Welcome to this month's journal walkthrough — we're covering the June 2026 issue of Dermatologic Surgery, and I've got four pieces for you today: a short communication on a do-it-yourself plume evacuation setup, an original ultrasound imaging study on filler nodules, a systematic review of hemostatic techniques for the interpolated forehead flap, and a systematic review updating management of head and neck Merkel cell carcinoma. Let's get into it.

First up is a communication — really a technical note rather than a formal study — describing a low-cost plume evacuation method using a household HEPA vacuum. The clinical problem here is one you know well: CO2 laser ablation, radiofrequency coagulation, and electrocautery all generate surgical plume containing ultrafine particulates and volatile byproducts, and we've had data going back to the Sawchuk paper in the late eighties showing infectious HPV DNA can be recovered from that plume. Commercial smoke evacuators solve this, but they're expensive, need consumable filters, and in smaller or resource-limited practices they're often just not there. Improvised fixes like wall suction or kitchen chimney setups exist in the literature but have weak capture efficiency because of low airflow or long diffusion paths before the plume gets captured.

So the authors — a group out of a hospital in India — simply positioned a consumer-grade vacuum cleaner with a sealed HEPA H13 or H14 filter three to five centimeters from the treatment site, mimicking the inlet distance recommended for medical-grade evacuators, and used it across CO2 laser ablation, RF coagulation, and electrocautery cases. This is not a controlled trial — there's no particle counting, no airflow profiling, nothing quantitative. It's a qualitative feasibility check: did the plume visibly decrease, did perceived odor improve, and was the setup ergonomically workable in terms of noise and maneuverability. Given this is a first description of a technique, that qualitative approach makes sense as a proof-of-concept before anyone invests in the equipment for formal particle-count validation.

The results were straightforward: a marked visible reduction in plume, particularly during laser ablation and electrocautery, a subjective improvement in odor — though the authors are careful to note HEPA filters trap particulates, not volatile gases, so that odor improvement is presumably from the reduced particulate load rather than true gas filtration — stable positioning within that five-centimeter working distance, and no overheating or interference with the procedure itself.

The honest caveat the authors raise themselves is that this system's airflow characteristics simply don't match a certified medical evacuator, which has optimized capture velocity and activated-carbon filtration for the gas phase that this setup cannot touch. So the takeaway for your practice: this is not practice-changing for anyone with access to a real smoke evacuator — it's not a substitute and shouldn't be framed as equivalent. But if you're supervising a lower-resource satellite clinic, teaching abroad, or working somewhere a commercial unit isn't available, this is a genuinely reasonable stopgap worth knowing about, with the caveat that it's an interim measure pending proper quantitative validation, and consumer HEPA filters still need to be sealed units and replaced on a routine schedule.

Second article — this is an original retrospective cohort study out of National Taiwan University Hospital, looking at ultrasound characteristics of dermal filler nodules. The clinical gap they're addressing is real: filler complications are climbing, nodules are one of the most common late presentations, and while biopsy can nail down etiology, patients understandably resist a procedure that risks scarring on the face. Ultrasound is noninvasive, but its filler-specific diagnostic patterns haven't been well mapped across the range of products now in use.

Methodologically, they pulled six years of records — February 2018 through December 2024 — searching ultrasound reports for terms like filler, nodule, granuloma, and foreign body, since there's no standardized terminology for these lesions. That search strategy is worth noting as a methodological point: because nodules get described inconsistently in radiology reports, casting a wide net across multiple free-text terms is really the only way to capture a representative cohort in a retrospective design. This yielded 62 patients, all imaged with a high-frequency 12-megahertz linear probe, which is the right tool for superficial soft tissue characterization. It's inherently a descriptive, retrospective design — there's no comparator group, no blinding of sonographic interpretation — which the authors don't belabor, but which is the natural limitation of a single-center chart-and-image review like this.

On to results. This was overwhelmingly a female population, about nine in ten patients, average age mid-forties. Hyaluronic acid was the leading filler at just over half of cases, followed by polycaprolactone and poly-D,L-lactic acid, with a handful of polyacrylamide and silicone cases. The midface dominated as the site of nodule formation, involved in over eighty percent of patients. Timing is clinically important here: median time from injection to nodule appearance was two years, with a wide range — five months to four years on the interquartile spread — and the authors separately note silicone nodules can present with an extraordinarily long latency, out to decades, consistent with its capacity for chronic low-grade inflammation. About a third of the cohort had received multiple filler treatments, and of those, roughly three-quarters had mixed different filler types, which the authors flag as a plausible risk factor for late complications, though this remains associative, not causal, in a retrospective design like this.

