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Surgical treatment of axillary osmidrosis
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Britsh JournulqfPhsfic Surger! (1990), 43.483485 7. i 990 The Trustees of Bntlsh Assocmtion of Plastic Surgeons
Surgical treatment of axillary osmidrosis R. YOSHIKATA, Department
A. YANAI,
T. TAKEI
of Plastic and Reconstructive
Summary-An over a 5-year
operative technique period are presented.
and H. SHIONOME Surgery, Juntendo
for axillary
University
osmidrosis
Malodour of the axilla is referred to as osmidrosis and is generally associated with hyperhidrosis, the problem of excessive perspiration. In Japan, many patients with osmidrosis attend plastic surgery outpatient departments and they commonly seek a decrease in perspiration in addition to cessation of the malodour. A number of reports have been published in Japanese (Inaba et al., 1974; Takato et al.. 1987; Katoet ai., 1988) but not many have been translated and published in English. Methods for the treatment of osmidrosis include the excision of subcutaneous tissue (Skoog and Thyresson, 1962; Inaba. 1978; Jemec and Hansen, 1978) en bloc excision of skin and subcutaneous tissue (Hurley and Shelley, 1963; Davis, 1971 : Eldh, 1971) and combined procedures (Hurley and Shelley, 1966; Weaver, 1970; Rigg, 1977). Our technique involves either one or two incisions and the excision of subcutaneous tissue. It is a reliable and safe method and postoperative scar contracture is rare. We describe our method below and report on the results of 30 patients on whom we have operated during the past 5 years.
School
is described
PreoperatizTe
of Medicine.
Tokyo, Japan
and 30 cases experienced
management
We operate in the area where axillary hair is growing as we presume apocrine glands are located in the same area. We therefore do not remove axillary hair before the operation. Operation
First, the operative area is marked out. The site of incision is dependent on the location of the axillary hair. When a small area of sweat glands is to be removed, a single incision is made, and when it involves a large area two incisions are made (Fig. 1). To avoid scar contracture, no skin is excised. Adipose tissue beneath the skin is removed with the use of scissors through the incision or incisions. We defat the area where we presume the sweat. glands exist (Fig. 2). The pliable skin is drawn upward with the fingertips to reveal its underside. The vascular plexus, apocrine and eccrine sweat glands and subcutaneous tissue are excised with scissors in the same manner as defatting is accomplished in preparing a full thickness skin
Materials and methods We believe secretions from the apocrine glands, which are fully grown when puberty is reached, and from the eccrine glands associated with bacterial colonisation, to be responsible for the malodour of osmidrosis. The aim of surgical treatment, therefore, is excision not only of the apocrine but also of the eccrine glands. Anaesthesia
If a unilateral operation is to be performed there is no necessity for hospitalisation. In the case of bilateral surgery, hospitalisation for at least 2 or 3 days is necessary as the patient must restrict postoperative movement of the axillary area. 483
Fig. 1 Figure l-Operattve
area in axilla and double inclslon
484
BRITISH JOURNAL
OF PLASTIC SURGERY
patients are permitted to have a bath after the sutures have been removed but are warned to abstain from severe exercise for about one month after the operation. Results Thirty patients (26 females, 4 males), ranging in age from 12 to 47 years, have been surgically treated for osmidrosis during the past 5 years. The results were classified as good, fair or poor based on the view of the patients and the people around them, as follows : Fig. 2 Figure 2-Excising
of subcutaneous
tissue with
-
scissors.
graft. Coagulation is carefully carried out during this procedure. We use a single layer closure. Drainage is not necessary when haemostasis has been properly achieved. Eight sutures are placed around the undermined area to prepare for a tie-over dressing (Fig. 3). Gauze moistened with a saline solution is placed over the undermined area and a tie-over dressing applied with mild pressure. Cotton wool is placed over this and fixed in place with a bandage, as in the case of a clavicular fracture. Tie-over dressings are removed 5 days after surgery. Bandages are left for 2 or more days and sutures are removed 7 days after surgery. The
Fig. 3 Figure S-Eight sutures placed preparation for tie-over dressmg.
5 mm from
excision
area
in
Good: neither the patient nor the persons close by are aware of malodour. Fair: the patient alone complains of malodour. Poor: (a) the patient complains of malodour and presents with axillary hair, or (b) we consider the results poor.
