Welcome back to the journal review. This is our September 2026 walkthrough of Dermatologic Surgery, and we've got four pieces on deck today — a genetics case report that should sharpen your index of suspicion in transplant patients, a neuromodulator case report tackling a tension-driven scar problem, a nicely designed pilot study on injection comfort that also doubles as a stats teaching moment, and a reconstructive conundrum out of the DFSP literature. Let's get into it.

First up is a case report titled "Delayed Recognition of SUFU-Associated Gorlin Syndrome in a Renal Transplant Recipient." This is a straightforward case report, so no methods or statistics beat here — just presentation, management, and the teaching point, which for this one is substantial.

The patient is a 30-year-old woman referred for a routine post-transplant skin check. Her backstory is dense: ovarian fibromas, a meningioma that caused seizures, and a medulloblastoma treated with radiation and chemotherapy in her teens, which itself caused the end-stage renal disease that led to her transplant. She's on a standard three-drug immunosuppressive regimen — tacrolimus, mycophenolate mofetil, and prednisone. On exam she has the umbilicated papules you'd recognize anywhere — periorbital and nasal ala — plus larger plaques on the vertex scalp and upper back, and a shave biopsy of the lower eyelid confirmed basal cell carcinoma. Here's the catch: no odontogenic jaw cysts, no classic Gorlin facies. Despite that, the combination of medulloblastoma, meningioma, and ovarian fibroma was enough to prompt a targeted gene panel, and it came back positive for a SUFU mutation rather than the far more common PTCH1.

Why does that distinction matter clinically? The authors walk through the Hedgehog pathway logic. PTCH1 normally restrains Smoothened; when Hedgehog ligand binds PTCH1, that brake comes off, Smoothened activates, and downstream GLI1 drives transcription. SUFU sits downstream of Smoothened, inhibiting GLI1 directly — so a SUFU mutation bypasses Smoothened entirely. That means Smoothened inhibitors like vismodegib and sonidegib, your usual go-to for extensive or unresectable BCCs in Gorlin patients, simply won't work here, because the resistance is baked into the mutation's location in the pathway. Itraconazole, which works partly through mTOR crosstalk with Hedgehog signaling, has shown some promise specifically in SUFU-mutated BCCs — but it was a nonstarter for this patient because of drug interactions with her tacrolimus.

The epidemiology is worth committing to memory: SUFU accounts for only about five percent of Gorlin syndrome, compared to the roughly two-thirds to three-quarters driven by PTCH1. But SUFU carries a distinctly different phenotype — later-onset BCCs, no jaw cysts, and substantially higher rates of medulloblastoma and meningioma, on the order of one-third and one-in-ten respectively in cohort data the authors cite. One cited cohort even lays out a rough timeline: medulloblastoma presenting around infancy, gonadal tumors in the young teens, and BCCs and meningiomas not showing up until the fourth or fifth decade. In other words, SUFU often announces itself as a brain and ovarian tumor syndrome years before it ever announces itself as a skin cancer syndrome — which is exactly why this diagnosis got missed for so long, especially with no known family history since she was adopted.

The practical fallout here is twofold. Clinically, her small periocular BCCs went on imiquimod and the larger lesions came to Mohs, while her transplant team reduced the mycophenolate dose and added niacinamide for chemoprevention, alongside reinforced sun protection — the standard transplant-BCC risk mitigation playbook layered on top of Gorlin-specific surveillance. But the bigger takeaway for you as a Mohs surgeon is a pattern-recognition one: if you see a transplant patient — or really any patient — with multiple BCCs and a history of medulloblastoma or meningioma, raise your suspicion for Gorlin syndrome even without jaw cysts or classic facies, and even without a known family history. That combination alone should trigger a targeted multigene panel including SUFU. This is genuinely practice-changing in the sense of changing your threshold for genetic workup — it doesn't change how you do Mohs, but it changes whether you send the referral and whether you counsel about Smoothened inhibitor futility before someone reflexively starts vismodegib on a SUFU patient.