The imaging findings are really the heart of the paper, and they're clinically useful shorthand. Hyaluronic acid nodules start as anechoic, homogeneous "jelly-like" structures early on, then as the hydrophilic component metabolizes — as early as two months out — they transition to a hypoechoic "storm-cloud" pattern of small hypoechoic streaks in connective tissue. Polycaprolactone nodules show a fibrotic, hyperechoic cystic pattern with fibrillar echoes they term "dragon-beard candy," evolving over time into a layered "water-ripple" appearance as fibrosis and degradation progress. Poly-D,L-lactic acid produces well-circumscribed hyperechoic "snow-globe" nodules — fine hyperechoic microsphere residue inside a defined hypoechoic capsule. And silicone gives a diffuse, ill-defined "snowstorm" pattern — essentially the snow-globe pattern without the discrete boundary. Separately, infectious nodules looked different from all of these — ragged, ill-defined capsules with heterogeneous internal echoes consistent with pus and debris, which is a useful discriminator when you're trying to decide whether you're dealing with a foreign-body granuloma versus something that needs cultures and antibiotics. On that point, only about eight percent of the cohort had positive bacterial cultures, mostly common skin flora, though the authors are appropriately cautious that culture-negative doesn't rule out biofilm involvement given known culture-method limitations — and there was one notable case of Mycobacterium abscessus presenting just nine days after a poly-L-lactic acid injection, a reminder to keep atypical mycobacterial infection on the differential for early rapid-onset nodules.

Practically, this is useful but not practice-changing in the sense of altering your management algorithm outright — it doesn't replace biopsy when histology is truly needed, and it's a single-center, retrospective, descriptive series without validation against a blinded reference standard. But the filler-specific sonographic vocabulary they've proposed — jelly to storm-cloud for hyaluronic acid, dragon-beard-candy to water-ripple for polycaprolactone, snow-globe for poly-D,L-lactic acid, snowstorm for silicone — is a genuinely handy noninvasive framework you can use at the bedside to narrow your differential and counsel patients before deciding whether biopsy or aspiration is even necessary.

Third, a systematic review on pharmacologic methods to reduce postoperative bleeding after the first stage of the interpolated forehead flap — essentially the paramedian forehead flap pedicle. You know the problem cold: pedicle bleeding twenty-four to forty-eight hours after stage one is the most common complication, and it's clinically relevant because roughly four in ten Mohs patients are on anticoagulants or antiplatelet therapy that we typically continue perioperatively.

Methodologically, this was a straightforward PubMed search from April 2025, no date restriction, combining forehead-flap terminology with bleeding and hemostasis terms, English-language only. Importantly, they deliberately excluded the bread-and-butter techniques you already use — subcutaneous epinephrine, electrocautery, pressure dressings, positional changes — because the goal was specifically to catalog additional pharmacologic adjuncts beyond standard practice. That's a sensible scoping choice for a review aimed at a surgeon audience that already knows the basics and wants to know what else is out there. Of 277 initial hits, 11 articles ultimately described a specific technique, yielding nine unique methods.

Because this is a narrative synthesis of case series and small reports rather than comparative trials, there's no pooled effect size to report — the "results" here are really a catalog, and that's an honest limitation of the underlying evidence base, not a flaw in the review itself. Let me run through what they found. Hydrophilic polymer combined with potassium ferrate powder works independent of the clotting cascade — it dehydrates plasma and agglutinates blood proteins to form a seal — making it appealing in anticoagulated patients; the main downside is foreign body reaction, which can mimic recurrence. Ferric subsulfate, better known as Monsel's solution, is a chemical styptic with bacteriostatic properties, but carries real practical downsides — tissue staining, hyperpigmentation, necrosis, and it can create imaging artifacts — though the authors point out that since the pedicle itself gets excised at stage two, staining and foreign body reaction are largely inconsequential here; the main safety concern is accidental ocular exposure. Oxidized regenerated cellulose gauze mechanically tamponades and provides a scaffold for clot formation, is weakly bacteriostatic, and its acidity may actually promote vasodilation in the pedicle, theoretically helping flap viability — main risk again is foreign body reaction, and there's a risk of rebleeding once the gauze is removed. Gelatin sponge is an absorptive scaffold, easy to apply, but carries a higher tissue-reactivity profile and a theoretical infection nidus. Thrombin-based agents convert fibrinogen to fibrin directly, working through the clotting cascade itself rather than around it — useful specifically in patients with platelet dysfunction — with the main risk being a rare immune-mediated coagulopathy. Aluminum chloride acts as a chemical cautery through protein precipitation and vasoconstriction; it avoids the staining problem of ferric subsulfate, but the senior author's own opinion, stated in the review, is that it's a weaker hemostatic agent, and it can be painful on application. Cyanoacrylate tissue adhesive physically seals bleeding vessels through rapid polymerization and is FDA-approved for skin use. The review also identifies skin grafting and tranexamic acid as described techniques, though the excerpt available doesn't detail their specific application protocols the way it does for the others.

The overall conclusion is that no single technique has comparative head-to-head data — this is level of evidence drawn entirely from case series and expert recommendation, so it's genuinely a menu rather than a hierarchy. Practically speaking, I'd frame this as interesting and useful reference material rather than practice-changing: if you already have a go-to hemostatic method for your pedicles, this review doesn't give you comparative data compelling you to switch. But it's a nice single reference to have on hand when your usual approach isn't cutting it in a particular patient — for instance, reaching for a thrombin-based agent in someone with known platelet dysfunction, or favoring the polymer-and-potassium-ferrate combination in a heavily anticoagulated patient where you want a mechanism independent of the clotting cascade.

