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Below are links to two relevant articles and abstracts published in medical journals. More studies regarding other treatments can be found here :. Local procedural approaches for axillary hyperhidrosis. Treatment of axillary hyperhidrosis: a combination of the starch-iodine test with the tumescent liposuction technique. Patients Family and Friends. Medical Professionals. Linked to Breast Cancer? Laundry Solutions. Menu Know Sweat What is hyperhidrosis? Your Health.
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More studies regarding other treatments can be found here : Local procedural approaches for axillary hyperhidrosis Treatment of axillary hyperhidrosis: a combination of the starch-iodine test with the tumescent liposuction technique.
Latest Blog Posts 08 Nov. Think You KnowSweat? November is Hyperhidrosis Awareness Month! Master class review. Tweets by weknowsweat 4WeHelp Movers Cincinnati. November 1, And in as little as one treatment, you can start seeing results and start feeling your best.
As of now, miraDry is only FDA cleared for treating the underarm area. However, research is currently being performed by Sientra, a medical aesthetics company, to receive approval for treating other areas, including the hands and feet.
Regardless of your gender, age, or skin type, you can enjoy the full benefits of miraDry. Remember, you should never feel embarrassed about excessive sweating or have to live with it either! What is Hyperhidrosis? In the manual vacuum suction, a syringe is coupled to the cannula, which is inserted into the tissue to be removed before the plunger is withdrawn.
A mechanical lock to hold the plunger open is necessary. However, this system does not provide a continuous deep vacuum. A disadvantage is that the vacuum may be lost if the cannula is accidentally partially withdrawn when suctioning close to the incisions site.
If this occurs, the air must be removed from the syringe before reuse. When a mechanical suction system is chosen, the cannulae is connected to a collection bottle through a tube. The tissue mobilized by the cannulae is brought to the receptacle by means of a collecting system, using negative pressure generated by a vacuum pump.
The size of the cannula and its opening, plus the amount of vacuum applied and the velocity of the stroke of the cannula directly affect the amount of tissue removed. The surgeon's non-dominant hand can assist in the procedure by compressing the overlying skin.
Rho et al 73 perform copius irrigation and meticulous hemostasis at the end of the procedure, and then close the surgical incisions.
They suggest the use of anchor sutures in the area treated with aggressive liposuction and curettage, since this would reduce the formation of hematomas. Dressing can be done with antibiotic ointment. There are reports on the use of arthroscopic shavers for the accomplishment of the procedure. Such instruments have a double cannula structure. The inner cannula is used for rotation, functioning as a continuous curette.
The outer cannula is used to protect the epidermis from direct damage during curettage and liposuction. When an arthroscopic shaver is used to perform the procedure, it is positioned in the axilla after the dermis and the subcutaneous cellular tissue have been dissected with a scissor.
Tunneling is performed before the activation of the blade or the suction device. The scraper blade should only be turned on in the withdrawal phase, and the device should not be passed more than once or twice in the same region.
A suction tube is connected to the handle of the shaver, in order to allow the rapid removal of the curetted tissue. The number of rotations per minute of the inner cannula varies in different studies. Lee et al 72 indicate that the system should be adjusted to maintain the inner cannula at rpm, in the oscillatory mode. Wu et al 80 used it at rpm, while Chern et al 74 would rather have it at rpm.
Arneja et al 75 suggest that the suction device is set to 50mmHg. Larson et al 13 suggest that an assistant physician should perform manual traction to stabilize the axillary skin, both during tissue dissection with scissors and during curettage itself, in order to prevent skin perforations.
A study conducted by Beer et al 87 demonstrated that the majority of all types of sweat glands eccrine, apocrine and apo-eccrine of the axilla of adult Caucasians is located in the subcutaneous cellular tissue, at the interface with the dermis, and not in the dermis itself.
This finding suggests the optimization of type I surgery, with the abandonment of more radical surgical techniques types II and III , which have a higher infection rate and result in large unsightly scars. Tsay et al 88 conducted a study comparing the techniques of liposuction and curettage associated with liposuction to treat osmidrosis.
The results showed that the second technique is preferred over liposuction alone. Although this method have many advantages - such as small wounds, short recovery periods, low complication rates and inconspicuous scars -, some of the sweat glands are firmly attached to the dermis and are hardly entirely removed with this type of procedure.
With the performance of superficial liposuction alone, it would be impossible to eradicate all subcutaneous glands, since a considerable force would be required for the disruption of the glands from their ducts. Histopathological analyzes performed on three patients by Park and Shin 89 have shown that there is an insufficient removal of sweat glands when blunt liposuction cannulae are used for scraping the dermis.
