Welcome to this month's journal review, covering the Journal of the American Academy of Dermatology, June twenty twenty-six issue. We've got four brief reports today, spanning reconstructive surgery logistics, two SEER registry analyses in cutaneous and genital oncology, and a claims-based look at who's actually doing the cutting and closing in dermatology practices. Let's get into it.

First up is a retrospective single-center study comparing complication rates for paramedian forehead flaps performed in the outpatient setting versus the inpatient setting. The clinical question here is a practical one that a lot of us have opinions about but limited data on: can paramedian forehead flaps be done safely outside the hospital, and does site of care actually change complication rates.

Methodologically, this is a chart-pull study out of UC Davis, done by keyword searching "paramedian flap," "forehead flap," and the relevant CPT code across four years. That's a sensible, low-cost way to identify a cohort of a fairly uncommon procedure without needing a multi-institutional design — you're essentially mining your own EHR for a rare event. They ended up with 126 repairs total, three-quarters done inpatient by otolaryngology — mostly concentrated in one facial plastic surgeon — and one-quarter done outpatient by a single dermatologic surgeon. Patients essentially self-selected or were triaged toward one pathway or the other at consultation, so this is an observational comparison, not a randomized one, and that selection process matters for how you read the results.

On the outcomes side, there were no statistically significant differences between inpatient and outpatient repairs for bleeding calls, emergency department visits for bleeding, flap necrosis, or infection. The raw numbers actually trended a bit higher in the outpatient group for several of these — postoperative infection was around four percent inpatient versus nine percent outpatient, flap necrosis about one percent versus six percent — but none of these differences reached significance, and the authors are upfront that with only thirty-two outpatient cases, each individual complication swings the percentage much harder than it does in the ninety-four-patient inpatient group. So this is a classic underpowered-but-informative comparison: reassuring direction, but not enough numbers to rule out a real difference.

Interestingly, hemostatic technique differed completely by venue — outpatient cases used injected tranexamic acid in over a third of patients and never used topical thrombin matrix or oxidized regenerated cellulose, while inpatient cases used thrombin matrix in nearly all cases and never used injected tranexamic acid. Despite outpatient patients being older and having roughly double the rate of anticoagulant or antiplatelet use, bleeding complications weren't higher. Repair complexity also differed: inpatient cases were more likely to be staged in three stages and coded as adjacent tissue transfers, and used mucosal hinge or septal mucosal flaps for full-thickness defects, while outpatient repairs were more often single-stage and used folded flaps for full-thickness defects — differences that likely reflect surgeon training and preference as much as defect severity, since median defect area didn't differ between groups.

The authors' bottom line is that paramedian forehead flaps can reasonably be performed outpatient by dermatologic surgeons without a clear increase in complications, and that outpatient repair looks acceptable even in an older population, which is relevant for patients with anesthesia contraindications. The honest limitations are real, though: small sample size, especially on the outpatient side, only one outpatient surgeon representing the entire outpatient arm, and confounded technique differences that make it hard to isolate "site of care" as the only variable. For practice, I'd call this interesting and supportive rather than practice-changing — it doesn't give you new safety data robust enough to change informed consent conversations, but it does add to the case that in-office paramedian forehead flap repair by an experienced dermatologic surgeon is a reasonable option, particularly for older or anesthesia-averse patients, and it's a nice citation to have when you're making that case administratively.

Next, a SEER-based analysis looking at second primary cancer risk after vulvar squamous cell carcinoma. This isn't a Mohs paper per se, but it's relevant to anyone in dermatologic oncology who manages genital squamous cell carcinoma or coordinates surveillance with gynecologic oncology. The gap they're addressing is that survivorship data after vulvar squamous cell carcinoma is thin, even though survival has improved and there's now a meaningful population of long-term survivors.

This is a registry-based cohort study using the Surveillance, Epidemiology, and End Results program, spanning diagnoses from 2000 to 2022. Methodologically, they used the standard approach for second-cancer studies: calculating person-years at risk starting two months after the index diagnosis, then comparing observed second primary cancers to the number expected based on age-, sex-, race-, and calendar-year-matched general population rates, expressed as a standardized incidence ratio. This design makes sense here because you need very large numbers and long follow-up to detect elevated risk at specific anatomic sites, and a national registry is really the only practical way to get that.

