Welcome back to the journal review. This is Dermatologic Surgery, July twenty twenty-six, volume fifty-two, issue seven — and we've got four pieces to get through today: a systematic review on wrong-site surgery prevention, an invited commentary responding to it, and two reconstructive conundrum cases, one on the central face and one on the shoulder. Let's get into it.

First up is a review article — a systematic review titled "Optimization and Prevention of Error in Surgical Site Identification," by McTighe, Young, and Lane. This tackles a problem every one of us has felt in our gut at least once: wrong-site surgery, or WSS, in the Mohs setting. The authors frame the stakes right away, citing a never-events analysis where wrong-site surgery was the second most common never-event behind hospital falls, but carried the highest median settlement of any category — over a billion dollars in aggregate across two decades of claims. And the harm data are sobering to actually hear stated plainly: wrong-site surgery caused death in a small fraction of cases, but permanent injury in roughly a third, and temporary injury in the majority of reported events. A Veterans Administration review is cited showing that two out of every three adverse events reported specifically by dermatology were wrong-site surgery — which tells you this isn't a generic surgical safety issue, it's disproportionately a dermatology problem, almost certainly because of our unique workflow: high volume, healed biopsy sites, delayed excisions, and multiple providers touching the same chart.

Methodologically, this is a narrative systematic review, not a meta-analysis — and the authors are explicit about that choice, stating they didn't perform risk-of-bias scoring or quantitative synthesis because the goal was descriptive and narrative rather than statistical pooling. That's the right call here, because the included literature is a grab-bag of survey studies, retrospective chart reviews, and pilot quality-improvement projects — nothing homogeneous enough to pool into an effect size. They searched PubMed and Google Scholar for studies from 2014 through 2025, identified a starting pool of a hundred forty-four studies, narrowed to forty-one after screening, and ended up including thirty-seven in the final review.

The results are organized around root causes and then mitigation strategies. On root causes, a few numbers are worth holding onto because they're genuinely clinically useful. A survey of dermatology residents found that the vast majority — over eighty percent — admitted to copy-pasting prior documentation, and nearly all of them, in the high nineties percent range, reported having misstated laterality at some point during an excision or biopsy. Separately, in a study of a thousand Mohs cases, only about one in five charts contained documentation detailed enough to reliably identify the biopsy site. And from Ahmed and colleagues' prospective work, over sixty percent of patients could not identify their own biopsy site on the day of surgery, with the single biggest driver of surgeon uncertainty being an ambiguous anatomic location on the original biopsy report itself — not patient forgetfulness, not photo quality, but the referring documentation. That's a clinically meaningful finding because it tells you where to intervene upstream.

On the mitigation side, the review lands on a clear message: no single tool solves this. Photography is now treated as a standard-of-care expectation, though adoption is inconsistent — roughly six in ten physicians report using it daily, but only about one in five photograph every single patient. The review highlights two structured protocols worth knowing by name. The "mark, magnify, map" method — marking the lesion, taking a magnified shot, and a landmark shot — reportedly took one group from about six in ten adequate photographs up to over eight in ten. And the "BIOPSY one-two-three" protocol is a patient-driven smartphone documentation approach that keeps a running photographic record over time. The review also discusses coordinate-based measurements using x and y distances from fixed anatomic landmarks as an alternative or adjunct to photography, arguing these may actually outperform photos in real-world referral workflows, because faxed images are often degraded and not every practice has secure image transfer set up.

The discussion and limitations here are mostly implicit rather than a dedicated section, since this is a narrative synthesis rather than a study with its own dataset — but the honest caveat baked into the design is that this is heterogeneous evidence: pilot studies, single-center surveys, and retrospective reviews, not randomized comparisons of one intervention against another. So conclusions about which single strategy is "best" would be overreaching; the appropriate takeaway is about layering safeguards, not picking a winner.

For practical purposes, this is genuinely practice-relevant, even if none of it is revolutionary. The concrete, actionable pieces are: treat photography as non-negotiable rather than optional, build redundant cross-checks into documentation rather than relying on any single note, and recognize that ambiguous language on the original biopsy report is probably your single highest-yield failure point to fix at the referral-intake level.

That leads directly into our second piece, which is a commentary responding specifically to that review, written by Tisack and Nijhawan from UT Southwestern. Commentaries like this don't carry their own methods or results — they're an expert reaction laying out the authors' own practice approach, so I'll walk through it as the opinion piece it is. They open by endorsing the review's framing of the problem, then stake out a clear personal position: standardized clinical photography is, in their view, the single most valuable tool for site identification, and they'd like to see it become a mandatory component of every Mohs referral, not just something obtained when convenient. Practically, they suggest that if a referral arrives without adequate photos, office staff should proactively request them from the referring office, and if no photo was taken at the time of biopsy, the patient should be contacted to self-photograph the healing site — leaning on that "biopsy site selfie" literature.

Their specific technical recommendation is at least two photographs per site: one taken from a moderate distance that captures nearby anatomic landmarks in frame — their example is a cheek lesion where both the nose and ear should be visible — and a second close-up to delineate the actual tumor borders. They also emphasize standardized surface anatomy terminology when labeling both the chart and the photographs themselves, referencing the recent surface anatomy nomenclature literature.

The part of this commentary that I think is most useful to actually carry into your own workflow is their decision algorithm for the uncertain case. Their rule is straightforward: any uncertainty, regardless of photo quality, means you do not proceed. If you're not confident, refer back to the biopsying physician. And if that physician is also uncertain, their recommendation is to biopsy the most suspicious site or sites and specifically ask pathology to comment on the presence of scar if no tumor is found — because finding scar at that location is itself indirect confirmation you've got the right site, at which point close observation may be reasonable if there's no residual malignancy. And they close on something that's easy to skip past but matters medicolegally and ethically: the patient needs to be an active, informed participant at every step of that uncertainty algorithm, not a passive bystander. There's no new data here — this is entirely a reasoned opinion piece — but as a distillation of a defensible, reproducible site-uncertainty protocol, it's worth having memorized.

