INNOVATIVE TECHNIQUES AESTHETIC

A Minimally Invasive Procedure for Axillary Osmidrosis:Subcutaneous Curettage Combined with Trimming Througha Small Incision

Rongrong Wang • Jie Yang • Jiaming Sun

Received: 10 May 2014 / Accepted: 7 November 2014

� Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract

Background Though minimally invasive procedures

often yield excellent esthetic results for axillary osmidrosis,

the high recurrence rates of malodor limit its further

application. Incomplete removal of the apocrine glands

would lead to recurrence of the axillary bromhidrosis,

while excessive resection of the apocrine glands firmly

attached to the dermis would easily result in local skin

necrosis. Therefore, accurate management of the apocrine

glands is extraordinarily important, particularly with a

limited access. Herein, we would like to introduce an

effective and minimally invasive procedure combining

subcutaneous curettage and trimming for the treatment of

axillary osmidrosis.

Methods A 5-mm incision was marked at the inferior

pole of the central axillary crease. Subcutaneous under-

mining was done clinging to the axillary superficial fascia.

The whole procedure was performed in the following

sequence of ‘‘scraping–trimming–scraping’’ against the

undermined skin flap until the remaining hairs were easily

pulled out.

Results All the wounds healed primarily without signifi-

cant complications. Out of 300 axillae, 294 (98 %) showed

good to excellent results for malodor elimination. Scars

were invisible in 280 axillae (93.3 %) and slightly visible

in 18 axillae (6 %). The dermatology life quality index

score decreased significantly after the operation.

Conclusion The procedure is an efficacious and mini-

mally invasive method for the treatment of axillary

osmidrosis.

Level of Evidence IV This journal requires that authors

assign a level of evidence to each article. For a full

description of these Evidence-Based Medicine ratings,

please refer to the Table of Contents or the online

Instructions to Authors www.springer.com/00266.

Keywords Axillary osmidrosis � Minimally invasive

procedures � Subcutaneous trimming � Curettage

Introduction

It has long been a severe psychological burden for patients

who possess axillary malodor, especially for Asian people.

It is generally accepted that osmidrosis is due to the

interaction between bacterial activity and hyper-secretion

of apocrine gland [1].

Current treatments for osmidrosis include antibacterial

products, deodorants, botulinum toxin injections, subcuta-

neous laser, percutaneous ethanol injections, and various

surgical methods [2–7]. However, to achieve permanent

resolution of axillary bromhidrosis, surgical eradication of

the apocrine sweat glands is necessary.

A histological study by Byron and associates showed

that the apocrine sweat glands of the axilla extended from

the lower dermis deeply into the subcutaneous fat [7]. As

the reticular dermis is composed of dense irregular con-

nective tissue, technically, removal of the apocrine glands

firmly attached to the lower dermis is relatively more dif-

ficult compared with those located subcutaneously.

Incomplete removal of the apocrine glands would lead

to recurrence of the axillary bromhidrosis, while excessive

R. Wang � J. Yang � J. Sun (&)

Department of Plastic Surgery, Wuhan Union Hospital, Tongji

Medical College of Huazhong University of Science and

Technology, Wuhan 430022, Hubei, People’s Republic of China

e-mail: sunjm1592@126.com

123

Aesth Plast Surg

DOI 10.1007/s00266-014-0431-2

resection of the apocrine glands firmly attached to the

dermis would easily result in local skin necrosis [8, 9].

Therefore, accurate management of the apocrine glands is

extraordinarily important throughout the whole process,

particularly with a limited access.

Herein, we would like to present a minimal incision

procedure combining subcutaneous curettage and trimming

of the axillary skin flap for the treatment of axillary

osmidrosis.

Patients and Methods

Patients’ Demography

One hundred fifty-eight patients with primary bilateral

bromhidrosis were treated using this technique between

January 2009 and December 2013 at our department. There

are 52 males and 106 females. The mean ± SD age was

21.5 ± 5.8 (age range: 18–42 years). The mean body-

mass-index (BMI) was 20.6. One hundred twenty-three

patients (77.8 %) had a family history of the disease.