The results in our 30 cases were 11 good, 10 fair, 5 poor and 4 unknown because follow-up was not possible. Unilateral reoperation was necessary in two bilateral cases and the results were good. Complications included one case of haematoma, 2 cases of partial skin necrosis and 2 cases of abscess formation. Conservative therapy led to good results in all 5 cases. Discussion The principle in the treatment of osmidrosis is the excision of a sufficient volume of subcutaneous tissue from a sufficiently large area. If this is accomplished there should be no axillary hair present after surgery. We believe that our technique is aesthetically superior to those involving skin excision, is more reliable than the Skoog technique (Skoog and Thyresson, 1962) and causes less skin necrosis than the Skoog technique or Z-plasties. Generally, persons of Caucasian and negroid races seek treatment primarily for hyperhidrosis rather than osmidrosis. Japanese, on the other hand, intensely dislike malodour and, as any person afflicted with osmidrosis may be shunned by others, we have many opportunities for treating osmidrosis. Bisbal et al. (1987) and Kato et al. (1988) stated that they first determined the area of sweating by means of the iodine-starch test. We do not utilise this test because the primary purpose of our technique is to eliminate malodour and not to bring about a decrease in the degree of hyperhidrosis, so
SURGICAL
TREATMENT
OF AXILLARY
485
OSMIDROSIS
we do not have to determine the area of sweating. We are of the opinion that the area in which w’ have to excise sweat glands coincides with the area of axillary hair. We have achieved good or fair results in 7OY of our cases. Two of 5 cases of bilateral surgery required unilateral reoperation because of regeneration of axillary hair, and the results were good. References Bisbal, J.. Cache, C. and Casalots, J. (1987). Surgical treatment of axillary hyperhidrosis. Annuls of Plastic Surgery, 18.429. Davis, P. K. B. (1971). Surgical treatment of axillary hyperhidrosis. British Journal of Plastic Suraerv, 24.99. Eldh, J. (1971). Surgical treatment df hyperhidrosis axillae. Scandinavian Journal qf’Plastic and Reconstructive Surgery, 10, 227. Hurley, H. J. and Shelley, W. B. (1963). A simple surgical approach to the management of axillary hyperhidrosis. Journal @‘the American Medical Association, 186, 109. Hurley, H. J. and Shelley, W. B. (1966). Axillary hyperhidrosis. British Journalof Dermatology, 18, 127. Inaba, M. (1978). Radical operation to stop axillary odor and hyperhidrosis. Plastic and Reconstructive Surgery, 62, 355. Inaba, M., Takagi, M., Matsuyama, H. and Fujinami, Y. (1974). Radical treatment of osmidrosis axillae. Japanese Journal oj Plastic and Reconstructioe Surgery, 17, 300. Jemec, B. and Hansen, B. H. (1978). Follow-up of patients operated on for axillary hyperhidrosis by subcutaneous
curettage. Scandinavian Journal qf Plastic and Reconstructive Surgery, 12.65. Kate, H., Nakajima, T., Yosbimura, Y., Oonishi, K., Nakanisbi, Y., Yoneda, T., Kawagucbi, M. and Nisbiyama, T. (1988). Aesthetic surgical treatment of osmidrosis. Jaoanese .Journal of Surgererv,1155, 1988. Rigg, B. M. (1977). Axillary hyperhidrosis. Plastic and Reconstructive Surgery, 59. 334. Skuug, T. and Thyressun, N. (1962). Hyperhidrosis of the axillae : a method of surgical treatment. Acta Chirurgica Scandinocica, 124.531. Takato, T., Nakatsuka, T. and Motizuki, M. (1987). Surgical treatment of osmidrosis. Rinsho Derma (Tokyo), 143, 1987. Weaver, P. C. (1970). Axillary hyperhidrosis. British Medical Journal, 1.48.
The Authors Rie Yoshikata, MD, Senior Assistant Akira Yanai, MD, Assistant Professor Takako Takei, MD, Senior Resident Hizuru Shionome, MD, Senior Resident Department
of Plastic
and Reconstructive
Surgery,
University School of Medicine, 2-l-l Hongo. Bunkyo-ku.
