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Skin Adnexectomy Periprocedural Care

  • Author: Christian N Kirman, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Dec 19, 2014
 

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.

Patient instructions

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.[18]

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]

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Pre-Procedure Planning

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.

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Equipment

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]

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Patient Preparation

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.

The hair bearing skin of the patient's axilla is m The hair bearing skin of the patient's axilla is marked in preparation for surgery.

Anesthesia

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.

Local anesthetic of 0.5% lidocaine with 1/200,000 Local anesthetic of 0.5% lidocaine with 1/200,000 epinephrine using a 25-G or smaller needle should be injected superficially in the subcutaneous tissue to create elevation of the dermis. The entire hair-bearing area of skin in the axilla should be injected and can be done prior to sterile surgical preparation and draping of the site.

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.[18]

Positioning

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.

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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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Contributor Information and Disclosures
Author

Christian N Kirman, MD Clinical Instructor, Department of Surgery, Division of Plastic Surgery, University of California, San Francisco, School of Medicine

Christian N Kirman, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments The author would like to thank David Larson, MD, for his instruction and expertise in the surgical management of axillary hyperhidrosis and the arthroscopic shaving technique.

References
  1. Amir M, Arish A, Weinstein Y, Pfeffer M, Levy Y. Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): preliminary results. Isr J Psychiatry Relat Sci. 2000. 37(1):25-31. [Medline].

  2. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004 Aug. 51(2):241-8. [Medline].

  3. Park YJ, Shin MS. What is the best method for treating osmidrosis?. Ann Plast Surg. 2001 Sep. 47(3):303-9. [Medline].

  4. Qian JG, Wang XJ. Effectiveness and complications of subdermal excision of apocrine glands in 206 cases with axillary osmidrosis. J Plast Reconstr Aesthet Surg. 2010 Jun. 63(6):1003-7. [Medline].

  5. Liu Q, Zhou Q, Song Y, Yang S, Zheng J, Ding Z. Surgical subcision as a cost-effective and minimally invasive treatment for axillary osmidrosis. J Cosmet Dermatol. 2010 Mar. 9(1):44-9. [Medline].

  6. Homma K, Maeda K, Ezoe K, Fujita T, Mutou Y. Razor-assisted treatment of axillary osmidrosis. Plast Reconstr Surg. 2000 Mar. 105(3):1031-3. [Medline].

  7. Park DH, Kim TM, Han DG, Ahn KY. A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures. Ann Plast Surg. 1998 Nov. 41(5):488-97. [Medline].

  8. Morioka D, Ohkubo F, Amikura Y. Clinical features of axillary osmidrosis: a retrospective chart review of 723 Japanese patients. J Dermatol. 2013 May. 40(5):384-8. [Medline].

  9. Nyamekye IK. Current therapeutic options for treating primary hyperhidrosis. Eur J Vasc Endovasc Surg. 2004 Jun. 27(6):571-6. [Medline].

  10. Stolman LP. Treatment of hyperhidrosis. J Drugs Dermatol. 2003 Oct. 2(5):521-7. [Medline].

  11. Beer GM, Baumüller S, Zech N, et al. Immunohistochemical differentiation and localization analysis of sweat glands in the adult human axilla. Plast Reconstr Surg. 2006 May. 117(6):2043-9. [Medline].

  12. [Guideline] Hornberger J, Grimes K, Naumann M, et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004 Aug. 51(2):274-86. [Medline].

  13. Gee S, Yamauchi PS. Nonsurgical management of hyperhidrosis. Thorac Surg Clin. 2008 May. 18(2):141-55. [Medline].

  14. Bajaj V, Langtry JA. Use of oral glycopyrronium bromide in hyperhidrosis. Br J Dermatol. 2007 Jul. 157(1):118-21. [Medline].

  15. Basciani M, Di Rienzo F, Bizzarrini M, et al. Efficacy of botulinum toxin type B for the treatment of primary palmar hyperhidrosis: a prospective, open, single-blind, multi-centre study. Arch Dermatol Res. Feb 2014. [Medline].

  16. Vergilis-Kalner IJ. Same-patient prospective comparison of botox versus dysport for the treatment of primary axillary hyperhidrosis and review of literature. J Drugs Dermatol. 2011 Sep 1. 10(9):1013-5. [Medline].

  17. Heidemann E, Licht PB. A comparative study of thoracoscopic sympathicotomy versus local surgical treatment for axillary hyperhidrosis. Ann Thorac Surg. Jan 2013. 95(1):264-8. [Medline].

  18. Larson DL. Definitive diagnosis and management of axillary hyperhidrosis: the VapoMeter and suction-assisted arthroscopic shaving. Aesthet Surg J. 2011 Jul. 31(5):552-9. [Medline].

  19. Chern E, Yau D, Chuang FC, Wu WM. Arthroscopic shaver with refinement for axillary osmidrosis. Int J Dermatol. 2010 Jul. 49(7):813-7. [Medline].

  20. Arneja JS, Hayakawa TE, Singh GB, et al. Axillary hyperhidrosis: a 5-year review of treatment efficacy and recurrence rates using a new arthroscopic shaver technique. Plast Reconstr Surg. 2007 Feb. 119(2):562-7. [Medline].

  21. Kim SW, Choi IK, Lee JH, et al. Treatment of axillary osmidrosis with the use of Versajet. J Plast Reconstr Aesthet Surg. May 2013. 66(5):125-8. [Medline].

  22. Kim HG. A new osmidrosis procedure, the scrape and suction technique: review of 4,322 patients. Aesthetic Plast Surg. 2014 Apr. 38(2):282-7. [Medline].

  23. Ding Z, Zheng J. A comparison of two different sub-dermal trimming techniques for the treatment of axillary osmidrosis. J Plast Reconstr Aesthet Surg. 2013 Nov. 66(11):1569-74. [Medline].

 
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Both apocrine and eccrine sweat glands are present in the skin of the axilla.
The hair bearing skin of the patient's axilla is marked in preparation for surgery.
Local anesthetic of 0.5% lidocaine with 1/200,000 epinephrine using a 25-G or smaller needle should be injected superficially in the subcutaneous tissue to create elevation of the dermis. The entire hair-bearing area of skin in the axilla should be injected and can be done prior to sterile surgical preparation and draping of the site.
After anesthetic administration and preparation of the axilla, a 1-cm incision is made in the anterior axillary fold at the marked site.
The arthroscopic shaver is a powered device consisting of 2 concentric cannulas on which the exposed inner cannula rotates at a rate of 900 rpm in an oscillating motion, debriding the flap of its subcutaneous tissue and sweat glands. The device has suction applied that simultaneously removes the debrided tissue from the area.
The exposed inner cannula rotates at a rate of 900 rpm in an oscillating motion, debriding the flap of its subcutaneous tissue and sweat glands.
The oscillating tip of the device is held up against the underside of the skin flap and away from the underlying deeper tissues. With skin traction applied, the tip is placed at the edge of the dissected plane and slowly brought back toward the incision, maintaining contact with the skin flap.
 
 
 
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