Welcome back to the journal review. This is the February 2026 issue of Dermatologic Surgery, and we've got four pieces worth your time this month — two technique-driven case series, one systematic review on hemostasis, and one instructive case report. Let's get into it.

First up is a retrospective case series out of the Medical College of Wisconsin describing a technique the authors call "raising the base," aimed at improving second intention healing outcomes for alar defects after Mohs micrographic surgery. The clinical problem here is one every Mohs surgeon knows intuitively — second intention healing works beautifully on the ala, but depth matters enormously for final scar contour, and a deep defect that heals by granulation and contraction alone can leave you with a depressed, poorly contoured scar even when everything else about the repair goes fine. Their fix is mechanically simple: after tumor clearance, they circumferentially incise the fibrofatty base of the defect with a number fifteen blade, essentially coring out a cylindrical plug of tissue that stays attached by an inferior pedicle, then they lift that plug up and secure it in its new, more superficial position with buried horizontal mattress sutures — either polyglactin nine-ten or poliglecaprone twenty-five — trimming the edges flush with the skin surface. Functionally, you're converting a deep defect into a shallow one using the patient's own subcutaneous tissue as an autologous filler, before letting the wound re-epithelialize on its own.

Methodologically, this is a retrospective series of thirty-seven patients treated over roughly seven years, which is really the only reasonable design for introducing a brand-new technique — you don't randomize against a comparator until you've established feasibility and a safety signal. What elevates this beyond a simple case series, though, is their outcome assessment: fifteen of the thirty-seven patients had adequate follow-up photography to be graded, and that grading was done by three attending dermatologic surgeons plus a fellow, all blinded, using the validated modified Manchester scar scale, with a pre-specified cutoff for "favorable" healing borrowed from prior alar second-intention literature. That's a meaningful methodological upgrade over an eyeball assessment — using a validated instrument with multiple blinded raters reduces the subjectivity that otherwise plagues cosmetic outcome reporting.

The results were good. Every single defect in the cohort had fibrofatty tissue at its base, most were one or two stage nodular or micronodular basal cell carcinomas, though about one in six had infiltrative features, and the mean defect size was around half a square centimeter. This was not a low-risk population from a healing standpoint either — about two in five patients were on an antiplatelet or anticoagulant, roughly a quarter were diabetic, about one in ten were active smokers, and a small fraction were immunosuppressed. Despite that, there were no infections, no alterations in nasal valve function, and no alar retraction. Five patients had minor, easily managed complications like bleeding or hypergranulation tissue. On the graded subset, fourteen of fifteen — that's about ninety-three percent — achieved a favorable scar score below the pre-specified threshold, with a mean score right around nine. Notably, neither BCC subtype, defect size, nor patient age predicted a worse score, and the domain that drove most of the variability was contour rather than color or distortion, which tells you the technique is doing exactly what it's designed to do — flatten the base without necessarily eliminating every bit of topographic irregularity.

The authors are appropriately measured in their discussion. This is a retrospective series, the photographic grading subset was small, there's no patient-reported outcome data, and depth assessment was purely qualitative rather than measured. Lighting variability in photographs is also a real confounder for any scar-scoring exercise like this. But the practical takeaway is straightforward: this is a genuinely useful addition to your reconstructive toolbox for deep alar defects when you're leaning toward second intention healing anyway. It avoids the morbidity of flaps or grafts, it's fast, it doesn't require suture removal on the wound surface, and — importantly for surveillance — it preserves your ability to visually monitor for recurrence in a way a flap wouldn't. I'd call this practice-adoptable rather than fully practice-changing given the small graded sample, but the technique is simple enough and the downside risk low enough that it's reasonable to start incorporating into your own alar second-intention cases.

Second, a study from the Plastic Surgery Hospital at the Chinese Academy of Medical Sciences describing a modified technique for repairing the "defective type" of congenital earlobe cleft — the most severe end of the Kitayama classification, where there's near-complete absence of recognizable earlobe structure rather than just a simple notch or split. This is outside our usual Mohs reconstructive territory, but the flap logic is worth knowing. Existing repair techniques for this subtype, per the authors, lack standardization and often leave visible scarring or incomplete correction. Their solution is what they term a preformed, inverted, and anastomosed subauricular tongue-shaped flap — they design a tongue-shaped flap along the inferior ear border, dissect the retroauricular skin to raise it with a pedicle rooted in the subauricular region, carefully match the size of the flaps on either side of the cleft, and then overlap and inset them to rebuild both volume and contour rather than just closing a linear defect.