Thus, whenever the curettage is performed, cutting instruments are necessary to allow the effective removal of sweat glands that are located in the deep dermis. In a study published in , Bechara et al 78 confirmed, through histopathological analysis of the material aspirated during surgery, that curettage with liposuction is effective in removing sweat glands. Normal or destroyed glands were found in the material of all patients, and portions of connective tissue were found within the aspirate.
This suggests that this method not only allows the removal of glands in subcutaneous fat but also enables curettage of the deep dermis. In all biopsies of patients who had undergone this method of treatment, histopathology demonstrated that the operated axillary skin was similar to a total skin graft. From a total of 15 patients assessed by this technique, 1 one showed only a slight reduction in the sweating rate.
However, the authors concluded in this case that the procedure had not been performed in a sufficient or sufficiently aggressive way, since histopathological analysis revealed a large number of residual sweat glands. The technique consisting of curettage and mechanical suction, performed with the use of arthroscopic shavers, would have the advantage of allowing a faster surgery, when compared to manual curettage.
However, surgeons who are inexperienced in the use of the technique should beware of the possibility of perforation of the axillary skin. If the suction is too strong, the dermis could be strongly sucked against the blade. Bechara et al 90 point out that a more extensive training would be necessary to avoid such perforations, when compared to other techniques such as curettage, superficial liposuction and liposuction curettage.
The authors also highlight the high costs of the material needed. Thus, suction-curettage is a considerably more favorable method in terms of cost-benefit, and offers similar results.
In a study for the treatment of osmidrosis, Lee et al 72 reported a reduction in cases of skin perforation with the use of a modified outer cannula. This outer cannula had a grid on its orifice in order to protect the dermis from the inner curette. The same authors suggest that a careful palpation of the axillary skin thickness is carried out, in order to avoid deep planes and consequent risk of vascular damage.
To Bechara et al , 11 minimally invasive surgeries will only offer promising results if a strong resection of the glands at the dermis-subcutaneous interface is performed, leaving the skin looking like a total graft tissue. This area would have its blood supply from the surrounding skin, which has not been submitted to the procedure.
Thus, cutting instruments would be necessary when performing curettage of the deep dermis, in order to effectively remove the sweat glands Figure 2. However, the choice of the cannula to be used varies greatly among authors. In general, this choice is based on the surgeon's personal experience or on suggestions taken from isolated case reports.
Instruments used for curettage examples : A: Fatemi Cannula;77 B: Capistrano Cannula; C: Recamier gynecologic curette, Cassio cannula, Schroeder gynecological curette from the left to the right ; D: Arthroscopic shaver The Fatemi cannula has a 3-mm diameter and cm length.
It has the ability of simultaneously performing suction and curettage. Its ability in removing both eccrine and apocrine glands has been already demonstrated.
In addition, it has a very small diameter. Although the Fatemi cannula has cutting edges, it presents structural limitations that would hinder the achievement of enough pressure to reach the deep dermis when a more aggressive approach is required.
Nevertheless, this cannula could be used at the beginning of the procedure for dissecting the dermis of the subcutaneous cellular tissue. The Capistrano cannula is very similar to the Fatemi cannula, and also does not seem to offer the perfect mechanical properties for a radical resection of the glands. The scraping edges of its holes are only slightly elevated and the cannula is slightly sharp.
Therefore, a rasping-type cannula would be more appropriate to perform a more aggressive procedure and consequently achieve higher curative rates. The Cassio cannula could serve that purpose, because it has a cutting edge and a large hole. However, additional care should be taken when using these cannulas alone.
If used too aggressively, they can lead to skin necrosis. Thus, Kim et al 92 suggest the association of the Fatemi and Cassio cannulas as a solution to this problem. One cannula would complement the deficiencies of the other, improving the final result and reducing the risk of complications.
Bechara et al 94 , however, do not recommend the combined use of two cutting devices in the same procedure. A study conducted by these authors had to be suspended due to complications in four patients, that were generated by the use of a combination of dermal curette and sharp rasping cannula. Such a combination would lead to extensive skin damage, impairment of the dermal vascular plexus, and no additional gains in the results. In an article published in , Bechara et al 34 compared the use of three different cannulas: one liposuction cannula with only 1 hole and a flattened tip; another cannula with three holes and a rounded tip; and the third cannula, especially created for curettage with liposuction, with 3 cutting holes and sharp rasps among the holes.
