The research, led by Ou Jia Emilie Wang and Quinn Stewart of the Faculty of Medicine at the University of British Columbia together with Jincheng Shi of the Division of Dermatology at The Ottawa Hospital and the University of Ottawa, was structured as a research letter but carries the weight of a large-scale audit. Two independent reviewers went through the figure collections of seven textbooks that are widely used in dermatologic surgery training, classifying every image by Fitzpatrick skin type and recording the associated diagnoses, procedures, and pigmentation findings. The Fitzpatrick scale, originally developed in 1975 to standardize responses to ultraviolet light, remains the dominant classification framework in dermatology despite well-documented limitations, and its six-category spectrum from type I, pale skin that always burns, to type VI, deeply pigmented skin that never burns, provided the study’s core metric.

The aggregate figure of 8.7 percent conceals a steeper drop-off in the subspecialties where visual pattern recognition matters most. Images depicting skin of colour were scarcest in Mohs micrographic surgery, the tissue-sparing technique for skin cancer removal, where they accounted for just 1.5 percent of figures. Facial reconstruction fared worst of all at 0.6 percent, followed by tumour imagery at 2.4 percent and wound care at 3.2 percent. These are precisely the domains in which surgeons must judge erythema, margins of inflammation, postoperative pigmentary change, and scarring patterns against a baseline that differs fundamentally from the pale skin that dominates the literature.

The clinical stakes of this visual deficit are not abstract. In highly pigmented skin, erythema may appear subtle or violaceous rather than bright red, making the early recognition of infection, flap ischemia, or allergic contact reactions considerably harder for a trainee who has never seen these presentations. Post-inflammatory hyperpigmentation and hypopigmentation, both common sequelae of surgical trauma in skin of colour, follow different courses and respond to different interventions than in lighter skin. Keloidal scarring, which occurs disproportionately in genetically darker skin, demands different surgical planning and adjunctive therapy. A recent systematic review of post-inflammatory hyperpigmentation treatment in skin of colour, cited by the authors, underscores how much of the evidence base itself is built on studies that under-recruit darker-skinned patients, compounding the textbook gap at every level of the educational pipeline.

The consequences extend into oncology. Acral lentiginous melanoma, the subtype that arises on the palms, soles, and nail apparatus, occurs at similar rates across populations but is disproportionately represented among people with darker skin, precisely because ultraviolet-driven melanomas are rarer there. Yet because educational imagery overwhelmingly shows melanoma on light skin, delayed diagnosis of acral lesions remains a documented driver of the survival gap, with population-level analyses from the United States showing worse outcomes for this subtype dating back decades. When a surgical textbook shows a trainee one hundred examples of melanoma and only a handful on brown or Black skin, the pattern-matching machinery of clinical judgment is calibrated accordingly.

The authors also flagged a structural problem that goes beyond simple counts: the near-total absence of standardized Fitzpatrick skin type labelling in the figures themselves. Without explicit labelling, readers cannot reliably identify which images depict which skin types, cannot gauge representation in any given chapter, and cannot use the images for calibrated self-testing. The lack of standardized annotation limits the educational value of whatever diverse imagery does exist and makes it difficult for publishers to track progress over time. In effect, the audit found both a quantitative shortfall and a qualitative infrastructure problem, since even the minority of skin-of-colour images are not systematically curated, tagged, or indexed for teaching purposes.

The new study builds on and extends a growing body of audit literature. A widely cited 2021 cross-sectional analysis published in the Journal of the American Academy of Dermatology by Alvarado and Feng found similar underrepresentation of dark skin in educational resources for common dermatologic conditions, helping to catalyze a wave of similar audits across journals, board review materials, and medical school curricula. The present analysis is notable for focusing specifically on dermatologic surgery, a procedural discipline in which the visual baseline matters not only for diagnosis but for intraoperative decision-making, and for its sheer scale, with more than three thousand figures classified by two independent reviewers rather than sampled or estimated.

The disparities documented in the textbooks mirror documented inequities in care. A 2025 comprehensive review of disparities in surgical site infection diagnosis and management in highly pigmented skin tones, cited in the study, describes how delayed recognition of infection in darker skin contributes to worse outcomes, while work on Mohs micrographic surgery in skin of colour has highlighted both the technical adaptations required and the scarcity of guidance available to surgeons. Educational materials are not the sole cause of such disparities, but they are a modifiable upstream factor: a resident who trains exclusively on images of light skin enters practice with a systematically skewed prior, and no amount of individual goodwill fully compensates for a curriculum that never showed them the relevant presentations.

