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Treatment of axillary osmidrosis with the use of Versajet
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, e125ee128
Treatment of axillary osmidrosis with the use of Versajet Sang Wha Kim, Ik Kyun Choi, Jung Ho Lee, Jong Won Rhie, Sang Tae Ahn, Deuk Young Oh* Department of Plastic Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea Received 8 August 2012; accepted 27 January 2013
KEYWORDS Osmidrosis; Apocrine glands; Excision
Summary Axillary osmidrosis is a distressing problem. Since the secretion from apocrine glands is believed to be responsible for malodour, many treatment modalities have been developed to remove the glands. Local surgery with the excision of the apocrine glands has been proved to be most effective. We introduce the treatment of axillary osmidrosis, using Versajet (Versajet hydrosurgery system, Smith & Nephew, Memphis, TN, USA). From October 2010 to February 2012, 31 patients (21 females and 10 males) whose age ranged from 12 to 63 years were treated. All patients were followed up for 13.1 months on average. Thirty patients were very satisfied and recommended this procedure and one patient was satisfied with the result. We experienced one haematoma and one wound dehiscence. Excision of glands, using Versajet, makes the operation a simple and efficient procedure. Moreover, precise and even debridement reduces complications by preserving the skin flap and subdermal plexus. ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Axillary osmidrosis is a distressing problem that includes unpleasant odour and staining of clothing. Although it is not a life-threatening problem, many people are embarrassed by the odour.
* Corresponding author. Department of Plastic Surgery, The Catholic University of Korea, College of Medicine, Seoul St. Mary’s Hospital, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Republic of Korea. Tel.: þ82 2 2258 2842; fax: þ82 2 594 7230. E-mail address: [email protected] (D.Y. Oh).
Secretion from apocrine glands is believed to be responsible. Many treatment modalities for axillary osmidrosis have been developed, since the first surgical treatment was reported in 1962.1 Despite long recovery periods and occasional wound complications, local surgery with the excision of the apocrine glands has been proved to be the most effective modality.2e6 For excision of the glands, we used Versajet (Versajet hydrosurgery system, Smith & Nephew, Memphis, TN, USA), which delivers a high-pressure jet of saline for precise debridement of the tissue, while irrigating and aspirating the wound.
1748-6815/$ - see front matter ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. http://dx.doi.org/10.1016/j.bjps.2013.01.029
e126
S.W. Kim et al.
Figure 1 a. Two transverse skin incisions are made parallel to the axillary crease. b. The skin flap is elevated to reveal the underlying apocrine glands. c. View after total excision of apocrine glands using Versajet. d. Postoperative 3 months view.
Patients and methods From October 2010 to February 2012, 31 patients with axillary osmidrosis were treated with the excision of the glands via the use of Versajet. The patients ranged from 12
Table 1 Effectiveness of the surgical treatment of axillary osmidrosis.
to 63 years of age (mean, 27.4 years) and the female to male ratio was 21 to 10. Six months after the operation, we conducted a survey for subjective assessment of the results. The patients were asked if they were satisfied or unsatisfied with the operation and were asked to describe the results of malodour elimination, reduced hair growth and sweating elimination in three levels.
Surgical refinements
Subjective assessment Very satisfactory and recommend operation Satisfactory Unsatisfactory
30/31 1/31 0/31
Malodour elimination Good Fair Poor
30/31 1/31 0/31
Table 2
Reduced hair growth Much (>75%) Moderate (50e70%) Little (<50%)
31/31 0/31 0/31
Sweating elimination Significant Improved No change
The axilla was exposed with the patient in a supine position and the arms abducted to 90 . The areas to be treated were marked, extended to 1 cm beyond the location of the axillary hair, as it is believed that the apocrine glands are located within this area. Under local anaesthesia, two transverse skin incisions, about 3 cm in length, were made parallel to the axillary crease. Through this incision,
30/31 1/31 0/31
Complications.
