A Comparison of 3 Minimally Invasive Surgeries for Treating Axillary Osmidrosis

Abstract

Background

Axillary osmidrosis is a common cause of physical and social discomfort. Although many treatments are available, there is still room for improvement.

Objective

For treatments of axillary osmidrosis 3 minimally invasive surgical methods of nasal endoscope-assisted suction cutting device, liposuction combined with subcutaneous curettage, and small incision trimming method are compared for the clinical efficacy, advantages and disadvantages.

Methods

Two hundred fifty-one axillary osmidrosis patients treated respectively with nasal endoscope-assisted suction cutting device, Liposuction with curettage, or small incision trimming method are investigated and the surgical outcomes and complications are analyzed.

Results

The effective rate is higher in the endoscopic group compared to the trimming and liposuction with curettage group (P < 0.025). The postoperative Vancouver Scar Scale and total complication rate in the trimming group are significantly higher than those in the endoscopic and liposuction groups (P < 0.025). The Hyperhidrosis Disease Severity Scale and overall satisfaction rate was superior in the endoscopic group compared to both liposuction with curettage and trimming groups.

Conclusions

Liposuction with curettage has fewer complications and is safer, but with a lower cure rate. The small incision trimming method provides a more thorough treatment but with a higher complication rate. Relatively, nasal endoscope-assisted suction cutting device ensures thorough removal with fewer complications, making it a more recommended method.

Axillary osmidrosis is a common condition, with significant differences in incidence among different ethnic groups.¹ It predominantly affects adolescents, especially young females, causing substantial social and psychological impacts on patients. Currently, treatment options mainly include nonsurgical therapies (such as injection therapy, radiofrequency, and microwave therapy) and surgical interventions. Surgical treatment, which can completely remove or destroy sweat glands, offers relatively precise efficacy. With continuous improvements in surgical techniques, the most widely used approach today is the small incision trimming method for axillary sweat gland excision. In recent years, with the advancement of minimally invasive surgery, endoscopic surgery has become increasingly prevalent. Yoo et al² utilized endoscopic-assisted ultrasonic liposuction for treating axillary odor, which offers advantages of small incisions, rapid postoperative recovery, and minimal scarring. However, due to the unclear demarcation between the deep-seated apocrine glands and the dermis, thorough removal is challenging, leading to a higher recurrence rate. Subsequently, many scholars have explored the use of suction cutting devices under blind vision to remove apocrine glands,³ or adopted various combined procedures to improve the cure rate through tiny incisions. In recent years, our institution has adopted endoscopic-assisted suction cutting device for axillary sweat gland excision,⁴ achieving good treatment outcomes. A comparative analysis of the characteristics of the 3 minimally invasive surgical techniques, including negative pressure superficial liposuction combined with subcutaneous curettage and small incision trimming surgery, has been conducted.

MATERIALS AND METHODS

Patients

General Information: From May 2015 to March 2023, our department treated 251 patients, aged 17–44 years, with an average age of 22.79 ± 5.49 years. Among them, there were 88 male patients and 163 female patients, with 21 cases having a family history. Ninety-six patients underwent nasal endoscope-assisted suction cutting device surgery, 74 patients underwent liposuction combined with curettage, and 81 patients underwent small incision trimming surgery. All surgeries were performed by the same surgeon. According to the criteria outlined by Young-Jin Park et al,⁵ the severity of axillary osmidrosis was graded. Among them, 166 cases were classified as grade II, and 85 cases were classified as grade III (Table 1).

TABLE 1.

Case Data

Data	Endoscopic Group	Liposuction With Curettage Group	Trimming Group	Total	P
Cases	96	74	81	251
Age (year)	23.51 ± 5.81	22.38 ± 4.85	22.31 ± 5.61		0.261
Female	59	48	56	163
Male	37	26	25	88
Park 2	57	51	58	166	0.194
Park 3	39	23	23	85
Axillary hair area (cm2)	32.50 ± 6.83	32.12 ± 6.99	31.45 ± 6.75		0.598

Surgical Procedure

All patients showered the day before surgery and shaved their armpits. The armpit hair area was measured using a grid table, and the surgical excision range was marked according to the positive area of the starch test. Local tumescent anesthesia was administered, with 80 mL of normal saline solution mixed with 20 mL of 2% lidocaine and 0.25 mg of adrenaline for tumescent anesthesia, approximately 60 mL per side.