This is a retrospective single-center cohort of twenty patients, all with unilateral, previously untreated, defective-type clefts — a deliberately narrow inclusion strategy, and the authors are explicit about why: they wanted the technique tested against a single, well-defined, severe phenotype rather than diluting results across the whole spectrum of cleft severity. For outcome assessment, they again used blinded, independent raters — here, two board-certified plastic surgeons with no involvement in the surgeries or the research team, scoring each patient on a purpose-built fifteen-point scale across five domains: contour symmetry, tissue quality, scar quality, earlobe position, and complications.

The results were strong. Mean score was thirteen-point-four out of fifteen, with ninety percent of patients landing in the "good" outcome category and the remaining ten percent rated "fair" — nobody scored poor. Interrater agreement was substantial. Looking at individual domains, tissue quality scored highest, scar quality showed the most variability between patients, and the complications domain scored well overall, with only two patients developing minor facial scarring. Patient satisfaction tracked tightly with the objective scores — eighty-five percent were "very satisfied" with overall appearance, satisfaction was highest for earlobe size, a bit lower for symmetry and color, and there was a strong correlation between the surgeon-rated outcome score and how satisfied the patient actually was. No major complications — no flap necrosis, dehiscence, or infection — occurred in this series.

The authors don't spell out a formal limitations paragraph in what's provided here, but a few caveats are worth flagging as my own read on the study: this is a small, single-center, single-technique cohort with no comparator arm, follow-up capped at three to six months — which tells you little about long-term earlobe stretch or scar maturation — and results are specific to the defective subtype, so they may not generalize to the more common longitudinal or transverse cleft patterns. For a Mohs surgeon, this isn't something you'll use often, but the conceptual pearl — using an inverted, anastomosed local tongue flap to rebuild both volume and contour rather than just re-approximating skin edges — is a nice one to file away if you're ever reconstructing a large lobular defect after tumor excision in that region.

Third, and probably most directly relevant to daily practice, a systematic review out of a multi-institutional group led by authors from Louisiana State University and University of Miami, examining locally administered hemostatic agents as alternatives to electrocautery during Mohs surgery. The premise is one most of us feel every week — bleeding remains one of the most common perioperative complications, more patients are arriving on anticoagulation than ever, we're generally not supposed to hold those agents preoperatively, and on top of that there's growing occupational-health concern about surgical plume from electrocautery. So the authors set out to systematically catalog what evidence exists for topical or locally injected hemostatic agents as adjuncts or alternatives.

Methodologically, this followed PRISMA guidelines, searching four databases through March of twenty twenty-four, restricting inclusion to original studies — so reviews, case reports, and non-human or non-Mohs studies were excluded. That's the right call for a review meant to inform practice — you want primary data, not opinion pieces. From over four hundred initial hits, seven studies survived screening, totaling well under five hundred patients combined, which immediately tells you this is still an emerging evidence base rather than a mature one.

Walking through what they found: tranexamic acid, or TXA, had the most data behind it, across three separate studies. In a retrospective cohort of interpolated flap repairs — a higher-risk bleeding scenario by nature — patients who received discretionary subcutaneous TXA had essentially no major bleeding events, compared to roughly three in ten patients in the non-TXA group experiencing a major bleed, with no increase in flap necrosis or clotting complications in either arm. A separate randomized, placebo-controlled trial injecting subcutaneous TXA before the first Mohs stage on the head and neck showed a significantly smaller bloodstain-to-wound-size ratio in the TXA group, an effect that was especially pronounced in patients already on anticoagulants — which is exactly the population you'd want this to work in. And a third randomized trial applying TXA-soaked pads directly to granulating wounds after Mohs, rather than injecting it, found essentially no postoperative bleeding in the TXA group versus about one in ten patients with active bleeding in the saline control group. Tolerability across all three TXA studies was excellent, with only a single mild local allergic reaction reported.

Preoperative brimonidine zero-point-three-three percent gel, an alpha-2 agonist, was tested in a small randomized trial in anticoagulated patients undergoing Mohs for basal cell or squamous cell carcinoma of the face. The treatment arm had about two-thirds less blood loss over thirty seconds compared to controls, and — this is the detail that matters for the plume-avoidance argument — every patient in the treatment group needed less than half their wound bed cauterized, while the large majority of controls needed more than half cauterized. That's a direct, clinically meaningful reduction in electrocautery reliance, not just a cosmetic difference in bloodstain size.

