Skin Adnexectomy 

Updated: Feb 15, 2018
Author: Christian N Kirman, MD; Chief Editor: Dirk M Elston, MD 

Overview

Background

Removing the skin adnexa, or adnexectomy, is a procedure that attempts to remove the skin appendages, such as sweat glands, for conditions such as excessive sweating (hyperhidrosis), malodor (bromhidrosis or osmidrosis), or hidradenitis suppurativa. The goal of the surgery is to reduce these problems long term while minimizing unwanted side effects and complications. Multiple methods to remove the sweat glands in the axillary region have been described.

For more information regarding the treatment of hidradenitis suppurativa, refer to the Medscape Drugs & Diseases topic Surgery for Hidradenitis Suppurativa.

Epidemiology

Hyperhidrosis is increasingly becoming recognized as a significant social and occupational impairment.[1]  An estimated 3.12% of the US population is affected by axillary hyperhidrosis.[2] Systemic hyperhidrosis that affects the face, palms, soles of the feet, and axilla affects 2.8 million people (2.8% of the population).[3] Among patients with axillary hyperhidrosis, one third specified that the excessive sweating frequently interfered with their daily activities. Thus, hyperhidrosis can be a debilitating diagnosis that can impair social and occupational activities.[1, 2]

No ethnic predilection for hyperhidrosis has been reported; however, multiple studies have described axillary osmidrosis as a significant issue in Far Eastern populations.[4, 5, 6, 7, 8, 9] Axillary osmidrosis or bromhidrosis is unpleasant odor arising from the axilla, which can cause significant personal discomfort and social impairment, especially in Asian societies. In Western countries, people tend to be primarily concerned with axillary hyperhidrosis, whereas in Asian countries, people seek out treatment for osmidrosis.[5]

Individuals with hyperhidrosis may frequently have a family history positive for the diagnosis.

Etiology

Excessive axillary sweating, termed hyperhidrosis, is defined by excessive perspiration greater than the normal physiologic response for the body for thermoregulation.[10] Under normal physiologic conditions, sweat glands are stimulated when body temperature elevates, which then produce moisture at the skin surface that may cool the body through the process of evaporation. Sweating may occur episodically, continuously, or seasonally and may be exacerbated by emotions, such as anxiety or nervousness.[10] Hyperhidrosis can be divided into primary or secondary. Primary hyperhidrosis has recognizable cause, but many causes of secondary hyperhidrosis have been described, including fevers, metabolic or endocrine disorders, medications, or various physiologic states (eg, menopause, exercise).[11]

Pathophysiology

Two main types of sweat glands are recognized: eccrine sweat glands and apocrine sweat glands (see image below).

Both apocrine and eccrine sweat glands are present Both apocrine and eccrine sweat glands are present in the skin of the axilla.

Eccrine sweat glands are the primary producers of sweat and are located diffusely throughout the skin of the body, with the highest concentrations of glands found in the axilla, palms, and soles of the feet. Eccrine sweat glands secrete sweat through pores located on epidermal ridges and empty directly to the skin surface. Apocrine sweat glands are a subset of glands located in the axilla and genital regions that become active during puberty, under the influence of androgen hormones.[4] Apocrine glands secrete sweat into the follicular canal of their associated hair follicles. These glands secrete fluid that is thought to cause offensive odor, which is termed osmidrosis or bromhidrosis when excessive.

In white patients, either all or nearly all eccrine and apocrine sweat glands are not found in the dermis layer in the skin itself but rather within the subcutaneous tissue itself or at the interface of the subcutaneous tissue and the dermis.[12] The anatomic location of the sweat glands themselves provides the basis for the various surgical procedures available for the treatment of hyperhidrosis and osmidrosis.

Indications

Axillary adnexectomy is indicated for primary hyperhidrosis and for significant osmidrosis. Primary hyperhidrosis has been defined as focal, visible, excessive sweating lasting at least 6 months without apparent cause, with at least 2 of the following characteristics[13] :

  • Bilateral and relatively symmetric locations

  • Impairment of activities of daily living

  • Frequency of one or more episode per week

  • Age of onset younger than 25 years

  • Positive family history

  • Cessation of focal sweating during sleep

Contraindications

Although no absolute contraindications to axillary adnexectomy are recognized, several relative contraindications may exist. A thorough attempt at nonsurgical management of hyperhidrosis or bromhidrosis should be tried prior to considering surgical treatment. Patients must also understand the risk of recurrence even after surgical intervention; treatment may have to be repeated or continued.

Patients who have had prior surgical procedures in the axilla, such as sentinel lymph node biopsy or axillary lymph node dissection, may be at a higher risk for developing lymphedema, or painful swelling in the arm. These patients may be at risk for lymphedema with subsequent procedures in the axilla.

Technical Considerations

Best practices

Before any invasive methods are used, patients should first attempt treatment with easily obtainable over-the-counter antiperspirant or deodorant products. If these products prove inefficacious, stronger clinical strength formulas may be tried as well aluminum chloride products available by prescription.[14] Treatment with topical antiperspirants are only temporary of course, with the duration of treatment lasting at most 2-3 days, and frequent reapplication is necessary.