The authors argue that deliberate, structured inclusion of skin of colour in surgical dermatology resources is necessary to support diagnostic accuracy and promote more equitable care. In practice, that means commissioning and licensing clinical photography that represents the full Fitzpatrick spectrum, standardizing skin type labelling across figures, and prioritizing the subspecialty areas where the deficit is most acute, particularly facial reconstruction and Mohs surgery. Some publishers and educational platforms have begun such initiatives in response to earlier audits, but the new data suggest that the field’s foundational textbooks, the reference works against which trainees are examined, have not yet caught up. The study’s authors received no external funding for the analysis and declare no competing interests.

As dermatology confronts a demographic reality in which the majority of the global population has pigmented skin, and as populations in North America and Europe grow increasingly diverse, the visual canon of the specialty is under pressure to change. The message of this audit is quantitative and unambiguous: out of 3,334 images across seven authoritative textbooks, fewer than three hundred showed the skin types carried by most of humanity. Closing that gap will require more than good intentions; it will require the same systematic curation, labelling, and editorial accountability that the field applies to its evidence base, so that the next generation of surgeons learns to read every skin the way it has long been trained to read one.

Subject of Research: Representation of skin of colour in dermatologic surgery textbook imagery

Article Title: Skin of colour representation in dermatologic surgery textbooks: an image analysis

Article References: Wang, O. J. E., Stewart, Q., & Shi, J. (2026). Skin of colour representation in dermatologic surgery textbooks: an image analysis. Archives of Dermatological Research, 318(1), Article 385. https://doi.org/10.1007/s00403-026-04853-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04853-8

Keywords: dermatologic surgery, skin of colour, Fitzpatrick skin type, medical education, health equity, Mohs surgery, textbook imagery, facial reconstruction, post-inflammatory hyperpigmentation, diagnostic disparity, dermatology training, wound care

The term basosquamous carcinoma has been around for nearly a century. Montgomery described basal squamous cell epithelioma back in 1928, and the debate over whether BSC is a true hybrid entity, a collision tumor of two adjacent cancers, or simply a BCC that has undergone squamous differentiation has never fully been resolved. What is not in dispute is the clinical stakes. Compared with conventional BCC, BSC shows higher rates of recurrence and metastasis, which means that misclassifying it as an ordinary BCC can have real consequences for patients.

Part of the difficulty is that BSC cannot be reliably distinguished from BCC on clinical examination alone. The tumors look similar on the skin’s surface, often presenting as lesions on sun-exposed areas such as the head and neck of older patients. This is where modern imaging tools are beginning to earn their place. Dermoscopy, the examination of skin lesions with a handheld magnifying device, and reflectance confocal microscopy, a technique that provides near-histological resolution of living skin without a scalpel, may both assist in diagnosis. Studies of BSC under these modalities reveal a mixed picture: features suggestive of the basaloid component alongside characteristics pointing to squamous differentiation. Line-field confocal optical coherence tomography, a newer hybrid technology, has been used in case series with histopathological correlation to map this dual identity in vivo.

Despite these advances, the gold standard for diagnosis remains histopathology, the microscopic examination of tissue, complemented by immunohistochemical techniques that use antibodies to flag specific proteins and help delineate the basaloid and squamous components. Biopsy strategy matters here as well; work on head and neck BSC has emphasized that the features seen on biopsy are critical to reaching the diagnosis of what some authors still call metatypical basal cell carcinoma. Even with these tools, interobserver agreement can be imperfect, and the boundary between a BCC with squamous differentiation and a bona fide BSC remains a matter of ongoing debate among pathologists.

The molecular story has become clearer in recent years, and it leans firmly toward the BCC side of the family. Genetic studies of BSC have identified mutations underlying what researchers call phenotypic plasticity, the tumor’s ability to shift between basaloid and squamous states. These findings support the idea that BSC is fundamentally a BCC variant whose cells can adopt squamous characteristics, rather than a separate cancer arising from two lineages. Circulating microRNA biomarkers studied across melanoma and non-melanoma skin cancers may eventually add another layer of diagnostic and prognostic information, though their role in BSC specifically is still exploratory.

Epidemiological data have also matured. A multicenter study published in Scientific Reports provided clinical and epidemiological analysis of BSC across multiple institutions, and a comprehensive single-center study in Skin Research and Technology characterized the disease’s epidemiological, clinical, dermoscopic, and confocal features. Together with earlier case series characterizing BSC as a distinct type of keratinizing tumor, these studies paint a picture of a cancer that is uncommon but not rare, and one that disproportionately affects chronically sun-exposed skin.

