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Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis
British Journal of Plastic Surgery (2000), 53, 212-214 9 2000 The British Association of Plastic Surgeons DOI: 10.1054/bjps. 1999.3266
BRITISH
JOURNAL
OF
[~J
PLASTIC
SURGERY
Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis S. Chung, W. M. Yoo, Y. G. Park, K. S. Shin and B. Y. Park
Department of Plastic and Reconstructive Surgery, Yonsei University Medical Center, Seoul, Korea SUMMARY. Ultrasonic surgical aspiration of axillary apocrine glands with endoscopic confirmation was used for treating osmidrosis in 87 patients. Ultrasound energy liquefies fat and sweat glands via cavitation, but minimally affects blood vessels and nerves at the same energy level. We hypothesised that since the apocrine glands were located within the subcutaneous fat layer, ultrasound liposuction would be effective in its removal and also preserve vasculature of the axillary skin for optimal wound healing. The endoscope was used to visually confirm adequate removal of fat and sweat glands. Our method was effective in 84 patients (96.5%) and recurrence of odour occurred in three patients (3.5%). There were no cases of haematoma, seroma, or skin necrosis. Our method leaves a small inconspicuous scar, maintains normal axillary hair pattern and avoids contracture of the axillary skin after a short and comfortable recovery period. 9 2000 The British Association of Plastic Surgeons
Keywords:osmidrosis, axillary apocrine glands, ultrasonic aspiration, endoscopy. Osmidrosis (bromhidrosis) or 'underarm odour' is a common condition usually managed by regular showering and use of commercially available antiperspirants or deodorants. The cause of osmidrosis has been the topic of several papers, but it is generally agreed that the odour originates from bacterial decomposition of sweat secreted from apocrine glands located in the subcutaneous fat layer. 1 3 When compared to individuals not suffering from osmidrosis, increase in the ratio of apocrine to eccrine glands has also been reported. 4 Treatment methods such as excision and repair of the axillary hair bearing area, 5-1~undermining of skin with removal of sweat gland and subcutaneous fat (currettage, subcutaneous shaving or subcutaneous defatting) 11-13 and most recently liposuction14 have been reported. However, complications related to impaired blood supply of the skin flaps such as skin necrosis, haematoma and seroma formation were not uncommon, and most importantly, effectiveness was inconsistent and visible scarring of the axillae was inevitable. Ultrasound surgical aspiration of fat for body contouring has been popular in Europe for many years. Ultrasound energy creates cavities within fluid. In adipocytes, the cavitation is followed by blasting and liquefaction of fat within the fat cells. As such, ultrasound energy is more effective within fat tissue since it is less dense as compared to more cohesive tissues such as blood vessels, nerves and muscle. Therefore, it offers the advantages of nearly effortless removal of fat, with less bleeding due to minimal destruction of more solid tissue such as blood vesselsY We hypothesised that since the apocrine glands were located within the subcutaneous fat layer, ultrasound surgical aspiration would be effective in its removal while minimally affecting blood vessels and thus preserve circulation of the axillary skin. The endoscope was used to visually confirm the removal of fat and sweat glands.
We report our relatively simple method using ultrasonic surgical aspiration with endoscopic confirmation for removal of axillary apocrine sweat glands and subcutaneous fat for treating individuals with osmidrosis.