Although all the 3 cannulas have led to a significant reduction in sweat rates, there was a greater reduction in the group in which the sharp cannula specially created for this purpose was used.
In addition, patients operated with this cannula seemed to be more satisfied with the results. The authors attributed this success to the fact that the special cannula had the sharp rasps among its holes.
These would allow an aggressive scraping of the dermal tissue. The traditional liposuction cannulas would have a lower efficiency due to their own structure. Even those with more holes are not sharp. Bechara et al 91 believe that the slightly higher complications rate - found with the use of a more aggressive cannula - is acceptable, because the adverse effects are not permanent or severe, and are well accepted by most patients. The authors show, in this study, that a wider and more aggressive cannula has a significantly higher efficacy when compared to less aggressive cannulas.
Since patients are more interested in getting a positive result than concerned about having focal scars in hidden areas, Field 95 suggests that surgeons do not hesitate to curette the region aggressively in an attempt to avoid minor scarring complications.
According to the author, patients are always informed about the procedures and would rather have a more aggressive surgery as long as it is curative.
However, surgeons should be alert to the fact that curettage should be performed in such a way as to generate the best possible results with the fewest possible side effects Chart 4 and Figure 3. Parameters used to indicate sufficient curettage: A: skin is thin and easy to pinch; B: violet skin coloration; C: skin sucked through the holes of the suction cannula; D and E: easy detachment of hairs when gently pulled by the surgeon.
Field et al 96 reported that, during curettage, the tension and tightness of the overlying skin is of great importance. Even more important is the force applied during the scraping movements, so that the surgeon knows when to stop the procedure. Bechara et al 97 give some intraoperatory, clinical clues indicating sufficient curettage: complete elevation of axillary skin from subcutaneous cellular tissue; slight lividity of axillary skin; 'skin to skin' rolling, showing that there is no more fat adhering to the dermis; palpable hair follicles during 'skin to skin' rolling; 'sipping' sounds caused by the cannula due to the axillary 'cavity', demonstrating complete dissection of the dermis and subcutaneous cellular tissue.
Rho et al 73 indicate as signals of sufficient curettage: skin thickness skin becomes very thin and easy to pinch, as if it were a piece of clothing ; and overlying skin coloration skin becomes slightly violet-colored, which indicates significant damage to the dermal vascular plexus.
Seo et al 86 report that, at the end of the procedure, the skin is very thin, violet to pale-colored, with a few petechiae. They also add another signal that the procedure should be interrupted: visualization of the skin being sucked through the holes of the cannula in use. Liu et al 98 believe that the procedure should be performed until the axillary hair can be easily detached when externally pulled by the surgeon.
Thus, the axillary hair should grow to a length of 2 to 4 mm before surgery. The authors also indicate as parameters for the interruption of surgery: 1 direct visualization of the dermis with the aid of two retractors. The small incisions would serve as windows for the visualization of possible residual apocrine glands; 2 palpation of the treated area to check the thickness of the dermis.
This is useful to beginners, who could train palpation of the optimum thickness by using endoscopic confirmation. Arneja et al 75 also state that the skin thickness should be evaluated by palpation during the entire procedure, which should be stopped when the glandular tissue is no longer palpable.
The axilla is a region of the body that is more prone to the formation of hematoma and seroma, due to the inability to properly compress the axillary cavity created by the surgical procedure during the initial postoperative period.
Patients should be advised to avoid abrupt movements of the arms especially abduction and elevation movements for 2 weeks. Strenuous physical exercise should be avoided for 1 month. Bienik et al 81 suggest the introduction, three weeks after surgery, of local measures for prevention and improvement of subcutaneous fibrosis, such as: local heat, massage, gels or ointments containing heparin or flavonoids. Such measures should be maintained for three months after the procedure. Chern et al 74 conducted a study for the treatment of 30 patients with osmidrosis, in which they dissected the subcutaneous tissue prior to curettage and liposuction.
The procedure was performed through cavities opened between the fibrovascular bands. No cases of hematoma or skin necrosis were reported. The authors therefore recommend the careful preservation of subcutaneous fibrovascular cords during liposuction-curettage with the arthroscopic shaver, which would result in a more effective clinical response with fewer complications.
Although minimally invasive techniques have shown a relatively low complications rate, a variety of mild to moderate side effects for the most part, temporary has been reported. Complications assotiated to the liposuction-curettage method - correlation with the instruments used.
