Welcome back to this journal review. We're covering the July 2026 issue of Dermatologic Surgery, and I've got four pieces for you today — two commentaries on original studies, a reconstructive conundrum case, and a systematic review. Let's get into it.

First up is a commentary — from Lucie Joerg, Julia Stolyar, and Jared Jagdeo out of SUNY Downstate and the VA — responding to a randomized controlled trial by Friedmann and colleagues comparing two at-home LED devices for mild to moderate inflammatory acne. The underlying trial pitted a novel handheld device combining red and blue light, six-sixty and four-fifteen nanometers, against an existing FDA-cleared blue-light-only device. Both devices reduced total and inflammatory lesion counts, and the combination device edged out blue light alone on investigator global assessment, though most other outcomes were fairly similar between the two arms.

The commentators frame this as an important and timely head-to-head study in a space that's exploding commercially — they cite the phototherapy device market sitting around one-point-eight billion dollars now and projected to approach two-point-seven billion within the decade, driven substantially by acne. Their point, and it's a good one for anyone fielding patient questions about these gadgets, is that market growth has far outpaced the clinical evidence base — most devices reach shelves via predicate clearance without dedicated trials, so any rigorous comparative study is valuable almost by default.

That said, the commentary is fairly pointed about this trial's limitations. The sample was small, twenty-three total completers, and unevenly split — fourteen in the combination arm versus nine in the blue-light arm — which weakens confidence in any between-group differences. Skin type diversity was essentially absent, enrollment was limited to Fitzpatrick two to three, and the authors note their own prior phase one work showing patients with more richly pigmented skin are at elevated risk for light-induced hyperpigmentation, so they're arguing hard for inclusive trial design going forward, ideally with stratified dosing and dyspigmentation follow-up. Perhaps the most clinically relevant flag for your own patient conversations: two participants in the combination-light arm developed self-limited first-degree facial burns, attributed to poor technique with a once-daily, five-minute, self-directed handheld regimen. The commentators suggest the frequency may simply be too aggressive for unsupervised home use and recommend built-in rest days between treatments, and they also favor hands-free full-face LED masks over handheld arrays for more even, technique-independent dosing. Their own STARS trial data, cited for context, showed even very high red-light fluences were well tolerated across skin types with only mild transient effects, which frames the observed burns here as more a device-design and adherence issue than a fundamental problem with photobiomodulation itself.

Practical takeaway: this isn't practice-changing for how you manage acne, but it's a useful data point if patients ask you which home LED device to recommend — the message is to favor devices that have actual published trial data behind them, be cautious about daily-use burn risk with handheld arrays, and recognize that the evidence base still doesn't extend to darker skin types, so temper enthusiasm accordingly for those patients specifically.

Second, a commentary from Lisa Ishii on a cross-sectional survey study by Cucalon and colleagues looking at how US board-certified dermatologists actually use botulinum toxin type A during pregnancy and lactation, versus what protocol or labeling would suggest. The survey found that about one in five respondents reported using the toxin during pregnancy, and a notably larger share, three in four, reported use during breastfeeding — either administering it to patients or, interestingly, using it themselves. No adverse outcomes were reported in the survey. Ishii flags that self-use data point as meaningful, since physicians presumably have a more sophisticated risk-benefit calculus than the general public might bring to the decision.

She walks through the regulatory backdrop — the toxin was historically pregnancy category C, and the newer labeling framework says use in pregnancy should only occur if benefit outweighs risk, given the absence of well-controlled studies in pregnant patients. She cites the large postmarketing safety review from Brin and colleagues, nearly three decades of data, showing that major fetal defect rates among live births with exposure were consistent with general population rates — reassuring, but Ishii is careful to note most of that exposure data comes from preconception or first-trimester dosing at doses used for migraine or movement disorders, which are typically higher than cosmetic doses, and there's limited data later in pregnancy. Her central argument is that this reassurance is much easier to lean on for therapeutic indications than for elective aesthetic ones — it's hard to construct a genuine benefit that justifies any incremental risk when the indication is purely cosmetic. She's clear that this postmarketing data is useful for counseling patients who discover a pregnancy after having already been treated, not as a green light to proceed electively.