Material and methods During the period from September 1997 to August 1998 a total of 87 consecutive patients were treated for osmidrosis using ultrasonic surgical aspiration with endoscopic confirmation. Six of the patients had been operated previously at a different hospital (two patients: excision and repair; four patients: subdermal shaving). The patients ranged from 14 to 56 years of age (mean: 28) and the female to male ratio was 63 to 24. All of the cases were done under local anaesthesia as outpatients. All patients were prepped with both arms abducted on a hand table. An incision 1.5 cm in length was marked along a central natural axillary fold which can be found by adducting the arm a few times. Local infiltration was with 5 ml of 2% Lidocaine mixed with adrenaline in 1:100 000 ratio. Additional infiltration was performed with 15ml of 0.5% Lidocaine for tumescence on each side. While waiting for the effect of local anaesthesia and tumescence, the ultrasonic aspirator was set up using a 5 mm diameter 4-hole cannula and the ultrasonic power set at 75% (Medicamat Bus Endotron Liprectron, Micromelac, France). The rate of saline irrigation was set at maximum (about 65 ml/min). A 4 mm diameter endoscope with a 30 degree viewing angle (Wells Endoscopic Company, USA) was connected to an endoscopic digital camera and colour monitor. About 20 minutes after local infiltration, an incision 1.5 cm in length was made along the previously marked 212
Treatment of osmidrosis natural central axillary fold. Undermining in the subcutaneous fat plane was performed using a metzenbaum with the scissor blades perpendicular to the skin to preserve the neurovascular bundles to the skin from the deep axilla. Undermining was carried out under the entire axillary hair bearing area. The endoscope was used to see via a colour monitor the subcutaneous fat on the undersurface of the axillary skin and the neurovascular bundles. (Fig. 1A). Ultrasonic aspiration was started by inserting the cannula through the incision. With the holes of the cannula directed towards the dermis and the skin and subcutaneous tissue pinched between the thumb and index finger, the cannula was stroked slowly back and forth. The ultrasound energy emitted from the titanium tip resulted in cavitation and subsequent fragmentation of the fat cells and sweat glands, and the suction allowed for removal of the liquefied fat and sweat glands. As the fat was sucked out, thinning of the skin could easily be felt between the fingers. Adequate removal of fat and apocrine glands can first be generally determined by the formation of skin dimpling over the cannula openings due to the suction pressure. At this stage skin hooks were used to lift the skin flap and counter traction was done to form an optical cavity for the endoscope. Effective removal of apocrine glands was demonstrated by the appearance of hair follicles and dermis (Fig. 1B). Any areas still showing fat and thus the possibility of residual apocrine glands were noted and additional ultrasonic aspiration performed. On average, the suction procedure took about 30 minutes per side. The wound was irrigated with saline and the incisions were closed in a single layer with three vertical mattress sutures using 5/0 nylon. No drains were used. Moderate compression was achieved with gauze and elastic adhesive tape, and the patient was advised to avoid fully raising the arm and heavy lifting for about 7 days. On the 4th postoperative day, all dressings were removed and showering at home was encouraged. All sutures were removed on the 9th postoperative day.
213 Results Follow-up ranged from 6 to 18 months (mean: 11 months). Recurrence was defined as any presence of odour noticed by the patient or family more than 3 months post surgery. Of the 87 patients, three had recurrence of odour (recurrence: 3.5%). Two of the patients were 15 and 16 years of age, and the third was a fully grown adult. The remaining 84 patients (96.5%) had no recurrence of odour. There were no cases of haematoma or seroma, skin flap sloughing or necrosis, wound dehiscence or other problems with wound healing. There were no cases of axillary contracture or any noticeable hair loss. There were no problems with overheating of the ultrasonic tip. Transient ecchymosis of the upper arm adjacent to the axilla were noted in the majority of cases, but spontaneously resolved without any management after about 14 days, Histologic specimens taken from the incision margin showed removal of subcutaneous fat and apocrine glands (Fig, 2). Discussion Osmidrosis or bromhidrosis is generally managed satisfactorily by good hygiene and regular use of deodorants and antiperspirants. However, in some individuals with osmidrosis conventional methods are not effective at controlling the foul odour, resulting in heightened self-consciousness and even sometimes social reclusion and exclusion. To treat such severe cases, numerous surgical methods have been described. 513 However, many problems with wound healing were reported: haematoma, seroma, skin necrosis and severe scarring. This was most likely due to severe tension on the wound after excision, impaired circulation to the skin flaps after excessive undermining or thinning of the skin to full thickness skin graft-like state after subcutaneous shaving or subdermal excision. Contracture and irregular axillary hair loss were frequently seen long-term results. The use of bulky and uncomfortable dressings for up to 2 weeks were also routine.
Figure I (A) Endoscopic view. Before ultrasonic liposuction. Subcutaneous [~t on lhe undersurface of" the axillary skin. (B) Endoscopic view. After ultrasonic liposuction. Whitish dermis and black hair roots arc visible after aspiration of the subcutaneous l'at and apocrme glands.
214
British Journal of Plastic Surgery
Figure 2--(A) Histology. Before ultrasonic liposuction. Normal axillary skin architecture showing apocrine and eccrine glands within the subcutaneous fat layer. (7 x magnification). (B) Histology. After ultrasonic liposuction. The apocrine glands with the subcutaneous fat layer have been removed. (7 x magnification).
