Welcome back to the journal review. This is our walkthrough of Dermatologic Surgery for June twenty twenty-six, and we've got four pieces to get through today — a technique communication on a hemostatic wax repurposed as a wound dressing, a case report on a genuinely strange pattern of post-surgical squamous atypia, a retrospective look at three-and-a-half decades of malpractice litigation touching Mohs surgery, and a short clinical pearl on breathwork during Mohs procedures. Let's get into it.

First up is a technique communication on bonewax-assisted second-intention healing. The clinical problem here is one you already live with every day: second-intention healing is the workhorse closure for shallow or concave defects, but our standard dressings have real shortcomings. Petrolatum-impregnated gauze adheres to granulation tissue and makes dressing changes painful. Nonstick Telfa pads are too rigid to conform to an irregular or deep wound bed. And anywhere you've got exposed cartilage or bone — the ear, the scalp, the nail unit — maintaining consistent occlusion gets genuinely difficult with conventional materials.

The authors' solve is bonewax, which of course most of us know only as the hemostatic putty from orthopedic, thoracic, and neurosurgical cases. It's a mix of beeswax, paraffin wax, and isopropyl palmitate, and functionally that gives you something moldable, nonabsorbable, and — critically — nonadherent to the wound bed. Their proposed technique is straightforward: achieve hemostasis, lay down a thin layer of petrolatum ointment, then mold the bonewax directly to the wound geometry. On a mobile site like the ear, they suture it in place, which actually lets the patient shower around the wound without disrupting things. A nonstick secondary dressing goes on top, and dressing changes happen weekly until granulation is complete.

They illustrate this with a case that's a nice showcase for the technique's niche: a sixty-one-year-old woman with a history of nail bed squamous cell carcinoma in situ, treated with Mohs three years prior, who presented with a new verrucous plaque involving the proximal and distal nail folds. Biopsy confirmed squamous cell carcinoma, and Mohs surgery left an almost two-by-two centimeter defect down to bone on the digit — about as unforgiving a second-intention site as you'll encounter. Bonewax was applied directly to the exposed bone, weekly dressing changes followed, and the site healed completely.

The stated advantages track logically from the material properties — no adherence pain at dressing changes, full occlusion even over irregular contours, less frequent dressing changes than gauze-based approaches, good tolerability in sensitive locations, and a cost the authors put at around five dollars per application, which is a trivial add to your supply budget. The caveats are the ones you'd expect for any wax-based occlusive: avoid it in contaminated or infected wounds, and avoid it where you actually need osteogenesis, since it will physically block bone regeneration at the interface. Rare foreign body reactions are also flagged as a possibility, though no denominator is given. There's no comparative data here — this is a technique report with a single illustrative case, not a trial against standard dressings — so the practical takeaway is modest but real: this is a low-cost, low-friction option worth having in your armamentarium specifically for exposed bone or cartilage defects on the ear, scalp, or digit, not a wholesale replacement for your existing second-intention dressing protocol.

Next, a case report that I think is worth sitting with, on migratory squamous atypia after Mohs surgery. The background concept is one most of you have already seen in some form — squamous atypia arising at a surgical site or a site of minor trauma, which the literature has variably labeled eruptive squamous cell carcinoma, eruptive squamous atypia, or eruptive keratoacanthoma. What makes this case worth a dedicated report is a migratory growth pattern that, as far as the authors can tell, hasn't been described before, plus a second lesion at an entirely separate, non-surgical trauma site in the same patient — which is about as clean a natural experiment for the "injury as trigger" hypothesis as you're likely to see clinically.

The patient was a sixty-nine-year-old man with heavy actinic damage and multiple prior nonmelanoma skin cancers, who presented with a well-differentiated squamous cell carcinoma on the right dorsal hand that had grown rapidly — to four by just over two centimeters in about six weeks — with no preceding trauma or treatment. Mohs achieved clear margins uneventfully, and the wound was allowed to granulate. Interestingly, because the lesion looked clinically atypical, the initial stage was sent for permanent sections, which showed well-differentiated squamous cell carcinoma with microabscesses — unusual enough that infection was considered, though bacterial, mycobacterial, and fungal stains all came back negative.

Seven weeks after surgery, painful keratotic nodules developed at the periphery of the healed surgical site. Repeat biopsy again showed well-differentiated squamous cell carcinoma with those same microabscesses, again with a fully negative infectious workup — this time including silver stain, acid-fast stains, cultures, and PCR. And here's the notable part: the lesion didn't just recur, it migrated, with hypertrophic growth advancing at the leading edge while the trailing portion involuted behind it.