Among nearly fourteen thousand patients with primary vulvar squamous cell carcinoma, about one in ten developed at least one second primary cancer, and the overall standardized incidence ratio was one point six — a statistically significant and clinically meaningful roughly sixty percent excess risk compared to the general population, translating to about seventy-three excess cancers per ten thousand person-years. Risk was higher in patients diagnosed before age sixty, in single patients, and in those with basaloid histology — a subtype strongly tied to HPV. The excess risk was highest in the first year after diagnosis, which raises the usual concern about synchronous or already-present but undetected cancers, but it remained elevated even past ten years of follow-up, so this isn't just a detection artifact.

The site pattern is the clinically important part: the highest relative risks were for vaginal cancer and anal or anorectal cancers, with significant excess risk also seen for cervical, oral cavity and pharyngeal, laryngeal, lung, esophageal, liver, kidney, and bladder cancers, plus acute myeloid leukemia. When grouped thematically, both HPV-associated cancers and tobacco-associated cancers were significantly elevated as a group, which fits the biology — persistent HPV infection across a shared mucosal field, plus shared behavioral risk factors like smoking. In multivariable competing-risk regression, chemotherapy was independently associated with higher second cancer risk, while radiotherapy was not an independent predictor once other factors were accounted for. Advanced stage and lack of surgical treatment were associated with lower second cancer risk — which sounds paradoxical until you remember this reflects competing mortality: patients with aggressive primary disease who didn't get surgery are dying of the vulvar cancer before they have time to develop a second one.

Limitations are the usual registry constraints — no data on HPV status or vaccination, no smoking history, no granular treatment or comorbidity detail, and the chemotherapy association can't be read as causal given how little detail SEER captures about regimens. But this is the largest study of its kind to date. The practical takeaway for us is mostly about surveillance awareness rather than anything you'd do differently at the Mohs table: patients with a history of vulvar squamous cell carcinoma, especially those with HPV-associated or basaloid histology, warrant a low threshold for full-body skin and mucosal surveillance and coordination with their gynecologic oncology team for extragenital HPV-related sites — this is useful context if you're the one managing a patient's cutaneous squamous cell carcinomas and want to understand their broader cancer risk landscape.

Third, a SEER-based analysis of sex differences in pleomorphic dermal sarcoma — this one is squarely in our wheelhouse. The background here is that pleomorphic dermal sarcoma is known to be strongly male-predominant, but nobody had really characterized whether presentation and outcomes differ by sex beyond that basic epidemiologic fact.

Design-wise, this is a straightforward SEER query using the specific histology code for pleomorphic dermal sarcoma, from 2000 to 2021, analyzed with chi-square and Fisher's exact tests, Kaplan-Meier survival curves, and multivariable Cox regression — a very standard toolkit for a registry-based cutaneous oncology cohort, chosen because you need Cox modeling to separate sex from confounders like age, stage, and tumor size when looking at mortality.

Of twenty-five hundred seventy-five patients, eighty-three percent were male. The age-adjusted incidence in men was about seven times that in women — two point nine versus zero point four per million person-years. But the more clinically interesting finding is the anatomic distribution: in men, tumors were overwhelmingly head and neck, over ninety percent, consistent with classic sun-damaged scalp and face presentation. In women, the pattern flips — nearly two-thirds were truncal, with head and neck accounting for only about one in ten. Women also had modestly larger tumors at diagnosis, about fifteen millimeters versus twelve, a difference that was statistically significant but that the authors reasonably attribute to site rather than biology, since truncal tumors tend to run larger in registry data generally, not because female tumors are inherently more aggressive.

Despite these presentation differences, outcomes were essentially the same. Five- and ten-year disease-specific survival were nearly identical between sexes, and in multivariable Cox regression adjusting for age, race, stage, location, tumor size, and surgery, sex was not an independent predictor of mortality — the point estimate favored women, but the confidence interval crossed one, so this is a clinically null result, not just a statistical footnote for a real protective effect. What did predict mortality, unsurprisingly, were age seventy-five and older, larger tumor size, and regional or distant stage at diagnosis — the standard prognostic drivers you'd expect regardless of sex.