Endoscopic group: Nasal endoscope-assisted suction cutting device was used to excise the apocrine glands in the armpits. The endoscope used was a 70° nasal endoscope (Olympus, Japan), and the suction cutting device was an inwardly curved cutting suction device (Stryker). An incision of about 1.5 cm was made in the central posterior part of the armpit hair area, and tissue separation was performed along the superficial fascia, creating a subcutaneous cavity. The skin flap was suspended at 3 points along the long axis of the skin flap with sutures, and an assistant pulled the sutures to form a tent-like operating space. The enlarged pink apocrine glands were visualized under the endoscopic view (Fig. 1). Using the suction cutting device under endoscopic guidance, the apocrine glands and partial subdermal fat were completely excised until the porcelain-white dermal layer was exposed (Fig. 2). The surgical endpoint was the absence of apocrine glands in the subcutaneous tissue. After confirming no residual apocrine glands and active bleeding, the wound was irrigated, a drainage tube was placed, the incision was sutured with 4-0 sutures, and a drainage tube was inserted. Gauze was evenly packed into the armpit, and elastic adhesive bandages were applied to compress both armpits⁴ (Figs. 1, 2).

FIGURE 1.

Before operation.

FIGURE 2.

After operation.

Liposuction combined with curettage group: An incision of about 0.5 cm was made along the wrinkles at the outer edge of the armpit hair area. A 600-kPa negative pressure was applied using a liposuction needle for subcutaneous gland scraping and suction. The suction hole of the liposuction needle faced the dermis, and a sawing motion was used for suction scraping. The subcutaneous superficial fat tissue and apocrine sweat glands were aspirated and scraped to a skin thickness of 2–3 mm, equivalent to the entire thickness of the skin. Then, any remaining glands were scraped with a curette, the wound was irrigated with normal saline, and the wound was sutured. Drainage and compression bandaging were applied similar to the endoscopic group.

Small incision trimming group: Patients underwent small incision subcutaneous trimming of apocrine glands.⁶ Incision of about 1.5–3.0 cm was made along the skin wrinkles in the center of the armpit hair area (the incision should be long enough for the surgeon to evert the skin flap and trim the range of surgical field). The superficial fat tissue was bluntly dissected and separated from the skin of the armpit. The apocrine glands, sweat ducts, and fat were trimmed with tissue scissors, avoiding skin breakage and protecting the subdermal vascular network as much as possible. After trimming, the remaining apocrine glands were further scraped, the cavity was irrigated, bleeding points were electrocoagulated, and the incision was sutured. Drainage and compression bandaging was applied similar to the endoscopic group.

Postoperative management: After surgery, compression bandaging with gauze and 3M adhesive tape was continued. All patients had their drainage tubes removed 48 hours postoperatively, and observation was made for any active bleeding or hematoma formation. Compression bandaging of the surgical area was maintained and shoulder joint movement was restricted for 1 week, and stitches were removed 7–9 days postoperatively. Rehabilitation exercises began after complete healing.

Postoperation Evaluation

Duration of operation, healing time, and efficacy, scar formation, and satisfaction at 12 months postoperatively were compared among the 3 groups. Healing time was defined as the duration from the initiation of surgery until complete wound healing was achieved. The Tung grading method⁷ was used to evaluate the cure rate, with the cure standard being that neither the patient nor individuals very close to them (within 20 cm of the patient's armpit) can detect any odor. Evaluation criteria: (1) cure: neither the patient nor others can smell any odor; (2) significant improvement: odor significantly reduced, slight odor may be detected after physical activity or sweating; (3) ineffective: no significant change before and after treatment. satisfaction was assessed using a questionnaire, with 0 points indicating dissatisfaction, 1 point for average satisfaction, 2 points for satisfaction, and 3 points for very satisfaction. The severity of axillary sweating postoperation was assessed by a self-report Hyperhidrosis Disease Severity Scale (HDSS). Scarring was assessed independently by plastic surgeons outside the surgical team using the VSS scale.

