Welcome back to the journal review. This month we're covering the June twenty twenty-six issue of Dermatologic Surgery, and I've pulled four pieces worth your time — a regenerative case report on facial scarring, a database study on treatment delays in extramammary Paget disease, a slick technique pearl for suction blister epidermal grafting in vitiligo, and a cautionary case report on a giant condyloma that sat untreated for two decades. Let's get into it.

First up is a case report — really a short communication — on combining autologous microfat and nanofat grafting with platelet-rich fibrin, or PRF, for early treatment of an atrophic facial scar. The clinical problem here is familiar: atrophic scars from trauma, acne, or surgery represent a loss of collagen and fibrous architecture, and when they land on the face they carry real psychosocial weight. The rationale for using fat comes from adipose tissue's mesenchymal stem cell content, which can differentiate toward fibroblasts, endothelial cells, and keratinocytes, giving it both a volumizing and a regenerative function. The case is a thirty-seven-year-old woman who presented just fifteen days after facial trauma with a ten-centimeter depressed linear scar running from the right malar area to the medial canthus, plus a shorter four-centimeter extension toward the medial eyebrow — so, notably, this is an early, immature scar, not a mature one, which matters for their argument later. Technique-wise, they harvested ten cc's of fat under tumescent anesthesia from the umbilicus using a two-point-four millimeter cannula, then sequentially filtered it — first through a two-point-four millimeter filter, then a one-point-two millimeter filter to isolate microfat, reserving two milliliters of that, while the remainder went through a six-hundred-micron filter to emulsify it into nanofat. After subcision, two milliliters of microfat went subdermally along the scar with a twenty-two gauge cannula, and one milliliter of nanofat was injected intradermally with a thirty gauge needle. They then followed with three sessions of PRF. At six months, the photographs show near-complete resolution of the depression and pigmentation change. The authors' stated rationale for this particular combination is worth teaching from directly: microfat was chosen over macrofat because the scar bed didn't have enough tissue thickness to accommodate larger fat particles, while nanofat's smaller, emulsified particle size let them address the epidermal atrophy component and deliver a concentrated growth factor payload — VEGF, PDGF, IGF, along with adipose-derived stem cells — directly into a thin dermis. They also explicitly chose not to use stromal vascular fraction here, reasoning that nanofat already carries a high concentration of adipose-derived stem cells while additionally providing volume, whereas SVF isolation is more resource-intensive without that added structural benefit. And they emphasize timing — citing prior work suggesting early fat grafting on immature scars may blunt the trajectory toward hypertrophic scarring, which is presumably why they intervened at just two weeks rather than waiting for the scar to mature. Now for the honest caveats, which the authors themselves raise: this is an N of one with no control, so we can't rule out spontaneous improvement of an early scar over six months, and they specifically flag that part of the visual improvement could simply be a volumizing effect similar to what you'd see with saline injections alone — a nice bit of self-skepticism. They also concede that PRF's contribution is unproven in this context and shouldn't be credited for the outcome. So where does this leave you practically? This is interesting, hypothesis-generating material, not practice-changing — a single uncontrolled case with a plausible mechanistic story, but the field genuinely needs split-scar trials with proper controls before this changes how any of us counsel patients with early atrophic facial scars.