Complications
No. of patients
Haematoma Seroma Wound dehiscence Skin necrosis Scar contracture
1/31 0/31 1/31 0/31 0/31
Total
2/31
Treatment of axillary osmidrosis a subcutaneous pocket was made at the marked area, using the dissecting scissors. The elevated skin flap was turned over with fingertips to expose subcutaneous apocrine glands, fat and hair follicles. A Versajet was used for the removal of the subcutaneous fat and apocrine glands leaving the subdermal plexus. After complete haemostasis, 100-cc suction drains were inserted. The wound was closed using 5/0 Vicryl sutures for the subcutaneous layer and Histoacryl (Tissueseal, Ann Arbor, MI, USA) was applied over the skin. The wound was then covered with gauze and slight compressive dressing. Drains were maintained for 24 h. The patients are recommended to restrict the arm movement for a week (Figure 1 and Video 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2013.01.029.
Results All patients were followed up for a minimum of 6 months with a mean of 13.1 months. Table 1 includes the subjective responses obtained at 6 months postoperatively. Hair Table 3
Various surgical methods for axillary osmidrosis.
Authors
Surgical method
e127 growth was reduced in all patients. Although hyperhidrosis was not a symptom in these patients, all patients reported a decrease in sweating and 30 patients experienced a significant reduction. Postoperative complications are listed in Table 2. There were no cases of hypertrophic scar.
Discussion Apocrine glands are located in the axilla, areolar of breast, inguinal area, external auditory canal and the eyelids (glands of Moll). They become active during puberty, as hormonal activities increase. Apocrine gland secretion is slightly cloudy, but does not smell until decomposed by the bacteria. The secretion and the activity of bacteria create the characteristic malodour of axillary osmidrosis. Histologically, the apocrine glands in the axilla extend from the lower dermis, deep into the subcutaneous fat. The greatest distribution is densely attached to the reticular dermis and is confined to the centre of the axilla with less distribution at the peripheral area of the axillary hair.3,7 Knowledge of the distribution of apocrine glands in the axillary region is
No. of patients
Complications (%)
Rhomboid skin excision
102
Tung and Wei,2 1997
Two transverse incisions
46
Park et al.,14 1997 Ou et al.,15 1998
One transverse incision & CO2 laser Superficial liposuction
20 20
Park et al.,16 1998
One transverse incision, manual excision Two transverse incision, shaving removal Two transverse incision, shaving plus manual
48
CO2 laser and subcutaneous tissue remover Ultrasonic aspiration with endoscopic confirmation
88
Wu et al.,
13
1994
Kim et al., 199911 Chung et al.,17 2000
42 38
Results (%) Good
Fair
Poor
11.1 (of patients) 6.7 (of wounds) 6.5 (of patients) 4.4 (of wounds) 15 (of patients) 2.5 (of wounds)
44.1
47.1
8.8
89.1
9.8
1.1
80 90
20 5
0 5
8.6 (of patients) 7.3 (of wounds) 23.8 (of patients) 15.6 (of wounds) 13.2 (of patients) 9.2 (of wounds)
44.8
47.9
7.3
30.3
63.1
6.0
50.9
44.7
5.3
4.6% (of patients)
90.9
7.9
1.2
87
96.5
10 10
10 80
70 20
20 0
91.4 11.4 92.1
6.3 69.3 7.9
2.3 19.3 0
72
19
Tsai and Lin,9 2001
Simple liposuction Liposuction and curettage
