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Original Article Surgical Treatment of Bromhidrosis Tratamento Cirúrgico Da Bromidrose

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Original Article Surgical Treatment of Bromhidrosis Tratamento Cirúrgico Da Bromidrose Original Article Surgical treatment of bromhidrosis Tratamento cirúrgico da bromidrose ALEXANDRE KATAOKA 1* ■ ABSTRACT Introduction: Bromhidrosis or osmidrosis causes many patients to seek specialized medical treatment. Removal of the sweat glands from the axillary region through excision and complementary liposuction is a minor, technically simple procedure, with few complications. The objective of this study is to review the role of surgery in bromhidrosis, complications of treatment, and the degree of patient satisfaction. Method: Thirty-two patients underwent liposuction and removal of axillary tissue under local anesthesia and sedation. The patients were followed up for at least 6 months postoperatively, to evaluate the outcome and possible complications. The Client Satisfaction Questionnaire was completed after 6 months. Results: After 6 months of follow- up, there were few complications and the questionnaire revealed a high degree of satisfaction. Conclusion: In addition to being easily performed, the procedure was safe, with few complications. Keywords: Sweat gland diseases; Treatment; Reconstructive surgical procedures; Sweat glands; Sweat. ■ RESUMO Introdução: A bromidrose ou osmidrose é um problema que leva inúmeros pacientes a procurar tratamento médico especializado. A remoção das glândulas sudoríparas da região axilar por meio de exérese e lipoaspiração complementar é um procedimento de pequeno porte, tecnicamente simples e com poucas complicações. O objetivo deste trabalho é mostrar a aplicação da cirurgia neste problema, suas complicações e o grau de satisfação dos pacientes. Método: Trinta e dois pacientes foram submetidos à lipoaspiração e retirada dos tecidos da axila, sob anestesia local e sedação. Acompanhou-se por no mínimo 6 meses estes pacientes no pós- operatório, avaliando a evolução e possíveis complicações e aplicou- se o questionário CSQ-8 para o grau de satisfação no sexto mês. Institution: Hospital Ruben Berta, Resultados: Após 6 meses de acompanhamento, poucas foram as São Paulo, SP, Brazil. complicações e as respostas ao questionário demonstraram alto grau de satisfação. Conclusão: Além de ser facilmente exequível, Article received: April 14, 2016. o procedimento se mostrou seguro e com poucas complicações. Article accepted: June 6, 2016. Descritores: Doenças das glândulas sudoríparas; Tratamento; Conflicts of interest: none. Procedimentos cirúrgicos reconstrutivos; Glândulas sudoríparas; Suor. DOI: 10.5935/2177-1235.2017RBCP0062 1 Secretaria de Justiça e Cidadania de São Paulo, São Paulo, SP, Brazil. Rev. Bras. Cir. Plást. 2017;32(3):377-382 377 Surgical treatment of bromhidrosis INTRODUCTION apocrine predominance appears after puberty. In con- trast, eccrine bromhidrosis predominates in childhood1. Bromhidrosis, also known as osmidrosis, is the Physical examination of individuals with axillary presence of strong and unpleasant body odor, despite (apocrine) bromhidrosis is usually normal. However, since proper hygiene. It is largely due to secretion by the apo- eccrine bromhidrosis is caused by bacterial degradation of crine glands, but may also be caused by metabolic dis- macerated keratin materials, a thick layer of moist keratin eases, food, drugs, or toxic materials, and is also associated may be found on occasion5. Some diseases may be associ- with hyperhidrosis1. Bacteria and debris release volatile ated with hyperhidrosis or bacterial overgrowth (obesity, components with unpleasant odors, and decomposition diabetes mellitus, hidradenitis suppurativa). products are also contributory. Bromhidrosis is a health The differential diagnosis of bromhidrosis should problem that affects personal life, work, and interpersonal consider associated disorders such as organic brain relationships2. lesions (olfactory hallucinations may be related to neu- Human secretory glands are divided into two rological diseases) and psychiatric disorders (paranoid types: eccrine and apocrine. The eccrine glands are dis- disorders, schizophrenia, phobias, and dysmorphic tributed over the surface of the body and are involved disorders)1. in thermoregulation by producing sweat. The apocrine Management involves treating the underlying glands release secretions into hair follicles, and have a pathogenic mechanism. distribution limited to the axilla, anogenital region, and Hygienic measures - Patients are advised to main- breasts. They do not participate in thermoregulation and tain proper hygiene, based on the use of antibacterial are responsible for the characteristic odor of pheromones. soaps and antiperspirants, by decreasing the bacterial They are located deep in the dermis or upper region