Skin Adnexectomy Periprocedural Care
- Author: Christian N Kirman, MD; Chief Editor: Dirk M Elston, MD more...
Patient Education & Consent
Patients with axillary hyperhidrosis or osmidrosis should be educated that these conditions are real diagnoses that can significantly impair their daily living and may be treatable using various methods.
Once the decision has been made to undergo surgical removal of the axillary skin sweat glands, an understanding should be reached between the patient and treating physician of the procedure and expected outcomes. Although the goal of the procedure is to effectively eliminate all or most of the sweat glands in the affected area, some sweat glands are likely to remain and some amount of excessive symptoms may persist, although this is relatively rare. If symptoms continue or recur, the procedure can be repeated at a later date.
The patient should be provided both verbal and written instructions for preoperative and postoperative care. A list of the patient’s current medications should be reviewed, and any medications that could affect bleeding should be discontinued prior to the procedure if possible.
Elements of informed consent
Appreciating the risks, benefits, and alternatives to the procedure to be performed are paramount to the success for the procedure for both the patient and physician. Any surgical procedure where the skin must be incised carries a risk of scarring, infection, and wound-healing difficulties. Although rare, the most common reported complications of the procedure are hematoma, skin flap perforation, skin sloughing or necrosis, axillary alopecia, infection, and recurrence.[19, 20]
The patient does not need to shave their axillae prior to the day of surgery. Most women typically maintain their axillae hair free and may be instructed to not shave or remove the hair for a few days prior, simply to allow easier identification of the hair-bearing skin area to be treated. Patients should not apply any topical antiperspirant or deodorant products for 24 hours prior to the procedure. If general anesthesia is to be used, patients should ideally have nothing by mouth for at least 8 hours prior to the procedure. Any required daily medications should be reviewed with the anesthesiologist prior to taking them the day of surgery.
Multiple surgical tools have been used to remove the subcutaneous tissue in the axilla. Removing tissue from the undersurface of the skin has been performed with scissors, rasps, curettes, disposable razors, powered and ultrasound-assisted liposuction cannulas, hydrosurgery systems, and endoscopic shaving devices.[3, 5, 6, 7, 18, 21]
Prior to the procedure, the hair-bearing axillary skin is marked, and any hair may be shaved at this time (see the image below). A skin crease in the anterior axillary line may be marked as well for incision placement to allow the scar to be concealed in an axillary fold.
Preoperative analgesic and anxiolytic medications may be given orally or intravenously prior to the surgical procedure. If general anesthesia is to be used, any preoperative medication should be given intravenously. Additionally, local anesthesia is given in the form of 20-30 mL 0.5% lidocaine with 1/200,000 epinephrine using a 25-gauge or smaller needle to minimize discomfort with injection.
Alternative concentrations of lidocaine may be used; however, the total dose for the patient should remain below 7 mg/kg. The anesthetic should be superficially injected in the subcutaneous tissue to create elevation of the dermis. The entire hair-bearing area of skin in the axilla should be injected; this can be done prior to sterile surgical preparation and draping of the site to allow a full 7 minutes to pass to allow full anesthesia and vasoconstrictive effects of epinephrine to take effect.
The patient is positioned supine on the operating table, with the arms externally rotated and abducted 100°. Care should be taken to prevent excessive abduction of the arms to minimize risk of nerve injury.
Monitoring & Follow-up
If general anesthetic or significant sedation is used, monitored anesthesia should be provided throughout the entirety of the procedure. The patient should remain under the care of health care personnel until they can be safely discharged with accompaniment for 24 hours.
External compression garments or bolsters as well as surgical drains are placed to minimize bleeding and wound-healing complications. Patients should be seen on the first postoperative day to remove surgical drains and bolsters and to assess for any hematoma formation. Patients should then be seen 1 week postoperatively to again assess for proper wound healing. Any permanent sutures placed in the skin should be removed at this time.
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