When it comes to treatment, the review is candid: no consensus exists on optimal management, and prospective studies are needed to better characterize the biology, treatment, and prognosis of this tumor. What the evidence does support is surgical intervention. Wide local excision and Mohs micrographic surgery, a technique in which tissue is removed in thin layers and examined microscopically until the margins are clear, are the most widely used therapeutic approaches. Mohs surgery has a substantial track record in BSC, but the literature is not uniformly triumphant; recurrence after Mohs surgery has been reported, underscoring that even meticulous margin control does not eliminate the tumor’s aggressive potential. A single-center clinicopathological evaluation has proposed an evidence-based protocol for managing BSC, reflecting the growing recognition that ad hoc approaches are inadequate for a tumor with this risk profile.

Beyond the scalpel, the options rest on thinner ice. Sentinel lymph node biopsy, a staging procedure used to detect early spread to regional lymph nodes, has been studied in primary cutaneous BSC, and chemotherapy and radiotherapy are supported only by limited evidence. Radiotherapy, however, may play a palliative role when surgery is not feasible, offering symptom control and local disease management for patients who cannot undergo resection. The National Comprehensive Cancer Network’s guidelines for basal cell skin cancer provide a framework, but BSC sits awkwardly within categories designed for purer entities.

The most exciting developments lie in targeted and immune-based therapies, borrowed from the two parent tumors. Sonic Hedgehog pathway inhibitors, drugs such as vismodegib and sonidegib that block the signaling pathway central to BCC biology, have produced encouraging results in case reports. Complete responses of locally advanced BSC to vismodegib have been documented, and neoadjuvant treatment with sonidegib, given before surgery to shrink tumors, has been described as an innovative approach. Hedgehog pathway inhibitor therapy for locally advanced and metastatic BCC has a strong evidence base from pooled analyses of interventional studies, and BSC appears to respond, at least in part, because of its molecular kinship with BCC.

On the immunotherapy front, anti-PD-1 immune checkpoint inhibitors, which unleash T cells against tumors by blocking a molecular brake, have also shown promise. One striking case report described an impressive response to just four cycles of cemiplimab in a sonidegib-resistant giant BSC of the midface, a tumor that had exhausted one targeted option and yet melted away under immunotherapy. A recent case series and literature review navigated the combined use of Sonic Hedgehog pathway inhibitors, immune checkpoint inhibitors, chemotherapy, and radiotherapy in locally advanced and metastatic BSC, supporting these agents as potential alternatives for unresectable, locally advanced, or metastatic disease. The overall message of the review is a pragmatic one: current evidence positions BSC as molecularly closer to BCC, but its clinical behavior warrants management as high-risk BCC with cSCC-like vigilance. For a tumor that has defied easy classification for nearly a hundred years, that dual strategy may be the most honest answer yet.

Subject of Research: The biology, diagnosis, and management of basosquamous carcinoma, a hybrid non-melanoma skin cancer

Article Title: Basosquamous carcinoma: closer to a basal cell carcinoma or a squamous cell carcinoma?

Article References: Maass, M., Vargas-Mora, P., González-Cuevas, R., Lobos-Guede, N., & Gárate, M. (2026). Basosquamous carcinoma: closer to a basal cell carcinoma or a squamous cell carcinoma?. Archives of Dermatological Research, 318(1), Article 390. https://doi.org/10.1007/s00403-026-04857-4

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04857-4

Keywords: basosquamous carcinoma, basal cell carcinoma, squamous cell carcinoma, skin cancer, dermoscopy, Mohs surgery, Sonic Hedgehog inhibitors, immune checkpoint inhibitors, immunohistochemistry, reflectance confocal microscopy, radiotherapy, sentinel lymph node biopsy

The review, led by June Y. Moon, Yasir Al-Dojaily, Zahidul Islam, and Lucy Wang of New York Medical College’s Department of Dermatology, together with senior author Amor Khachemoune, systematically combed the published literature for reports on managing superficial cutaneous wound dehiscence. The search was deliberately broad, reaching beyond dermatology into other surgical specialties where wound separation has been studied in greater depth. What the authors found was sobering: after excluding a single-patient case report, the entire body of relevant comparative evidence amounted to just three studies covering 185 patients.

Those 185 patients were divided between two fundamentally different management philosophies. The first is secondary re-closure, in which a surgeon reintroduces sutures or other closure devices to bring the wound edges together again, sometimes after a period of wound preparation or delayed primary closure. The second is secondary intention healing, in which the wound is left open and allowed to fill in from the base through granulation tissue, contraction, and re-epithelialization. Each approach carries its own logic. Re-closure promises faster coverage and potentially better cosmesis but risks trapping bacteria and recreating the conditions that caused the separation. Secondary intention avoids foreign material in a potentially contaminated wound but demands weeks of dressing changes and leaves healing to the body’s slower processes.