Tung,18 2001 Perng et al.,4 2004 Lee et al.,19 2005
Endoscopic shaver with liposuction Superficial liposuction Two 1 cm incisions, cartilage shaver
64 114 89
Yoo et al.,10 2006
Endoscopy-assisted ultrasonic surgical aspiration One transverse incision, subdermal excision Subcutaneous laser treatment Suction-assisted cartilage shaver
896
3.9 (of wounds) 3.73 (of patients) 1.1 (of patients) 0.6 (of wounds) 3.1 (of patients)
31
38.7 (of wounds)
96.8
3.2
12 156
33.3 92.3
66.7 5.1
One transverse incision, subdermal excision
206
16.7 (of patients) 7.7 (of patients) 5.1 (of wounds) 50.5 (of wounds)
Qian and Wang,5 2006 Ichikawa et al.,12 2006 Wu,7 2009 Qian and Wang,6 2010
97
3.4
9 0 0 2.6 0
e128 important because an incomplete removal and/or remnant apocrine glands results in recurrence of axillary osmidrosis. Many surgical techniques have been described since 1962.1 They can be categorised into three types, according to the extent of the surgery.8 Type I is only removal of subcutaneous tissue, without skin. Type 2 is en bloc excision of the skin and subcutaneous tissue and type 3 is the partial removal of the skin and subcutaneous tissue, which involves the surrounding area. Type 1 surgery seems to be the most reasonable procedure for axillary osmidrosis, being both safe and effective. Various surgical complications have been reported, such as haematoma, seroma, skin necrosis, scarring and long recovery period.2e4 Therefore, several minimally invasive methods have been introduced. Suction-assisted lipectomy, mechanical liposuction,9 ultrasonic liposuction,10 carbon dioxide vaporisation,11 subcutaneous laser treatment12 and suction-assisted cartilage shaver7 have been described to lessen the complications of radical surgery. Minimally invasive methods produced lower complications. However, they yielded high recurrence, as the apocrine glands remained (Table 3). Histology proved that the apocrine glands at the central portion of the axillar, which are densely attached to the reticular dermis, were not removed effectively by the minimally invasive methods.3,4 Thus, radical surgical treatment with local excision of the apocrine glands is the best curative method. We used Versajet to excise apocrine glands and subcutaneous fat. Versajet is a hydrosurgery system using a razor-thin saline jet for debridement of the tissue. Hydrosurgical excision enables precise excision and evacuation of tissue. Subdermal excision, using scissors, is timeconsuming and difficult, demanding great caution, since the depth of debridement is uneven due to the curvature of the scissor. It requires several movements to achieve an even in the surface. By using Versajet, smooth and even debridement could be achieved by simple movement of handpiece. Direct visualisation of the removed apocrine glands confirms the efficacy of the procedure. As the vascularity of the flap is ensured, the procedure is safe and reliable. Without damage to vascularity, complete haemostasis could be easily achieved and complications, such as skin necrosis or haematoma, are reduced.
Financial disclosure The authors have no disclosures and are without any relevant commercial associations.
Conflict of interest/funding None.
S.W. Kim et al.
Acknowledgement None.