Bechara et al describe the case of a patient who presented with bilateral seroma, a rare complication. The patient had previously undergone transaxillary surgery for breast enlargement, and presented many adhesions that could not be dissected only with a suction-curettage cannula, but had to be removed with the use of scissors. The authors propose that previous surgical interventions in the axillary region should be considered as a risk factor for a higher incidence of complications.
There has been a report of the occurrence of multiple epidermal inclusion cysts after liposuctioncurettage. Such damage would also be the factor responsible for the partial alopecia of the axillary skin after surgery. Rho et al suggest that the trauma would be associated with an abnormal repair of hair follicles, leading to the emergence of structures that are unable to produce hairs, but are capable of forming keratin.
Axillary hyperhidrosis is not only an aesthetic problem, but a disabling and distressing disease. Suction-curettage is effective and can significantly improve the quality of life of patients. However, recurrences may occur after the procedure. Although the exact cause for this fact is not clearly understood, many theories have been suggested, such as insufficient curettage and anatomical variations with large concentrations of sweat glands in the upper reticular dermis.
Other hypotheses are: compensatory hyperfunction of the remaining sweat glands, and curettage performed in a wrong anatomical tissue layer. This fact is corroborated by the findings of Lawrence et al 67 that showed the presence of sweat glands in the lower portion of the skin.
An average of mm of its thickness was found to be occupied by glandular tissue. Bechara et al evaluated 24 patients with recurrent sweating after performing minimally invasive procedures liposuction and liposuction-curettage using the starch- iodine test. The authors found three patterns of recurrence: circular, crescent and punctual at the site of the surgical incisions. These patterns indicate that surgeons focus mainly on the central axillary region, which is often the most hyperhidrotic area.
The crescent type was always observed at the lateral aspect of the pectoralis muscle, suggesting that the cupped depression that exists between the muscle and the axilla interferes with a careful curettage.
The areas around the incisions are not easily achieved by curettage, which is performed in a fan shape movement. This favors the persistence of sudoresis at these sites. The pressure that is necessary for scraping is not adequately performed around the cannula insertion points.
From these findings, the authors suggest the performance of preoperative marking of the hyperhidrotic area through the starchiodine test, followed by the performance of a precise surgery at all identified sweating sites. Small areas of recurrence of sweating can generally be identified with starch-iodine test. In these cases, the restricted areas can be easily excised with primary closure, avoiding a second minimally invasive procedure. Bechara et al 70 conducted a study in which they assessed the axillary blood flow of 11 patients undergoing liposuction-curettage.
Patients were assessed prior to surgery and on days 1, 7 and 28 after surgery. Measurements were performed in the central region, in the area that is located at two centimeters from the center but remains inside the curetted area, and in the surrounding normal skin through laser Doppler images. On days 1 and 7 after surgery, the central area and the area at 2 cm from the center were significantly less perfused, while the adjacent area showed greater perfusion values. This fact could match the clinical observation that skin necrosis always occurs in the central axillary region.
On day 28 after surgery, no region showed values significantly different from those obtained prior to surgery , although the central region still had slightly reduced perfusion. Kreyden et al point out that there is no clear distinction between physiological sweating and pathological excessive sweating. The perception of hyperhidrosis, according to these authors, is very individual. This would avoid patient dissatisfaction. Bechara et al propose that, for scientific studies, the effectiveness of surgical procedures for the treatment of axillary hyperhidrosis is assessed by at least one objective measuring method.
These authors report that it can be difficult to differentiate between patients in whom surgery was not effective and those who are dissatisfied, although iodine-starch and gravimetric tests are normal. Proebstle et al believe that a control interval of at least four weeks would be necessary for the performance of the gravimetric test after the surgical procedure. This is because during the first two weeks after surgery, sweating usually stops completely, and only thereafter is restored to a new individual level.
Swinehart et al consider that a successful outcome occurs when patients are capable of controlling their sweating by using conventional antiperspirants and deodorants, since the removal of all sweat glands is impossible. According to the analysis of table 1 , 7. Only satisfied patients and good to excellent outcomes were considered successful results. Surgery is generally well tolerated by patients and requires shorter times away from daily activities days , when compared to other surgical modalities.
Although the type IB techniques are usually quite effective and curative, patients who are not fully satisfied can be re-operated using the same method. This is done almost invariably with success. The mastery of technique is crucial for the safe performance of the procedure, with few complications and low recurrence rates. Although the present results are quite satisfactory, there is always room for innovation and improvement of techniques. Conflict of interest: None.
Financial Support: None.
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