Oral anticholinergic medications are available by prescription and may be effective in treating hyperhidrosis, such as glycopyrrolates. These medications reduce body secretions in the stomach, throat, and nose, as well as the sweat glands and other areas. However their use is associated with multiple side effects, including dry mouth, difficulty urinating, headaches, diarrhea, and constipation, among others. In one study of 24 patients using a glycopyrrolate medication to treat hyperhidrosis, one third had side effects significant enough to limit their treatment.[15]

Botulinum toxin injection into the axilla is another method approved by the US Food and Drug Administration (FDA) for the treatment of primary axillary hyperhidrosis and has also been shown to be effective in treatment of hyperhidrosis of the palms of the hands.[16] Botulinum toxin injection works by inhibiting the release of the neurotransmitter acetylcholine from the nerves that innervate eccrine sweat glands, which reduces production of sweat. This type of treatment is particularly important in improving the quality of life in children with hyperhidrosis.[17]

Botulinum toxin has been shown to begin reducing sweat production within 1-2 weeks of injection, and its effects may last as long as 9 months.[18] Botulinum toxin A injection for treatment of secondary axillary bromhidrosis has been reported with success, with effects lasting a median of 6 months (range, 1-12 months).[19] Treatment with botulinum toxin is only temporary and must be repeated for continued management of excessive sweating. Pressure jet injection has been used to minimize pain.[20]

Potential alternative therapies that show promise include laser treatment for axillary hyperhidrosis,[21] topical umeclidinium for primary axillary hyperhidrosis,[22] and topical oxybutynin 3% or 10% gel for primary focal hyperhidrosis,[23, 24] as well as sequential extended thoracoscopic sympathicotomy for palmo-axillo-plantar hyperhidrosis,[25] and computed tomography-guided percutaneous ethanol sympatholysis for primary hyperhidrosis.[26]

Outcomes

The surgical removal of the sweat glands of the axilla has the potential to provide the patient with hyperhidrosis or osmidrosis a long-lasting and often permanent treatment. Several variations on the technique of removing the sweat glands in the axilla have been shown to be effective and efficacious.[4, 5, 6, 7, 8, 27]

 

Periprocedural Care

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.[28]

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.[29, 30]

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.

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.[4, 6, 7, 8, 28, 31]

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.[28]

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.

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.

 

Technique

Approach Considerations

Again, multiple tools and techniques are available to effectively remove the sweat glands in the axilla. The technique with which the surgeon has the most experience and is readily available should be used. Some techniques may be more cost-effective based on both the patient’s and surgeon’s preferences. Results of the procedure may vary based on the technique used.[4, 8, 31, 32, 33]

Three classic methods of removing axillary sweat glands are primarily recognized.[12] Type I removes only the subcutaneous tissue of the axilla and spares the skin; type II removes the skin and subcutaneous tissue of the axilla en bloc, mostly in the hair-bearing dome of the axilla; and type III is a combination of type I and type II, removing skin and subcutaneous tissue centrally with removal of adjacent subcutaneous tissue as well. Limited en bloc resection based on sweat mapping with starch and iodine or cobalt chloride can be effective with less morbidity than total en bloc resection. Sweat mapping often reveals focal areas of hyperhidrosis amenable to excision.

A type I resection of only the subcutaneous tissue while sparing the skin is the primary focus of this technique.

Suction-Assisted Arthroscopic Shaving

After anesthetic administration and preparation of the axilla, a 1-cm incision is made in the anterior axillary fold at the marked site.

After anesthetic administration and preparation of After anesthetic administration and preparation of the axilla, a 1-cm incision is made in the anterior axillary fold at the marked site.

A plane is opened and developed at the interface of the deep dermis and the subcutaneous tissue with surgical scissors (eg, Metzenbaum scissors) in a spreading motion parallel with the skin surface, leaving minimal subcutaneous tissue on the skin flap. This plane is developed underneath the entire hair-bearing skin marked preoperatively and can be done rapidly in a bloodless fashion. During elevation of the skin flap and subsequent shaving of the skin flap, assistance with traction on the skin is important to achieve a taut skin surface. This stretching of the skin aids in defining the plane of dissection and minimizing trauma or cutting of the skin flap itself.

Once the skin flap is elevated, the undersurface is debrided of remaining subcutaneous tissue with the method chosen by the surgeon. Arthroscopic cartilage shaving devices are effective in debriding the skin flap of the associated sweat glands.[28, 29, 30]

The arthroscopic shaver is a powered device consis 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 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 which simultaneously removes the debrided tissue from the area.

The exposed inner cannula rotates at a rate of 900 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.

The oscillating tip of the device is held up again 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.

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. This process is repeated in a radial fashion around the dissected plane until all areas of the skin flap have been debrided of subcutaneous tissue. This method minimizes trauma to the deeper subcutaneous tissue as well as the hair follicles of the skin flap.

A closed suction drain or passive drain should be placed in the surgical site to minimize any dead space or fluid accumulation. The skin incision is then closed with sutures. A soft bolster dressing should be applied overlying the skin of the axilla to provide gentle pressure over the entire site which can be secured with sutures to the skin. The surgical drain and bolster dressing should be removed on the first postoperative day. Skin sutures can be removed 1 week postoperatively.