Last, a systematic review updating management of Merkel cell carcinoma of the head and neck, building on and expanding a 2014 review by Raju and colleagues. The background bears repeating even for this audience because the epidemiology keeps shifting — incidence is still under one per hundred thousand annually, but case counts have risen about ninety-five percent since 2000, outpacing melanoma's growth rate, largely attributable to an aging population plus UV exposure and immunosuppression from transplant, HIV, and hematologic malignancy. Head and neck involvement carries particular weight because nearly half of primary MCCs arise in sun-exposed skin, and lip lesions specifically carry higher mortality. By AJCC staging cohorts, five-year overall survival runs about fifty percent for localized disease, mid-thirties percent with nodal involvement, and down to the mid-teens with distant metastasis — sobering numbers that frame why optimizing locoregional treatment matters so much.

Methodologically, this followed PRISMA guidelines, searching PubMed and Google Scholar for the last ten years of literature combining Merkel cell, treatment, head and neck, and Mohs as search terms. They deliberately excluded case reports with three or fewer patients, studies without extractable head-and-neck-specific data, palliative-only series, and anything with less than three months follow-up — sensible exclusions to keep the pooled data clinically interpretable rather than diluted by tiny or unfollowed cohorts. They also applied the MINORS instrument to grade methodological quality of each included study, which is the appropriate tool here since every included study was retrospective — there simply isn't randomized-trial-level evidence in this disease space, which the authors acknowledge upfront rather than treating as a hidden limitation. Worth noting: mean MINORS scores landed around ten out of sixteen for noncomparative studies and about seventeen and a half out of twenty-four for comparative ones — middling quality, with the most common deficiency being lack of an explicitly unbiased outcome assessment or prospective sample size calculation. That's a real caveat to keep in mind before over-weighting any single finding below.

From 238 initial results, 30 retrospective studies survived screening, collectively covering over sixteen thousand head-and-neck MCC patients across eight countries, U.S.-based cohorts dominating. Mean follow-up across studies was right around three years. Surgery was used in the vast majority of cases — about nine in ten patients across the comparative studies — followed by adjuvant radiation in roughly four in ten, and chemotherapy in a small minority, only about three percent, reflecting its role being reserved mainly for advanced or unresectable disease. Only two studies reported on immunotherapy at all, underscoring how early we still are in that data.

On the actual comparative findings — and the authors are upfront that these are heterogeneous in how they reported statistics, mixing Cox models, p-values, and log-rank tests, so this is a qualitative synthesis of significance rather than a pooled hazard ratio — the general signal favors adjuvant radiation after surgery, particularly in higher-risk patients. Chen and colleagues found improved overall survival with surgery plus adjuvant radiation compared to surgery alone, especially in patients with positive margins, larger tumors, or male sex. Harley and colleagues found improved overall and disease-specific survival with adjuvant radiation specifically in sentinel-node-positive patients, while node-negative patients saw a disease-specific but not overall survival benefit. Yusuf and colleagues found the adjuvant radiation benefit held in both immunocompetent and immunosuppressed patients. Bierma's group found no difference in disease-specific survival between surgery alone versus surgery plus radiation, but did find a significantly lower local recurrence rate with the addition of radiation. Not every study agreed, though — Nayak and colleagues and Takagishi and colleagues found no survival difference at all between those two approaches, and Kwan's group found no significant recurrence difference across several treatment permutations, including radiation with or without chemotherapy. So the honest picture is a general, though not unanimous, tilt toward benefit from adding radiation, with the more consistent effect being on local recurrence rather than overall survival. On dosing, Patel and colleagues suggested radiation in the fifty-to-fifty-five Gray range outperformed both lower and higher dose bands for overall survival, an interesting but single-study observation.

For Mohs specifically, the abstract-level conclusion is that Mohs micrographic surgery was associated with lower recurrence and improved outcomes in select patients — which is obviously the finding most relevant to you directly — though the granular study-by-study Mohs data sits in a part of the paper not fully detailed here, so I'd treat that as a supportive signal worth reading in full rather than something I can quantify precisely for you right now.

Bottom line for practice: surgery plus adjuvant radiation remains the backbone of head and neck MCC management, and this review reinforces — without being definitively practice-changing given the retrospective, heterogeneous nature of the underlying data — that radiation after surgery is reasonable to favor in higher-risk scenarios like positive margins, larger tumors, or node-positive disease, and that Mohs has an emerging, favorable role in appropriately selected patients. Chemotherapy and immunotherapy remain evolving areas without enough data yet to call them standard, but worth watching as the systemic therapy landscape for MCC continues to mature.

That wraps our four articles for this issue. To summarize quickly: a clever low-cost plume evacuation workaround for resource-limited settings, a new sonographic vocabulary for characterizing filler nodules that's genuinely useful at the bedside, a practical catalog of hemostatic options for your forehead flap pedicles, and a reaffirmation — with some new nuance around radiation dosing and node status — of the surgery-plus-radiation paradigm in head and neck Merkel cell carcinoma, with Mohs continuing to carve out its role. Thanks for listening, and I'll see you next month.