The three studies that met the review’s criteria came from strikingly different clinical worlds. One was a randomized trial from obstetrics and gynecology, in which women with superficial dehiscence after gynecologic procedures were assigned to either secondary closure or healing by secondary intention. A second came from cardiothoracic surgery, examining superficial dehiscence after median sternotomy, the midline chest incision used to access the heart. The third was a retrospective case series in immunocompromised patients whose wounds were colonized by multidrug-resistant organisms, a population at extreme risk both from infection and from impaired healing.

Despite their differences, all three studies converged on a single descriptive finding: wounds that were re-closed healed faster than wounds left to heal by secondary intention. Two of the three studies also reported that re-closure required fewer clinic visits or fewer treatments, an outcome with real consequences for patients who face daily dressing changes over many weeks. In the sternotomy cohort, two closure failures were documented among the re-closed wounds, a reminder that suturing a previously opened wound back together does not always succeed. In the immunocompromised series, one late suture-associated abscess appeared, illustrating the infection risk that delayed closure is meant to mitigate but does not eliminate.

The authors are careful, and correctly so, to warn against over-reading these results. The studies differed substantially in design, wound characteristics, and how they reported outcomes, and none used the kind of rigorous, dermatology-specific framework that would allow confident generalization. The randomized trial did not provide detailed reporting of complications after re-closure, which makes a balanced risk assessment nearly impossible. Descriptive findings, the review emphasizes, do not establish superiority. A faster healing time in three heterogeneous, non-dermatologic cohorts is a signal worth investigating, not a treatment guideline.

For dermatologic surgeons, the gap is glaring. None of the three studies evaluated dehiscence after cutaneous surgery specifically, and none assessed cosmetic outcomes or patient satisfaction, two endpoints that matter enormously when the wound in question sits on a patient’s face, nose, or ear. Dermatologic surgery wounds differ in important ways from sternotomies or abdominal incisions: they are often smaller, frequently on sun-damaged skin with different biomechanics, frequently closed under significant tension on convex surfaces, and managed in an outpatient setting where healing is supervised by the operating surgeon rather than an inpatient team. Extrapolating from a 1992 obstetric trial or a cardiothoracic series to a nose defect after Mohs reconstruction is a leap that the evidence simply cannot yet support.

The biology of why wounds separate, and why they might behave differently when closed a second time, adds further nuance. Dehiscence usually follows a combination of factors: excessive tension across the closure, infection or hematoma beneath the surface, patient factors such as diabetes, smoking, immunosuppression, or advanced age, and mechanical forces from movement or trauma. Once the skin has opened, the wound bed is no longer a clean, surgically prepared plane. It is a contaminated, granulating surface colonized by bacteria, and the question of whether to close it becomes a question of whether the benefits of apposing the edges outweigh the risk of sealing microorganisms inside. The concept of delayed primary closure, well described in the plastic surgery literature, occupies the middle ground: the wound is managed briefly with dressings or negative pressure, then closed once it appears clean, theoretically capturing speed without sacrificing safety.

In practice, the review concludes, dermatologists currently manage dehiscence based on clinical experience, expert opinion, and extrapolation from other specialties. Many factors inform individual decisions: the size and depth of the wound, its location, the burden of contamination, the patient’s immune status and healing capacity, and the patient’s tolerance for repeated visits versus an open, healing wound. Some wounds on concave surfaces, such as the medial canthus or ear concha, are well suited to secondary intention and may heal with acceptable cosmetic results without re-closure. Others, under tension on convex surfaces, may benefit from being reapproximated once the infection risk is controlled. But the evidence base underlying any of these choices, when a wound actually opens, is essentially anecdote and judgment.

That is why the authors’ closing call for prospective dermatologic studies carries such weight. Wound dehiscence after skin surgery is common enough that well-designed trials, comparing re-closure against secondary intention with standardized measures of healing time, complication rates, cosmetic outcomes, and patient satisfaction, would be feasible and would transform a judgment-driven corner of practice into an evidence-based one. Until such trials exist, the review offers dermatologic surgeons something less satisfying but honest: a clear-eyed account of what is known, what is not, and where the field must go. When a wound separates, the surgeon’s hands may know what to do. The published literature, this review makes clear, does not yet.

Subject of Research: Evidence for managing postoperative cutaneous wound dehiscence in dermatologic surgery

Article Title: Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery

Article References: Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery. (n.d.). https://doi.org/10.1007/s00403-026-05005-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-05005-8

Keywords: wound dehiscence, dermatologic surgery, secondary re-closure, secondary intention healing, delayed primary closure, surgical complications, Mohs surgery, wound healing, systematic review, steronomy, infection risk, evidence gap

The patient’s history is central to the case. Ten years earlier, he had undergone complete surgical excision of a basal cell carcinoma at another hospital with a 5-millimeter margin extending to the level of the subcutaneous tissue. Histopathological examination at that time had judged the surgical margins to be negative. Approximately one year before presentation at Kindai University Hospital, however, an erythematous plaque appeared at the same site and gradually enlarged. When the tumor was excised with what appeared to be adequate margins, the lesion was followed without further treatment, and it eventually recurred after a long interval.

