Welcome back to the journal review. This is Dermatologic Surgery, June 2026, and we've got four pieces on the docket today — two reconstructive conundrums, a communications piece on private equity, and a cross-sectional data analysis on where dermatologic procedures are actually being performed. Let's get into it.

First up is a reconstructive conundrum out of Hadassah University Medical Center in Jerusalem, presenting a novel repair for a small nasal alar margin defect. This is a case-based technique piece, not a comparative study, so think of it as a "how I do it" framed around a single patient.

The setup: a 47-year-old woman, one year out from Mohs excision of a basal cell carcinoma involving the left alar rim. The original closure — a combination of primary and secondary intention — left her with skin and cartilage denudation and a visible notch in the alar rim contour. As you well know, that's one of the least forgiving cosmetic problems on the face — a small rim irregularity reads as obviously abnormal even when the defect itself is only a few millimeters.

The authors frame the existing options and why none of them are satisfying. Composite skin-cartilage grafts have historically disappointing take and contour rates. The forehead flap is the workhorse for lower nasal vault defects, but for something this small it's arguably overkill — multiple stages, weeks of pedicle carriage, donor site scarring on the forehead, and real cost and morbidity for a rim notch of three to five millimeters.

Their proposed solution is a single-stage local tissue rearrangement. The design: a medially oriented triangular recipient site is created, and a laterally based transposition flap with a split, finger-shaped distal edge is elevated through all soft tissue layers except mucosa, then rotated medially so that the split edge straddles the raw triangular defect — one limb fixed cephalad, one caudad. If the flap doesn't reach without tension, they'll incise the mucosa for extra mobility. Closure is layered — buried Vicryl for the subcutaneous tissue, fine nylon for skin, and Vicryl Rapide horizontal mattress sutures for the mucosal edges. The donor site left behind laterally is handled with a bit of superior undermining plus, if needed, secondary intention.

Now, this is a single case report, so there's no comparative data to round for you — no recurrence rates, no series of patients. The outcome reported is a six-month postoperative photograph showing good alar rim contour with minimal scar retraction and no visible deformity, despite some theoretical concern about mild tissue pull superiorly and laterally from scar contracture.

The honest limitation here, which the authors don't belabor but which you should keep in mind, is that this is an n-of-one with six-month follow-up — we don't have long-term contour stability data, we don't know how this performs on a more fibrotic or previously-radiated ala, and we don't know its limits once the defect grows beyond that three-to-five-millimeter depth they specify as the sweet spot.

Practical takeaway: this is an interesting, plausible addition to your reconstructive toolkit for a very specific, narrow problem — the small, full-thickness alar rim notch that's too small to justify a forehead flap but too three-dimensional for a simple graft. It's not practice-changing in the sense of overturning your default algorithm, but it's worth having in your back pocket as a lower-morbidity option to consider before reflexively reaching for a two-stage forehead flap on these small rim defects. I'd call it a technique worth trying on the right patient rather than one to adopt wholesale.

Next is a communications piece — an opinion and guidance article, not a data study — on private equity in Mohs micrographic surgery, co-written by a Mohs surgeon who himself works for a private-equity-affiliated group, which he discloses upfront.

The piece opens by situating private equity backed groups, or PEGs, in the broader landscape: significant growth through the 2010s, practices characterized by more nonphysician staff relative to physicians, leaner nonrevenue-generating overhead, and — notably — higher revenue and profit but also higher operating costs. Dermatology, and Mohs surgery specifically, has been an attractive acquisition target because of its procedural volume and revenue potential.

The authors are candid about why surgeons sell — practice value redemption, administrative relief, family time, retirement planning — while also flagging that promises around purchasing power and improved payor contracts are often speculative rather than guaranteed. They cite survey data: physicians broadly view PEG ownership negatively on well-being, cost, and health equity grounds, with innovation the only area rated favorably, though the survey didn't specify what that meant. Dermatology residents surveyed separately were largely unwilling to work for PEG-owned practices, citing autonomy and quality concerns. And in a claims comparison, PEG-controlled practices showed meaningfully higher charges per claim, higher allowed amounts, and more new patients and encounters than non-PEG controls — with no corresponding improvement in negotiated fee schedules. In other words, more utilization and cost without offsetting value.

The bulk of the article is really a negotiation guide, and this is where it earns its keep for a practicing Mohs surgeon actually contemplating a sale. The authors walk through the specific contract terms worth protecting: clinical autonomy over case selection, pathology reads, and scheduling, spelled out explicitly rather than left implicit; protected CME and training budgets; retained hiring and firing authority over your surgical support staff, since PEGs have been known to swap experienced assistants for less experienced ones post-acquisition; governance representation, including pushing for a seat on any PEG Mohs advisory board; a clean exit pathway without financial penalty or unreasonable noncompetes, since most deals run three-to-five-year terms but culture mismatches often prompt early departures; and clearly defined, non-unilaterally-modifiable compensation terms, whether that's RVU-based, collections-based, or another productivity framework, with bonus structures and equity terms spelled out and clawback provisions scrutinized.

There's no methods or limitations section here in the traditional sense — this is guidance, not a study — but the takeaway is squarely practical: if you're a Mohs surgeon fielding a PEG offer, or you're already inside one, this article functions as a checklist of contractual protections to insist on before signing, centered on preserving clinical autonomy, staffing control, transparent compensation, and an exit ramp.

Third, another reconstructive conundrum, this time from UC Davis, addressing correction of oral incompetence after Mohs surgery — a case report walking through a complication and its successful revision.