References 1. Skoog T, Thyresson N. Hyperhidrosis of the axillae. A method of surgical treatment. Acta Chir Scand 1962;124:531e8. 2. Tung TC, Wei FC. Excision of subcutaneous tissue for the treatment of axillary osmidrosis. Br J Plast Surg 1997;50:61e6. 3. Park YJ, Shin MS. What is the best method for treating osmidrosis? Ann Plast Surg 2001;47:303e9. 4. Perng CK, Yeh FL, Ma H, et al. Is the treatment of axillary osmidrosis with liposuction better than open surgery? Plast Reconstr Surg 2004;114:93e7. 5. Qian JG, Wang XJ. Radical treatment of axillary osmidrosis by subdermal excision of apocrine glands: a prospective study in 31 cases. J Plast Reconstr Aesthet Surg 2006;59:860e4. 6. Qian JG, Wang XJ. Effectiveness and complications of subdermal excision of apocrine glands in 206 cases with axillary osmidrosis. J Plast Reconstr Aesthet Surg 2010;63:1003e7. 7. Wu WH. Ablation of apocrine glands with the use of a suctionassisted cartilage shaver for treatment of axillary osmidrosis. Ann Plast Surg 2009;62:278e83. 8. Bisbal J, del Cacho C, Casalots J. Surgical treatment of axillary hyperhidrosis. Ann Plast Surg 1987;18:429e36. 9. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg 2001;27:446e8. 10. Yoo WM, Pae NS, Lee SJ, et al. Endoscopy-assisted ultrasonic surgical aspiration of osmidrosis: a retrospective review of 896 consecutive patients from 1998 to 2004. J Plast Reconstr Aesthet Surg 2006;59:978e82. 11. Kim IH, Seo SL, Oh CH. Minimally invasive surgery for axillary osmidrosis: combined operation with CO2 laser and subcutaneous tissue remover. Dermatol Surg 1999;25:875e9. 12. Ichikawa K, Miyasaka M, Aikawa Y. Subcutaneous laser treatment of axillary osmidrosis: a new technique. Plast Reconstr Surg 2006;118:170e4. 13. Wu WH, Ma S, Lin JT, et al. Surgical treatment of axillary osmidrosis: an analysis of 343 cases. Plast Reconstr Surg 1994; 94:288e94. 14. Park JH, Cha SH, Park SD. Carbon dioxide laser treatment vs subcutaneous resection of axillary osmidrosis. Dermatol Surg 1997;23:247e51. 15. Ou LF, Yan RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg 1998;102:1479e85. 16. Part DH, Kim TM, Hand DG, Ahn KY. A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures. Ann Plast Surg 1998;41:488e97. 17. Chung S, Yoo WM, Park YG, Shin KS, Park BY. Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis. Br J Plast Surg 2000;53:212e4. 18. Tung TC. Endoscopic shaver with liposuction for treatment of axillary osmidrosis. Ann Plast Surg 2001;46:400e4. 19. Lee JC, Kuo HW, Chen CH, et al. Treatment of axillary osmidrosis with suction-assisted cartilage shaver. Br J Plast Surg 2005;58:223e7.
Treatment of axillary osmidrosis with the use of Versajet Sang Wha Kim, Ik Kyun Choi, Jung Ho Lee, Jong Won Rhie, Sang Tae Ahn, Deuk Young Oh* Department of Plastic Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea Received 8 August 2012; accepted 27 January 2013
KEYWORDS Osmidrosis; Apocrine glands; Excision
Summary Axillary osmidrosis is a distressing problem. Since the secretion from apocrine glands is believed to be responsible for malodour, many treatment modalities have been developed to remove the glands. Local surgery with the excision of the apocrine glands has been proved to be most effective. We introduce the treatment of axillary osmidrosis, using Versajet (Versajet hydrosurgery system, Smith & Nephew, Memphis, TN, USA). From October 2010 to February 2012, 31 patients (21 females and 10 males) whose age ranged from 12 to 63 years were treated. All patients were followed up for 13.1 months on average. Thirty patients were very satisfied and recommended this procedure and one patient was satisfied with the result. We experienced one haematoma and one wound dehiscence. Excision of glands, using Versajet, makes the operation a simple and efficient procedure. Moreover, precise and even debridement reduces complications by preserving the skin flap and subdermal plexus. ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Axillary osmidrosis is a distressing problem that includes unpleasant odour and staining of clothing. Although it is not a life-threatening problem, many people are embarrassed by the odour.
* Corresponding author. Department of Plastic Surgery, The Catholic University of Korea, College of Medicine, Seoul St. Mary’s Hospital, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Republic of Korea. Tel.: þ82 2 2258 2842; fax: þ82 2 594 7230. E-mail address: [email protected] (D.Y. Oh).