All data were analyzed using SPSS 22.0 software. One-way analysis of variance was employed to compare quantitative data among the 3 groups. For comparisons of quantitative data between groups, the t test was utilized. Nonparametric data were analyzed using the chi-square test and Mann-Whitney U test. A P value less than 0.025 was considered statistically significant.

RESULTS

Duration of surgery: There was no difference between the endoscopic surgery group and the trimming group, but both were better than the liposuction with curettage group (P < 0.025). Healing time: There was no statistical difference between the endoscopic group and the liposuction with curettage group, both of which were better than the trimming group (P < 0.025). Effective rate: Endoscopic group > trimming group > liposuction with curettage group, with statistically significant differences among the 3 groups (P < 0.025) (Table 2).

TABLE 2.

Duration of Surgery, Healing Time, and Cure Rate of Each Group

	Duration of Surgery (min)	Healing Time (d)	Therapeutic Outcome			Efficacy
			Cure	Valid	Invalid
Endoscopic group	53.14 ± 5.39	7.30 ± 1.42	91	4	1	98.9%
liposuction with curettage group	61.36 ± 6.73	7.47 ± 1.78	32	33	9	87.8%
Trimming group	54.67 ± 5.27	10.37 ± 2.42	58	19	4	95.1%
P value	0.000	0.000				0.000

Comparing postoperative complications, there was no statistically significant difference in the occurrence rates of hematoma, infection, and skin flap necrosis among the 3 groups (P > 0.025). However, the trimming group had significantly higher score of postoperative Vancouver Scar Scale and overall complication rates compared to the endoscopic and liposuction groups (P < 0.025) (Tables 3, 4). A total of 5 cases experienced transient paresthesia postoperatively (2 in the endoscopic group, 1 in the liposuction with curettage group, and 2 in the trimming group), all of which resolved within 1 week. Pigmentation improved significantly in most cases within 1 year, with only 6 cases exhibiting persistent pigmentation at the 1-year follow-up (2 in the endoscopic group, 1 in the liposuction with curettage group, and 3 in the trimming group). No statistically significant differences were observed among the groups.

TABLE 3.

Postoperative Complications and Postoperative Satisfaction

	Hematoma or Seroma	Infection	Skin Necrosis	Prominent Scar	Total Number of Complications	Complication Rate	Postoperative Satisfaction
							0	1	2	3
Endoscopic group	3	0	0	1	5	5.2%	1	2	8	85
liposuction with curettage group	1	0	0	1	3	4.1%	9	13	31	21
Trimming group	4	1	2	11	17	21.0%	6	11	19	45
P value	0.545	0.618	0.189	0.000	0.000	0.000

(Fisher's exact test).

TABLE 4.

Postoperative Vancouver Scar Scale and HDSS Scale

	Vancouver Scar Scale						HDSS Scale
	0	1	2	3	4	5	1	2	3	4
Endoscopic group	63	27	5	1	0	0	91	3	1	1
liposuction with curettage group	61	13	0	1	0	0	33	26	9	6
Trimming group	41	19	10	6	3	2	55	13	11	2
P value	0.000						0.000

At the 12-month postoperative mark, the overall satisfaction rate was higher in the endoscopic group compared to both the liposuction with curettage and trimming groups (χ² = 61.55, P < 0.01). Additionally, the satisfaction rate in the trimming group was higher than that in the liposuction with curettage group (P < 0.01). Notably, the lower satisfaction rate in the liposuction with curettage group was primarily due to perceived efficacy, while in the trimming group, it was primarily related to postoperative scarring.

HDSS scale: Endoscopic group < trimming group < liposuction with curettage group, with statistically significant differences among the 3 groups (P < 0.025) (Table 4).

DISCUSSION

The apocrine glands, also known as large sweat glands, are primarily distributed in the armpits, areolas, groin area, external auditory canal, and eyelids. After puberty, with the increase in hormone levels in the body, the apocrine glands become more active in secretion. When sweat is broken down by bacteria, it produces an odor, leading to the formation of axillary odor.^8,9 Patients with axillary odor typically have a greater number and larger volume of apocrine glands.² Immunohistochemical localization analysis of the axillary sweat glands reveals that the majority of sweat glands is located in the subcutaneous superficial fat layer, with a small portion in the dermis.¹⁰ Moreover, the distribution of apocrine glands usually extends beyond the coverage of armpit hair, making it challenging to completely remove the apocrine glands through surgery.