At presentation, the clinical picture was deceptively simple. An ill-defined erythematous plaque measuring approximately 7 centimeters in diameter extended from the occipital region to the posterior neck, accompanied by a palpable subcutaneous nodule. Computed tomography showed a corresponding high-density lesion without lymph node enlargement or distant metastasis, and a skin biopsy confirmed recurrent basal cell carcinoma. The tumor was excised with a 1-centimeter margin, and the defect was reconstructed using a full-thickness skin graft.

Histopathological examination of the excised specimen revealed the technical crux of the case: infiltrative basal cell carcinoma with deep invasion and superficial lateral microextension extending beyond the clinically apparent lesion. The lateral margin was positive, and the minimum distance between the tumor and the deep surgical margin was only 0.5 millimeters. Infiltrative basal cell carcinoma is one of several histological subtypes in which tumor nests infiltrate in cord-like or micronodular patterns, which often obscure tumor boundaries both clinically and histopathologically.

Examination of the primary excision specimen showed that tumor nests were distributed predominantly within the subcutaneous tissue, with only limited continuity with the epidermis. Such a distribution may be difficult to recognize clinically as a superficial lesion and may lead to underestimation of tumor extent at the time of initial excision. Because the surgical margins had been judged negative, the lesion was followed without additional treatment, and the tumor eventually recurred after a long interval. The report suggests that this pattern of deep subcutaneous growth with limited epidermal continuity may explain why the tumor extent was difficult to appreciate clinically and why conventional margin determination based on surface findings was insufficient.

In the recurrent lesion, the tumor formed a nodular mass within the deeper subcutaneous tissue, suggesting a more aggressive growth pattern. At the same time, the tumor retained subtle lateral microextension within the superficial subcutaneous layer beyond the deep nodular component, making accurate margin determination difficult. Changes in skin coloration and a palpable subcutaneous nodule were used as clinical landmarks for estimating the tumor boundary; however, margin determination based solely on palpation was insufficient to capture the lateral tumor spread within the superficial subcutaneous layer.

To address this challenge, the surgical team employed a mapping biopsy strategy. Three weeks after the initial excision, mapping biopsies were performed at 13 sites to assess lateral tumor spread. The biopsies extended approximately 5 millimeters in depth to include the superficial subcutaneous tissue. Approximately 6 weeks later, additional excision was performed, with the resection boundary determined by connecting tumor-negative mapping biopsy sites. Histopathological examination confirmed complete tumor clearance, and no recurrence was observed at 6 months after the final excision.

Mohs micrographic surgery, a technique in which tumor is removed layer by layer with immediate microscopic examination of margins, is recommended for high-risk basal cell carcinoma. However, its availability varies among institutions. In retrospect, given the difficulty in clinically determining the tumor extent in this case, the authors suggest that temporary coverage with artificial dermis at the initial excision, followed by definitive reconstruction after histopathological confirmation of clear margins, might have been a reasonable alternative approach. In situations where Mohs surgery is not feasible, mapping biopsy may be useful for assessing tumor extent and guiding appropriate surgical margins.

The case underscores a broader principle in skin cancer surgery: histological subtype matters. In certain subtypes, including infiltrative basal cell carcinoma, tumor nests infiltrate in cord-like or micronodular patterns that often obscure tumor boundaries both clinically and histopathologically. It has also been reported that recurrent lesions may exhibit atypical patterns of tumor spread. The combination of deep nodular formation and superficial lateral microextension observed here represents one such atypical pattern, in which the clinically visible lesion substantially underestimated the true tumor extent in multiple directions.

For clinicians managing high-risk or recurrent basal cell carcinoma, the report offers a practical message. When tumor boundaries cannot be reliably determined clinically, particularly in infiltrative subtypes or recurrent lesions, surgeons should consider strategies that verify margins histopathologically before definitive reconstruction. Whether through Mohs micrographic surgery where available, temporary artificial dermis coverage pending margin confirmation, or mapping biopsy to delineate lateral spread, the goal remains the same: ensuring complete tumor clearance while avoiding unnecessary sacrifice of healthy tissue. In this case, a staged approach combining initial excision, systematic mapping biopsies, and definitive second excision achieved complete tumor clearance with no recurrence at 6 months.

