Welcome to this month's journal review, covering Dermatologic Surgery for January 2026. We've got four pieces this time — a commentary on patient adherence, a couple of case reports, one of which pairs a rare genodermatosis with Mohs technique and the other an interesting cosmetic application of radiofrequency microneedling, plus a really elegant reconstructive conundrum on the lateral cheek. Let's get into it.

First up is a commentary — Huang, Feldman, and Doerfler responding to a review by Lewis on optimizing patient adherence in dermatologic and Mohs surgery. This isn't a study with its own data; it's a discussion piece reacting to another author's review, so think of it as expert perspective rather than new evidence. The core problem they're addressing is one we all recognize but rarely name explicitly: our patients are highly motivated — nobody wants residual cancer or a bad scar — but motivation doesn't translate into adherence. Poor understanding of instructions is cited as a major driver, and the commentary walks through what's actually within the surgeon's control. Their central argument is that adherence isn't binary; most patients fall somewhere in the middle of a spectrum, and the surgeon's job is to actively gather information — through preoperative conversation or even a short intake questionnaire about occupation, dexterity, and support systems — and then tailor the postoperative plan accordingly. Practically, they point to things you can build into your workflow to reduce the burden of adherence itself: Unna boots, tissue adhesives, absorbable suture, intraoperative antibiotics, and long-acting intralesional analgesia all shift responsibility away from a patient who may have low dexterity, no ride to the pharmacy, or a rotating cast of caregivers. They also make a case for choosing second-intention healing over primary closure in patients whose lifestyle predicts they won't respect activity restrictions — the classic example being the manual laborer versus the sedentary nonagenarian. There's also a nice discussion of giving patients your personal phone number for postop check-ins; their experience, echoing Lewis, is that patients rarely abuse it, and the mere gesture builds trust, while the rare call that does come in often reveals a gap in your instructions worth fixing systemically. The takeaway here isn't practice-changing in the sense of a new technique, but it is a useful reframe: build systems that reduce required adherence rather than just tools that assume it, and treat any adherence failure as information about your process rather than a reason to blame the patient.

Next, a case report from Zalla and Zalla describing what they believe is the first reported case of Mohs surgery in a patient with Hailey-Hailey disease. This is a straightforward case presentation, so we'll walk through presentation, management, and the teaching points rather than forcing it into a methods-and-results shape it doesn't have. The patient was an 80-year-old man with a fifty-year history of Hailey-Hailey, referred for Mohs excision of a squamous cell carcinoma on the shoulder. Notably, he'd had hernia surgery six weeks earlier, and removal of a defibrillator pad had stripped off a ring of skin — a vivid illustration of just how fragile epidermal adhesion is in this disease, even in areas not classically affected by the intertriginous eruption. Two teaching points fall out of this case. The first is histopathologic: Mohs sections showed broad areas of acantholysis with mild acanthosis and focal dyskeratosis, and the authors emphasize the real risk of confusing this with an acantholytic actinic keratosis at the margin — a distinction that matters because misreading it could prompt unnecessary treatment. The differentiating features they highlight are that Hailey-Hailey acantholysis tends to spare adnexal structures and shows only mild dyskeratosis, whereas actinic keratoses typically show hyperkeratosis, nuclear pleomorphism and hyperchromasia against a background of solar elastosis. They also flag the reverse scenario — unexpected acantholysis in a patient without clinical actinic damage should prompt you to ask about personal and family history, since this could unmask previously undiagnosed Hailey-Hailey. The second teaching point is purely practical: dressing choice. Given this patient's demonstrated fragility to adhesives, they avoided their usual liquid adhesive, cross-elastic tape, and transparent film, using paper tape alone intraoperatively and postoperatively, and had the patient shower through the dressing to ease removal. The result was a clean closure with only a single small erosion at suture removal at eleven days. For sites where friction from suture itself is a concern, they suggest low-friction options like polypropylene or a rapidly absorbable braided suture. There's no control group and no generalizable data here — it's one patient — but the practical takeaway is genuinely useful and low-risk to adopt: in any patient with a discohesive epidermal disorder, whether Hailey-Hailey, pemphigus, pemphigoid, or dystrophic epidermolysis bullosa, default to paper tape or non-adhesive wrap-based dressings, and keep this differential in mind whenever you see unexpected acantholysis on a Mohs section.