Treatment was a long slog through multiple modalities. Intralesional triamcinolone gave partial improvement but the migratory pattern persisted; a second triamcinolone injection a month later did nothing; topical triamcinolone ointment did nothing; three monthly rounds of intralesional five-fluorouracil produced partial improvement; topical clobetasol did nothing; and it was ultimately a single intralesional methotrexate injection at the advancing border that produced durable resolution. In the interim, the patient sustained a dog scratch to the contralateral, left dorsal hand and developed a biopsy-proven well-differentiated squamous cell carcinoma there too, with the same migratory pattern, which responded to intralesional and topical steroid alone. Both sites had fully involuted by around eleven months after the original surgery.

The discussion frames this within what's already known about eruptive squamous atypia — it favors sun-damaged extremity skin, median onset is around six weeks post-surgery or post-trauma, it should be on your differential for any new lesion at a clear-margin surgical site, and essentially any surgical procedure can theoretically trigger it. The authors flag the reproducible finding of sterile microabscesses on histology as potentially a useful predictive clue distinguishing this reactive process from true squamous cell carcinoma, though they're careful to note this needs further validation, not blind reliance. They also make an important management point: surgical treatment of these lesions should be approached cautiously, since further trauma may simply incite more reactive atypia — which is why the medical therapy ladder here, ending in intralesional methotrexate, is the more instructive part of this report than the diagnosis itself. There's no formal limitations section since this is a single case, but the obvious caveat is generalizability — this is one patient, and whether the migratory pattern is a true biological phenomenon or was partly shaped by the sequence of treatments tried is explicitly left open by the authors. The practical takeaway for you: this isn't practice-changing in the sense of altering your surgical technique, but it is a genuinely useful pattern-recognition pearl — if a "recurrence" at a clean-margin surgical site shows this expanding-with-trailing-involution behavior and microabscesses on repeat biopsy, consider eruptive squamous atypia before escalating straight to more surgery, and know that intralesional therapy, including methotrexate as a last-line option, has a track record here.

Now to a retrospective cross-sectional study, and this one's squarely in the practice-management lane: state and federal malpractice litigation involving Mohs surgery from nineteen eighty-eight through 2024. The gap they're addressing is that while prior work has looked at malpractice trends in general dermatology and even specifically around Mohs, this group wanted to take another pass using a different data source and see whether the same patterns held.

Methodologically, they searched the LexisNexis academic legal database for cases mentioning Mohs surgery, micrographic surgery, and skin cancer, removed duplicates, and excluded anything without a documented Mohs procedure. It's worth pausing on why a legal database like this makes sense as a study source, and to be fair, the authors are explicit about this rationale themselves: this database captures state, federal, and appellate cases going back to nineteen seventy, which gives a systematic, searchable window into formal litigation — but by its nature it only captures cases that actually went to court and were appealed. It cannot capture out-of-court settlements or cases resolved through arbitration, which the authors flag as a real structural blind spot. Given the small resulting sample, they also made the methodologically honest choice to skip formal statistical significance testing on pairwise comparisons and just report descriptive summary statistics — which is the right call when your denominator is this small; forcing p-values onto seventeen cases split into subgroups would have been more misleading than informative.

And seventeen cases is indeed the final count. About six in ten appellants were male. Geographically, the Northeast and South each accounted for about four in ten cases, with the West and Midwest trailing well behind. Roughly two-thirds of cases involved cosmetically sensitive sites like the face or head, and basal cell carcinoma was the most commonly cited cancer type, in about four in ten cases. Most cases — about two-thirds — were ultimately decided in favor of the appellee, meaning the party defending against the appeal prevailed. Dermatology was the specialty named in the large majority of cases, and within that group, about two-thirds of the dermatologist-defendants were actually performing Mohs surgery themselves, with the rest being non-Mohs surgeons. Of the Mohs surgeons involved, just over half were fellowship-trained.

Here's the part I'd flag as clinically actionable: across all cases, delay in diagnosis or delay in referral was the single most common reason for litigation, present in about half. But when you split by defendant type, the picture diverges sharply. For non-Mohs surgeons, delay in diagnosis was essentially the only reason for litigation — one hundred percent of those cases. For Mohs surgeons specifically, the leading reason was lack of informed consent, followed by fraudulent billing. And within those informed-consent cases, three-quarters involved fellowship-trained Mohs surgeons, while every single fraudulent billing case involved a non-fellowship-trained provider.