Tucked in alongside that case report in the print layout — worth a quick mention since it's genuinely a separate case report — is "Neuromodulator-Assisted Tension Reduction in Refractory Bilateral Mandibular Hypertrophic Scars." A 34-year-old man had over a decade of symmetric, linear hypertrophic scars along the mandibular border overlying his masseters, with no antecedent trauma, no personal or family keloid history — the working hypothesis was chronic mechanical tension from mastication, bruxism, and platysmal pull perpetuating the scars, analogous to how tension drives striae. He'd already failed seven years of conventional scar-directed therapy: pulsed dye laser, combined pulsed dye and Nd:YAG, fractional resurfacing, intralesional steroid, intralesional 5-fluorouracil, and subcision. Over the following three years the authors layered on dozens more sessions of the same modalities, but the inflection point came when they added neuromodulator injections into the masseters and platysma specifically to cut dynamic tension across the scar lines — repeated every three to six months. That's when they saw their most substantial and sustained improvement in erythema, thickness, and contour, with a bonus reduction in lower facial width from masseteric chemodenervation. The teaching point for your practice: in scars sitting over a dynamically mobile, high-tension zone — masseter, platysma, anywhere mechanotransduction plausibly perpetuates a hypertrophic scar — neuromodulator-based tension reduction is a reasonable adjunct to add into your multimodal toolkit when standard laser and intralesional therapy alone are plateauing. It's a single case, so treat this as a promising adjunct to consider, not an established algorithm.

Now to the pilot study, "Improving Patient Comfort of Vibratory Anesthetic Devices With a Dampener." This is a genuine original study with a real statistical analysis, so let's walk it through properly.

Background: vibratory anesthetic devices are a well-established gate-control mechanism for reducing injection pain during dermatologic procedures, but some patients find the vibration itself harsh, particularly at sensitive sites like the nasal ala or ear helix — and that discomfort is presumably a barrier to more universal adoption. The gap here is simple and practical: can a trivial modification, a cotton buffer, make the vibration itself more tolerable without sacrificing efficacy?

Methods: single-site, participant-blinded pilot study, 53 adults, comparing a dampened device — the vibrating unit wrapped in a nitrile glove thumb padded with cotton — against the standard bare device, at five sites: lateral nasal wall, submalar cheek, ear helix, lateral neck, and dorsal forearm. Design choice worth flagging: they used a within-subject, contralateral, randomized-order design — each patient got both devices at each site, one per side — which is smart here because it controls for patient-level variability in pain sensitivity and vibration tolerance that would otherwise muddy a between-subjects comparison. Every patient serves as their own control, so you need a much smaller sample to detect a real preference signal.

Statistically, they used binomial tests to ask, at each site, whether preference deviated from a fifty-fifty coin flip — that's the right tool because the outcome is a simple binary choice per site, and the null hypothesis is genuine equipoise. Then a Cochran Q test was used to see whether preference rates differed across the five sites simultaneously — think of it as the categorical, repeated-measures cousin of a chi-square test, appropriate because the same patients are being compared across more than two paired conditions. Where the Cochran Q flagged an overall difference, they followed up with McNemar tests, which are the correct paired test for two related binary outcomes — again fitting the contralateral, same-patient design. On the qualitative side, they ran free-text preference reasons through Word2vec, a neural-network natural language processing technique that maps words into a high-dimensional vector space so that semantically similar words land near each other, then measured similarity by cosine distance and grouped the results with hierarchical clustering — a nice touch for generating reproducible themes from open-ended patient language rather than an investigator eyeballing free text and imposing categories.

Results were about as clean as pilot data gets: the dampened device was preferred at every single site, ranging from about three in four patients on the forearm up to around nine in ten at the nasal wall and ear helix — all statistically significant. Preference was strongest at the face and head-and-neck sites, which is exactly where you'd predict harsh vibration matters most given tissue thinness and nerve density. None of age, sex, neuropathy, or chronic pain history predicted overall preference, though there was a nonsignificant trend toward patients with chronic pain preferring the dampened device at all five sites — worth flagging as a "significant versus meaningful" moment in reverse: this trend didn't even reach significance, so don't over-read it, but it's biologically plausible given heightened baseline sensory sensitivity in chronic pain patients. The qualitative clustering nicely triangulated with the quantitative preference: patients preferring the dampened device described it with words clustering into smoothness, gentleness, controlled, low frequency, low intensity, and less bothersome, while the minority preferring the standard device cited soothing, stability, and clarity — essentially trading comfort for a more distinct, "massage-like" sensory signal.

Limitations are exactly what you'd expect from a pilot: this measures patient-reported comfort preference, not objectively measured pain scores or analgesic efficacy, so we don't actually know whether the dampened version still provides equivalent gate-control anesthesia. It's single-site, and the authors themselves note comfort was their explicit primary focus rather than a weakness to apologize for.

Practical takeaway: this is a low-cost, essentially zero-risk modification — a cotton buffer around your existing vibration device — that you could implement in your own practice tomorrow, particularly for facial and periocular work where patients tend to flinch hardest at the vibration itself. I'd call this practice-changing in the small-but-real sense: it costs you nothing, and the preference signal is large and consistent across a genuinely sensitive-site distribution. What it is not yet is a validated equivalence claim on anesthetic efficacy — that's the next study to look for.