Next, a retrospective database study looking at factors affecting time to definitive surgery in extramammary Paget disease, or EMPD. The gap here is clean: prior work has characterized delays to definitive surgery in other rare cutaneous malignancies like dermatofibrosarcoma protuberans and sebaceous carcinoma, but nobody had done this analysis for EMPD specifically. The authors pulled cases from SEER-seventeen, the Surveillance, Epidemiology, and End Results database, spanning two thousand to twenty twenty-one, using the relevant ICD-O-3 histology codes, and excluded anyone who only had a diagnostic biopsy without subsequent definitive surgical treatment — meaning excision, Mohs surgery, or a partial or total primary-site procedure like vulvectomy. A national cancer registry is really the only feasible design here — EMPD is rare enough that no single institution could generate meaningful numbers, and SEER lets you look at population-level sociodemographic associations, though as we'll see that comes at the cost of clinical granularity. They ran multivariate regression to generate adjusted odds ratios for hitting various time-to-surgery thresholds. The cohort came to nearly sixteen hundred patients, average age right around seventy-one, and notably about three in four were female. Two findings stand out as both statistically and clinically meaningful. First, a striking treatment pattern: only about one in a hundred female patients underwent Mohs surgery, compared to roughly one in seven male patients — a significant and clinically substantial gap. Second, female sex was independently associated with longer delays to surgery — more than double the odds of falling into the thirty-one-to-sixty-day bucket, and about a fifty percent higher odds of falling into the sixty-one-to-ninety-day bucket, both statistically significant. Unmarried patients had roughly seventy percent higher odds of waiting more than ninety days for surgery, also significant. Race and ethnicity did not show a significant association with delay. The authors' interpretation ties these two findings together nicely: female patients are more likely to be steered toward radical excisional procedures like vulvectomy rather than Mohs, and vulvectomy inherently carries more delay because of operating room scheduling and the need for separate pathologist review of margins after the fact, whereas Mohs allows real-time margin assessment as an office-based procedure. They also candidly acknowledge the counterargument — that female anogenital anatomy involves central structures like the vagina, clitoris, urethra, and anus, genuinely requiring more complex, multidisciplinary surgical planning that may just take longer regardless of bias, particularly at smaller centers without ready gynecologic oncology support. The marital status finding is framed as an extension of the broader social-determinants-of-health literature linking marital status to cancer outcomes generally. Limitations are the expected SEER constraints: no recurrence data, no way to identify staged excision with complete margin assessment — so-called slow Mohs — no insurance status, and no Fitzpatrick phototype data. So, practically: this isn't practice-changing in the sense of altering your technique, but it is a call to actionable awareness — if you're a Mohs surgeon capable of treating genital EMPD in female patients, this data suggests a real referral and access gap worth addressing at the multidisciplinary level, and marital status as a marker of possible social support deficits is worth flagging when you're coordinating care for these patients.

Third is a "How We Do It" piece — a pure technique article, no results-and-limitations scaffolding, just a practical pearl — on optimizing donor graft fixation in suction blister epidermal grafting for vitiligo. Suction blister epidermal grafting has been around since Falabella described it in nineteen seventy-one, and it remains a go-to for vitiligo in anatomically tricky, high-motion areas like the lips, eyelids, and nipples. The persistent problem is fixation: fibrin glue gives biological adhesion but is costly and carries safety concerns; petrolatum-coated acetate sheets help with handling in linear lesions; dressing-free techniques work in select areas like the lips but risk dislodgement from incidental touch; micropore tape has been proposed mainly to prevent the graft from curling during harvest. The authors' solution here is to use a one-sided adhesive, mesh-structured silicone dressing — specifically Mepitel One — as a handling scaffold. The technique: after suction blister induction and harvest, the epidermal graft is laid flat, epidermal side up, on a glass slide, and the adhesive side of the silicone dressing is applied directly to that epidermal surface, leaving the dermal side exposed for grafting. This gives you a supported, non-folding graft that can be precisely trimmed with scissors to match the recipient defect, minimizing wasted donor tissue. The recipient site is prepped with an ablative erbium:YAG laser, the silicone-backed graft is transferred directly onto the ablated bed, the mesh acts as a scaffold to hold orientation during placement, and a pressure dressing goes on top to prevent shifting. They demonstrate this in two cases of localized, stable vitiligo; at one week the grafts showed excellent adherence with the dressing usefully absorbing exudate and keeping the wound bed clean, and by four weeks the submandibular case had achieved near-complete repigmentation, with no adverse events in either case. As a technique pearl, the practical takeaway is straightforward: this is a low-cost, easy-to-adopt modification — you're essentially using a widely available wound-care product as a rigid handling backbone for a notoriously fragile graft — and it's particularly worth considering in mobile or contoured recipient sites where conventional dressings tend to fail. It's based on only two cases, so treat the repigmentation outcome as supportive rather than definitive, but the fixation logic itself is sound and easy to trial in your own practice without any real downside.