Inclusion criteria: (1) patients should meet the diagnostic

criteria of axillary osmidrosis, and (2) no swollen axillary

lymph nodes or local skin inflammation; normal coagulant

activity. Patients with any previous treatment for axillary

bromhidrosis were excluded.

The severity of malodor was determined by the sub-

jective judgment of two independent surgeons. With the

patient sitting quietly for 30 min at room temperature, the

bilateral axillae were exposed. The severity of malodor was

defined as follows. Mild: slight malodor can be detected at

a close distance of 10 cm and no malodor at a distance of

30 cm; moderate: slight malodor at a distance of 30 cm;

severe: strong malodor at or beyond a distance of 30 cm.

All operations were performed on an outpatient basis.

The follow-up period ranged from 6 to 18 months, with an

average of 11.2 months (Table 1).

Surgical Technique

With the patient in a supine position, the axillae were

exposed with the upper arms abducted slightly above the

shoulder level. Bilateral axillary hair was shaved. Short

(2–4 mm) axillary hairs were left as indicators. The area

was marked 0.5–1 cm beyond the hair-bearing area for

dissection. A 5-mm incision was marked at the inferior

pole of the central axillary crease as the access (Fig. 1). For

patients who have longer axis of the hair-bearing area, an

additional incision could be marked in parallel with the

original incision. The operating field was routinely pre-

pared with Povidone-iodine, and then the draping was

done. Local anesthesia was given using 0.5 % lidocaine

with 1:200,000 epinephrine. The incision was made

through the axillary skin down to the subcutaneous fat

tissue using a No. 11 blade along the marked incision.

Subcutaneous undermining was performed clinging to the

superficial fascia with a pair of ophthalmic scissors

(Fig. 2). A 4 9 7 mm fenestrated cup curette was used to

Table 1 Demographics of patients

Variables Value

Number of patients 158

Age range, (mean ± SD) 18–42, (21.5 ± 5.8)

Female 106

Male 56

BMI, (mean ± SD) 17.3–27.4, (20.6 ± 3.8)

Family history 123

Combined hyperhidrosis 56

Follow-up time, (mean ± SD) 6–18, (11.2 ± 4.1)

Fig. 1 A 5-mm incision was marked at the inferior pole of the central

axillary crease as the access. As for patients who have longer axis of

the hair-bearing area, an additional incision could be marked in

parallel with the original incision

Fig. 2 Subcutaneous undermining was performed clinging to the

superficial fascia with a pair of ophthalmic scissors

Aesth Plast Surg

123

scrape back and forth against the undermined flap to

remove the apocrine sweat glands. Apparent tissue resis-

tance can be felt at the tip of the curette. Slow but

numerous stroke movements were continued until no more

tissue block was drained out through the incision site. The

mixture contained the destroyed sweat glands, adipose

tissue, and other skin appendages (Figs. 3, 4). Then the

residual tissue attaching to the dermis was resected blindly

using a pair of ophthalmic scissors. With the blunt tips

facing down, the flap was elevated by the scissors. The

pulp of the index finger of the non-dominant hand was used

to press the axillary flap against the scissors to assist in

efficient trimming (Fig. 5). Next, the area was scraped

again gently to remove the residual tissue that was not

completely detached. No more resistance could be felt at

the tip of the curette (Figs. 6, 7). The axillary hairs were

easily pulled out at the time. Last, the subdermal pocket

was irrigated repeatedly with normal saline to remove tis-

sues remaining in the subdermal pocket. Pressure was

maintained in the area for 3–5 min to achieve adequate

hemostasis. No drainage was placed. The incision was

closed with 5–0 nylon followed by bulky compressive

Fig. 3 Scrape back and forth against the undermined flap using a

4 9 7 mm fenestrated cup curette to remove the apocrine sweat

glands

Fig. 4 The drained mixture contained the destroyed sweat glands,

adipose tissue, and other skin appendages

Fig. 5 Blind trimming with the ophthalmic scissors. With the blunt

tips facing down, the flap was elevated by the scissors. The pulp of the

index finger was used to press the axillary flap against the scissors to

assist in efficient trimming

Fig. 6 Secondary scraping against the axillary flap to remove the

residual tissue that is not completely detached

Fig. 7 The smooth underlying surface of the axillary skin flap

Aesth Plast Surg

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dressings. The dressings were changed on the second

