Welcome to this July twenty twenty-six review of Dermatologic Surgery. We've got four pieces worth your time this month — a reconstructive conundrum in the periocular region, a rare tumor literature review, a retrospective look at anesthetic physiology in rosacea patients, and an anatomic imaging study on the temple. Let's get into it.

First up is a reconstructive conundrum — one of the journal's case-based teaching pieces built around a single complex defect. An eighty-three-year-old woman with a history of keratinocyte carcinoma had an infiltrative basal cell carcinoma involving the left upper eyelid, lower eyelid, and medial canthus, cleared with Mohs. The resulting defect took about half the upper eyelid, forty percent of the lower eyelid, and the entire medial canthal subunit — a defect measuring roughly two and a half by two centimeters. This is about as unforgiving a periocular defect as you'll encounter, and the piece walks through the single-stage reconstruction the authors chose.

They combined three local flaps in one sitting: a V-Y advancement myotarsocutaneous flap off the lateral upper eyelid to restore upper lid contour, a Tenzel semicircular flap rotated in from the lateral canthus to handle the lower lid while preserving the margin and avoiding ectropion, and a glabellar transposition flap — bifurcated distally — to reconstruct the medial canthus and bridge between the two eyelid repairs. The rationale, which the authors state explicitly, was patient preference for a single stage, given her age and desire to minimize postoperative burden.

The outcome was good but not perfect. Healing was uneventful, but she developed moderate upper lid ptosis, attributed to intraoperative sacrifice of the levator palpebrae superioris, which had been tumor-infiltrated and had to go for oncologic clearance. At six months, the ptosis was stable, non-progressive, she had no ectropion, and she was satisfied cosmetically, compensating for the mild visual field deficit by brow elevation.

The discussion is really the value-add here — it's explicit about the tradeoffs. The alternative would have been a staged, bilamellar reconstruction: posterior lamella with a contralateral tarsoconjunctival graft, hard palate mucosa, or auricular cartilage, and an anterior lamella with a paramedian forehead flap or combined local flaps. That route offers more room for lid opening but at the cost of multiple stages and more morbidity. The authors are candid that levator advancement, Müller's muscle resection, or frontalis suspension remain options for secondary ptosis correction if function becomes limiting — this patient simply declined further surgery. The practical takeaway for your practice: this is a nice reminder that a three-flap coordinated single-stage repair is a legitimate option for combined bilateral-eyelid-plus-canthus defects in appropriately selected, typically older patients who prioritize fewer procedures — but counsel explicitly for ptosis risk any time levator involvement is suspected preoperatively, since that risk is a direct tradeoff of the single-stage, tissue-conserving approach rather than a technical complication to be avoided.

Next, a literature review on digital papillary carcinoma — a rare adnexal sweat gland tumor of the digits with real metastatic potential, and one most of us see only a handful of times in a career, which is exactly why a pooled literature synthesis is useful here. The authors searched MEDLINE and Embase through October twenty twenty-four and pulled together every case they could find with usable outcome data — a hundred fifty-five cases across eighty-one articles. Methodologically, this is the only feasible design for a disease this rare — there's no cohort large enough anywhere to study prospectively, so pooling published cases, despite all the obvious bias that comes with case-report literature, is really the only way to get any signal on outcomes.

The demographics: mean age at diagnosis was around fifty-two, a strong male predominance at roughly seventy percent, lesions averaging about a year and a half in duration before presentation, and a notable right-side and upper-extremity predominance — three-quarters were in the upper extremity, and among those, the third digit was the single most affected site at roughly a third of cases. Mean lesion size was about a centimeter and a half.

On management, this is the part that matters clinically. Of the cases with treatment data, about half were managed with excision, about forty percent with amputation, and only a small handful — six cases — with Mohs. Recurrence tracked with modality: excision and amputation had essentially identical recurrence rates, right around one in four to three in ten. Mohs had zero recurrences, but that's out of only three cases with recurrence data — far too small a number to draw a firm conclusion, and the authors say so explicitly. Biopsy alone, unsurprisingly, had the worst recurrence rate at roughly two in three. On the more concerning end, about one in five cases had metastasis, most commonly to lung and lymph nodes, and of the minority of cases reporting survival data, about one in five of those died of widespread metastatic disease.

The authors are appropriately modest in their conclusions: no consensus exists on optimal management, excision and amputation look comparable, and Mohs is promising but underpowered as evidence. The obvious limitation, which they name themselves, is that this is entirely retrospective case-report-level data with all the publication and selection bias that implies. Practically, this isn't practice-changing in the sense of proving Mohs superiority — but it is useful ammunition supporting margin-controlled excision as a tissue-sparing alternative to amputation on a digit, and it reinforces that these tumors need long293 follow-up given the metastatic potential, even when they look and behave indolently at first presentation.

Third, a retrospective study addressing something a lot of us have felt anecdotally but never seen quantified — reduced epinephrine efficacy in rosacea patients during central facial Mohs surgery. The premise is straightforward: rosacea involves dilated postcapillary venules and chronically altered vascular architecture, so the authors asked whether that translates into a blunted response to epinephrine-induced vasoconstriction intraoperatively.