Last is a case report describing a two-decade history of an untreated suprapubic growth that turned out to be a Buschke-Löwenstein tumor, or giant condyloma acuminatum, in a patient with myelofibrosis. Giant condyloma is an HPV-driven tumor, typically the low-risk subtypes six and eleven, occurring mostly in the anogenital region, and it's clinically important because it's considered by some to be an intermediary lesion between benign condyloma and frank squamous cell carcinoma, with documented cases of malignant transformation. The patient was a fifty-eight-year-old man with type two diabetes, heart failure, hypertension, pericardial effusion, and myelofibrosis on hydroxyurea, who had carried a dark suprapubic plaque for twenty years, with a wart-like growth emerging from its center and enlarging over the preceding year, now bleeding and discharging mucus on contact. On exam this was a substantial lesion — fourteen by ten centimeters — a verrucous plaque with a friable exophytic component. Initial punch biopsies were complicated significantly: three days later the patient landed in the emergency department with major bleeding from the biopsy site, a hemoglobin down around seven, requiring transfusion, and a secondary acute kidney injury from the blood loss — a useful reminder that even small sampling biopsies on large vascular anogenital tumors can bleed dramatically. The initial pathology, despite showing acanthosis, papillomatosis, horn pseudocysts, and positive p53 staining, was read out as seborrheic keratosis. Here's the teaching moment: the treating team recognized that diagnosis simply didn't fit the clinical picture — a large, friable, actively growing, bleeding lesion is not behaving like a seborrheic keratosis — so dermatology pursued a repeat, larger shave biopsy two weeks later. That specimen showed papillomatosis with acanthotic keratinocytic proliferation, perinuclear halos, and full-thickness atypia, yielding a final diagnosis of squamous cell carcinoma in situ arising in association with condyloma acuminatum, consistent with Buschke-Löwenstein tumor. Management was staged surgical excision in conjunction with surgical oncology and plastic surgery, with the defect packed to allow final pathology to return before proceeding to closure with tissue transfer and a local muscle flap. On the discussion side, the authors note Buschke-Löwenstein tumor has an estimated prevalence around one in a thousand, with a male predominance of roughly three to one, and that while treatment isn't standardized given the rarity, wide local excision remains the primary approach, with CO2 laser, imiquimod, electrosurgery, chemotherapy, and radiation reported as adjuncts or alternatives with variable success; HPV vaccination has also been floated as a potential adjunctive strategy. Their own read on this specific case is that the patient's myelosuppressed, immunocompromised state from myelofibrosis likely contributed both to the tumor's two-decade persistence and to its progression toward malignant transformation, despite the classic association of this tumor type with low-risk HPV. The clinical takeaway here is squarely practice-relevant, even if the case itself is anecdotal: maintain a high index of suspicion for malignancy in any longstanding or atypical anogenital lesion, don't let a reassuring initial pathology report override a discordant clinical picture, and have a low threshold to repeat and deepen your biopsy — ideally with a generous shave or incisional sample rather than a small punch — when the histology doesn't match the size, growth rate, or friability you're seeing in front of you.

That's the June issue. To sum up where the actionable signal actually lives this month — the vitiligo grafting pearl is something you could reasonably adopt in your next case tomorrow, the EMPD data is a disparity worth flagging in your own referral patterns even though it doesn't change technique, the fat grafting report is intriguing but needs controlled follow-up before it changes counseling, and the Buschke-Löwenstein case is really a diagnostic vigilance lesson dressed up as a case report. Thanks for listening, and I'll see you next month.