Subject of Research: Recurrent infiltrative basal cell carcinoma with deep nodular formation and superficial lateral microextension

Article Title: Recurrent infiltrative basal cell carcinoma with deep nodular formation and superficial lateral microextension

Article References: Maeda, M., Yamamura, Y., Fujii, K., Nishimura, K., Usui, S., & Otsuka, A. (2026). Recurrent infiltrative basal cell carcinoma with deep nodular formation and superficial lateral microextension. Journal of Cutaneous Immunology and Allergy, 9, Article 17511. https://doi.org/10.3389/jcia.2026.17511

Image Credits: AI Generated

DOI: 10.3389/jcia.2026.17511

Keywords: basal cell carcinoma, skin cancer, tumor recurrence, mapping biopsy, surgical margins, infiltrative growth, Mohs surgery, dermatology, case report, subcutaneous invasion, Recurrent, infiltrative

The study, led by Federico Venturi and Emi Dika with colleagues in Bologna and Ancona, focused specifically on recurrent lentigo maligna of the face. Adults who had previously undergone complete surgical excision of a facial lentigo maligna and then developed a histologically confirmed recurrence at the same site within 24 months were enrolled. Recurrence was defined strictly: a new lesion had to arise after a documented disease-free interval and be verified by biopsy or excision. This is a notoriously difficult patient population, because the previous surgery leaves fibrotic tissue that both conceals subclinical tumor strands and complicates any attempt to judge margins by eye. The researchers compared two management pathways in a prospective, single-center design: one group of 21 patients had their surgical margins mapped preoperatively with handheld reflectance confocal microscopy, while a control group of 33 patients was planned using standard clinical and dermoscopic assessment alone.

Reflectance confocal microscopy is a noninvasive optical technique that uses a low-power laser focused on a single point within the skin and measures the light scattered back from tissue structures. By scanning the beam laterally and at different depths, the device builds grayscale horizontal images, sometimes described as optical sections, at near-cellular resolution down to roughly the depth of the superficial dermis. In the hands of a trained reader, this makes it possible to identify the hallmark features of lentigo maligna in vivo: proliferation of atypical, bright, round and dendritic cells along the basal layer of the epidermis, irregular honeycomb or disordered patterns of the epidermis, and pagetoid spread of melanocytes upward through the epidermal layers. Crucially, the handheld version of the device trades some of the stability of traditional benchtop confocal systems for portability, allowing clinicians to examine patients directly in the clinic or at the bedside and to probe skin anywhere on the body, including curved facial contours that a fixed microscope cannot easily reach.

The Bologna team used a standardized adhesive tape technique to translate confocal findings into a practical surgical map. After identifying the outermost confocal extension of the tumor, the clinicians marked the skin and applied adhesive suture tapes bearing grid markings, creating a durable record of the mapped boundary that could be handed directly to the surgeon. This approach, which the group has refined in earlier work on non-melanoma skin cancers of the head and neck, effectively converts a live optical examination into a physical template for excision. In the study, surgical margins were subsequently verified by permanent-section histopathology in every case, meaning the accuracy of the preoperative maps could be judged against the gold standard of laboratory examination of the removed tissue.

The results were striking. Complete margin clearance in a single surgical stage was achieved in 85.7 percent of patients in the confocal-mapping group, compared with 60.6 percent of those planned conventionally. In other words, roughly nine out of ten patients whose tumors had been mapped with the handheld device left the operating room after one procedure, while nearly four in ten of the conventionally planned patients needed additional excisions to reach clear margins. Each repeat excision carries costs beyond the operating schedule: more anesthesia, more scarring on cosmetically sensitive facial skin, longer healing times, and greater patient anxiety. Avoiding staged procedures is therefore one of the most meaningful outcomes a preoperative planning tool can deliver.

The size of the surgical defects told a similar story. The mean defect diameter in the confocal group was 1.7 centimeters, with a standard deviation of 0.6, versus 2.4 centimeters, with a standard deviation of 0.8, in the clinical group, a difference that reached statistical significance at p less than 0.01. Smaller defects matter enormously on the face, where the availability of local tissue governs what kind of closure is possible. This translated directly into the study’s primary outcome: only 28.6 percent of patients in the confocal-mapped group required invasive reconstructive procedures, such as flaps or grafts, compared with 60.6 percent of the conventionally planned group, a reduction that was statistically significant at p equal to 0.009. The authors describe this as downstaging the surgical repair, a phrase that captures the practical benefit: the same tumor can be managed with a simpler, more conservative operation when its boundaries are known in advance.

Perhaps the most important question for any technique that narrows surgical margins is whether it compromises cancer control. On this point the study was reassuring, at least over the short follow-up window. Local recurrence rates at 12 months were low and statistically comparable between the two groups, at 4.7 percent in the confocal group and 6.1 percent in the clinical group. The investigators emphasize that the confocal approach did not cut corners oncologically; rather, it delineated the subclinical extension of the tumor more accurately than visual inspection, so the excision could be tailored to the disease rather than to a generous default margin. Because lentigo maligna can recur years after treatment, longer follow-up will be needed to confirm that the early equivalence holds, and the authors themselves frame the recurrence data as short-term oncologic control.