On lactation, she notes toxin has been detected in breast milk after cosmetic injection in small studies, though at levels well below any theoretical infant lethal dose, and that the common "pump and dump" advice some injectors give patients is essentially anecdotal, with no established duration or evidence base behind it.

There's no methods or results section to walk through here beyond what the survey itself reported, since this is a commentary on a survey — Ishii's real contribution is the framing: this is a snapshot of practice variation, not a validation of that practice, and plenty of basic questions remain unanswered, including whether dose or trimester matters, and what a rational pump-and-dump interval would even look like. Practical takeaway — interesting, not practice-changing. It's useful for calibrating how you counsel a patient who was inadvertently treated before discovering a pregnancy, but it shouldn't shift your default approach toward offering elective cosmetic toxin during pregnancy or lactation.

Third, a reconstructive conundrum — a case-based technique piece out of UC Davis, presented by Rajkumar, Kim, and Eisen. The case is a sixty-seven-year-old man with a basal cell carcinoma of the left anti-helix, cleared after seven stages of Mohs, leaving a substantial five by four centimeter defect — about forty percent of the superior anterior ear and thirty percent of the posterior ear, down to perichondrium. This is a genuinely large, through-and-through-adjacent auricular defect, and the piece walks through why each of the usual auricular reconstructive options was rejected before landing on the answer.

Secondary intention was out because of the risk of chondritis and contour distortion from contracture. Wedge excision was declined given the patient's preference to preserve normal ear shape — understandable given the size here. Helical advancement, bilobed, and mastoid interpolation flaps were all judged to have insufficient local tissue reservoir for a defect this large. A full-thickness skin graft was ruled out for inadequate recipient vascularity, and a temporoparietal fascial flap with grafting, while feasible, was judged more technically demanding than the chosen alternative. The authors settled on a superiorly based retroauricular neck banner flap — essentially an interpolated flap drawing on the large, hairless, well-vascularized reservoir of lateral neck skin, which allows primary closure of the donor site since it's hidden behind the ear.

Technique-wise, the pedicle was designed to run superiorly behind the ear to just below the posterior defect, elevated superficially through the paddle and down to fascia at the handle for a robust pedicle, then transposed and folded over the auricle to resurface both anterior and posterior aspects simultaneously. A key pearl here: because the flap has to fold over the auricle, it effectively shortens, so the authors recommend deliberately oversizing the flap beyond your measured dimensions to compensate — in their case, the triangular fossa and inferior crux were left slightly undercovered after stage one and were allowed to granulate. At division, three weeks later, those granulated zones were resurfaced with a full-thickness graft harvested conveniently from the redundant pedicle tissue itself.

At three months the flap was viable but bulky and didn't match the native auricular contour, which the authors addressed with electroblation — essentially a grid of small electrosurgical punctures into the subcutaneous plane that induces dermal contraction, analogous conceptually to fractionated CO2 resurfacing — combined with electrodesiccation to smooth the flap-to-skin transition. By six months the patient was satisfied and declined further revision.

The teaching points here are practical and transferable: the ear's small intrinsic tissue reservoir means large defects often require distant tissue transfer rather than local subunit-based repair; the retroauricular banner flap, while not a true axial flap, is robust enough to be folded over itself to cover both surfaces of the ear; oversizing is essential when folding is planned; and bulky flap revision has a whole toolkit — electroblation, electrodesiccation, intralesional steroid, or straightforward surgical debulking. This is a solid technique reference to file away for the next large combined anterior-posterior auricular defect that lands on your table.

Last is a systematic review from a University of South Florida group — Moffitt, Rizk, Alford, Rivera, Boby, and colleagues in plastic surgery — looking at surgical interventions for hidradenitis suppurativa through the lens of quality-of-life impact, specifically the Dermatology Life Quality Index, or DLQI.

The background rationale is straightforward: HS is graded by Hurley stage, surgery is generally reserved for Hurley two and three disease that's failed or is unlikely to respond to systemic therapy, and the disease carries a genuinely severe quality-of-life burden — the authors cite a mean DLQI around thirteen for HS patients, which lands in the "very large effect" band on the standard interpretation scale, and is notably worse than the quality-of-life burden reported for atopic eczema, psoriasis, or even epidermolysis bullosa in comparable prior work. The specific gap they're addressing is that while plenty of literature describes surgical outcomes for HS in terms of recurrence or wound complications, DLQI as the specific outcome of interest hadn't been systematically pulled together across surgical techniques.

