Although it is not a serious disease, axillary bromidrosis can be significantly disturbing when it gives off the malodor, which causes psychological distress and social embarrassment. The main cause of offensive odor is the interaction of the apocrine sweat glands with microorganisms (11). Apocrine sweat secretion is no foul-smelling when it just reaches the surface. However, after a few hours, it gives off the malodor as fatty acids liberate by local bacterial flora, including lipophilic and large colony diphtheroids (11). Thus, it has been believed that destruction or remove of the apocrine sweat glands by surgical modalities could eradicate this problem.
The treatment of en bloc excision of the local skin and subcutaneous tissue has already been abnegated, because it always accompanied the obvious scar formation and partial functional disorder (12). Then, based on the knowledge that most glands are localized in the subcutaneous tissue, selective local surgical excision of the apocrine sweat glands without skin excision has been performed. However, previous methods such as carbon dioxide laser treatment (13), subcutaneous shaving (14), upper thoracic sympathectomy (15) have various complications including wound infection, hematoma or seroma, skin flap necrosis, noticeable scar and incomplete removal of sweat glands. Thus, some modified methods combining some special instruments such as special shaving or razor instruments, ultrasonic liposuction have been used (10). Nowadays, local injection of botulinum toxin A or ethanol for treating axillary bromhidrosis also has been introduced, which might be new therapeutic approachs for patients (16, 17). But the long-term effect still needs to be further investigated.
A recent review with a meta-analysis (18) which includes forty studies published before February 2016 demonstrated that surgical modality was the most effective treatment for axillary bromhidrosis. Among the surgical modalities, liposuction was identified as the most effective method, with the lowest number of associated complications. Besides, combining the curettage treatment was an ideal option for lowering recurrence rate in surgery and liposuction treatments, which supports our option of surgical methods. We applied tumescent liposuction-curettage modality, and in order to ensure the remove of sweat glands, we used pruning through small incisions.
Here we listed previous reports which also chose liposuction and curettage for the treatment of axillary bromhidrosis (Table 3). In 1998, Ou et al. (19) first reported 20 patients involved in this procedure with the mean follow-up time of 14 months. Among them, 90% of patients got good results, but with 20% complications and one minor wound infection. After that, other doctors also reported their results with this treatment. We can see in the table that most doctors chose only liposuction and curettage. Most of the patients did get good results, but the complication rate was still high. In 2011, Li et al. (20) described that the application of liposuction with subcutaneous pruning could not only get good results, but also with low complications. But the study only involved 28 patients. Our surgical process added pruning after liposuction and curettage, which could ensure the complete removal of sweat glands as well as the low complication rate.
Gross observation showed that the distribution range of large sweat glands was basically the same as that of axillary hairs. The range over axillary hairs 0.5 cm was rare. Thus, we chose an average of 0.5 cm outlines beyond the bilateral axillary hair lines to mark the surgical area. Then the local tumescent anesthesia not only reduces intraoperative hemorrhage, but also causes the previously sunken axillary region to swell, ensuring the insertion of suction needle without damaging the deep tissue. Histological examinations of preoperative tissues showed numerous and large apocrine glands while after the operation, the specimen showed significant decrease in subcutaneous tissue. That’s because we finally used the eye scissors to prune the subcutaneous skin, apart from liposuction and curettage.