ARTICLE
Axillary hyperhidrosis is a functional, non-inflammatory abnormality
of the eccrine sweat glands [1, 2]. The extreme sweat production, even
at rest, can be very distressing to the patients. Not only are the social
problems obvious, but clothes may be damaged and various occupations become
impossible [3, 4]. The cause of genuine hyperhidrosis is unknown and therefore
no specific corrective therapy is available [1, 2, 5, 6]. Local antiperspirants,
aluminium salts, and astringents act for a very short time and the use
of iontophoresis is limited in the axillary region [7, 8]. Local radiation
is contraindicated and open or endoscopic sympathectomy has untoward complications
such as pneumothorax, Horner's syndrome, and recurrence [7, 9]. Therefore,
local surgical treatment is the method of choice in axillary hyperhidrosis.
Various surgical methods have been described for axillary hyperhidrosis
which can be considered from three major approaches: (1) removing only
subcutaneous tissue without removing skin [10-14]; (2) removing skin and
subcutaneous tissue by wide excision [15-18]; (3) partial excision of
skin and subcutaneous tissue as well as open curettage of the adjacent
area [19-23]. We prefer the technique as first described by Jemec in 1975
which implies the removal of subcutaneous tissue of the axilla by means
of curettage [12].
Patients and methods
At the Department of Dermatology, Municipal Clinics of Kassel, Germany,
during the years 1979-1992, a total of 74 patients suffering from genuine
axillary hyperhidrosis were treated by subcutaneous curettage. Complete
follow-up including subjective and objective examination was achieved
in 52 patients (28 males, 24 females, average age: 33.2) in a median postoperative
interval of 78 months. Postoperative follow-up was not achieved in 22
patients; 17 of these lived too far away, 5 moved without leaving change
of address information.
At re-examination, local control of the scars and arm motility was performed.
All patients underwent a second Minor's sweat test to confirm the reduction
of hyperhidrosis. Questionnaires were handed out to the patients for subjective
assessment of complaints before the operation, six months postoperatively,
and at the time of the last follow-up. The patients were asked to check
the amount of axillary sweating according to a score ranging from 1 (minimal
axillary secretion) to 5 (high axillary secretion). Sweating at rest and
under physical stress were assessed. In addition, the patients were asked
if they were satisfied with the quality of the scar and the overall result
of the operation.
Surgical technique
Prior to the operation, Minor's sweat test was performed in order to
mark the zone of maximum sweating in the axillary region. This was done
using iodine solution and starch powder. The indicated area was outlined
with a water resistant skin marker. The surgical procedures were carried
out under general anesthesia in all patients.
During the operation the patient is placed in a supine position with
the arms abducted 90 degrees. A 2 to 3 cm incision is made caudal to the
posterior pole of the marked zone (Fig.
1A). Next, a Metzenbaum scissors is used to undermine the entire
marked area of hyperhidrosis. Then, the undermined area is curetted using
a sharp curette, as used in gynecology (Fig.
1B). Both the superficial and deep surfaces are scraped to remove
the sweat glands and inevitably other tissue (Fig.
1C). A size 12-14 CH suction drain is inserted and the wound closed
with subcutaneous and skin sutures. The postoperative dressings should
apply soft pressure to minimize hematoma formation. The suction drain
is removed after the secretion has decreased to less than 10 ml per day,
which is usually on the fourth to fifth day. The sutures are removed on
about the tenth day.
Results
The overall complication rate was 6.8%. Three patients had postoperative
bleeding that was managed by replacement of a suction drain in two patients
and axillary revision in one patient. One patient experienced prolonged
wound healing and another one had marked seroma formation, however, both
resolved spontaneously ad integrum.
Objective re-examination by means of the sweat test (Fig.
2) revealed a very good reduction of hyperhidrosis in 24 patients
(46.2%), a good reduction in 17 patients (32.7%), and a moderate reduction
of sweating in 10 patients (19.2%). Three patients with partial recurrence
were re-operated on by subcutaneous curettage with a good final result.
One patient had a complete recurrence of axillary hyperhidrosis, and a
subsequent operation by means of partial excision and adjacent curettage
was carried out. Scar formation was good in all patients and no keloids
were seen. Reduction of axillary hair growth was noted in 16 patients
(marked: 2, moderate: 5, minimal 9). None of the patients experienced
dysaesthesia or impairment of arm motility.
Subjective assessment revealed great or very great satisfaction in 37
patients (Table I). Fourty-five
patients would recommend the operation to other patients suffering from
hyperhidrosis. Fourty-two patients were satisfied with the appearance
of the scar. Assessment according to the score elicited good results of
axillary sweating at rest and at physical stress after 6 months and at
the time of the last follow-up (Figs.
3 and 4).
No significant differences were seen between female and male patients.
In addition, the reduction of sweating was not related to reduced axillary
hair growth after the operation (Fig.
5).
Discussion
Axillary hyperhidrosis is a relatively common problem that afflicts
about 0.6-1.0% of all young adults without predilection of race or gender
[1, 2, 7]. Excessive sweating is often present at rest and may be further
provoked by emotional and thermal stimuli or physical stress. Bromhidrosis
is less likely owing to the large amount of axillary perspiration that
flushes away apocrine secretion and bacterial colonisation [24]. However,
social stigmatisation and secondary emotional and psychological problems
are common.
Before seeking surgical relief, the patients have usually been treated
with all known antiperspirant agents. Surgical intervention may be the
only curative method for this disease and several operative approaches
are known. Because sympathectomy carries the risk of severe complications
and side effects such as compensatory hyperhidrosis [9], local surgical
approaches are currently preferred [25]. The axillary sweat glands in
the axillae consist of apocrine and eccrine glands and their distribution
shows a strong connection to the hair-bearing area [1, 19]. The aim of
surgical intervention is to reduce the number of both eccrine and apocrine
glands, which leads to both subjective and objective improvement. Through
these procedures, the sympathetic nerves supplying the eccrine glands
are also totally destroyed, but after about 3 to 6 months they begin to
regenerate and the residual glands begin to function again while normal
sweating usually returns [25]. This fact stresses the need for a long
term follow-up when evaluating a particular method.
There are several recommended, local operations
for hyperhidrosis in the literature, based mainly on three principles
viz. subcutaneous resections such as liposuction [24] or curettage
[11, 12], open curettage with partial excision [21, 23] or wide excision
with plastic repair [16, 17]. Of these we used subcutaneous curettage
as our method of choice because of its low complication rate. Furthermore,
our results show that good long term results can be achieved with a reduction
of axillary sweating at rest and at physical stress as shown by the patients'
subjective assessment scores. 82.7% of all patients were satisfied with
the result of the operation and only one patient had a complete recurrence
of hyperhidrosis.
The advantage of subcutaneous curettage is that it can be repeated,
if necessary, or even followed by other methods such as partial excision
may be used [25]. The technique leads to only minimal scar formation in
the axillary region, and contractures that may lead to impairment of shoulder-arm
mobility are only rarely seen [11, 12]. A similar approach is axillary
liposuction; however, this method will require greater personal and technical
expertise so it should be performed mainly in cases of recurrences [24].
Finally, although subcutaneous curettage can be performed on an out-patient
basis [11, 12] we prefer hospitalisation in all cases as it provides a
closer postoperative control for local wound care and possible complications
such as hematomas or seromas that can be managed immediately. In summary,
subcutaneous curettage represents an elegant and efficient treatment for
axillary hyperhidrosis with a good cosmetic outcome.
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