Juntendo Tokyo,
Japan. Requests
for reprints
to Dr Yoshikata
Paper received 13 September 1989. Accepted 5 March 1990 after revision.
at the above address
Britsh JournulqfPhsfic Surger! (1990), 43.483485 7. i 990 The Trustees of Bntlsh Assocmtion of Plastic Surgeons
Surgical treatment of axillary osmidrosis R. YOSHIKATA, Department
A. YANAI,
T. TAKEI
of Plastic and Reconstructive
Summary-An over a 5-year
operative technique period are presented.
and H. SHIONOME Surgery, Juntendo
for axillary
University
osmidrosis
Malodour of the axilla is referred to as osmidrosis and is generally associated with hyperhidrosis, the problem of excessive perspiration. In Japan, many patients with osmidrosis attend plastic surgery outpatient departments and they commonly seek a decrease in perspiration in addition to cessation of the malodour. A number of reports have been published in Japanese (Inaba et al., 1974; Takato et al.. 1987; Katoet ai., 1988) but not many have been translated and published in English. Methods for the treatment of osmidrosis include the excision of subcutaneous tissue (Skoog and Thyresson, 1962; Inaba. 1978; Jemec and Hansen, 1978) en bloc excision of skin and subcutaneous tissue (Hurley and Shelley, 1963; Davis, 1971 : Eldh, 1971) and combined procedures (Hurley and Shelley, 1966; Weaver, 1970; Rigg, 1977). Our technique involves either one or two incisions and the excision of subcutaneous tissue. It is a reliable and safe method and postoperative scar contracture is rare. We describe our method below and report on the results of 30 patients on whom we have operated during the past 5 years.
School
is described
PreoperatizTe
of Medicine.
Tokyo, Japan
and 30 cases experienced
management
We operate in the area where axillary hair is growing as we presume apocrine glands are located in the same area. We therefore do not remove axillary hair before the operation. Operation
First, the operative area is marked out. The site of incision is dependent on the location of the axillary hair. When a small area of sweat glands is to be removed, a single incision is made, and when it involves a large area two incisions are made (Fig. 1). To avoid scar contracture, no skin is excised. Adipose tissue beneath the skin is removed with the use of scissors through the incision or incisions. We defat the area where we presume the sweat. glands exist (Fig. 2). The pliable skin is drawn upward with the fingertips to reveal its underside. The vascular plexus, apocrine and eccrine sweat glands and subcutaneous tissue are excised with scissors in the same manner as defatting is accomplished in preparing a full thickness skin
Materials and methods We believe secretions from the apocrine glands, which are fully grown when puberty is reached, and from the eccrine glands associated with bacterial colonisation, to be responsible for the malodour of osmidrosis. The aim of surgical treatment, therefore, is excision not only of the apocrine but also of the eccrine glands. Anaesthesia
If a unilateral operation is to be performed there is no necessity for hospitalisation. In the case of bilateral surgery, hospitalisation for at least 2 or 3 days is necessary as the patient must restrict postoperative movement of the axillary area. 483
Fig. 1 Figure l-Operattve
area in axilla and double inclslon
484
BRITISH JOURNAL
OF PLASTIC SURGERY
patients are permitted to have a bath after the sutures have been removed but are warned to abstain from severe exercise for about one month after the operation. Results Thirty patients (26 females, 4 males), ranging in age from 12 to 47 years, have been surgically treated for osmidrosis during the past 5 years. The results were classified as good, fair or poor based on the view of the patients and the people around them, as follows : Fig. 2 Figure 2-Excising
of subcutaneous
tissue with
-
scissors.
graft. Coagulation is carefully carried out during this procedure. We use a single layer closure. Drainage is not necessary when haemostasis has been properly achieved. Eight sutures are placed around the undermined area to prepare for a tie-over dressing (Fig. 3). Gauze moistened with a saline solution is placed over the undermined area and a tie-over dressing applied with mild pressure. Cotton wool is placed over this and fixed in place with a bandage, as in the case of a clavicular fracture. Tie-over dressings are removed 5 days after surgery. Bandages are left for 2 or more days and sutures are removed 7 days after surgery. The
Fig. 3 Figure S-Eight sutures placed preparation for tie-over dressmg.
5 mm from
excision
area
in
Good: neither the patient nor the persons close by are aware of malodour. Fair: the patient alone complains of malodour. Poor: (a) the patient complains of malodour and presents with axillary hair, or (b) we consider the results poor.
