Distribution of Apocrine Sweat Glands in Han Patients with Axillary Osmidrosis and Its Surgical Treatments

Full Length Research Paper

Distribution of apocrine sweat glands in Han patients with axillary osmidrosis and its surgical treatments

H. Chen1*, C. X. Li2, J. Du1, H. Y. Chen1 and Y. J. Wang1

1Department of Cosmetic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, China. 2Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi’an 710038, China.

Accepted 11 August, 2010

The present study aimed to detect the distribution range and layer of apocrine sweat gland in Han patients with axillary osmidrosis and to select proper therapeutic regimen. Skin and subcutaneous tissue in axillary region were examined by H&E staining. The location of apocrine sweat gland in skin and tissue of axillary region and its correlation with other skin and tissue were observed under microscope. Axillary osmidrosis was treated by tumescent anesthesia, negative pressure aspiration and scissors pruning. The distribution range and depth of apocrine sweat gland in patients with axillary osmidrosis were basically identical with those of hair follicles of hirci, and they are mainly distributed in the reticular layer of corium and superficial adipose layer. The wounds of 56 patients healed well in our group, without recurrence. Tumescent anesthesia, negative pressure aspiration and scissors pruning could be adopted in the treatment of axillary osmidrosis, and good therapeutic effects were obtained.

Key words: Axillary osmidrosis, apocrine sweat gland; distribution; treatment.

INTRODUCTION

Axillary osmidrosis is a common and frequent disease males and 38 females, aged 16 - 35 years. 17 patients were which usually occurs in young adults. It is generally recurrent cases after other surgical treatments. 10 volunteers with considered that axillary osmidrosis is related to the auxiliary osmidrosis (mean age: 22 years old), having full-thickness skins in the middle of the axillary region and the edge region of abnormal secretion of apocrine sweat gland, with obvious hirci, were selected, and as a result, 0.5 and 1.0 cm from the edge heredity (Lai, 1983). Previously, there were many surgical of hirci were examined by H&E staining. therapeutic methods for axillary osmidrosis (Zhang et al., 2002; Zheng and Li, 2004; Liu et al., 2008), with their own Surgical methods advantages and disadvantages. The reasons of poor therapeutic efficacy included the indefinite distribution Design and anaesthesia range of apocrine sweat gland, the unclear construction features of tissues and the unreasonable surgical Patient was placed in a supine position, with upper limb abduction, methods. We detected the distribution range of apocrine elbow flexion and embracing head. The operation incision was sweat gland in Han patients with axillary osmidrosis and designed in armpit crimple and reached the edge of the hirci. Local anesthesia was performed in the skin incision with 1% lidocaine. adopted tumescent anesthesia, negative pressure aspira- 0.2 ml epinephrine and 10 ml 2% lidocaine were added into 100 ml tion and scissors pruning to treat axillary osmidrosis, and normal saline, and then tumescent anesthesia was performed in the good therapeutic effects were obtained. subcutaneous tissue of operation region. The range of tumescent anesthesia reached 2.0 cm out of the edge of hircus. About 0.2 × 0.3 cm spindle-shaped full-thickness skins from the middle of PATIENTS AND METHODS axillary region, the edge region of hirci, 0.5 and 1.0 cm out of the edge of hircus were resected for pathological examination, Patients respectively.

A total of 56 Han patients were enrolled in our study, including 18 Method of operation

The operation area was disinfected with iodophors. After successful *Corresponding author. E-mail: [email protected]. Tel: local anesthesia, a 0.5 cm long incision was made in the median +8629-84777777. line of armpit crimple, and skin as well as subcutaneous tissue was Chen et al. 2557

Figure 1. H&E staining of skin and tissue in the middle of axillary region: more apocrine sweat glands were seen; Figure 3. H&E staining of skin and tissue in 1.0 cm out of the arrow indicates the apocrine sweat gland (×40). the edge of hirci: normal skin and subcutaneous tissue without any apocrine sweat gland (×100).

glands in patients with axillary osmidrosis were basically identical with those of hair follicles of the hirci (Figure 1). There still existed, a small amount of apocrine sweat glands in 0.5 cm out of the edge of the hirci (Figure 2), and there were no apocrine sweat glands in 1.0 cm out of the edge of hircus (Figure 3). Apocrine sweat gland mainly distributed in reticular layer of corium and superficial adipose layer. The reticular layer of corium in axillary region was thick, loose and soft, and the dermal fibres showed high elasticity and toughness, therefore, it was very difficult to remove the apocrine sweat glands.

