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Local Surgical Procedures
Treatment of severe hyperhidrosis by excision of sweat glands
is clearly only feasible for axillary disease. The eccrine
sweat glands are located in the deep dermis and in the upper
subcutaneous layer.[88]
There have been many different procedures used to remove axillary
sweat glands; they can be grouped into three major categories.[49]
Excision of both skin and underlying sweat glands is the most
radical approach. Removing subcutaneous glands through a small
incision by scraping the glands from the undersurface of the
dermis with a curette or by liposuction are two major variants
of the same approach. The third category is a mixture of the
first two—a limited central excision is combined with curettage
of the surrounding axillary subcutaneous glands.[9,49]
All of these procedures can be done under tumescent local
anesthesia.[49]
Radical sweat gland removal can be done with excisions of
various shapes and sizes.[49]
Either transverse or longitudinal elliptical excisions centered
in the hair-bearing area, removing a variable amount of the
eccrine-gland-bearing tissue, were the first techniques used.[88]
Large cosmetically unacceptable and at times motion-limiting
scars often resulted from these early procedures.[145]
In an attempt to reduce functional disability, a Z-plasty
repair can be used after a wide elliptical incision.[49]
Procedures that combine radical excision with the creation
of vascular flaps or skin grafts have also been used.[88] Combining
removal of the entire sweat-producing area, as documented
with a starch-iodine test, with a Z-plasty repair has led
to long-term success rates of over 90% to 95%, at the expense
of a large unsightly scar.[49]
The second group of procedures, scraping or suctioning the
eccrine glands from the dermal-subcutaneous border and from
the subcutaneous fat layer through small incision(s), will
lead to smaller scars.[49]
Since some of the eccrine glands are in the dermis, these
procedures are less likely to remove all of the glands.[49]
In a series of 38 patients followed with gravimetry before
and after a curettage procedure, the average reduction in
sweat output was 38% of baseline value, and 93% of those with
the highest rate of sweat production, over 50 mg per minute,
had their sweat output reduced to less than 50% of baseline.[108]
In another study, the subjective outcomes for 90 patients
treated with subcutaneous curettage were compared to those
of 23 patients treated with botulinum toxin injections.[114]
Patients had similar satisfaction rates for the 2 procedures,
and over 90% of each group would recommend the procedure
to another patient. The patients’ subjective score for
amount of axillary sweating at rest fell by 40% at 6 months
and by 46% at median follow-up of 28 months for those undergoing
curettage. For the BTX-A-treated patients, the assessment of
sweating at rest fell by 49% at 6 months. The mean duration
of sweat reduction was 7.6 months, but several patients had
periods of decreased sweating that lasted 14 and 18 months,
respectively.
Although postoperative morbidity is less than with radical
excision, complications of curettage include partial skin
necrosis, wound infection, and hematoma formation requiring
drainage.[114]
The scraping and suctioning of the subcutaneous layer through
a small incision risks injury to the subdermal vascular plexus,
leading to the development of small areas of full-thickness
skin loss requiring more-intensive wound management.[49]
Liposuction results seem comparable to those seen with curettage,
but there are fewer long-term reports of patients treated
with liposuction.[114]
Using starch-iodine testing 6 months after liposuction, an
80% to 90% improvement is common; some patients have found
that the maximum sweat reduction may take up to 8 months after
the procedure.[140]
If sweat reduction has not been sufficient, it is also possible
to repeat liposuction or curettage, but this is rarely necessary.[88,114,140]
The third category of procedure for local removal of eccrine
glands in the axilla is combined excision and curettage. Usually
a small central ellipse, about 2 by 5 centimeters, is removed
and the surrounding skin is undermined with removal of sweat
glands on the undersurface of the dermis by curette. Small
scars and high patient satisfaction are reported.[49]
Local procedures for axillary hyperhidrosis have a definite
place in the therapeutic armamentarium, being simple to perform
under local anesthesia and clearly less invasive than ETS. However, many of the reports
of local procedures in the literature focus on operative technique
and offer less information on outcome and patient satisfaction.[99]
Satisfaction rates that have been reported for local surgery
are generally higher than the rates of 37% to 68% reported for
the treatment of axillary hyperhidrosis by ETS.[49,151]
Local surgery avoids some of the major complications seen
with ETS, such as compensatory sweating.
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List your practice or search for colleagues. |
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The makers of BOTOX® Botulinum Toxin Type A generously support
the International Hyperhidrosis Society. |
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