The use o f an ultrasonic aspirator allowed us to remove the o d o u r causing axillary apocrine glands successfully and avoid the m a n y complications reported with other operative methods. The ultrasonic energy caused cavitation in high fluid content tissues such as fat and sweat glands, resulting in liquefaction and subsequent removal by suction. But at the same energy level, solid adjacent structures such as blood vessels and nerves were minimally affected. Thus, we believe preservation o f circulation to the axilla skin m a y have been crucial in none o f our cases having any w o u n d healing problems in the early postoperative period, and also none developing contracture or noticeable axillary hair loss even after a mean follow-up o f 11 months. Recently, O u et a114 reported using superficial liposuction for axillary bromhidrosis. Their rationale for using liposuction is basically the same as ours: removal o f apocrine glands in the subcutaneous fat layer via a small incision. While conventional liposuction m a y be used, ultrasonic liposuction offers the advantage o f less injury to blood vessels, and use o f the endoscope allows for direct visual confirmation o f adequate sweat gland removal. In o u r study, recurrence was seen in three patients. Two patients were aged 15 and 16 years o f age, and the third was an adult. All three patients were operated on during the first m o n t h o f the study period. We believe insufficient removal o f fat and apocrine glands m a y have been the cause since recurrence o f o d o u r was noted during the immediate postoperative period. However, all three patients noted decrease in the degree o f o d o u r postoperatively and have recently received a second ultrasonic aspiration with g o o d results (not included in present study period). I n the six patients who h a d received various types o f surgery previously but still suffered from persistent symptoms, our m e t h o d was effective in all cases. Again, there were no w o u n d healing problems, thus ultrasound liposuction c a n be safely used in the scarred axillae. We believe that o u r m e t h o d o f using ultrasonic surgical aspiration with endoscopic confirmation for treating osmidrosis has the advantages o f being a relatively simple, safe and effective m e t h o d by which
axillary apocrine glands can be removed while preserving blood circulation to the axillary skin. References 1. Strauss JS, Kligman AM. The bacteria responsible for apocrine odor. J Invest Dermatol 1956; 27: 67-71. 2. Shehadeh N, Kligman AM. The bacteria responsible for axillary odor. II. J Invest Dermatol 1963;41: 3. 3. Leyden J J, McGinley K J, H61zle E, Labows JN, Kligman AM. The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol 1981; 77: 413-16. 4. Bang YH, Kim JH, Paik SW, Park SH, Jackson IT, Lebeda R. Histopathology of apocrine bromhidrosis. Plast Reconstr Surg 1996; 98: 288-92. 5. Hurley H J, ShelleyWB. A simple surgical approach to the management of axillary hyperhidrosis. JAMA 1963; 186: 109-12. 6. Tipton JB. Axillary hyperhidrosis and its surgical treatment. Plast Reconstr Surg 1968; 42: 137-40. 7. Davis PKB. Surgical treatment of axillary hyperhidrosis. Br J Plast Surg 1971; 24: 99-100. 8. Bretteville-Jensen G. Radical sweat gland ablation for axillary hyperhidrosis. Br J Plast Surg 1973; 26: 158-62. 9. Eldh J, Fogdestam I. Surgical treatment of hyperhidrosis axillae. Scand J Plast Reconstr Surg 1976; 10: 227-9. 10. Skoog T, Thyresson N. Hyperhidrosis of the axillae: a method of surgical treatment. Acta Chir Scand 1962; 124:531-8. 11. Jemec B, Hansen BH. Follow-up of patients operated on for axillary hyperhidrosis by subcutaneous currettage. Scand J Plast Reconstr Surg 1978; 12:65 7. 12. Inaba M, Anthony J, Ezaki T. Radical operation to stop axillary odor and hyperhidrosis. Plast Reconstr Surg 1978;62: 355-60. 13. Yoshikata R, Yanai A, Takei T, Shionome H. Surgical treatment of axillary osmidrosis. Br J Plast Surg 1990; 43:483 5. 14. Ou LF, Yan RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg 1998; 102: 1479-85. 15. Zocchi ML. Ultrasonic assisted lipoplasty: technical refinements and clinical evaluations. Clin Plast Surg 1996; 23: 575-98. The Authors Seum Chung MD, PhD, Assistant Professor, Won-Min Yoo MD, Instructor, Yun-Gyu Park MD, Senior Resident, Keuk-Shun Shin MD, FACS, Professor, Beyoung-Yun Park MD, Professor and Chairman,
Department of Plastic and Reconstructive Surgery, Yonsei University Medical Center, CPO Box 8044, Seoul, Korea. Correspondence to Dr Seum Chung. Paper received 9 April 1999. Accepted 11 October 1999, after revision.