Surgical effects Figure 2. H&E staining of skin and tissue in 0.5 cm out of the edge of hirci: a small amount of apocrine sweat glands were seen; the arrow indicates the apocrine The surgical wounds of 56 patients healed well in our sweat gland (×100). group, without recurrence or necrosis of skin. The scar, which was tiny and hidden, did not affect the function and

motion of double upper extremities, and the hirci hardly then cut open. Blunt separation was performed along the regrew (Figures 4 and 5). subcutaneous adipose layer using a peel shear. Then, a special spatula for axillary osmidrosis was used to simply clear the fat, sebaceous glands, hair follicles and sweat glands on the skin flap DISCUSSIONS and the superficial adipose layer, sebaceous glands and sweat glands on the basilar raw surface. The incision was extended to the edge of the hirci, and the flap was uncovered and turned over. Axillary osmidrosis is characterized by an excessive, Connective tissue on the skin flap, such as fat, sebaceous glands, unpleasant odor that originates from the apocrine glands hair follicles and sweat glands were pruned by dissecting scissors, in the axillary area (Kao et al., 2004). The exact etiology in order to form intermediate split thickness skin graft. After reliable of axillary osmidrosis is still unknown, but is generally hemostasis, the incision was sutured interruptedly using 5 - 0 suture considered to be related with the abnormal secretion of silk, and two rows of No.1 line suture was carried out at 0.5 cm out apocrine sweat glands. In Bovell’s study serial sections of of the edge of hirci. It was wrapped by pressure bandaging. 10 days after operation, stitches were taken out. axillary skin have been examined by histology and immunofluorescence (Bovell et al., 2007). The markers reported to discriminate between apocrine and eccrine RESULTS glands were found to be nonspecific. No evidence of apoeccrine glands was found either by histology or by Pathological examination immunofluorescence. Axillary osmidrosis is a common familial disease with a young female predominance, and The distribution range and depth of apocrine sweat is commonly found in white and black races, with low 2558 Sci. Res. Essays

could rarely be found in 0.5 cm out of the edge of hirci. Apocrine sweat glands were mainly distributed in the reticular layer of corium and superficial adipose layer, which were inconsistent with the previous report (Beer et al., 2006). The reticular layer of corium in axillary region was thick, loose and soft, and the dermal fibres showed high elasticity and toughness, therefore, it was very difficult to remove apocrine sweat glands through aspiration and scraping. Removing the apocrine sweat glands in axillary region is the basic method to treat axillary osmidrosis. Currently, there are several commonly used methods in clinical practice (Zhang et al., 2002; Zheng and Li, 2004; Liu et al., 2008): (1) Fusiform excision: This method is simple, with an exact effect, but it may produce obvious scarring and influence the motion of upper extremities. (2) Subcu- taneous tissue removal via a small incision with shaving is performed through clipping, stripping and scoraping Figure 4. The status before operation for axillary osmidrosis. using special spatula. This method could thoroughly remove sweat glands, fat, hair follicles, with also an exact therapeutic effect. However, the procedure for removing the sweat glands, fat and hair follicles is performed blindly due to the small incision. The apocrine sweat glands could not be thoroughly removed and the apocrine sweat glands in superficial adipose layer also could not be cleared. Therefore, recurrence potential still remains. (3) “S” incision is designed in the middle of axillary region and the skin flap is turned over. Wu (2009) found that there was no recurrent malodor, contracture scars, arm abduction limitation, or any nerve injury in “S” incision, so it can be an efficient and predictable treatment choice for axillary osmidrosis. The distribution region of apocrine sweat glands is thoroughly pruned into full thick skin graft and intermediate split thickness skin graft, which could basically avoid postoperative recurrence, but it could not also clean up the apocrine sweat glands in superficial adipose layer. Moreover, the incision is easier reveal, which may impact the beautiful outlook.