The authors' discussion ties this back nicely to prior literature — earlier work using different data sources similarly found that most Mohs-related legal claims target non-Mohs surgeons and that delay in diagnosis is the dominant driver there, which lines up with what they found. Where they diverge from a prior survey-based study is instructive about methodology itself: that earlier survey found wrong-site surgery and functional outcomes to be the leading reasons for litigation against Mohs surgeons specifically, and the authors here reasonably attribute the discrepancy to two things — survey data is vulnerable to recall bias and underreporting, and that prior study captured cases settled out of court, which is precisely the category this LexisNexis-based study structurally cannot see. So the two studies aren't really contradicting each other so much as sampling different slices of the malpractice universe. The honest limitation, stated plainly by the authors, is that this analysis therefore does not capture the full landscape of malpractice risk — no settlements, no arbitration, just appealed court cases — and the sample size is small enough that these proportions should be read as descriptive signal, not precise risk estimates.

Practically, here's what I'd pull from this for your own practice and for anyone running a fellowship program: overall litigation volume tied to Mohs surgery remains low relative to the volume of procedures performed, which is reassuring background context. But the specific finding that informed consent is the leading litigation driver among Mohs surgeons — and skews toward fellowship-trained providers — is a genuine signal to double down on documentation of the informed consent conversation, especially around anticoagulation risk, alternative treatments, and the possibility of additional procedures or reconstructive steps, all of which show up explicitly in their case summaries. And the fraudulent billing cluster among non-fellowship-trained providers is a reminder that billing compliance training belongs in fellowship curricula alongside clinical technique. This is a modest-evidence, high-relevance piece — not practice-changing in a clinical sense, but worth a genuine look at your consent process.

Last, a short clinical communication rather than a formal study — a pearl on using box breathing to reduce stress and anxiety during Mohs surgery. This one is explicitly experience-based, not data-driven, so I'll treat it that way. Box breathing, for anyone who hasn't encountered the term, is a paced breathing technique — inhale, hold, exhale, hold, each phase lasting about four seconds, tracing out a mental "box." The authors ground this in existing physiology and psychology literature: controlled breathwork has been shown to outperform mindfulness meditation for improving mood and lowering respiratory and heart rate, plausibly through brainstem cardiorespiratory control centers and limbic system engagement, and separately, breathing exercises have been shown in a meta-analysis to reduce oxidative stress markers in both healthy people and those with diabetes, hypertension, or COPD. There's also a randomized trial showing diaphragmatic breathing improves pulmonary function after cardiac bypass surgery, and — closer to home — a single-blinded study is the only prior report in dermatologic surgery specifically, showing that deep breathing reduces intraoperative pain perception and anxiety. The authors are upfront that no prior report exists on box breathing specifically during Mohs surgery, and that their own contribution here is anecdotal clinical observation, not a controlled study — they describe noticing, informally, that anxious patients became visibly more compliant and relaxed with repeated use of the technique across a case.

Their practical recommendation is to introduce box breathing right at the start of the encounter, giving brief guided instruction so the patient can visualize the pattern, and to let the procedure begin within the first or second breathing cycle, continuing the exercise through the uncomfortable portions. For Mohs specifically, they suggest it's most valuable right at local anesthesia — typically the most stressful moment for patients — and then reinforced as needed through each subsequent stage. To their credit, the authors don't oversell this: they explicitly state that the evidence base in dermatologic surgery is essentially just the one prior study, that the role of relaxation techniques in this field remains genuinely unclear, and that the appropriate next step is a controlled study with a comparison group measuring patient-reported satisfaction and anxiety. So the honest framing for your own practice is this: this is a zero-cost, zero-risk intervention with a plausible physiologic rationale and supportive anecdote, worth trying at chairside for anxious patients, but it's an interesting-not-yet-actionable-by-evidence pearl rather than anything backed by dermatologic surgery outcomes data.

That closes out this June issue — a nail bed and auricular dressing trick worth adding to your kit, a squamous atypia case that sharpens your pattern recognition for post-surgical "recurrences," a legal dataset reminding us where informed consent documentation actually matters most, and a low-stakes breathing technique worth trying on your next anxious patient. Thanks for listening, and I'll see you next month.