postoperative day and every 3 days thereafter. Sutures

were removed 7 days postoperatively. Patients were

advised to restrict shoulder movement for approximately

2 weeks postoperatively (Figs. 8, 9). Postoperative oral

antibiotics were not routinely administered.

Evaluation

Patients were asked to estimate the effect of the operation

6 months after surgery. A detailed record of postoperative

complications, malodor elimination, reduced hair growth,

scar formation, and patient satisfaction was obtained for

every patient. The degree of axillary malodor elimination

was evaluated as excellent (no odor occurs after intense

exercise), good (mild odor occurs after intense exercise),

fair (mild odor occurs after daily activity or moderate odor

occurs after intense exercise), and poor (moderate to severe

odor occurs after daily activity). Recurrence was consid-

ered when the outcome was worse than ‘‘fair.’’ The level of

hair growth reduction was divided into four categories:

significantly reduced, moderately reduced, mildly reduced,

and no significant change. The postoperative scar was

assessed as invisible, slightly visible, conspicuous, and

very conspicuous, respectively. The patient satisfaction

level was evaluated in a 5-tier system: very satisfied, sat-

isfied, neutral, dissatisfied, and very dissatisfied.

Dermatology Life Quality Index

The quality of life was assessed using the DLQI, which

includes a 10-item questionnaire to evaluate the effects of

skin problems on daily life activities. Each question has

four different responses: ‘‘not at all,’’ ‘‘a little,’’ ‘‘a lot,’’

and ‘‘very much’’ with corresponding scores of 0, 1, 2, and

3, respectively. Total scores range from 0 to 30, with

higher scores indicating greater impairment. The quality of

life was evaluated preoperatively and 6 months postoper-

atively [9].

Statistics

The collected data for pre- and 6-month postoperative

DQLI scores were analyzed using 2-sided paired non-

parametric tests, with statistical significance at the 95 %

confidence level. The analyses were conducted with SPSS

version 13.0 (SPSS Inc., Chicago, IL, U.S.A).

Results

All the wounds (158 cases with 316 axillae) healed pri-

marily without significant complications like skin necrosis,

wound dehiscence, or inflammation. The follow-up dura-

tion ranged from 6 to 18 months. Of all the 158 cases, 93

patients came back to our clinic for a follow-up visit, 57

received a telephone follow-up, and 8 patients were lost to

follow up 6 months postoperatively. Table 2 includes the

postoperative complications and patient subjective assess-

ments obtained 6 months after the surgery. The most

common postoperative complication was skin ecchymosis

(19 axillae, 6.3 %), which spontaneously faded away

within 2 weeks. Three cases of hematoma (1.3 %) occur-

red, two of which were males. The two cases in males both

occurred on the right side, while the one case in a female

occurred bilaterally. After aspiration and proper pressure

dressing, the wound healed primarily. As for malodor

elimination, 294 axillae (98 %) showed excellent to good

results. The other three cases (2 %) who had poor to fair

results received a re-operation in the same manner, and all

of them showed excellent results afterwards. Hair growth

was reduced significantly in 214 axillae (71.3 %) and

moderately in 81 axillae (27 %). There was no hyperpig-

mentation, hypertrophy, or atrophy of scars. Scars were

invisible in 280 axillae (93.3 %) and slightly visible in 18

Fig. 8 The right axillary fossa 7 days postoperatively

Fig. 9 The right axillary fossa 14 days postoperatively

Aesth Plast Surg

123

axillae (6 %), which was totally acceptable. Overall patient

satisfaction rates were high, and 146 patients (97.3 %)

were very satisfied or satisfied with the final outcome.

