When Testosterone Needs to be Contrasted: A Preliminary Study of Scar Prevention in Transmen Top Surgery with an Innovative Galenic Preparation.

BACKGROUND: Transmen are individuals who live a marked incongruence between the assigned gender and the experienced gender. Crucial and life-changing steps in their transition are testosterone treatment and mastectomy to remove the stigma of feminine identity. After surgery, patients' attention turns to the scars, often not aesthetically pleasant. We thus created an innovative galenic preparation for scar treatment after surgery composed by spironolactone, alfa bisabolol and silicone gel. Functional outcomes, side effects and satisfaction were assessed. METHODS: For the present prospective randomized controlled study, 30 patients with similar demographic characteristics who underwent double incision mastectomy with NA grafts between February 2014 and June 2019 were selected. The treatment Group A (n = 15) was treated for 12 months with "Top Surgery Scar go," the control Group B (n = 15) with silicon gel. Statistical analysis including Wilcoxon test and Kruskal-Wallis test per variable was performed. To assess satisfaction, a second Wilcoxon test was applied. RESULTS: The differences between Group A and Group B were statistically significant, especially at T12 with very low p values. Satisfaction was greater in Group A (p value = 3e-4). No major side effects were noticed in Group A. CONCLUSIONS: TSSgo scar innovative treatment showed long-term efficacy in comparison with silicon gel in terms of improved scar tissue texture, pigmentation, pliability and height. It is easy to set up, cost-effective and safe. Further studies are necessary to better assess efficacy and validity of TSSgo, but it appears to be promising as the new treatment of reference for scar management after top surgery in transmen. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A clinical, pathological and immunohistochemical series of 9 cases of primary cutaneous apocrine carcinomas of the head and neck.

BACKGROUND/OBJECTIVES: Primary cutaneous apocrine carcinoma is a rare malignant adnexal skin tumour that can recur locally, spread to regional lymph nodes and metastatize to visceral organs. Wide dissemination and death from disease are much less common. The axilla is the most common site of presentation. It is infrequently reported in the head and neck region. METHODS: All cases diagnosed as primary cutaneous apocrine carcinoma of the head and neck were retrospectively collected from the archives of the Division of Pathological Anatomy, University of Florence from 1996 to 2016. There was no history or clinical evidence of breast cancer. Clinical data and follow-up were collected by the clinicians. RESULTS: Nine cases were found, with a mean age of 76 years, ranging in size between 0.3 and 3.5 cm. Clinically, they were frequently mistaken for basal cell carcinomas. Histopathologically, all the tumours showed decapitation secretion, a tubular, solid or mixed (tubulo-papillary and solid-tubular) growth pattern and were predominantly classified as grade 2 tumours. GCDFP-15 and hormone receptors were variably expressed. HER2 and podoplanin were negative in all cases. In one case, spreading to regional lymph nodes was observed. No cases were associated with death due to the disease. CONCLUSION: As immunohistochemical analysis lacks specificity in distinguishing primary cutaneous apocrine carcinoma from a cutaneous metastasis of breast carcinoma, detailed clinical history, breast examination, adequate treatment and follow-up are necessary to confirm a diagnosis of primary cutaneous apocrine carcinoma.

Changing Trends in Mastectomy and Breast Reconstruction. Analysis of a Single-institution Experience Between 2004-2016.

BACKGROUND/AIM: Recently, "conservative" mastectomy with immediate breast reconstruction (M-R) has become the gold standard when the breast must be removed. We analyzed the evolution in the choice of mastectomy type in our Unit, focusing on factors associated with renounce to reconstruction and risk factors for its failure. PATIENTS AND METHODS: Clinical-pathological and surgical features of 132 patients who underwent mastectomy in our Unit from 2004 to 2016 were analyzed. M-R rate and different mastectomy techniques' rates between 2004-2009 and 2010-2016 were compared. RESULTS: M-R was associated with younger age at diagnosis (p<0.001) and early tumor stage (p=0.03). M-R rate increased from 49.1% to 72.2% (p=0.002) in the last years, with prominent use of nipple-sparing-mastectomy (p<0.001). M-R failure rate was associated with previous or subsequent irradiation/chemotherapy in 92.3% of cases. CONCLUSION: M-R and particularly nipple-sparing-mastectomy represented the standard in more recent years; reconstruction failure was associated with irradiation/chemotherapy, especially in implant-based reconstructions.

