control group, so there's no way to know from this data alone how mini grafts compare to leaving the wound to heal by secondary intention, or to the other grafting techniques mentioned, in terms of healing time, recurrence, or cosmetic outcome. Practical takeaway: this is an interesting, low-barrier reconstructive option to have in your back pocket for hidradenitis excision defects, particularly in areas like the axilla where primary closure under tension is unappealing and secondary intention is slow — but given the absence of a comparator arm and the modest numbers, I'd call this an option worth knowing about rather than one with evidence strong enough to change your default reconstructive approach.

That wraps up this month's roundup — a stage-stratified refinement of sentinel node selection criteria in desmoplastic melanoma worth incorporating into your counseling, a couple of practical technique tweaks worth trying, and an early but promising graft strategy for hidradenitis defects. Thanks for listening, and we'll see you next month.