The results in our 30 cases were 11 good, 10 fair, 5 poor and 4 unknown because follow-up was not possible. Unilateral reoperation was necessary in two bilateral cases and the results were good. Complications included one case of haematoma, 2 cases of partial skin necrosis and 2 cases of abscess formation. Conservative therapy led to good results in all 5 cases. Discussion The principle in the treatment of osmidrosis is the excision of a sufficient volume of subcutaneous tissue from a sufficiently large area. If this is accomplished there should be no axillary hair present after surgery. We believe that our technique is aesthetically superior to those involving skin excision, is more reliable than the Skoog technique (Skoog and Thyresson, 1962) and causes less skin necrosis than the Skoog technique or Z-plasties. Generally, persons of Caucasian and negroid races seek treatment primarily for hyperhidrosis rather than osmidrosis. Japanese, on the other hand, intensely dislike malodour and, as any person afflicted with osmidrosis may be shunned by others, we have many opportunities for treating osmidrosis. Bisbal et al. (1987) and Kato et al. (1988) stated that they first determined the area of sweating by means of the iodine-starch test. We do not utilise this test because the primary purpose of our technique is to eliminate malodour and not to bring about a decrease in the degree of hyperhidrosis, so
SURGICAL
TREATMENT
OF AXILLARY
485
OSMIDROSIS
we do not have to determine the area of sweating. We are of the opinion that the area in which w’ have to excise sweat glands coincides with the area of axillary hair. We have achieved good or fair results in 7OY of our cases. Two of 5 cases of bilateral surgery required unilateral reoperation because of regeneration of axillary hair, and the results were good. References Bisbal, J.. Cache, C. and Casalots, J. (1987). Surgical treatment of axillary hyperhidrosis. Annuls of Plastic Surgery, 18.429. Davis, P. K. B. (1971). Surgical treatment of axillary hyperhidrosis. British Journal of Plastic Suraerv, 24.99. Eldh, J. (1971). Surgical treatment df hyperhidrosis axillae. Scandinavian Journal qf’Plastic and Reconstructive Surgery, 10, 227. Hurley, H. J. and Shelley, W. B. (1963). A simple surgical approach to the management of axillary hyperhidrosis. Journal @‘the American Medical Association, 186, 109. Hurley, H. J. and Shelley, W. B. (1966). Axillary hyperhidrosis. British Journalof Dermatology, 18, 127. Inaba, M. (1978). Radical operation to stop axillary odor and hyperhidrosis. Plastic and Reconstructive Surgery, 62, 355. Inaba, M., Takagi, M., Matsuyama, H. and Fujinami, Y. (1974). Radical treatment of osmidrosis axillae. Japanese Journal oj Plastic and Reconstructioe Surgery, 17, 300. Jemec, B. and Hansen, B. H. (1978). Follow-up of patients operated on for axillary hyperhidrosis by subcutaneous
curettage. Scandinavian Journal qf Plastic and Reconstructive Surgery, 12.65. Kate, H., Nakajima, T., Yosbimura, Y., Oonishi, K., Nakanisbi, Y., Yoneda, T., Kawagucbi, M. and Nisbiyama, T. (1988). Aesthetic surgical treatment of osmidrosis. Jaoanese .Journal of Surgererv,1155, 1988. Rigg, B. M. (1977). Axillary hyperhidrosis. Plastic and Reconstructive Surgery, 59. 334. Skuug, T. and Thyressun, N. (1962). Hyperhidrosis of the axillae : a method of surgical treatment. Acta Chirurgica Scandinocica, 124.531. Takato, T., Nakatsuka, T. and Motizuki, M. (1987). Surgical treatment of osmidrosis. Rinsho Derma (Tokyo), 143, 1987. Weaver, P. C. (1970). Axillary hyperhidrosis. British Medical Journal, 1.48.
The Authors Rie Yoshikata, MD, Senior Assistant Akira Yanai, MD, Assistant Professor Takako Takei, MD, Senior Resident Hizuru Shionome, MD, Senior Resident Department
of Plastic
and Reconstructive
Surgery,
University School of Medicine, 2-l-l Hongo. Bunkyo-ku.
Juntendo Tokyo,
Japan. Requests
for reprints
to Dr Yoshikata
Paper received 13 September 1989. Accepted 5 March 1990 after revision.
at the above address