The findings arrive amid a growing body of evidence supporting confocal margin mapping for this tumor type. Previous prospective work has shown that confocal delineation of lentigo maligna margins correlates well with staged excision histology, and a 2025 systematic review and meta-analysis concluded that reflectance confocal microscopy is a reliable tool for margin assessment in lentigo maligna melanoma. A Dutch group has gone further, reporting the successful implementation of handheld confocal microscopy as a standard of care in the surgical management of lentigo maligna at their head and neck center. The Bologna study adds a specific and clinically valuable data point: the technique works even in the hardest scenario, recurrent disease at a previously operated site, where scarring has traditionally made margin assessment least reliable.

The broader significance of the study lies in what it suggests about the future of skin cancer surgery. Noninvasive imaging modalities, including reflectance confocal microscopy, optical coherence tomography, and dermoscopy-guided high-frequency ultrasound, are increasingly being tested as ways to plan excisions of skin cancers before the patient reaches the operating table. For lentigo maligna in particular, where histologic margins routinely exceed clinical margins by wide margins, the economic and human calculus is compelling: a handheld device examination in clinic is far cheaper and less burdensome than a second operation, a flap reconstruction, or a prolonged staged excision process. The adhesive tape mapping method also lowers the barrier to adoption, since it requires no exotic materials and integrates with existing surgical workflows.

Limitations remain, and the authors are careful about them. The study was single-center, the two groups were not randomized in the traditional sense, and the confocal cohort was smaller than the comparison cohort, all of which counsel caution before declaring a new standard of care. Reader expertise is also a genuine constraint, because interpreting confocal images of sun-damaged facial skin requires training and experience, and false negatives at the margin edge remain a risk. Still, the direction of the evidence is consistent across multiple independent groups, and the Bologna data address the scenario where the clinical need is most acute. For elderly patients with recurrent facial lentigo maligna, many of whom have limited tissue reserve and significant comorbidities, a technique that converts a major facial reconstruction into a modest excision is not a small technical refinement. It is the difference between a procedure that reshapes a nose or cheek and one that does not, achieved with a laser the size of a large pen and a strip of adhesive tape.

Subject of Research: Pre-surgical margin mapping of recurrent facial lentigo maligna using handheld reflectance confocal microscopy

Article Title: Pre-surgical mapping of recurrent lentigo maligna of the face with handled confocal microscopy: a useful tool to downstage surgical repair

Article References: Venturi, F., Veronesi, G., Magnaterra, E., Scotti, B., Baraldi, C., & Dika, E. (2026). Pre-surgical mapping of recurrent lentigo maligna of the face with handled confocal microscopy: a useful tool to downstage surgical repair. Archives of Dermatological Research, 318(1), Article 402. https://doi.org/10.1007/s00403-026-04895-y

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04895-y

Keywords: lentigo maligna, melanoma, reflectance confocal microscopy, handheld confocal microscopy, surgical margin mapping, dermatologic surgery, facial reconstruction, recurrent melanoma, preoperative imaging, skin cancer, dermoscopy, Mohs surgery

The study, led by Omeed Modiri of the David Geffen School of Medicine at UCLA together with colleagues at the Icahn School of Medicine at Mount Sinai, including senior author Jesse M. Lewin, surveyed members of the American College of Mohs Surgery, the professional home of physicians who perform Mohs micrographic surgery. This technique, considered the gold standard for many skin cancers, involves removing thin layers of tissue and examining each one under a microscope until no cancer cells remain. It is a discipline that demands precision, real-time pathological judgment, and careful reconstructive planning, making it an especially revealing setting in which to gauge how surgical specialists perceive AI.

The researchers distributed an anonymous twelve-question survey to ACMS members and analyzed the responses using Fisher’s exact tests, with a p value below 0.05 considered statistically significant. Thirty-six surveys were completed, a modest sample that the authors themselves flag as a key limitation alongside sampling and recall bias inherent to survey-based research. Even so, the results sketch a coherent picture of a specialty in transition. Forty-two percent of respondents reported having already used AI tools in some capacity, and sixty-seven percent of all participants said they were likely to incorporate AI into their clinical practice within two years. In other words, adoption is no longer a hypothetical question for Mohs surgeons; it is a matter of when and how.

The platforms these surgeons gravitate toward say a great deal about what they currently trust AI to do. ChatGPT dominated, used by ninety-six percent of those who reported AI experience, followed by OpenEvidence at thirty percent and Gemini at twenty-two percent. Custom AI models, the kind purpose-built for specific clinical tasks, saw only limited use. This pattern suggests that Mohs surgeons are relying on general-purpose large language models and medical literature search tools rather than bespoke surgical applications, treating AI today less as a scalpel and more as an assistant for information gathering and workflow support.

