Advances and Controversies in Surgical Dermatology, Mohs Surgery, and Regenerative Aesthetics

Conclusions

• Mohs surgery remains the preferred gold-standard treatment for many skin cancers because it offers the highest cure rates and strong tissue-sparing margin control.
• Immunohistochemistry is increasingly being integrated into Mohs surgery, improving margin detection and reducing local recurrence, especially for melanoma and rare aggressive tumors.
• Mohs for melanoma is expanding but remains controversial, with growing support for carefully selected cases where tissue conservation is critical.
• New imaging tools, including reflectance confocal microscopy, optical coherence tomography, and high-frequency ultrasound, may improve preoperative planning and reduce the number of surgical stages.
• Artificial intelligence is expected to enhance dermatologic surgery by supporting detection, margin assessment, reconstruction planning, and workflow efficiency.
• Multidisciplinary tumor boards appear to improve outcomes for complex skin cancers and may reduce mortality in advanced melanoma and other high-risk tumors.
• Neoadjuvant immunotherapy can shrink tumors before surgery, improving outcomes and potentially reducing surgical extent and scarring.
• Hedgehog pathway inhibitors, including emerging topical formulations, can downstage basal cell carcinomas and may reduce the morbidity of surgery.
• Treatment decisions in very elderly patients are becoming more individualized, with functional status and patient goals often mattering more than age alone.
• Superficial radiation therapy and brachytherapy may have a role in selected patients, but their long-term effectiveness, safety, and cost-effectiveness still need clearer evidence.
• Mobile skin cancer detection apps currently have limited reliability and can either falsely reassure patients or generate unnecessary referrals.
• Reconstruction is evolving with greater use of skin substitutes, biologic matrices, and AI-assisted planning, but high cost and limited comparative evidence remain major barriers.
• Laser and energy-based treatments can meaningfully improve scars, including functional scars, and may improve both appearance and mobility.
• Mechanical tissue microcoring is a promising minimally thermal technique, but safe treatment limits and real-world scarring risk still need refinement.
• The 1726 nm laser appears well suited for selectively treating acne by targeting sebaceous glands while sparing surrounding skin.
• Regenerative aesthetic therapies such as PRP, PRF, stem cells, and exosomes are promising, but most still lack strong standardization, long-term safety data, or robust FDA-approved dermatologic products.
• Exosomes in particular may help with wound healing, scars, hair growth, and rejuvenation, but current evidence and regulatory support are still insufficient for routine widespread use.
• Overall, the field is moving toward precision, multidisciplinary, technology-assisted, and more regenerative dermatologic surgery, but many innovations still require stronger evidence before they become standard care.