Welcome back to the journal review. This month we're covering the July 2026 issue of Dermatologic Surgery, and we've got four articles on the docket — two original studies on treatment trends and patient satisfaction, a small prospective study out of hair restoration, and a sustainability review that's genuinely useful for anyone running an outpatient Mohs practice. Let's get into it.

First up is an original article: Increasing Mohs Micrographic Surgery Utilization in Darker Skin Phenotypes From 2011 to 2022, out of Penn and MD Anderson. The background here is something you've probably sensed anecdotally — there's been a persistent worry in the literature that patients with darker skin, SCE IVa through VI in this paper's terminology, are more likely to get shuffled toward wide local excision or destruction rather than Mohs, even though single-center data suggest they often present with larger, more complex tumors that would seem to argue for Mohs, not against it. The existing literature on this was a mess of conflicting single-center, single-city, or frankly dated studies from the 1998-to-2010 era, so nobody really knew what was happening nationally, recently.

Methodologically, this is a retrospective claims-based cohort study using Optum's Clinformatics Data Mart, a large deidentified commercial and Medicare Advantage claims database that the authors note demographically mirrors the US Census — which is their stated rationale for choosing it, since it gives them the national scope that single-center studies simply can't. They identified same-day CPT and ICD-9/10 codes for Mohs, wide local excision, and destruction, paired with skin cancer diagnoses, from 2011 through mid-2022, and split patients by race-derived skin color categories. They used Mann-Kendall tests to detect a monotonic trend and Joinpoint regression to calculate average annual percent change and to test whether the two groups' trend lines were actually parallel or statistically distinct. Worth noting for methodology's sake: race and skin color here are inferred algorithmically from geography and surname, not documented Fitzpatrick exam findings — a limitation baked into essentially every claims-based skin-of-color study, and one the authors are transparent about.

The results are genuinely reassuring. Across one point six million patients and over four million procedures, Mohs frequency — meaning Mohs as a share of all procedural skin cancer treatments — rose substantially in both groups over the decade: about a 54% relative increase in the darker-skin group and a 47% increase in the lighter-skin group, both highly significant trends. And critically, the Joinpoint analysis found these two trend lines were not parallel — the darker-skin group's Mohs uptake actually accelerated slightly faster. Meanwhile wide local excision and destruction both significantly declined in both groups, at similar rates. Tumor types, anatomic distribution, reconstruction patterns — mostly linear closures, then secondary intention, then flaps — and Mohs staging numbers were all essentially comparable between the two populations.

The authors' discussion reasonably attributes the overall rise in Mohs to the usual multifactorial suspects — better skin cancer awareness, expanding access, maturation of the Mohs Appropriate Use Criteria, more fellowship-trained surgeons, an aging population. They're appropriately cautious about the limitations: claims data can't capture clinical nuance like actual Fitzpatrick phototype, tumor histologic subtype detail, or the anatomic H-versus-M-versus-L distinctions that drive real-world Mohs decision-making, and a race-derived proxy for skin color is a blunt instrument.

Practically, this one is more reassuring-context than practice-changing — it doesn't tell you to do anything differently tomorrow, but it's a useful data point to have in your back pocket when you're thinking about equity of access in your own practice or writing about disparities: at a national level, the access gap for Mohs in darker-skinned patients appears to be narrowing, not widening, over the past decade, even if it hasn't fully closed.

Next, an original article from Washington University: Patient Satisfaction With Outcomes of Mohs Micrographic Surgery, using something called the Oxford Skin Cancer Treatment Scale. The gap they're addressing is that most prior Mohs satisfaction literature uses ad hoc or single-domain instruments, so this group applied a newly validated twelve-item scale — the first time it's been used specifically in Mohs — that breaks satisfaction into four domains: aesthetic outcome, treatment choice, treatment experience, and post-treatment concerns about recurrence.