BRITISH
JOURNAL
OF
[~J
PLASTIC
SURGERY
Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis S. Chung, W. M. Yoo, Y. G. Park, K. S. Shin and B. Y. Park
Department of Plastic and Reconstructive Surgery, Yonsei University Medical Center, Seoul, Korea SUMMARY. Ultrasonic surgical aspiration of axillary apocrine glands with endoscopic confirmation was used for treating osmidrosis in 87 patients. Ultrasound energy liquefies fat and sweat glands via cavitation, but minimally affects blood vessels and nerves at the same energy level. We hypothesised that since the apocrine glands were located within the subcutaneous fat layer, ultrasound liposuction would be effective in its removal and also preserve vasculature of the axillary skin for optimal wound healing. The endoscope was used to visually confirm adequate removal of fat and sweat glands. Our method was effective in 84 patients (96.5%) and recurrence of odour occurred in three patients (3.5%). There were no cases of haematoma, seroma, or skin necrosis. Our method leaves a small inconspicuous scar, maintains normal axillary hair pattern and avoids contracture of the axillary skin after a short and comfortable recovery period. 9 2000 The British Association of Plastic Surgeons
Keywords:osmidrosis, axillary apocrine glands, ultrasonic aspiration, endoscopy. Osmidrosis (bromhidrosis) or 'underarm odour' is a common condition usually managed by regular showering and use of commercially available antiperspirants or deodorants. The cause of osmidrosis has been the topic of several papers, but it is generally agreed that the odour originates from bacterial decomposition of sweat secreted from apocrine glands located in the subcutaneous fat layer. 1 3 When compared to individuals not suffering from osmidrosis, increase in the ratio of apocrine to eccrine glands has also been reported. 4 Treatment methods such as excision and repair of the axillary hair bearing area, 5-1~undermining of skin with removal of sweat gland and subcutaneous fat (currettage, subcutaneous shaving or subcutaneous defatting) 11-13 and most recently liposuction14 have been reported. However, complications related to impaired blood supply of the skin flaps such as skin necrosis, haematoma and seroma formation were not uncommon, and most importantly, effectiveness was inconsistent and visible scarring of the axillae was inevitable. Ultrasound surgical aspiration of fat for body contouring has been popular in Europe for many years. Ultrasound energy creates cavities within fluid. In adipocytes, the cavitation is followed by blasting and liquefaction of fat within the fat cells. As such, ultrasound energy is more effective within fat tissue since it is less dense as compared to more cohesive tissues such as blood vessels, nerves and muscle. Therefore, it offers the advantages of nearly effortless removal of fat, with less bleeding due to minimal destruction of more solid tissue such as blood vesselsY We hypothesised that since the apocrine glands were located within the subcutaneous fat layer, ultrasound surgical aspiration would be effective in its removal while minimally affecting blood vessels and thus preserve circulation of the axillary skin. The endoscope was used to visually confirm the removal of fat and sweat glands.
We report our relatively simple method using ultrasonic surgical aspiration with endoscopic confirmation for removal of axillary apocrine sweat glands and subcutaneous fat for treating individuals with osmidrosis.