Third is another case report, this one from Williams and Skelsey, describing radiofrequency microneedling for residual fibrofatty change after spontaneous involution of an infantile hemangioma. Background here is that involuted hemangiomas leave residual telangiectasia, fibrofatty tissue, redundant skin, or scarring in roughly half to two-thirds of untreated cases, and even in half of those treated with pulsed dye laser — yet there's very little published guidance on managing these long-term sequelae, especially in darker skin types where the risk of dyspigmentation from more aggressive interventions is a real concern. The patient was a 45-year-old woman, Fitzpatrick three to four, with an atrophic, telangiectatic, hyperpigmented cheek patch and redundant skin left over from a childhood hemangioma. She underwent two sessions of radiofrequency microneedling three months apart, using an insulated bipolar fractional device with three passes at decreasing depths from three millimeters down to just over one millimeter. The rationale for insulated needles is worth flagging for anyone using these devices in skin of color: the nonconductive coating limits energy release to the needle tip, sparing the epidermis and reducing dyspigmentation risk, which is precisely why this device was chosen for this patient's skin type. One month after the second treatment, she showed visible improvement in atrophy, fine wrinkling, and laxity, with only transient hyperpigmentation and erythema that resolved. The authors tie their mechanism back to histologic data showing that radiofrequency microneedling at depths beyond about three millimeters can induce adipocyte lipolysis — meaning the improvement they saw likely reflects both dermal collagen and elastin remodeling and some direct necrosis of the residual fibrofatty tissue itself. This is a single case, so obviously there's no way to generalize a response rate or durability, and the authors themselves call for further histologic study and protocol optimization. The clinical takeaway is not practice-changing but is a genuinely interesting proof-of-concept: if you're managing post-hemangioma sequelae in a darker-skinned patient and want to avoid the dyspigmentation risk of more aggressive resurfacing, insulated radiofrequency microneedling is a reasonable option to have on your radar, particularly for fibrofatty atrophic change rather than pure telangiectasia.

There's also a short research letter tucked in alongside these cases worth a quick mention — a nearly decade-long follow-up on subdermal trimming for bromhidrosis, originally published by these same authors in 2017. In the original two-patient study, subdermal trimming through a single one-centimeter axillary incision produced greater than 98% reduction in key odor-associated molecules at two months, measured objectively by mass spectrometry, with levels still down more than 86% at six months. The notable finding here in the 2025 re-analysis is durability: both patients, tested again with the same protocol nearly ten years later, showed odor molecule levels still suppressed by roughly 98 to 99% compared to baseline — essentially as good as, or even slightly better than, their six-month results. It's only two patients, so it's more a durability signal than a powered outcome, but for a procedure question patients frequently ask about — does this actually last — this is reassuring long-term objective data supporting subdermal trimming as a durable option for bromhidrosis.

Finally, our reconstructive conundrum, from Dubash, Laws, and Affleck, tackling a forty-five by twenty-three millimeter defect on the lateral upper cheek and lower temple after single-stage Mohs clearance of a recurrent basal cell carcinoma. This is a technique-and-decision-making piece, so the value is in the reasoning and the steps, not in trial data. The core challenge they lay out is that the lateral cheek — the parotidomasseteric unit — has little subcutaneous fat and is tightly adherent to underlying fascia, which makes island pedicle advancement flaps, workhorses in the medial cheek, far less effective here. Compounding this, it was a recurrent tumor, meaning the local skin reservoir was already diminished and surrounding tissue was tight with minimal laxity. They list the alternatives they considered and rejected: partial closure with standing cone excision and second intention centrally, partial closure with a Burow's full-thickness skin graft, or a free full-thickness graft — all reasonable but none ideal for restoring contour or achieving single-stage closure given the shape of this particular defect. What they settled on, and what makes this case worth remembering, is a myosubcutaneous propeller flap based on perforators of the superficial temporal artery at the pre-tragal region, rotated clockwise through a wide 170-degree arc to close the defect using inferior parotidomasseteric cheek skin as the donor reservoir. A propeller flap, for anyone wanting the formal definition, is an island flap that reaches its recipient site via axial rotation around a perforator pedicle, characterized by three variables — the nourishing pedicle type, the degree of rotation, and the source vessel. The technical pearl in their dissection is calibration of the pedicle: too much thinning risks a small pedicle and vascular compromise, too little dissection leaves an excessively bulky pedicle that restrains rotation and creates tension — so the goal is incorporating just enough muscle fibers at the base to protect the perforators while keeping the pedicle mobile. They achieved full flap viability without Doppler mapping or direct perforator visualization, though they note other authors advocate for Doppler confirmation when the rotation exceeds ninety degrees, which this case well exceeded. Cosmetically at three months the result showed good contour restoration and skin match. The practical takeaway for a Mohs and reconstructive audience is that this pre-tragal superficial temporal artery propeller flap is a genuinely underutilized option for upper lateral cheek, lower temple, and zygomatic defects specifically when local tissue laxity is poor — as it often is after recurrent tumor excision — and it's worth adding to your mental toolkit as an alternative to skin grafting when you want to preserve contour and keep tension off the free margin by shifting it to a more redundant secondary defect.

That wraps our four articles for January. Thanks for listening, and we'll be back next month with more from the surgical literature.