Last article: a Reconstructive Conundrum, "Reconstruction of a Large and Deep Multisubunit Neck and Chest Defect in a Young Patient." As a conundrum piece, this follows the case-presentation-then-repair-strategy format rather than a methods and results structure, so let's walk it as intended.

A 37-year-old man presented with a large exophytic mass on the left lateral neck, biopsied as fibrosarcomatous dermatofibrosarcoma protuberans, FNCLCC grade 2 — so a higher-grade variant with real metastatic potential, not your garden-variety DFSP. He first underwent wide local excision with otolaryngology using two-centimeter margins, and the final pathology came back with positive margins throughout — a vivid demonstration of why clinical margins, even generous ones, are unreliable for a tumor with this kind of irregular subclinical spread, especially with fibrosarcomatous transformation layered on. Multidisciplinary tumor board recommended re-excision with three-centimeter margins plus free flap reconstruction under general anesthesia. Instead, given the anatomic sensitivity and the need for true circumferential margin control, he was referred for Mohs. Clearance took four stages, leaving a defect just under eleven centimeters by three and a half centimeters spanning the lateral neck into the superior chest, down to cervical musculature.

The reconstructive challenge: mismatched tissue mobility between the mobile neck and the stiffer chest wall, high-tension vectors crossing the clavicle, and real risk of a longitudinal scar contracture limiting neck range of motion if closed the wrong way. Their solution was a rhombic transposition flap combined with a double Z-plasty and an M-plasty. Walking through the logic: the rhombic flap was raised in the deep subcutaneous plane to restore volume after the extirpation, the double Z-plasty broke up the closure tension and recruited lax lateral chest skin to help cover the mismatch, and the M-plasty at the terminal limbs eliminated dog-ear redundancy while protecting flap perfusion. They closed in layers with buried Vicryl and propylene epidermal sutures, and interestingly the authors self-critique in retrospect that finer 5-0 propylene at the skin surface might have given a better early scar appearance — a small but honest technical reflection worth banking.

Why same-day closure instead of the free flap plastics had recommended, or a staged skin graft? The authors are explicit: it avoided the morbidity of a staged procedure or free flap harvest, and it was feasible only because of the skin laxity available in the adjacent tissue reservoirs — this wasn't a universal solution, it was enabled by this specific patient's local tissue availability.

The broader teaching points the authors draw out are worth internalizing. First, fibrosarcomatous DFSP demands complete circumferential margin assessment — this case is basically a natural experiment demonstrating that a generous two-centimeter clinical margin failed while Mohs succeeded in four stages with tissue conservation. Second, the fact that medical and orthopedic oncology recommended MMS themselves reflects a broadening recognition of Mohs as the appropriate modality for margin-sensitive head and neck sarcomas, not just BCC and SCC — a nice data point for how you pitch your own multidisciplinary referral relationships. Third, this patient went on to twenty-five fractions of adjuvant radiation given the metastatic risk profile of fibrosarcomatous DFSP, and developed grade 3 radiation dermatitis, managed with clobetasol taper to triamcinolone — a reminder that as dermatologists first, Mohs surgeons are well positioned to manage radiation dermatitis in these patients rather than punting it elsewhere. And fourth, at six months, healing was good with no flap necrosis, but there was residual hypertrophic scarring and postinflammatory hyperpigmentation, which the authors attribute partly to the patient's Middle Eastern background — a genuine risk factor for hypertrophic scarring — compounded by the adjuvant radiation. That's a preoperative counseling point you can lift directly: patients with elevated genetic scar risk undergoing combined surgery and radiation need that conversation up front.

Practical takeaway here: this isn't new technique innovation — rhombic flaps, Z-plasties, and M-plasties are all in your existing repertoire — but it's a well-argued case for combining them intelligently across a tension mismatch zone, and more importantly a strong argument, with actual before-and-after margin data, for why FS-DFSP belongs in your chair rather than automatically escalating straight to free flap reconstruction.

That wraps our four articles for September. To summarize the through-line: raise your suspicion for Gorlin syndrome in transplant patients even without the classic facies, consider neuromodulators as an adjunct for tension-zone hypertrophic scars, think about a cheap cotton dampener for your vibration devices especially on the face, and remember that Mohs has real data behind it now for high-grade DFSP variants when circumferential margin control is the priority. Thanks for listening — see you next month.