However, as we detected the distribution range and Figure 5. The scar was hidden and the hirci layer of apocrine sweat glands in axillary osmidrosis hardly regrew 6 months after operation. patients, we adopted many methods including incision in armpit crimple, tumescent anesthesia, removing superficial adipose layer through negative pressure aspiration, thoroughly pruning the distribution region of apocrine low morbility in yellow race. Currently, there are many sweat glands into intermediate split thickness skin graft. therapeutic regimens to axillary osmidrosis, including These methods had the following features: (1) Tumescent non-operative treatment and operative treatment anesthesia “thickened” the subcutaneous tissues. Nega- according to the necessity of operation. However, it is tive pressure aspiration could not only effectively clean up mainly difficult to obtain ideal therapeutic efficacy due to apocrine sweat glands in superficial adipose layer, but the unknown pathogenetic mechanism of axillary also avoid the injury of deep tissues in axillary region. (2) osmidrosis or the indefinite distribution of apocrine sweat A hidden long incision in armpit crimple could satisfy the gland or the unclear construction of skin and tissue in requirement of pruning the skin flap into intermediate split axillary region. We detected the distribution range and thickness skin graft. (3) The thorough removing of layer of apocrine sweat gland in axillary osmidrosis apocrine sweat glands in corium layer and superficial patients and found that the distribution range and depth adipose layer could avoid postoperative reoccurrence. (4) of apocrine sweat glands were basically identical with Wrapping fixation, pressure bandaging and favourable those of hair follicles of hirci, and apocrine sweat glands attendance ensured the survival of intermediate split Chen et al. 2559

thickness skin graft (Cui et al., 2007). This surgical Bovell DL, Corbett AD, Holmes S, Macdonald A, Harker M. (2007). The method had an exact effect for axillary osmidrosis of absence of apoeccrine glands in the human axilla has disease pathogenetic implications, including axillary hyperhidrosis. Br. J. different extents, especially for those patients with posto- Dermatol., 156(6): 1278-1286. perative recurrence.(5)The wounds of 56 patients healed Cui YJ, Chen H, Du J (2007). Perioperative nursing in bromhidrosis well in our group, without recurrence. (6)The hirci could radical resection of aspiration and pruning through axilla crease be removed when axillary osmidrosis was treated, and it incision. Chin. J. Aest. Med., 16(12): 1742-1743. Lai RX (1983). A Preliminary Genetic Study on Osmidrosis Axillae: could even be said “kill two birds with one stone” for Heredity, 5(4): 39. female patients. Liu QY, Song YG, Zheng JH, Ding Z, Yang SL (2008). Full skin flap In conclusion, our study found that the distribution treatment of axillary osmidrosis. Chin J Aest Med., 17(4): 479-482. range and depth of apocrine sweat gland in patients with Kao TH, Pan HC, Sun MH (2004). Upper thoracic sympathectomy for axillary osmidrosis or bromidrosis, J. Clin. Neurosci., 719-722. axillary osmidrosis were basically identical with those of Wu WH (2009). Ablation of apocrine glands with the use of a suction- hair follicles of hirci, and they are mainly distributed in the assisted cartilage shaver for treatment of axillary osmidrosis: an reticular layer of corium and superficial adipose layer. The analysis of 156 cases. Ann. Plast. Surg., 62(3): 278-283. treatment of axillary osmidrosis adopted tumescent anes- Zhang KC, Wu JH, Du F (2002). Bromhidrosis radical resection through tumescent anesthesia and small incisions aspiration. Chin. J. Aest. thesia, negative pressure aspiration and scissors pruning Med., 11(4): 320. that proved to be therapeutic effective, which was Zheng DN, Li QF (2004). Excision of apocrine glands for the treatment completed with no recurrence, less scar, good look and of osmidrosis. Chin. J. Aest. Med., 13(4): 419-421. would not affect the function and motion of double upper extremities.

REFERENCES

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