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. There have been many different procedures used to remove axillary sweat glands; they can be grouped into three major categories. 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.
Radical sweat gland removal can be done with excisions of various shapes and sizes. 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. Large cosmetically unacceptable and at times motion-limiting scars often resulted from these early procedures. In an attempt to reduce functional disability, a Z-plasty repair can be used after a wide elliptical incision. Procedures that combine radical excision with the creation of vascular flaps or skin grafts have also been used. 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.
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. Since some of the eccrine glands are in the dermis, these procedures are less likely to remove all of the glands. 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.
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. 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. 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.
Liposuction results seem comparable to those seen with curettage, but there are fewer long-term reports of patients treated with liposuction. 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. 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.
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. 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.