Now let's shift into the two reconstructive conundrums, which are case-based technique pieces rather than studies, so I'll walk through each as presentation, defect, reconstructive reasoning, and technique.

The first is "Reconstruction of a Large Defect of the Nasal Sidewall, Medial, and Infraorbital Cheek," from the Mount Sinai group. An eighty-nine-year-old woman had an infiltrative basal cell carcinoma of the left nasal sidewall cleared after three stages of Mohs, leaving a four by two-and-a-half centimeter defect spanning the nasal sidewall into the medial and infraorbital cheek — right up against the free margin of the medial canthus. The authors walk through their differential of reconstructive options and, importantly, explain why each alternative was rejected before landing on their final choice, which is exactly the kind of reasoning worth absorbing. A linear repair was off the table given the size. A full-thickness skin graft would have avoided tension vectors but risked poor color and texture match plus potential canthal distortion if the graft contracted — a real concern that close to a free margin. An inferiorly based cheek rotation flap couldn't reach the medial extension of the defect. A laterally based Mustardé rotation flap would have handled the infraorbital cheek but not the lateral nasal sidewall component. They even mention their own previously published combination repair pairing a cheek rotation flap with a glabellar transposition flap, but rejected it here specifically because this patient had extensive scar tissue from prior surgery and diminished facial volume, making that combination less reliable.

What they landed on was a V-Y, or island pedicle, advancement flap, raised inferior to the defect and drawing on cheek laxity for a single-stage closure. The technique detail worth noting is the undermining strategy: lateral undermining was performed at a forty-five-degree angle on both sides specifically to preserve a thick vascular pedicle, with incremental distal undermining until the leading edge could advance superiorly without tension — and additional lateral undermining was needed to get enough medial reach to cover the lateral nasal sidewall component, ultimately creating a superomedially based subcutaneous pedicle. At four-month follow-up they report an excellent functional and cosmetic result with no eyelid malposition. The teaching point they emphasize is one worth remembering for your own defect planning: a single V-Y flap can successfully bridge multiple cosmetic subunits — nose and cheek together — when the alternative would be stacking two separate flaps or a flap-plus-graft combination, provided you have adequate cheek laxity to draw from.

The second conundrum is "Shoulder Defect Involving the Deltopectoral Groove," from Russell and Knackstedt. A fifty-six-year-old woman had a recurrent basal cell carcinoma of the right anterior shoulder, and after a single Mohs stage the defect had expanded considerably from the preoperative tumor size — going from under five centimeters to an eight by nearly eight centimeter final defect, which the authors attribute to tissue dynamics, a reminder that recurrent tumors and mobile trunk skin can produce dramatically larger defects than the preoperative measurement suggests. The defect spanned laterally across the shoulder, medially onto the chest, and inferiorly into the axilla — landing right in the deltopectoral groove, a region bounded by the deltoid and pectoralis major and containing the cephalic vein and thoracoacromial artery branches, with the added complication of being a high-mobility joint region prone to scar contracture.

Their solution combined a partial linear closure at the superior aspect to reduce the defect size, followed by mobilization of axillary tissue as a V-Y island pedicle advancement flap. The anatomic teaching point here is the emphasis on plane of dissection: staying in a superficial subcutaneous plane, above the investing fascia of the axillary contents, to avoid injury to the long thoracic nerve, the thoracodorsal nerve and vessels, the axillary vein, brachial plexus branches, and axillary lymphatics — structures whose injury could mean winged scapula, lymphedema, or hematoma, well beyond a cosmetic complication. They're candid about the donor-site tradeoffs too: potential restriction of shoulder abduction, cosmetic issues in hair-bearing axillary skin, and reduced flap reliability in patients without adequate axillary laxity or adipose reservoir. Notably they give an actual postoperative activity timeline, which is the kind of number worth quoting to patients directly — abduction restricted initially, gradual reintroduction starting around two weeks, and full unrestricted movement by four weeks, balancing the risk of compromising the flap against the risk of permanent shoulder stiffness from over-immobilizing.

They also explicitly walk through rejected alternatives: secondary intention was excluded given the size and risk of delayed healing; full-thickness grafting was rejected because of the mobile muscle bed and poor durability and contour match over a joint; a bilobed transposition flap was considered but felt to add donor-site complexity without a clear benefit; and keystone-type island pedicle flaps were deemed unsuitable here specifically because those work best when the defect is confined entirely to the trunk or extremity, whereas this defect spanned both the chest and the shoulder joint itself. At six months, they report an excellent cosmetic outcome with preserved range of motion. The practical takeaway is a reminder that the axilla is an underused but legitimate donor reservoir for anterior shoulder and deltopectoral defects, provided you respect the fascial plane and give patients a structured, staged return to shoulder motion.

That wraps our four articles for this issue. The throughline connecting the first two pieces is really an upstream-versus-downstream safety argument — fix your documentation and photography protocols before the patient ever gets to your chair, and have a clean decision algorithm for the moments when uncertainty still slips through. And the two reconstructive cases both reinforce that the V-Y island pedicle advancement flap remains one of the most versatile single-stage solutions in our toolkit, whether you're spanning nasal and cheek subunits or bridging chest and shoulder across a mobile joint. Thanks for listening, and I'll see you next issue.