This was a prospective cohort of 114 enrolled patients, ultimately 106 analyzed, across three Mohs surgeons at one institution, surveyed at time of closure, one week, and four weeks. Why prospective and repeated-measures rather than a single retrospective survey? The authors don't spell out the rationale explicitly, but it's fairly obviously because satisfaction is expected to evolve as swelling resolves and scars mature, so a single time point risks capturing a transient dip rather than the trajectory — and indeed that's exactly what they were testing. They used repeated-measures analysis of variance for the time-course question and multivariate repeated-measures linear regression, with a fairly rigorous variable-selection process, for the predictor question, screening candidate predictors at a lenient threshold before building a final parsimonious model and checking for collinearity along the way — a nice example of disciplined regression-building worth noting methodologically.

The headline result: overall satisfaction does not change significantly over the four-week window — reassuring, since it means the immediate postoperative dip clinicians sometimes worry about isn't really showing up here in aggregate, though aesthetic satisfaction and future-recurrence-concern scores did show a nonsignificant wobble worth watching in a larger sample. Treatment choice was consistently the highest-scoring domain at every time point — patients feel good about having chosen Mohs, essentially across the board — while future concerns about recurrence were consistently the lowest scorer at baseline and four weeks. In the multivariable predictor models, four factors independently predicted higher total satisfaction: a history of diabetes, immunosuppression, linear closure, and interestingly more Mohs stages was also associated with higher satisfaction in this cohort — each of these effects was modest in absolute point terms on a 12-to-60 scale, so statistically real but not enormous swings. Linear closure in particular predicted higher satisfaction not just overall but specifically in the aesthetic and treatment-experience domains.

The limitations are the ones you'd expect from a single-institution, English-speaking, largely Fitzpatrick I-to-II cohort — race and skin type had to be dropped from analysis entirely for lack of variation, which limits generalizability meaningfully, and the cohort size, while reasonable for a prospective survey study, is modest for teasing apart smaller effects like suture type.

The practical takeaway: this isn't practice-changing in the sense of altering your surgical decision-making, but it is useful reassurance to relay to patients — satisfaction with Mohs stays stable rather than dipping in the first month, and if you have a choice between closure types where linear is reasonable, patients tend to report higher satisfaction with it. The diabetes and immunosuppression findings are interesting but almost certainly reflect relief-and-gratitude effects in a more medically vulnerable population rather than anything actionable in your consent conversation.

Third, an original article, though I'll flag upfront that this one warrants a more skeptical read: Platelet-Rich Plasma Accelerates Donor Area Healing After Follicular Unit Excision, a single-author prospective study out of a private hair clinic. The clinical question is legitimate — PRP is heavily marketed as a hair-growth adjunct, but its effect on donor-site wound healing after FUE harvesting specifically is understudied, and faster punch-site healing would plausibly reduce crusting, erythema, and discomfort.

The design was a split-scalp, intrapatient control study in nineteen healthy men: two equal one-centimeter-squared occipital areas were harvested with a 1.1-millimeter punch, one area got a small intradermal PRP injection, the other served as an untreated control, and wound surface area was measured by image analysis immediately and at 24 hours, giving 49 evaluable wounds. The intrapatient design is a sensible methodological choice since it controls for interpatient variability in healing, and the authors are upfront that they deliberately used an oversized 1.1-millimeter punch rather than the more clinically typical sub-millimeter punches specifically to standardize wound size for measurement purposes — a reasonable trade-off for a proof-of-concept study, though it does mean the wounds studied aren't quite the ones you'd see in routine practice.

The result: wound surface reduction at 24 hours was roughly 21% in controls versus roughly 50% in PRP-treated sites, a statistically significant and, on its face, fairly dramatic difference.

Here's where I'd urge real caution before this changes anything in your practice. This is a single surgeon, single center, unblinded study — the same investigator harvesting, injecting, and by all appearances also assessing the images, with a proprietary, unspecified image-analysis system, so there's substantial risk of measurement and expectation bias. The endpoint is a 24-hour surface-area reduction, which is a very early surrogate — it tells you nothing yet about final scar quality, pigmentation, or actual patient-reported comfort, and the author is explicit that pain, erythema, and edema were never measured at all despite being invoked in the discussion. The statistical reporting itself is a bit muddled in the manuscript — a paired design analyzed with reference to both paired and independent t-tests, and some editorializing about "134% improvement" that's just a restatement of the same two percentages rather than new information. And there's a stray comment about this technique being particularly useful in patients requiring larger punches, including a reference to Afro-American patients, that isn't supported by any subgroup data in this study and reads as speculative rather than evidenced. The author himself acknowledges the core limitations honestly — tiny sample, 24-hour follow-up only, no long-term scar or pigment data, and a need for future controlled, blinded, longer-term work.