Secretion from apocrine glands is believed to be responsible. Many treatment modalities for axillary osmidrosis have been developed, since the first surgical treatment was reported in 1962.1 Despite long recovery periods and occasional wound complications, local surgery with the excision of the apocrine glands has been proved to be the most effective modality.2e6 For excision of the glands, we used Versajet (Versajet hydrosurgery system, Smith & Nephew, Memphis, TN, USA), which delivers a high-pressure jet of saline for precise debridement of the tissue, while irrigating and aspirating the wound.
1748-6815/$ - see front matter ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. http://dx.doi.org/10.1016/j.bjps.2013.01.029
e126
S.W. Kim et al.
Figure 1 a. Two transverse skin incisions are made parallel to the axillary crease. b. The skin flap is elevated to reveal the underlying apocrine glands. c. View after total excision of apocrine glands using Versajet. d. Postoperative 3 months view.
Patients and methods From October 2010 to February 2012, 31 patients with axillary osmidrosis were treated with the excision of the glands via the use of Versajet. The patients ranged from 12
Table 1 Effectiveness of the surgical treatment of axillary osmidrosis.
to 63 years of age (mean, 27.4 years) and the female to male ratio was 21 to 10. Six months after the operation, we conducted a survey for subjective assessment of the results. The patients were asked if they were satisfied or unsatisfied with the operation and were asked to describe the results of malodour elimination, reduced hair growth and sweating elimination in three levels.
Surgical refinements
Subjective assessment Very satisfactory and recommend operation Satisfactory Unsatisfactory
30/31 1/31 0/31
Malodour elimination Good Fair Poor
30/31 1/31 0/31
Table 2
Reduced hair growth Much (>75%) Moderate (50e70%) Little (<50%)
31/31 0/31 0/31
Sweating elimination Significant Improved No change
The axilla was exposed with the patient in a supine position and the arms abducted to 90 . The areas to be treated were marked, extended to 1 cm beyond the location of the axillary hair, as it is believed that the apocrine glands are located within this area. Under local anaesthesia, two transverse skin incisions, about 3 cm in length, were made parallel to the axillary crease. Through this incision,
30/31 1/31 0/31
Complications.
Complications
No. of patients
Haematoma Seroma Wound dehiscence Skin necrosis Scar contracture
1/31 0/31 1/31 0/31 0/31
Total
2/31
Treatment of axillary osmidrosis a subcutaneous pocket was made at the marked area, using the dissecting scissors. The elevated skin flap was turned over with fingertips to expose subcutaneous apocrine glands, fat and hair follicles. A Versajet was used for the removal of the subcutaneous fat and apocrine glands leaving the subdermal plexus. After complete haemostasis, 100-cc suction drains were inserted. The wound was closed using 5/0 Vicryl sutures for the subcutaneous layer and Histoacryl (Tissueseal, Ann Arbor, MI, USA) was applied over the skin. The wound was then covered with gauze and slight compressive dressing. Drains were maintained for 24 h. The patients are recommended to restrict the arm movement for a week (Figure 1 and Video 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2013.01.029.
Results All patients were followed up for a minimum of 6 months with a mean of 13.1 months. Table 1 includes the subjective responses obtained at 6 months postoperatively. Hair Table 3
Various surgical methods for axillary osmidrosis.
Authors
Surgical method
e127 growth was reduced in all patients. Although hyperhidrosis was not a symptom in these patients, all patients reported a decrease in sweating and 30 patients experienced a significant reduction. Postoperative complications are listed in Table 2. There were no cases of hypertrophic scar.