The index case: a 72-year-old woman with squamous cell carcinoma of the right lower lip, requiring three Mohs stages and leaving a three-by-two-and-a-half centimeter defect spanning vermilion and cutaneous lip. The initial reconstruction was a modified Gillies flap. At two weeks, things looked reasonable — viable flap, intact wound — though she had numbness and denture discomfort, with some lumpiness along the suture line. But by two months, she'd developed a real problem: a vertical height mismatch between the lateral lip remnant and the advanced flap, hypertrophic and indurated scarring, contraction, and — functionally significant — fluid leakage with eating from frank oral incompetence.

The authors talk through why they rejected the more obvious revision options. Z-plasty is excellent for lengthening a contracted scar along tension lines, but it doesn't recruit new tissue volume, and this patient's problem was fundamentally a height deficit — she needed more tissue brought into the superior lip, not just scar realignment. So four months after the index procedure, they performed a V-Y advancement flap with a mucosal approach: a full-thickness triangular incision down to the gingival sulcus, an adipofascial pedicle developed and mobilized tension-free into the defect, sized specifically to match the height differential, closed with Vicryl Rapide.

The result: at two months post-revision, the patient had complete restoration of oral sphincter competence and improved contour, and that held at six months. Again, this is a single case, so there's no rate or percentage to give you — the outcome is a durable, functional and cosmetic success in one patient, supported by the authors' citation of other series and a systematic review showing V-Y flaps generally achieve high satisfaction and functional success in oncologic lip reconstruction, albeit with occasional need for revision.

The teaching point the authors want you to take away is really about flap selection logic for a specific failure mode: when a lip reconstruction fails because of a height or volume mismatch rather than a pure tension or scar-orientation problem, a V-Y advancement flap gives you robust tissue recruitment that a Z-plasty simply can't provide, and it's underutilized as a secondary, salvage option in this exact scenario. For your own practice, this isn't a new primary reconstructive algorithm — it's a useful, evidence-supported revision strategy to keep in mind specifically when a lower lip repair leaves you with oral incompetence driven by vertical mismatch.

Last, a cross-sectional analysis of Medicare data examining the sustained shift toward office-based care for dermatologic procedures from 2014 to 2023 — this is a genuine data study, so let's walk through it properly.

The background is straightforward: dermatologists already do most skin cancer excisions, repairs, flaps, and grafts in outpatient office settings rather than ambulatory surgery centers or hospitals, and that pattern matters because office-based care sidesteps facility fees and infrastructure costs while aligning with value-based care priorities. The gap here is simply updating and quantifying that trend over a full decade, and benchmarking dermatology against plastic surgery and otolaryngology.

Methodologically, they used the Medicare Physician and Other Practitioners Provider and Service Public Use File, a publicly available claims dataset, from 2014 through 2023. This is a sensible design choice for this question — you can't easily get decade-long, specialty-wide, site-of-service procedural volumes without a large claims database, and Medicare's public use files are exactly the kind of national administrative dataset built for this sort of trend analysis. Because it's publicly available de-identified aggregate data, it didn't require IRB review. They tracked defined CPT code groups — excisions, repairs, flaps and grafts, and Mohs surgery — and classified each physician's billing by place of service, either facility or office, then computed office-to-facility ratios over time.

The results are striking. By 2023, dermatologists billed about two-and-a-half million procedural services total, up roughly a quarter from 2014. Of that 2023 volume, about ninety-six percent occurred in the office — office volume rose about thirty percent over the decade while facility volume fell by a similar magnitude in the other direction, around twenty-two percent down. The office-to-facility ratio for dermatology grew from about thirteen-to-one in 2014 to over twenty-two-to-one by 2023. Breaking that down by procedure type, the growth was concentrated in office-based Mohs surgery, up about fifty-six percent, and repairs, up about forty percent, while excisions actually declined by around fourteen percent and flaps and grafts were essentially flat. Meanwhile, among dermatologists who did bill in facilities at all, volumes fell across every procedure category, with facility-based excisions hit hardest, down about forty-four percent. And when you look at the physician workforce itself, dermatologists billing exclusively in the office grew by about a fifth, while facility-only and dual-site dermatologists both shrank meaningfully over the same period. For comparison, plastic surgeons and otolaryngologists showed much lower total procedural volumes and far smaller office-to-facility ratios, only around two- or three-to-one, meaning they remain considerably more facility-dependent than dermatology.

The authors' discussion ties this to reimbursement policy — they point to site-neutral payment reforms as a lever intended to equalize payment across settings specifically to discourage more expensive facility-based care, and they frame dermatology's office-based dominance as well-aligned with that direction of travel, reducing cost while, per the low complication rates they cite for office cutaneous procedures, maintaining safety.

Limitations are modest but real and the authors state them directly: the CPT code selection was finite and can't capture every possible procedure, coding selection may vary across specialties in ways that muddy comparisons, and — importantly for us — the dataset can't attribute or adjust for surgical case complexity, so a shift in volume doesn't tell you anything about whether the case mix moving to the office has stayed the same in difficulty.

Practical takeaway: this is confirmatory and policy-relevant rather than practice-changing at the individual surgeon level — it's not going to alter how you operate on Monday morning. But it's genuinely useful ammunition for anyone involved in advocacy, payer negotiations, or practice administration, since it quantifies, in hard Medicare numbers, that Mohs surgery is the fastest-growing office-based procedure category in dermatology and that the office-based model is becoming even more entrenched, not less — which matters directly for how site-neutral payment policy conversations and facility fee arguments get made going forward.

That wraps our four articles for June. A local flap solution for a stubborn alar rim notch, a candid negotiating guide for anyone weighing a private equity offer, a nice illustration of V-Y advancement flap logic for salvaging lip competence, and hard Medicare data confirming just how thoroughly dermatologic surgery has migrated into the office. Thanks for listening, and we'll see you next month.