Shape, Position and Dimension of the Nipple Areola Complex in the Ideal Male Chest: A Quick and Simple Operating Room Technique.

INTRODUCTION: The anatomical features of the chest identify an individual as male or female and even the smallest details of these features determine the appropriate appearance for each gender. In female-to-male patients, the creation of an aesthetically pleasing male chest is the most important step. Incorrect positioning of the nipple areola complex (NAC) on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. PATIENTS AND METHODS: We have analyzed the anatomical chest features of 26 water polo players, to verify our hypothesis of the relationship between the pectoralis major muscle and NAC and to create a method for repositioning the NAC that is applicable in the operating room, is easy, practical and reproducible without the use of formulas and based on an easily identifiable landmark. RESULTS: In our reference group, the NAC has a constant relationship with the pectoralis major muscle, positioned on average 3 cm medial to the lateral border of the pectoralis muscle and 2.5 cm above the inferior pectoralis major insertion. This supports our hypothesis and our surgical technique. We use the index finger to find a vertical axis and a line 2.5 cm above the inferior pectoralis shadow to find the horizontal axis. We also introduce a modification to the receiving site to recreate an oval areola more similar to that of an ideal male chest. CONCLUSIONS: Our anatomical study and statistical analysis support a consistent relationship between the position and shape of the NAC and the borders of the pectoral muscle. We have used this relationship to develop our "trick," which is easily applicable in the operating room to find the NAC position without using formulas and numbers. This method allowed us to place the NAC in a position very close to that of a typical male subject, and it permitted us to reduce the surgery time. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

V-shaped Internal Nasal Vestibular Flap for Reconstruction of Iatrogenic Columellar Defect.

Columella is an important structure in the center of the face, and its structural integrity has an important functional, social, and psychological role. Columella reconstruction can be very challenging for surgeons and the ideal technique remains elusive. This article describes a reconstruction technique in a young woman with columella necrosis due to nasal continuous positive airway pressure treatment. The method of reconstruction described here, with a V-shaped internal nasal vestibular flap and a cartilage grafts from lateral crura, is simple and easily reproducible, providing an optimal aesthetic result and in addition the donor site does not create a secondary deformity by disrupting normal anatomy.

Masculine Chest-Wall Contouring in FtM Transgender: a Personal Approach.

BACKGROUND: Chest-wall contouring surgery is one of the first steps in sexual reassignment in female-to-male (FtM) transsexuals that contributes to strengthening of the self-image and facilitates living in the new gender role. The main goal is to masculinize the chest by removing the female contour. Chest contour, scar placement, scar shape, scar length, nipple-areola position, nipple size and the areola size are the key points. METHODS: Between July 2013 and June 2016, 25 FtM transgender patients underwent surgical procedures to create a masculine chest-wall contour. In our study, we just considered 16 patients who have undergone chest surgery with the double incision method. RESULTS: The patients' survey revealed a high satisfaction rate with the aesthetic result. In our group, no complications occurred, and two patients have undergone supplementary surgery for axillary dog-ear revision and nipple reconstruction. CONCLUSION: The authors propose a new technical approach and indications for FtM transgender patients' surgery. A longer scar that emphasizes the pectoralis muscle, a smaller nipple and a resized and refaced areola are the key points of our technique to give a masculine appearance to the chest. The scars are permanent, but most of them will fade and the patients are enthusiastic with their new "male" chest appearance. The high level of satisfaction, the great aesthetic result and the low rate of complications suggest to us the use of this technique in medium- and large-size breasts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

MSCs seeded on bioengineered scaffolds improve skin wound healing in rats.

Growing evidence has shown the promise of mesenchymal stromal cells (MSCs) for the treatment of cutaneous wound healing. We have previously demonstrated that MSCs seeded on an artificial dermal matrix, Integra (Integra Lifesciences Corp., Plainsboro, NJ) enriched with platelet-rich plasma (Ematrix) have enhanced proliferative potential in vitro as compared with those cultured on the scaffold alone. In this study, we extended the experimentation by evaluating the efficacy of the MSCs seeded scaffolds in the healing of skin wounds in an animal model in vivo. It was found that the presence of MSCs within the scaffolds greatly ameliorated the quality of regenerated skin, reduced collagen deposition, enhanced reepithelization, increased neo-angiogenesis, and promoted a greater return of hair follicles and sebaceous glands. The mechanisms involved in these beneficial effects were likely related to the ability of MSCs to release paracrine factors modulating the wound healing response. MSC-seeded scaffolds, in fact, up-regulated matrix metalloproteinase 9 expression in the extracellular matrix and enhanced the recruitment of endogenous progenitors during tissue repair. In conclusion, the results of this study provide evidence that the treatment with MSC-seeded scaffolds of cutaneous wounds contributes to the recreation of a suitable microenvironment for promoting tissue repair/regeneration at the implantation sites.