The median DQLI score was 9 (range: 4–16) before the

operation and decreased to 0 (range: 0–3) 6 months post-

operatively. The relative reduction of impairment was

78.6 % (range: 66.7–100 %, P \ 0.05). Subscores of

questions 1, 2, 4, 5, 6, and 7 significantly decreased after

the procedure (P \ 0.05). Subscores of the remaining

questions showed no significant decrease (P [ 0.05)

(Table 3).

Discussion

It is generally believed that the secretion of the apocrine

glands and the activity of bacteria create the characteristic

malodor of axillary osmidrosis. The apocrine glands of

osmidrosis patients are both hypertrophic and hyperplastic,

which has been confirmed by the published studies [10,

11]. To achieve permanent resolution of axillary

bromhidrosis, efficient removal and destruction of the

axillary apocrine glands should be guaranteed [8]. Surgical

procedures tend to provide a more definite treatment for

solving this problem.

An optimal operative procedure for axillary osmidrosis

should include the following features: minimal axillary

scar, rapid wound healing, fewer complications, a shorter

convalescent period, and a low recurrence rate [7]. Or it

needs to generate a both esthetically and functionally

pleasing result.

Basically, three types of surgical methods can be iden-

tified for the treatment of osmidrosis. Type 1, only sub-

cutaneous tissue is removed and not the skin. Type 2, skin

and subcutaneous tissue are removed en bloc. Type 3, the

skin and subcutaneous tissue are partially removed en bloc,

as well as the subcutaneous tissue of the adjacent area [12].

The latter two methods have gradually been abandoned for

the unsightly scarring and partial function disorders. Type

1 tends to be the most reasonable method for being both

safe and efficient for the treatment of axillary osmidrosis

[13].

Various minimally invasive procedures have been pro-

posed, including mechanical liposuction, curettage, suc-

tion-assisted cartilage shaver, scissors trimming, and many

combined techniques [6, 7, 10, 13–17], many of which

have shown highly promising results. All of those

Table 2 Postoperative evaluation of patients

Variables N (%)

Postoperative complications

Ecchymosis 19/300 (6.3)

Hematoma 4/300 (1.3)

Skin necrosis 0

Wound dehiscence 0

Wound infection 0

Malodor elimination

Excellent 264/300 (88)

Good 30/300 (10)

Fair 5/300 (1.7)

Poor 1/300 (0.3)

Reduced hair growth

Significant 214/300 (71.3)

Moderate 81/300 (27)

Mild 4/300 (1.4)

No significant 1/300 (0.3)

Scar formation

Invisible 280/300 (93.3)

Slightly visible 18/300 (6)

Conspicuous 3/300 (1)

Very conspicuous 0

Patient satisfaction

Very satisfied 128/150 (85.3)

Satisfied 18/150 (12)

Neutral 3/150 (2)

Dissatisfied 1/150 (0.7)

Very dissatisfied 0

Table 3 Median DQLI scores before and 6 months after the surgery

Preoperative 6 months

postoperatively

Median DQLI score (range) 9 (4–16) 0 (0–3)a

Clinical symptoms

Question 1 1 0a

Self-conscious

Question 2 2 0a

Daily activities

Question 3 1 0

Question 4 2 0a

Leisure

Question 5 2 0a

Question 6 1 0a

Work or study

Question 7 1 0a

Personal relationship

Question 8 1 0

Sexual relationship

Question 9 0 0

Treatment

Question 10 0 0

DLQI dermatology life quality indexa Statistically significant, P \ 0.05

Aesth Plast Surg

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successfully performed operations have one thing in com-

mon; they manage to remove the residual apocrine sweat

glands firmly attached to the dermis.

Liu developed a minimally invasive surgical subsection

method for axillary osmidrosis. The glandular tissue was

removed by manual excision with scissors through a 1-cm

incision. The whole procedure was performed ‘‘blindly.’’