Discussion Apocrine glands are located in the axilla, areolar of breast, inguinal area, external auditory canal and the eyelids (glands of Moll). They become active during puberty, as hormonal activities increase. Apocrine gland secretion is slightly cloudy, but does not smell until decomposed by the bacteria. The secretion and the activity of bacteria create the characteristic malodour of axillary osmidrosis. Histologically, the apocrine glands in the axilla extend from the lower dermis, deep into the subcutaneous fat. The greatest distribution is densely attached to the reticular dermis and is confined to the centre of the axilla with less distribution at the peripheral area of the axillary hair.3,7 Knowledge of the distribution of apocrine glands in the axillary region is
No. of patients
Complications (%)
Rhomboid skin excision
102
Tung and Wei,2 1997
Two transverse incisions
46
Park et al.,14 1997 Ou et al.,15 1998
One transverse incision & CO2 laser Superficial liposuction
20 20
Park et al.,16 1998
One transverse incision, manual excision Two transverse incision, shaving removal Two transverse incision, shaving plus manual
48
CO2 laser and subcutaneous tissue remover Ultrasonic aspiration with endoscopic confirmation
88
Wu et al.,
13
1994
Kim et al., 199911 Chung et al.,17 2000
42 38
Results (%) Good
Fair
Poor
11.1 (of patients) 6.7 (of wounds) 6.5 (of patients) 4.4 (of wounds) 15 (of patients) 2.5 (of wounds)
44.1
47.1
8.8
89.1
9.8
1.1
80 90
20 5
0 5
8.6 (of patients) 7.3 (of wounds) 23.8 (of patients) 15.6 (of wounds) 13.2 (of patients) 9.2 (of wounds)
44.8
47.9
7.3
30.3
63.1
6.0
50.9
44.7
5.3
4.6% (of patients)
90.9
7.9
1.2
87
96.5
10 10
10 80
70 20
20 0
91.4 11.4 92.1
6.3 69.3 7.9
2.3 19.3 0
72
19
Tsai and Lin,9 2001
Simple liposuction Liposuction and curettage
Tung,18 2001 Perng et al.,4 2004 Lee et al.,19 2005
Endoscopic shaver with liposuction Superficial liposuction Two 1 cm incisions, cartilage shaver
64 114 89
Yoo et al.,10 2006
Endoscopy-assisted ultrasonic surgical aspiration One transverse incision, subdermal excision Subcutaneous laser treatment Suction-assisted cartilage shaver
896
3.9 (of wounds) 3.73 (of patients) 1.1 (of patients) 0.6 (of wounds) 3.1 (of patients)
31
38.7 (of wounds)
96.8
3.2
12 156
33.3 92.3
66.7 5.1
One transverse incision, subdermal excision
206
16.7 (of patients) 7.7 (of patients) 5.1 (of wounds) 50.5 (of wounds)
Qian and Wang,5 2006 Ichikawa et al.,12 2006 Wu,7 2009 Qian and Wang,6 2010
97
3.4
9 0 0 2.6 0
e128 important because an incomplete removal and/or remnant apocrine glands results in recurrence of axillary osmidrosis. Many surgical techniques have been described since 1962.1 They can be categorised into three types, according to the extent of the surgery.8 Type I is only removal of subcutaneous tissue, without skin. Type 2 is en bloc excision of the skin and subcutaneous tissue and type 3 is the partial removal of the skin and subcutaneous tissue, which involves the surrounding area. Type 1 surgery seems to be the most reasonable procedure for axillary osmidrosis, being both safe and effective. Various surgical complications have been reported, such as haematoma, seroma, skin necrosis, scarring and long recovery period.2e4 Therefore, several minimally invasive methods have been introduced. Suction-assisted lipectomy, mechanical liposuction,9 ultrasonic liposuction,10 carbon dioxide vaporisation,11 subcutaneous laser treatment12 and suction-assisted cartilage shaver7 have been described to lessen the complications of radical surgery. Minimally invasive methods produced lower complications. However, they yielded high recurrence, as the apocrine glands remained (Table 3). Histology proved that the apocrine glands at the central portion of the axillar, which are densely attached to the reticular dermis, were not removed effectively by the minimally invasive methods.3,4 Thus, radical surgical treatment with local excision of the apocrine glands is the best curative method. We used Versajet to excise apocrine glands and subcutaneous fat. Versajet is a hydrosurgery system using a razor-thin saline jet for debridement of the tissue. Hydrosurgical excision enables precise excision and evacuation of tissue. Subdermal excision, using scissors, is timeconsuming and difficult, demanding great caution, since the depth of debridement is uneven due to the curvature of the scissor. It requires several movements to achieve an even in the surface. By using Versajet, smooth and even debridement could be achieved by simple movement of handpiece. Direct visualisation of the removed apocrine glands confirms the efficacy of the procedure. As the vascularity of the flap is ensured, the procedure is safe and reliable. Without damage to vascularity, complete haemostasis could be easily achieved and complications, such as skin necrosis or haematoma, are reduced.