Material and methods During the period from September 1997 to August 1998 a total of 87 consecutive patients were treated for osmidrosis using ultrasonic surgical aspiration with endoscopic confirmation. Six of the patients had been operated previously at a different hospital (two patients: excision and repair; four patients: subdermal shaving). The patients ranged from 14 to 56 years of age (mean: 28) and the female to male ratio was 63 to 24. All of the cases were done under local anaesthesia as outpatients. All patients were prepped with both arms abducted on a hand table. An incision 1.5 cm in length was marked along a central natural axillary fold which can be found by adducting the arm a few times. Local infiltration was with 5 ml of 2% Lidocaine mixed with adrenaline in 1:100 000 ratio. Additional infiltration was performed with 15ml of 0.5% Lidocaine for tumescence on each side. While waiting for the effect of local anaesthesia and tumescence, the ultrasonic aspirator was set up using a 5 mm diameter 4-hole cannula and the ultrasonic power set at 75% (Medicamat Bus Endotron Liprectron, Micromelac, France). The rate of saline irrigation was set at maximum (about 65 ml/min). A 4 mm diameter endoscope with a 30 degree viewing angle (Wells Endoscopic Company, USA) was connected to an endoscopic digital camera and colour monitor. About 20 minutes after local infiltration, an incision 1.5 cm in length was made along the previously marked 212
Treatment of osmidrosis natural central axillary fold. Undermining in the subcutaneous fat plane was performed using a metzenbaum with the scissor blades perpendicular to the skin to preserve the neurovascular bundles to the skin from the deep axilla. Undermining was carried out under the entire axillary hair bearing area. The endoscope was used to see via a colour monitor the subcutaneous fat on the undersurface of the axillary skin and the neurovascular bundles. (Fig. 1A). Ultrasonic aspiration was started by inserting the cannula through the incision. With the holes of the cannula directed towards the dermis and the skin and subcutaneous tissue pinched between the thumb and index finger, the cannula was stroked slowly back and forth. The ultrasound energy emitted from the titanium tip resulted in cavitation and subsequent fragmentation of the fat cells and sweat glands, and the suction allowed for removal of the liquefied fat and sweat glands. As the fat was sucked out, thinning of the skin could easily be felt between the fingers. Adequate removal of fat and apocrine glands can first be generally determined by the formation of skin dimpling over the cannula openings due to the suction pressure. At this stage skin hooks were used to lift the skin flap and counter traction was done to form an optical cavity for the endoscope. Effective removal of apocrine glands was demonstrated by the appearance of hair follicles and dermis (Fig. 1B). Any areas still showing fat and thus the possibility of residual apocrine glands were noted and additional ultrasonic aspiration performed. On average, the suction procedure took about 30 minutes per side. The wound was irrigated with saline and the incisions were closed in a single layer with three vertical mattress sutures using 5/0 nylon. No drains were used. Moderate compression was achieved with gauze and elastic adhesive tape, and the patient was advised to avoid fully raising the arm and heavy lifting for about 7 days. On the 4th postoperative day, all dressings were removed and showering at home was encouraged. All sutures were removed on the 9th postoperative day.
213 Results Follow-up ranged from 6 to 18 months (mean: 11 months). Recurrence was defined as any presence of odour noticed by the patient or family more than 3 months post surgery. Of the 87 patients, three had recurrence of odour (recurrence: 3.5%). Two of the patients were 15 and 16 years of age, and the third was a fully grown adult. The remaining 84 patients (96.5%) had no recurrence of odour. There were no cases of haematoma or seroma, skin flap sloughing or necrosis, wound dehiscence or other problems with wound healing. There were no cases of axillary contracture or any noticeable hair loss. There were no problems with overheating of the ultrasonic tip. Transient ecchymosis of the upper arm adjacent to the axilla were noted in the majority of cases, but spontaneously resolved without any management after about 14 days, Histologic specimens taken from the incision margin showed removal of subcutaneous fat and apocrine glands (Fig, 2). Discussion Osmidrosis or bromhidrosis is generally managed satisfactorily by good hygiene and regular use of deodorants and antiperspirants. However, in some individuals with osmidrosis conventional methods are not effective at controlling the foul odour, resulting in heightened self-consciousness and even sometimes social reclusion and exclusion. To treat such severe cases, numerous surgical methods have been described. 513 However, many problems with wound healing were reported: haematoma, seroma, skin necrosis and severe scarring. This was most likely due to severe tension on the wound after excision, impaired circulation to the skin flaps after excessive undermining or thinning of the skin to full thickness skin graft-like state after subcutaneous shaving or subdermal excision. Contracture and irregular axillary hair loss were frequently seen long-term results. The use of bulky and uncomfortable dressings for up to 2 weeks were also routine.
Figure I (A) Endoscopic view. Before ultrasonic liposuction. Subcutaneous [~t on lhe undersurface of" the axillary skin. (B) Endoscopic view. After ultrasonic liposuction. Whitish dermis and black hair roots arc visible after aspiration of the subcutaneous l'at and apocrme glands.
214
British Journal of Plastic Surgery
Figure 2--(A) Histology. Before ultrasonic liposuction. Normal axillary skin architecture showing apocrine and eccrine glands within the subcutaneous fat layer. (7 x magnification). (B) Histology. After ultrasonic liposuction. The apocrine glands with the subcutaneous fat layer have been removed. (7 x magnification).