of flora of the skin. Underarm hygiene can be maintained the hypodermis. during the day using alcohol wipes. Contrary to belief, Like the sebaceous glands, the odoriferous (apo- antiperspirants with aluminum, zirconium, or zinc salts crine) sweat glands are stimulated by sex hormones and have not shown this action in the apocrine glands, but become functional at puberty. The secretion contains are effective in the eccrine glands. In a patient with hy- proteins, carbohydrates, lipids, and ammonia, as well perhidrosis, it is vital to keep the skin dry. Treatments as pheromones, which are involved in sexual attraction. that decrease local moisture may be beneficial for both Initially odorless, it acquires an acrid or musky odor in apocrine and eccrine bromhidrosis. response to bacterial decomposition3. Dietary treatment - Avoiding certain foods and In a healthy adult, the axillary apocrine glands beverages (garlic, spices, alcohol) that may be contribut- are the greatest contributors to body odor. Apocrine ing factors can improve this clinical condition. secretions are sterile and odorless when they reach the Medical treatment - Before starting specific surface of the body. However, bacteria begin to degrade therapies for bromhidrosis, the existence of a treatable the secretions, yielding fatty acids and ammonia as the underlying organic disorder should be ruled out. Topical odiferous products of decomposition. It is believed that antibiotics that act to control the growth of bacteria are odor is associated with growth of bacterial species, pos- an important therapy with rewarding results1. sibly Corynebacterium4. Surgical treatment for bromhidrosis is limited Excessive eccrine secretion may favor apocrine because of the risks of morbidity inherent in these proce- production and contribute to bromhidrosis. In certain dures. Surgery aims to reduce secretions and the number circumstances, odorless eccrine secretion becomes un- of apocrine glands by aspiration and/or direct removal. pleasant, usually occurring after eating certain foods, such Current techniques include aspiration of glandular con- as garlic, onions, spices, alcohol, or certain medications. tent, complete excision of tissue, or a combination of Other theories postulate that eccrine secretion softens both; liposuction is only complement to excision, since keratin, allowing some bacteria to degrade proteins and it cannot treat the entire area affected by bromhidrosis. produce unpleasant odors1. These procedures are associated with the following The use of deodorants and antiperspirants to complications: skin necrosis, dehiscence, hematoma, and control odor produced by the apocrine glands has an keloid formation. estimated cost of 400 million dollars annually in the USA. Superficial liposuction is a less traumatic tech- There are no data on the prevalence of bromhidrosis in nique, and is performed under local anesthesia with the general population. Although it affects individuals minimal incisions. According to the literature, the relapse of all ethnicities, it is believed to be more common in rate is approximately 40% when used alone, and achieves dark-skinned individuals (Africans have larger apocrine more than 90% success when used to complement tissue glands). There is male predominance, reflecting the exis- excision6,7. Skin and subcutaneous excision removes all tence of more active apocrine glands. Bromhidrosis with tissue in order to eliminate skin and cellular attachments. 378 Rev. Bras. Cir. Plást. 2017;32(3):377-382 Kataoka A www.rbcp.org.br However, it is more invasive, cannot treat the entire af- water from sweating appears purple, thus delimiting the fected region, and is often complemented by liposuction7. region with excess sweat and the area to be lipoaspirated and resected (Figure 1). OBJECTIVE The aim of this study was to evaluate the use of bromhidrosis surgery, its risks and complications, and the degree of patient satisfaction with the combined techni- que of liposuction and excision of subcutaneous tissue. All patients were followed up for at least 6 months and completed a validated Client Satisfaction Questionnaire (CSQ-8). METHOD A retrospective observational study was performed between February 2011 and October 2014 at the Ruben Berta Hospital, São Paulo, SP, Brazil, with patients of both sexes undergoing combined liposuction and excision of axillary sweat glands. All patients signed an informed consent form approved by the Ruben Berta Hospital, and consented to participate in data collection for scientific work. The inclusion criteria for bromhidrosis surgery were failure of nonsurgical treatment and clinical confirmation of bromhidrosis. The treatment was explained to the patients, and all possible complications of the surgical procedure, such as extensive and unaesthetic scarring, hardening of the region, hematoma, infection, and local
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