Financial disclosure The authors have no disclosures and are without any relevant commercial associations.
Conflict of interest/funding None.
S.W. Kim et al.
Acknowledgement None.
References 1. Skoog T, Thyresson N. Hyperhidrosis of the axillae. A method of surgical treatment. Acta Chir Scand 1962;124:531e8. 2. Tung TC, Wei FC. Excision of subcutaneous tissue for the treatment of axillary osmidrosis. Br J Plast Surg 1997;50:61e6. 3. Park YJ, Shin MS. What is the best method for treating osmidrosis? Ann Plast Surg 2001;47:303e9. 4. Perng CK, Yeh FL, Ma H, et al. Is the treatment of axillary osmidrosis with liposuction better than open surgery? Plast Reconstr Surg 2004;114:93e7. 5. Qian JG, Wang XJ. Radical treatment of axillary osmidrosis by subdermal excision of apocrine glands: a prospective study in 31 cases. J Plast Reconstr Aesthet Surg 2006;59:860e4. 6. Qian JG, Wang XJ. Effectiveness and complications of subdermal excision of apocrine glands in 206 cases with axillary osmidrosis. J Plast Reconstr Aesthet Surg 2010;63:1003e7. 7. Wu WH. Ablation of apocrine glands with the use of a suctionassisted cartilage shaver for treatment of axillary osmidrosis. Ann Plast Surg 2009;62:278e83. 8. Bisbal J, del Cacho C, Casalots J. Surgical treatment of axillary hyperhidrosis. Ann Plast Surg 1987;18:429e36. 9. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg 2001;27:446e8. 10. Yoo WM, Pae NS, Lee SJ, et al. Endoscopy-assisted ultrasonic surgical aspiration of osmidrosis: a retrospective review of 896 consecutive patients from 1998 to 2004. J Plast Reconstr Aesthet Surg 2006;59:978e82. 11. Kim IH, Seo SL, Oh CH. Minimally invasive surgery for axillary osmidrosis: combined operation with CO2 laser and subcutaneous tissue remover. Dermatol Surg 1999;25:875e9. 12. Ichikawa K, Miyasaka M, Aikawa Y. Subcutaneous laser treatment of axillary osmidrosis: a new technique. Plast Reconstr Surg 2006;118:170e4. 13. Wu WH, Ma S, Lin JT, et al. Surgical treatment of axillary osmidrosis: an analysis of 343 cases. Plast Reconstr Surg 1994; 94:288e94. 14. Park JH, Cha SH, Park SD. Carbon dioxide laser treatment vs subcutaneous resection of axillary osmidrosis. Dermatol Surg 1997;23:247e51. 15. Ou LF, Yan RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg 1998;102:1479e85. 16. Part DH, Kim TM, Hand DG, Ahn KY. A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures. Ann Plast Surg 1998;41:488e97. 17. Chung S, Yoo WM, Park YG, Shin KS, Park BY. Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis. Br J Plast Surg 2000;53:212e4. 18. Tung TC. Endoscopic shaver with liposuction for treatment of axillary osmidrosis. Ann Plast Surg 2001;46:400e4. 19. Lee JC, Kuo HW, Chen CH, et al. Treatment of axillary osmidrosis with suction-assisted cartilage shaver. Br J Plast Surg 2005;58:223e7.