The authors' interpretation is that the male predominance and site distribution are best explained by cumulative ultraviolet exposure patterns — occupational sun exposure, photoprotective behavior differences, and factors like male pattern scalp hair loss increasing UV exposure to the scalp — rather than by any sex-specific tumor biology, and they note that genomic studies to date haven't found sex-specific mutational signatures in this tumor. Limitations are the standard SEER caveats: retrospective, no risk factor or comorbidity granularity, and the ever-present risk of diagnostic overlap between pleomorphic dermal sarcoma and atypical fibroxanthoma given how closely related and difficult to distinguish these entities can be histologically. The practical takeaway for practice: don't let sex bias your index of suspicion — expect pleomorphic dermal sarcoma on the trunk in women even though the textbook picture is a bald sun-damaged male scalp, and remember that once you adjust for stage, size, and age, prognosis tracks the tumor itself, not the patient's sex. This is a "know your differential geography" paper more than a "change your margins" paper.

Last, a claims-based analysis of shifts in procedural dermatology, looking at the growing role of physician assistants and nurse practitioners across lesion sizes and repair types, using MarketScan commercial claims from 2007 to 2023. The gap being addressed is that prior workforce studies mostly looked at evaluation-and-management visits or a narrow slice of procedures, without breaking things down by how big the lesion was or how complex the repair was — which is really the question that matters for supervision and training policy.

Methodologically, the authors restricted the dataset to procedure codes only, deliberately excluding E-and-M visits, and they scrubbed out physician assistants and nurse practitioners whose billing patterns looked inconsistent with dermatology — things like electrocardiography or obstetric codes — to reduce misclassification. They then grouped CPT codes into families: benign excisions, malignant excisions, destruction of malignant lesions, intermediate and complex repairs, flaps, and grafts, and further stratified by the CPT manual's own size, length, and area cutoffs, collapsing anatomic site where the data got sparse. This is a sensible design choice for a claims dataset — you can't observe clinical judgment or supervision directly, so stratifying by the objective size and complexity thresholds already built into CPT coding is the most defensible way to ask whether task allocation differs by case difficulty.

The results show two things worth sitting with. First, the shift toward physician assistant and nurse practitioner participation was broad-based, not confined to the simple stuff — dermatologists' procedural share declined over time across benign and malignant excisions, destruction of malignant lesions, intermediate and complex repairs, and flaps, with corresponding gains for physician assistants and nurse practitioners, and this pattern held even after collapsing anatomic sites and restricting to well-defined size and length strata. Second, and more provocative, there was a size gradient — the relative gains for physician assistants and nurse practitioners were largest, not smallest, in bigger lesions, longer repairs, and larger-area flaps. In other words, this isn't just advanced practice clinicians picking up straightforward shave biopsies and small excisions; they're increasingly doing the more complex closure work too. Malignant excisions showed a similar direction of change but more modestly, and grafts were too sparse in the dataset to draw firm conclusions.

The authors flag an important limitation that cuts against their own findings being overstated: complex procedures may sometimes get billed under the supervising physician's identity even when performed by the advanced practice clinician, which would mean the true physician assistant and nurse practitioner share is being underestimated here, not inflated. They're also careful to say this analysis says nothing about outcomes or appropriateness — it's a claims-based description of who bills for what, not a quality or safety study. For our purposes, this is important context rather than a mandate for action: it doesn't tell you whether outcomes are equivalent when advanced practice clinicians perform larger flaps or complex repairs, but it does tell you that this is happening at scale and increasing, which makes it a legitimate area for scrutiny around supervision standards, training pathways, and quality assurance in practices that use a team-based model. I'd call this workforce-relevant and worth discussing at a practice or training-program level, but not something that changes how any individual surgeon operates tomorrow.

That wraps up this month's four reports — a reassuring if underpowered look at outpatient paramedian forehead flap safety, a call for broader oncologic surveillance vigilance after vulvar squamous cell carcinoma, a clarifying look at how pleomorphic dermal sarcoma presents differently by sex without actually behaving differently, and a workforce trends paper that should prompt some institutional reflection on supervision as advanced practice clinicians take on more complex procedural work. Thanks for listening, and I'll see you next month.