Methodologically, this followed PRISMA guidance, searching PubMed, Embase, and Google Scholar from 1976 through 2023, requiring studies to report DLQI mean and standard deviation at both baseline and after intervention — a reasonably strict inclusion bar that's the right call here, since it forces genuine before-and-after comparability rather than just pooling loosely reported quality-of-life impressions. Screening was done by multiple independent reviewers with concordance requirements, and risk of bias was assessed with the ROBINS-I tool, appropriate given that essentially all included studies were observational rather than randomized — you can't ethically randomize or blind major HS surgery, so the authors reasonably treat this design limitation as inherent to the question rather than a fixable flaw. Ultimately eight studies met criteria, totaling two-hundred sixty-two patients.

On bias specifically, they flag that essentially all included studies carried serious risk in the outcome-measurement domain, simply because DLQI is patient-reported and inherently subjective — worth noting, though the authors are careful to say that doesn't diminish its value, since patient-perceived quality of life is exactly the outcome that matters here. Two of the retrospective studies also carried serious confounding-related bias due to small numbers and uneven distribution of Hurley stage across groups, and one study was flagged for lack of randomization since patients self-selected their surgical approach.

On results: cohort demographics skewed young, mean age right around thirty-two, with a high smoking prevalence — about six in ten among studies reporting it — and roughly half meeting criteria for obesity, both unsurprising given known HS risk-factor associations. DLQI was captured postoperatively somewhere between five months and a year out, which the authors reasonably argue is enough time for genuine recovery and quality-of-life stabilization rather than an artificially early or late snapshot.

Walking through the techniques: wide local excision, healed by secondary intention, had the shortest operative time but came with real costs — Posch and colleagues reported postoperative complications in nearly half of patients, driven mostly by pain and scarring, and recurrence rates around one in five, with the groin region disproportionately represented among recurrences, plausibly because wound care and tension control are simply harder there. On the positive side, pain scores in one study dropped substantially from baseline to six months, which is a reasonable thing to set as a patient expectation — pain gets meaningfully better, but it takes months, and wound care burden in the interim is real. Wide local excision paired with a split-thickness skin graft didn't show any clear advantage over excision alone, and actually came with its own complication profile — graft failure in over a third of patients and contracture in a quarter in one study, plus longer hospital stays and more follow-up visits, which the authors attribute partly to shear forces in high-tension areas like axilla and groin. For axillary disease specifically, wide excision combined with either a thoracodorsal artery perforator flap or a muscle-sparing latissimus dorsi flap appeared to offer the smoothest postoperative course and best recurrence prevention, consistent with the general reconstructive principle that well-vascularized regional flaps tolerate the tension and mobility demands of the axilla better than grafts do.

The overarching conclusion is that surgery meaningfully improves quality of life in HS, full stop, but technique selection genuinely matters and should be tailored to anatomic site and disease extent — there isn't one clearly superior approach across all locations. Limitations are honestly stated: small pooled numbers, exclusively observational source data with the bias issues already discussed, and real heterogeneity in how and when DLQI was measured across the eight included studies, which limits any formal pooled quantitative comparison.

Practical takeaway for your own practice: this reinforces something you likely already believe from clinical experience — that surgical intervention in Hurley two and three disease produces substantial, patient-reported quality-of-life gains, and that flap-based reconstruction is preferable to grafting in high-tension, high-mobility zones like the axilla. It's not a paper that hands you a new technique, but it is a useful piece to cite when counseling patients on why you're recommending flap reconstruction over grafting in a particular anatomic site, and it's a reminder to set expectations around timeline — meaningful quality-of-life improvement here is measured in months, not weeks.

That wraps our four articles for this issue — a cautionary look at at-home LED device safety and evidence gaps, a sober reality check on toxin use in pregnancy and lactation, a nicely detailed technique lesson on folding retroauricular flaps for large combined ear defects, and a quality-of-life-focused case for matching HS surgical technique to anatomic site. Thanks for listening, and I'll see you next issue.