Circumferential abdominoplasty.

BACKGROUND: In Italy, 34.2% of the population has a BMI higher than 25, and another 9.8% of the population has a BMI higher than 30. In Italy, there are 4 million and 700,000 obese people. Bariatric surgery has evolved as a very effective therapy for morbid obesity. After such dramatic weight loss, patients are usually left with redundant skin and unwieldy subcutaneous tissue. The circumferential truncal excess cannot be corrected by a regular abdominoplasty alone. In this group of patients, lateral excess can actually be over accentuated by a traditional abdominoplasty. In our institution, we are used performing abdominoplasty according to Pascal-Le Louarn's surgical technique. In our cases, the adoption of this technique has been successful with a high rate of very satisfied patients, no major complications and few minor complications primarily in the smoker patients. METHODS: The charts of 41 consecutive circumferential abdominoplasty were reviewed. The preoperative markings, the surgical technique, the post-operative course, and the complications are described. RESULTS: The average operative time was 220 min. The average lipoaspirate was 1,600 cc. The mean weight loss during the surgery was 3.4 kg. There were 18 immediate complications, including 11 seromas, and 7 partial wound dehiscences. There were 26 late complications, including 8 hypertrophic scars and 18 local hypoestesia. All seromas were resolved within 3 weeks. All patients were satisfied. CONCLUSION: Circumferential abdominoplasty performed with Pascal-Le Louarn's surgical technique is an effective, appropriate, and safe method to treat patients with lipodistrophy of the trunk following massive weight loss.

Autologous lipofilling: coenzyme Q10 can rescue adipocytes from stress-induced apoptotic death.

BACKGROUND: Autologous fat transplantation (or lipofilling) is an excellent technique for correction of cosmetic defects. The success of the procedure relies strongly on the techniques of harvesting and transferring viable adipocytes. The purpose of this study was to evaluate effects of two harvesting methods and coenzyme Q10 on the viability and apoptotic death of adipocytes collected for autologous lipofilling. METHODS: Human adipose tissue from six patients was collected by Luer-Lok syringe according to Coleman's technique or by means of an aspirator with a 680-mmHg vacuum. Half of each sample collected using Coleman's technique was treated with 10 muM Coenzyme Q10, and the other half served as untreated control. Viability and apoptosis were assessed by immunoenzymatic, biochemical, and morphological methods. RESULTS: The harvesting of adipose tissue by aspirator reduced the viability and increased apoptotic death significantly more than harvesting tissue using Coleman's technique. Biochemical and morphological analyses confirmed that treatment of adipose tissue with coenzyme Q10 reduced and even inhibited apoptotic death of harvested adipocytes. CONCLUSION: Coenzyme Q10 can rescue adipocytes from stress-induced apoptotic death.

Outcome of patients with melanoma and histologically negative sentinel lymph nodes: one institution's experience.

BACKGROUND: Since its introduction by Morton in 1992, sentinel lymph node (SLN) biopsy has become a standard procedure in the staging and treatment of primary melanoma and clinically negative regional lymph nodes. The primary aims of this procedure are to ascertain the individual lymphatic drainage patterns of primary tumors towards 1 or more different lymph node basins and to identify patients with micrometastatic lymphatic disease for selective lymphadenectomy. The aim of our study was to evaluate over time a cohort of patients who, having undergone SLN treatment, were found negative for metastases using routine histopathological and immunohistochemical analyses. METHODS: We studied 102 consecutive patients who underwent intraoperative lymphatic mapping at the Department of Plastic Surgery, University of Florence, Italy, for cutaneous melanoma and were found negative for metastatic melanoma in their SLNs using routine histopathological and immunohistochemical techniques. RESULTS: Of 102 patients with 103 cutaneous melanomas that underwent SLN resection and proved histologically negative to metastasis in that site, 15 patients (14.7%) developed melanoma recurrence during follow-up. CONCLUSIONS: The diagnostic and prognostic value of the absence of melanoma metastases in SLNs may be limited and not particularly significant, since satellite and in-transit metastases or direct distant metastases will not be detected and hematogenous spread may already have begun at the time of intervention.