Currently, there are various treatment methods for axillary osmidrosis, including nonsurgical and surgical approaches. Among them, surgical treatment has been shown to have a significantly higher cure rate than nonsurgical treatment and is considered the most effective method. However, there are many surgical techniques available, including traditional excision, small incision trimming, suction, water jet, endoscopic ultrasound-assisted suction, thoracoscopic T3-4 sympathetic nerve blockade, cartilage scaping, and subcutaneous excision combined with laser therapy.^{3,6,7,11–15} Park et al⁵ observed and compared four surgical methods, including manual trimming to remove dermal sweat gland tissue and subcutaneous fat tissue, superficial liposuction scraping, CO₂ laser ablation, and ultrasound-assisted liposuction. They found that the recurrence rate was lowest with manual trimming, indicating that complete removal of apocrine glands is more thorough and precise in treating axillary osmidrosis. Nomura M¹⁶ conducted a meta-analysis comparing suction curettage and open surgery, showing that the risk of acute adverse events with suction curettage was significantly lower than with open excision surgery, while the recurrence/ineffectiveness rate of open excision surgery was significantly better than that of suction curettage. However, open surgical methods can lead to skin infections, necrosis, and significant scarring, affecting patients' quality of life. Therefore, improving the cure rate and reducing scarring and other complications are the main goals of surgical improvement. As a single minimally invasive surgical technique often cannot completely eradicate sweat glands, scholars have begun to use a combination of multiple minimally invasive techniques to improve the cure rate while minimizing invasiveness.

According to the results of this study, the liposuction with curettage group has a lower cure rate, and the trimming group has slightly longer healing times and heavier scarring. The endoscopic-assisted suction cutting device surgery group has higher satisfaction rates than the liposuction with curettage and trimming groups. Overall, the endoscopic group achieved a better balance between minimally invasive techniques and cure rates. Most hyperhidrosis symptoms showed significant improvement compared to preoperative levels, and HDSS scores also demonstrated a notable decrease, indicating a concurrent positive effect on hyperhidrosis alleviation.

The reasons for these results are as follows: first, small incision trimming surgery is an improvement on traditional surgery, reducing incision length while ensuring the surgical scope, thereby reducing the trauma and postoperative complications such as skin necrosis and scarring associated with traditional axillary osmidrosis surgery. However, as the incision size decreases, the field of vision deteriorates. To address the larger distribution area of sweat glands, more incisions are needed, increasing the total incision length and the likelihood of infection, necrosis, and scarring. Second, regular small incision trimming surgery sacrifices ease of operation in pursuit of shorter incision lengths, making it more difficult to completely remove the sweat glands and avoid cutting the skin.

Liposuction with curettage causes minimal tissue damage, but due to the unclear boundary between the deep apocrine glands located partly in the dermis, and the surgery being performed entirely under blind vision, both suction and scraping are difficult to completely clear the sweat gland tissue.

The endoscopic system can utilize small incisions, aided by subcutaneous dissection, to provide clear visualization of the surgical field. The endoscope has magnifying capabilities, making the sweat glands more visible and less likely to be missed, thereby ensuring more thorough gland removal. Surgeons can easily control the cutting depth. Additionally, using thread suspension to expose the surgical field allows assistants to adjust the direction and force of pulling, making the skin flap more flexible and stable. This improves operational efficiency while also protecting important subcutaneous blood vessels and nerves from damage.

However, there are some limitations to endoscopic surgery. We have found that inadequate selection of suction or suction cutting device diameter can result in incomplete removal in a single procedure or skin being sucked into the cutting device, causing rupture. It is necessary to adjust the negative pressure intensity based on the local skin condition of different patients. For those with thinner skin, such as females, a relatively lower negative pressure of −100 mmHg to −200 mmHg is recommended. For males and those with thicker skin, a negative pressure of −200 to −300 mmHg is preferred. Furthermore, endoscopic surgery is associated with higher costs and requires certain skill and hardware conditions for the surgeon, but it is still worth promoting in units equipped with endoscopic surgical capabilities.

In addition, advancements in medical devices will bring more convenient surgical operations and better treatment outcomes for axillary osmidrosis. This aspect may represent the greatest breakthrough in surgical progress.