A combination solution of TXA, epinephrine, and lidocaine — soaked into gauze applied between Mohs stages — showed a meaningfully better bloodstain-to-defect ratio than saline, alongside a numerically lower rate of postoperative hematomas, though that particular comparison wasn't statistically tested. Importantly, the authors of that study confirmed lidocaine and epinephrine didn't blunt TXA's antifibrinolytic activity, which is a reasonable practical question if you're thinking about mixing these agents yourself. A hemostatic powder tested against a standard compressed foam sponge for second-intention wounds achieved hemostasis faster — roughly forty seconds versus a minute — with modestly better healing scores at each follow-up point. And finally, a microporous polysaccharide hemosphere bandage compared against electrocautery gave a mixed signal worth noting explicitly: it was associated with less active bleeding, but more bleed-through of the dressing itself — so a nuance between ongoing oozing under a dressing versus true active hemorrhage, not a clean win either way.

The authors' overall conclusion is that these locally administered agents are generally well tolerated and associated with reduced intraoperative and postoperative bleeding, particularly attractive in patients at elevated bleeding risk, and they call for larger controlled studies. The honest limitation here, which isn't spelled out at length in the text but is worth saying plainly, is that this is seven heterogeneous studies — different agents, different designs, some retrospective and some randomized, individually small, ranging from twenty-some to just over a hundred patients — pooled only narratively rather than meta-analyzed. So the practical takeaway: this is genuinely useful, actionable information for your anticoagulated or plume-averse patients — TXA in particular, whether injected or applied topically, has the most consistent supporting data and is low-risk and cheap to try. I'd call it a reasonable adjunct to adopt selectively now, especially for interpolated flaps or patients you can't safely hold anticoagulation on, while stopping short of calling it a wholesale replacement for electrocautery in routine cases.

Last, a brief case report from Northwestern describing reconstruction of a nasal ala defect using an antitragus composite graft. This one's a straightforward technique communication rather than a data-driven study, so there's no results or limitations section to walk through — just presentation, technique, and the teaching point. The setup is familiar: an eighty-nine-year-old man with a nodular and infiltrative basal cell carcinoma of the right nasal ala, cleared after two Mohs stages, leaving a one-point-one centimeter deep defect. For defects of this size and depth on the ala, the reconstructive ladder often pushes you toward an interpolated flap from the cheek or forehead, but that comes with a two-stage course, extended recovery, and some risk of infection or flap necrosis if the pedicle is compromised. The authors instead reached for a composite graft — full-thickness skin, cartilage, and perichondrium together — harvested not from the usual conchal bowl or helical crus, but from the antitragus, which they highlight as having minimal donor site morbidity while still delivering a good skin texture match and native structural scaffolding for the ala.

Technique-wise, they made a gauze template of the defect, traced it onto the antitragus, harvested the composite graft, debeveled the recipient site to maximize contact and graft survival, and secured it in place. The donor defect on the ear was then closed with a subcutaneous pedicled V-Y advancement flap, dissecting the lateral edges with an outward bevel specifically to preserve a broad subcutaneous pedicle and protect the vascular supply — a technique the authors note parallels the same V-Y approach commonly used for earlobe defects, given how anatomically close the antitragus and lobule sit. At six months, both the nasal and ear donor sites showed excellent cosmetic and functional results.

The teaching point here is really about expanding your composite graft donor site options. Antitragus composite grafts avoid the two-stage morbidity of an interpolated flap for alar defects in this size range, and the V-Y advancement gives you a clean, low-tension way to close the ear donor site without additional grafting. This is a single case, so it's illustrative rather than something you can generalize a success rate from — I'd file this as a nice technique pearl to have in your back pocket for the right patient, particularly someone who isn't a good candidate for a staged interpolated flap, rather than something that changes your default algorithm for alar reconstruction.

That covers all four articles this month — a practical base-elevation trick for alar second intention healing, a specialized flap for the most severe congenital earlobe clefts, a genuinely useful review on non-electrosurgical hemostatic options, and a composite graft pearl for the alar reconstructive ladder. Thanks for listening, and we'll see you next month.