Local Underarm Surgery

What do you think of when you hear the word "liposuction"? Perhaps U.S television's Dr. 90210 and his Beverly Hills' clients? How about axillary hyperhidrosis? No? Well, that's about to change.

While the most commonly discussed, criticized, and arguably unethically advertised surgery for hyperhidrosis may be endoscopic thoracic sympathectomy, there are other much less risky surgical options for people who suffer from excessive sweating of the underarms. These procedures are called "local" because the surgery is performed at the point of the sweating.

Underarm surgery techniques include: excision, curettage, liposuction, and laser. During excision, sweat glands may be cut out. Similarly, during curettage they may be scraped out. During liposuction they may be removed by suction. Using lasers, tissue containing sweat glands is liquefied. Combinations of curettage and central excision, or of curettage and liposuction may be used, as well as combinations of liposuction and laser treatments. Dermatologists often have good results with these techniques. Each of these procedures can be done under local anesthesia (meaning that the patient is not completely "out") and in an office setting (as opposed to in a hospital setting).

All of the techniques mentioned above have the same goal: to remove or injure the sweat glands so that they can no longer produce perspiration. Sweat glands are located just beneath the skin (where the skin and the underlying fat meet) and are thus accessible for these types of interventions. In the underarms, the sweat glands are also fairly localized, making surgery a viable option. For a number of reasons (including the dispersal of sweat glands and scarring) local surgeries are not done for palmar hyperhidrosis (excessive hand sweating), plantar hyperhidrosis (excessive sweating of the feet), or facial sweating. Other treatments such as iontophoresis and Botox are better choices for these non-armpit body areas.

During liposuction, a physician will use a small tube to suck out the superficial layer of fat in the armpit where the sweat glands are. During curettage, a special surgical tool with a circular loop on the end is used along the skin's under-surface to scrape out as many of the sweat glands as possible, or to at least damage them enough so that they no longer work. During suction-curettage the liposuction tube and the curettage scraping method are both used. It's important to note that excision, indicating the complete removal of underarm tissue containing sweat glands, is NO LONGER RECOMMENDED because heavy scarring can cause serious range of motion problems – even to the point where a person may not be able to move his or her shoulder normally.

A newer liposuction technique is showing promise for treatment of underarm hyperhidrosis. In this technique, liposuction is combined with the use of laser to liquefy the tissue containing the sweat glands. The laser's energy is applied directly to cells (including the cells of the sweat glands), causing them to rupture so that the body can drain them away and/or liposuction can remove the damaged cells.

One of the benefits of local surgery for excessive sweating is that for whatever glands you injure or remove, there is often a permanent result – the affected glands will not produce any more sweat. One of the difficulties is that sweat glands are too small to be seen, even with surgical instruments, so even the most experienced dermatologist is going in "blind." It is difficult for physicians to know how many sweat glands they are removing or damaging and therefore the results can be highly variable.

Axillary surgery can be performed in a physician's office under local anesthesia. Recovery is usually a couple of days although patients may feel sore for up to a week and need to limit their arm activity (sports, lifting above their heads, etc.) during that time. If sweat reduction has not been sufficient, it is also possible to repeat a procedure or to use Botox or antiperspirants to control sweating from remaining sweat glands. Compensatory sweating has not been associated with local surgery. As with any surgery, there are potential complications such as infection. There also may be bruising, swelling, loss of sensation in the underarms, and scarring depending upon the size and number of incisions that the physician uses.

Health insurance organizations often do not recognize local surgeries as a treatment for hyperhidrosis and so will usually not pay for it. Botox, on the other hand, is approved by the U.S. FDA for the treatment of axillary hyperhidrosis so it's much more likely to be covered by insurance. Often, patients who want an axillary surgery and are good candidates for it have to pay for it themselves. It may also be difficult to find a dermatologist who is experienced in sweating-related surgeries for the underarms. These are advanced techniques. So if you think this is something that may be right for you, do some research to find the right dermatologist to perform the surgery.

Below is a brief overview of accepted local surgical techniques for axillary (underarm) hyperhidrosis (excessive sweating):

Curettage: In small Taiwanese study of 19 patients (90%) had excellent to good response.

Liposuction: Sweat reduction rates range from 44% to 49%

Liposuction and Curettage: Sweat reduction rates approximately 63%

Laser: Reduction of sweating rated as "excellent" by >75% of patients studied, rated as "good" by 51-75% of patients, and rated as "fair" by 26-50% of patients.

Each of the above treatments has potential complications, which your physician should tell you about. [The above data overview was compiled from studies by Samantha Hill, MD an assistant professor of dermatology for the Medical College of Wisconsin.]

To get a first-hand real-life opinion of local surgery we talked to Dr. Dee Anna Glaser. Dr. Glaser is one of the founding Board of Directors members of the International Hyperhidrosis Society and Professor, Vice Chairman, and Director of Cosmetic and Laser Surgery with the Department of Dermatology at the Saint Louis University School of Medicine in St. Louis, MO. She treats hundreds of hyperhidrosis patients and is the Education Chief for the International Hyperhidrosis Society's physician training program.

"In my own personal experience," concludes Dr. Glaser, "I think I can get more consistent, reliable results with Botox for axillary hyperhidrosis than I can with liposuction-curettage. Other dermatologists may use a number of different techniques and say that they can get consistent good results, but these aren't procedures that are commonly performed and it's difficult to predict results because the dermatologist has to make a very educated guess as to where the glands are in order to remove them. Sweat glands are not like tumors or lesions that we can see and remove easily. It's not going to work for everyone."

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