When asked about the benefits, respondents pointed overwhelmingly to efficiency rather than clinical prowess. Seventy-six percent identified increased efficiency as the most significant advantage of AI in dermatologic surgery, while sixty-two percent cited reduced administrative burden. These figures align with a broader theme in medical AI research: the technology’s most immediate and reliable value often lies in taming the paperwork, documentation, and coding tasks that consume clinician time, rather than in making high-stakes decisions. Prior work by some of the same authors, for example, evaluated how accurately ChatGPT and Gemini assign Current Procedural Terminology billing codes in dermatologic surgery, a quintessentially administrative application where errors are recoverable and oversight is straightforward.

The concerns, however, were sharper and more consistent than the optimism. Eighty-six percent of respondents worried about inaccurate or unreliable information, the highest of any concern measured in the survey. Fifty-four percent flagged patient safety and liability, and forty-nine percent feared the dehumanization of care. These numbers reveal a profession that understands exactly where the fault lines lie. Large language models can generate fluent, confident text that is nonetheless wrong, a phenomenon that becomes far more dangerous when the output informs where to cut tissue or how to reconstruct a face. Liability questions compound the technical ones, since it remains legally murky who bears responsibility when an AI-assisted recommendation contributes to a poor surgical outcome.

Nowhere is this tension more visible than in the gap between expectation and comfort. Seventy-two percent of participants believed AI will change the practice of dermatologic surgery over the next five to ten years, yet only thirty-nine percent reported feeling any degree of comfort with AI-assisted tools guiding surgical margins or repairs. The surgeons, in effect, are saying that transformation is coming whether they like it or not, while drawing a firm line at delegating intraoperative judgment. When it came to patient outcomes, opinions split further: fifty percent believed AI would lead to improvement, nineteen percent expected a neutral effect, twenty-five percent were unsure, and six percent anticipated harm. That distribution captures a specialty that is cautiously hopeful but far from convinced.

Experience appears to shape attitudes, though the survey could not prove it statistically. Surgeons with fewer than five years in practice were 2.83 times more likely to report having used AI tools compared with those in practice longer, a substantial numerical difference that fell short of statistical significance with a p value of 0.21, likely a casualty of the small sample size. Still, the trend fits a familiar pattern across medicine: younger clinicians, trained alongside consumer AI tools, arrive in practice already fluent in them, while more senior surgeons encounter the technology later and often more skeptically. If the trend holds in larger samples, the demographic gradient of AI adoption could become a defining feature of how surgical specialties modernize.

The study’s technical limitations deserve honest weight. Thirty-six respondents represent a small fraction of the ACMS membership, and those motivated to answer a survey about AI are plausibly more interested in the topic than their peers, introducing sampling bias. Recall bias may also color self-reported usage patterns. The authors are transparent about these constraints and call for larger studies to validate the findings, as well as for standardized guidelines evaluating responsible AI use in healthcare. Their caution echoes wider calls in the literature, including proposals for formal requirements to mitigate patient harm risks from AI in medicine and frameworks for adopting large language models safely in clinical settings.

What emerges from this report is not a story of resistance or revolution but of calibrated pragmatism. Mohs surgeons, whose work demands microscopic precision and carries visible, personal consequences for patients, are welcoming AI into the margins of their practice, the scheduling, the documentation, the literature searches, while keeping it at arm’s length from the margin of excision. That distinction may prove to be the template for surgical AI adoption more broadly: efficiency gains first, decision support last, and rigorous validation, clear liability frameworks, and preserved human judgment as the non-negotiable conditions in between. As one of the first systematic looks at AI attitudes within this specialty, the survey suggests that the next five to ten years will test whether AI developers can earn the trust that these surgeons are not yet ready to give.

Subject of Research: A survey of American College of Mohs Surgery members on the current use, perceived benefits, and risks of artificial intelligence in dermatologic surgery.

Article Title: Current impact and future outlook of artificial intelligence among American College of Mohs Surgery members

Article References: Modiri, O., McGeough, O., Elder, A., Ensslin, C., & Lewin, J. M. (2026). Current impact and future outlook of artificial intelligence among American College of Mohs Surgery members. Archives of Dermatological Research, 318(1), Article 458. https://doi.org/10.1007/s00403-026-04791-5

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04791-5

Keywords: artificial intelligence, Mohs surgery, dermatologic surgery, ChatGPT, large language models, survey, skin cancer, clinical practice, patient safety, surgical margins, healthcare workflow, American College of Mohs Surgery