So the practical takeaway here: this is hypothesis-generating at best, not actionable. It's an interesting pilot signal that PRP might accelerate very early punch-site closure after FUE, but with single-author, unblinded, surrogate-endpoint data from nineteen patients, this should not be read as evidence to start injecting PRP into Mohs or excisional donor sites, or even into routine FUE cases, based on this paper alone.

Last, a review article: Reducing Waste in Dermatologic Surgery, an evidence-based sustainability review. This isn't a study with its own methods and results in the traditional sense — it's a structured literature synthesis, so it walks through the evidence phase by phase, preoperative, intraoperative, and postoperative, and grades the quality of evidence behind each recommendation using the Oxford CEBM and GRADE systems. The authors frame the stakes bluntly: health care generates something like 4 to 5% of global greenhouse emissions, each dermatologic procedure produces around half a kilogram of waste, and a busy Mohs surgeon doing several hundred cases a year is generating on the order of a few hundred kilograms of waste annually — and that's before counting sutures, blades, and gauze.

They identified 28 discrete strategies, with 15 backed by level 1-to-2 evidence, meaning these aren't just green aspirations, they're supported by decent trial or life-cycle-assessment data. On the preoperative side: nonsterile gloves show no significant infection-rate difference compared to sterile gloves across a large outpatient surgical literature, despite a far smaller carbon footprint; spray or foam chlorhexidine uses a fraction of the volume of single-use sachets; colored antiseptics like povidone-iodine actually improve field coverage compared to clear solutions, which is a nice safety-plus-waste win rather than a trade-off; and reusable cloth drapes appear safe, with one prospective clean-technique Mohs series of a thousand cases without sterile gloves, gowns, or drapes reporting an infection rate under 1%.

Intraoperatively, the highlights include longer-acting anesthetics — bupivacaine with epinephrine essentially eliminated the need for reinjection in one Mohs RCT, versus roughly a quarter to a third of lidocaine-only patients needing a top-up — low-dead-space syringes that cut residual medication waste roughly tenfold, procedure-specific instrument packs that meaningfully reduce unused sterile tools, keeping the same instrument set across Mohs stages rather than opening fresh trays each layer without an apparent safety penalty, and continuous suturing techniques that use substantially less suture material than interrupted closures across several surgical specialties, alongside absorbable sutures showing equivalent infection and scarring outcomes to nonabsorbable with a meta-analysis even favoring absorbable on cosmesis — and the added bonus of eliminating a suture-removal visit, which itself carries a travel-emissions cost the authors quantify from a Philadelphia dermatology clinic's carbon-footprint analysis. Postoperatively, occlusive dressings like hydrocolloids and alginates reduce material use and dressing-change frequency while showing equal or better infection rates and patient satisfaction compared with conventional layered dressings, and many are biodegradable to boot.

Because this is a review, there isn't a results-versus-limitations arc in the traditional sense, but the authors are honest that the evidence base is uneven — much of the life-cycle and waste-quantity data comes from orthopedic, cardiac, or obstetric literature rather than dermatology specifically, so some extrapolation is necessary, and dermatology-specific environmental outcome data remain sparse.

The practical takeaway here is probably the most immediately actionable item in this whole issue: several of these are zero-cost, zero-downside changes you could make in your practice this week — nonsterile gloves for clean cases, bupivacaine to cut reinjection rates, continuous or absorbable suturing where appropriate, procedure-specific trays, and occlusive rather than bulky layered dressings. None of these require new equipment purchases or practice redesign, and the evidence grading suggests real safety data behind most of them rather than just good intentions.

That wraps the July issue — a reassuring national trends paper on Mohs equity, a solid patient-satisfaction validation study, a small and decidedly hypothesis-generating PRP pilot that needs replication before it means anything clinically, and a genuinely practical sustainability review worth keeping on hand. Thanks for listening, and we'll see you next month.