The use o f an ultrasonic aspirator allowed us to remove the o d o u r causing axillary apocrine glands successfully and avoid the m a n y complications reported with other operative methods. The ultrasonic energy caused cavitation in high fluid content tissues such as fat and sweat glands, resulting in liquefaction and subsequent removal by suction. But at the same energy level, solid adjacent structures such as blood vessels and nerves were minimally affected. Thus, we believe preservation o f circulation to the axilla skin m a y have been crucial in none o f our cases having any w o u n d healing problems in the early postoperative period, and also none developing contracture or noticeable axillary hair loss even after a mean follow-up o f 11 months. Recently, O u et a114 reported using superficial liposuction for axillary bromhidrosis. Their rationale for using liposuction is basically the same as ours: removal o f apocrine glands in the subcutaneous fat layer via a small incision. While conventional liposuction m a y be used, ultrasonic liposuction offers the advantage o f less injury to blood vessels, and use o f the endoscope allows for direct visual confirmation o f adequate sweat gland removal. In o u r study, recurrence was seen in three patients. Two patients were aged 15 and 16 years o f age, and the third was an adult. All three patients were operated on during the first m o n t h o f the study period. We believe insufficient removal o f fat and apocrine glands m a y have been the cause since recurrence o f o d o u r was noted during the immediate postoperative period. However, all three patients noted decrease in the degree o f o d o u r postoperatively and have recently received a second ultrasonic aspiration with g o o d results (not included in present study period). I n the six patients who h a d received various types o f surgery previously but still suffered from persistent symptoms, our m e t h o d was effective in all cases. Again, there were no w o u n d healing problems, thus ultrasound liposuction c a n be safely used in the scarred axillae. We believe that o u r m e t h o d o f using ultrasonic surgical aspiration with endoscopic confirmation for treating osmidrosis has the advantages o f being a relatively simple, safe and effective m e t h o d by which
axillary apocrine glands can be removed while preserving blood circulation to the axillary skin. References 1. Strauss JS, Kligman AM. The bacteria responsible for apocrine odor. J Invest Dermatol 1956; 27: 67-71. 2. Shehadeh N, Kligman AM. The bacteria responsible for axillary odor. II. J Invest Dermatol 1963;41: 3. 3. Leyden J J, McGinley K J, H61zle E, Labows JN, Kligman AM. The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol 1981; 77: 413-16. 4. Bang YH, Kim JH, Paik SW, Park SH, Jackson IT, Lebeda R. Histopathology of apocrine bromhidrosis. Plast Reconstr Surg 1996; 98: 288-92. 5. Hurley H J, ShelleyWB. A simple surgical approach to the management of axillary hyperhidrosis. JAMA 1963; 186: 109-12. 6. Tipton JB. Axillary hyperhidrosis and its surgical treatment. Plast Reconstr Surg 1968; 42: 137-40. 7. Davis PKB. Surgical treatment of axillary hyperhidrosis. Br J Plast Surg 1971; 24: 99-100. 8. Bretteville-Jensen G. Radical sweat gland ablation for axillary hyperhidrosis. Br J Plast Surg 1973; 26: 158-62. 9. Eldh J, Fogdestam I. Surgical treatment of hyperhidrosis axillae. Scand J Plast Reconstr Surg 1976; 10: 227-9. 10. Skoog T, Thyresson N. Hyperhidrosis of the axillae: a method of surgical treatment. Acta Chir Scand 1962; 124:531-8. 11. Jemec B, Hansen BH. Follow-up of patients operated on for axillary hyperhidrosis by subcutaneous currettage. Scand J Plast Reconstr Surg 1978; 12:65 7. 12. Inaba M, Anthony J, Ezaki T. Radical operation to stop axillary odor and hyperhidrosis. Plast Reconstr Surg 1978;62: 355-60. 13. Yoshikata R, Yanai A, Takei T, Shionome H. Surgical treatment of axillary osmidrosis. Br J Plast Surg 1990; 43:483 5. 14. Ou LF, Yan RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg 1998; 102: 1479-85. 15. Zocchi ML. Ultrasonic assisted lipoplasty: technical refinements and clinical evaluations. Clin Plast Surg 1996; 23: 575-98. The Authors Seum Chung MD, PhD, Assistant Professor, Won-Min Yoo MD, Instructor, Yun-Gyu Park MD, Senior Resident, Keuk-Shun Shin MD, FACS, Professor, Beyoung-Yun Park MD, Professor and Chairman,
Department of Plastic and Reconstructive Surgery, Yonsei University Medical Center, CPO Box 8044, Seoul, Korea. Correspondence to Dr Seum Chung. Paper received 9 April 1999. Accepted 11 October 1999, after revision.