The method showed a very high percentage of good results,

which was confirmed by the histological examinations. But

thorough trimming using scissors alone blindly may result

in tearing of the skin. Further, for long lesions, a single

incision may not be enough to reach all the sweat glands

[16]. Li described a procedure combining tumescent lipo-

suction with subcutaneous pruning. Long-term follow-up

showed a high satisfaction rate as well. However, the

access incision was designed on the superior pole of the

center crease. Though the incidence rate of hematoma was

0 in their series, either for an esthetic or therapeutic view,

we believe that an incision designed on the inferior pole is

more advantageous [17]. Liu and associates excised the

central apocrine glands using scissors supplemented with

scraping against the marginal glands to treat osmidrosis.

Trimming performed under direct vision insured a more

radial removal of the apocrine glands while compromising

the appearance of scars [18].

Herein, we design a new method to combine subcuta-

neous curettage and trimming together to treat osmidrosis

through a limited incision. Subcutaneous curettage allows a

wide range of scraping toward the apocrine glands, while

mild to moderate curettage tends to result in incomplete

removal of the apocrine glands and aggressive curettage

may lead to scar formation. Thus, after a moderate curet-

tage, we detach the residual glands using a pair of oph-

thalmic scissors. The pulp of the index finger of the non-

dominant hand is used to press the axillary flap against the

scissors to assist in efficient detachment. There is no need

to drag or evert the skin flap. Lastly, scratch gently to

remove the sweat glands that are not completely off. Sharp

pruning combined with blunt scraping ensures a more

radical elimination of the apocrine glands while avoiding

excess mechanical injury to the skin flap. The whole pro-

cedure is followed through a ‘‘scraping–trimming–scrap-

ing’’ sequence. If the remaining hairs are not easily pulled

out after the secondary scraping, the ‘‘trimming–scraping’’

procedure can be repeated.

The technique holds many distinct advantages: (a) It

allows permanent elimination of axillary malodor com-

pared to those non-surgical methods. (b) The postoperative

scars are almost invisible and much more esthetically

pleasing than those of open surgeries. (c) It is applied with

the most basic surgical tools. The ophthalmic scissors and

fenestrated cup curette are the main tools we need.

(d) Compared to those curettage-only methods, it allows

more radical elimination of the apocrine glands. Combined

trimming allows more accurate removal of the residual

glands and reduces the incidence of skin necrosis to a large

extent. Compared to trimming-only methods, the combined

curettage treats broader areas of apocrine glands and can

greatly reduce the risk of skin tearing.

Besides, several key points should be noted during the

operation: (1) Incision design. Besides the routinely

designed inferior incision, never hesitate to add extra

incisions (which should be parallel to the skin crease) for

those patients with larger lesions. Non-continuous minimal

scars tend to be more esthetically pleasing than those long

incisions produced by open surgeries. (2) Trimming. Dur-

ing the trimming procedure, the axillary skin flap should be

elevated by the scissors to avoid damage to the underlying

well-known vessels and nerves. Rely on the sense of touch

of the pulp of the index finger and feel the thickness of the

managed skin flap. The residual apocrine glands should be

trimmed evenly as much as possible. (3) Secondary

curettage. After sequential scraping and trimming, the

axillary skin flap is super thin. Try not to scrape against the

same site aggressively. Otherwise, the skin flap circulation

could be compromised. (4) Irrigation. After the final

scraping, the subdermal pocket is thoroughly irrigated to

wash away the detached tissue block to prevent regenera-

tion of those residual glandular tissues. (5) Pressure

dressing. For that the relative position of the axillary skin

flaps and subcutaneous fat tissue changes from the supine

position to an erect stance, the axillary skin should never be

anchored to the underlying fascia to avoid displacement of

the axillary skin. The gauze pieces (15 cm 9 20 cm, 10

pieces) are fluffed and bound together to form a gauze ball,

which fits the axillary fossa perfectly. Then a routine fig-

ure-of-8 bandage is applied to maintain firm pressure under

each arm.