This was a retrospective review of five hundred nine patients undergoing Mohs and same-day reconstruction of the central forehead, nose, cheek, or chin, with about twenty-nine percent carrying a clinical diagnosis of erythematotelangiectatic rosacea. Blood loss was estimated by gauze weight, and blanching after infiltration was recorded by the surgeon — a reasonably pragmatic real-world design, though as the authors don't emphasize but is worth flagging, gauze-weight blood loss and subjective blanching assessment are both fairly rough proxies, and this was retrospective rather than a controlled prospective comparison.

The results are fairly striking. Rosacea patients had significantly higher blood loss during both the Mohs stage and the reconstruction, and remained an independent predictor of increased bleeding on multivariable analysis, alongside nasal or central forehead location, flap repair, and two or more Mohs stages — none of which will surprise you, but rosacea joining that list is the new finding here. The mechanistic piece is the most clinically interesting: in non-rosacea patients, adding epinephrine significantly cut blood loss, roughly forty to thirty milliliters. In rosacea patients, epinephrine made essentially no difference — blood loss was statistically the same whether or not epinephrine was used. Blanching told the same story — basically universal in non-rosacea skin with epinephrine, but only about half of rosacea patients blanched at all. And rosacea patients needed meaningfully larger anesthetic volumes to achieve comparable infiltration, regardless of epinephrine.

The authors' interpretation is that this reflects blunted alpha-adrenergic responsiveness in chronically hyperperfused, remodeled rosacea vasculature — the precapillary sphincters simply may not be able to constrict as effectively, so vascular tone never drops to baseline non-rosacea levels even with epinephrine on board. This is a single-center retrospective series, so generalizability and any unmeasured confounding around rosacea severity or comorbid vascular disease is a real caveat, but the effect size here is clinically meaningful, not just statistically significant — we're talking roughly fifty percent more blood loss in rosacea patients across the whole operative course. The practical takeaway: for central facial cases in rosacea patients, especially nose and forehead flaps with multiple Mohs stages, anticipate reduced hemostatic benefit from epinephrine, don't rely on blanching as your endpoint for adequate infiltration, build in more time between infiltration and incision, and lean more heavily on mechanical hemostasis rather than assuming the epinephrine is doing its usual job.

Last, an original anatomic study using microvascular ultrasound imaging to map the superficial and deep temporal arteries for filler safety planning. The clinical problem is familiar — temporal hollowing is a common cosmetic complaint, filler correction is effective, but the temple is a recognized high-risk zone for vascular complications including skin necrosis and, rarely, blindness, and prior cadaver and standard Doppler studies may simply miss small-caliber, low-flow vessels in vivo.

The design here was straightforward duplex and microvascular ultrasound imaging in living patients referred for vascular mapping — sixty-two patients for the superficial temporal artery and fifty-six for the deep temporal artery — measuring arterial depth relative to skin, periosteum, and the lateral orbital wall, with two independent radiologists to check reproducibility. Using microvascular imaging specifically, rather than standard Doppler, was the authors' deliberate choice, since this modality is better at picking up low-flow, small-caliber vessels that conventional color Doppler can miss — which matters because it's exactly those under-detected vessels that put injectors at risk.

The vessels were identified in the vast majority of patients — over ninety percent for both arteries — and interobserver agreement was excellent across all measured parameters, so the technique itself is reproducible. The clinically important numbers are the depth ranges: in some patients the deep temporal artery sat as close as three-tenths of a millimeter from the periosteum, and the superficial temporal artery came within about one millimeter of the skin surface — both well within range of a standard injection needle or cannula. Thinner soft tissue, meaning lower body mass index and younger age, correlated with shallower vessel depth for both arteries, which is an intuitive but useful confirmation. There was also a right-versus-left asymmetry noted for the superficial temporal artery's relationship to the periosteum and orbital wall, though the authors don't offer a mechanistic explanation for that laterality finding.

This is a straightforward anatomic mapping study, so there isn't a treatment outcome or recurrence endpoint to discuss — the discussion is really about translating these depth measurements into injection technique, and the authors do spend real space on this, reviewing subdermal, interfascial, and supraperiosteal approaches and how vessel proximity affects each. The limitation worth flagging, which the authors imply but don't dwell on, is that this is a single-center anatomic sample without any linkage to actual injection complication outcomes — it tells you where the vessels can be, not how often standard technique actually hits them. The practical takeaway for anyone doing or supervising filler work: this doesn't change the fundamental supraperiosteal or microdroplet techniques already in use, but it's a solid evidence-based argument for individualized pre-injection vascular mapping, particularly in thinner, younger patients, rather than assuming a fixed safe depth applies universally — the anatomic variability here is wide enough that a fixed millimeter rule of thumb is not reliable.

That wraps up this month's four articles — a periocular reconstructive conundrum showing the tradeoffs of single-stage multi-flap repair, a rare-tumor literature synthesis on digital papillary carcinoma, a retrospective signal that epinephrine simply doesn't work as well in rosacea-affected skin, and an anatomic ultrasound study reinforcing just how variable temporal vascular anatomy really is. Thanks for listening, and we'll see you next month.