The most serious complication in our practice was

hematoma. As there were no well-known vessels at such an

anatomical plane, though complete hemostasis under direct

vision is almost impossible through a limited incision,

hemostasis can basically be achieved through pressure

dressing and shoulder-arms limitations. Two cases of local

hematoma (males) both occurred on the right side and were

found on the second postoperative day. Needle aspiration

was conducted, followed by pressure bandages. The wound

healed eventually. The other case of hematoma happened

to a female patient (Fig. 10). She came back to our clinic

through an emergency ambulance service on the very

evening of the surgery. Serious errhysis was found on both

sides. Oddly, there was not any obvious bleeding spot, and

the blood seemed to be in a totally uncoagulated state. She

was not in her menstruation period or taking any antico-

agulant medicines. After careful inquiry, we found that she

had had pigeon soup supplemented with Dang Gui

Aesth Plast Surg

123

(Chinese angelica) and red dates immediately after the

operation. Out of all the ingredients, Dang Gui has been

demonstrated to possess the function of promoting blood

circulation and removing blood stasis [19]. The other

ingredients had been considered to assist in improving

blood circulation by ordinary Chinese people since long

before. Then, bilateral hematomas were removed and

intravenous hemostatics were given. No more hematoma

was formed at wound dressing changes 1 day later. Ulti-

mately, the wound healed in time. After this, we instructed

our patients that ‘‘No herbs can be taken only after detailed

consultation with the doctor.’’

In our series, the recurrence rate of axillary osmidrosis

was 2 %. Recurrence usually occurred at the periphery of

the axilla. We reached the above conclusion partly from the

observed phenomenon that obviously denser hair existed at

the peripheral area in those recurrent patients. Partly for

that the recurrent malodor was successfully eliminated

after re-operation of the area with denser hair. However,

for practical difficulties, we did not perform histological

examination. There was minimal to no scarring in the long

run. As for hair reduction, all female patients were glad to

have the axillary hair removed or significantly reduced.

While for the male patients, a detailed clarification was

needed preoperatively.

For those skilled and experienced plastic surgeons, the

above technique is relatively easy to master. Even though, it

is more difficult to operate blindly than under direct vision,

especially for those new practitioners. At the beginning of

the learning curve, there might be more unexpected out-

comes, for instance, hematoma due to uneven dissection

and loose postoperative dressings, skin necrosis or wound

dehiscence because of aggressive scratching, skin tearing as

a consequence of poor trimming, and of course malodor

recurrence due to incomplete removal of the sweat glands.

Thus, one should be fully aware of the regional anatomy

and skillful at the open surgeries prior to performing the

limited incision procedures. Also, indications for this

technique need to be followed: (a) Patients request perma-

nent elimination of axillary malodor; (b) Patients who are

very conscious of scars, they would rather undergo a re-

operation than to have unsightly postoperative scars;

(c) The operator should have a good command of the reg-

ular open surgeries for axillary bromhidrosis; (d) No

inflammation exists in the local area, and normal coagulant

activity is present; (e) For those male patients who possess

severe underarm malodor, the wide open resection approach

is usually suggested.

The dermatology life quality index was adopted to

measure the impact of axillary osmidrosis on the quality of

life of our patients. A median DLQI score was 9 before the

operation, compared with 0 postoperatively. The difference

is statistically significant. The procedure has a positive

effect on improving patients’ quality of life in the aspects

of clinical symptoms, self-conscious, daily activities, lei-

sure, work, and study.

The high satisfaction rates, low recurrence rates, and

decreased DLQI score all indicate the effectiveness of this

procedure. Further, randomized control trials are needed in

the future to compare the presented technique with the

other surgical methods in all aspects.

In conclusion, subcutaneous curettage combined with

trimming is an efficacious and minimally invasive method

for the treatment of axillary osmidrosis. It is worth being

adopted in the clinical practice.

Conflict of interest The authors declare that they have no conflicts

of interest to disclose.

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