LETTERS AND COMMUNICATIONS
Treatment options for AHA include bypassing agents, which circumvent factor VIII in activating the coagulant pathway, and immunosuppressant medications. The bypassing agents include both recombinant activated factor VII and the activated prothrombin complex concentrate anti-inhibitor coagulant complex.4 These drugs are the treatment of choice for active, potentially fatal bleeding, but may be associated with an increased risk of thrombosis. Immunosuppressants are used to lower factor VIII inhibitor titers. These medications thereby have the ability to both treat active bleeding that is mild and to prevent recurrent bleeding episodes from occurring. First-line immunosuppressants include systemic corticosteroids alone or with the addition of cyclophosphamide. Resistant cases occasionally require concomitant rituximab, azathioprine, calcineurin inhibitors, or other agents.4 Although immunosuppression is commonly withdrawn after normalization of factor VIII function, approximately 10% to 20% of patients relapse and may require longterm therapy. Surgical interventions for disorders that are not life-threatening should be postponed until the coagulopathy is resolved.1,4 Mohs micrographic surgery is performed with a highdegree of safety and is well tolerated by patients.3 Active bleeding after MMS is relatively rare, with a rate of 0.1% reported by a recent prospective multicenter study.2 Preoperative laboratory work-up to evaluate for a hemorrhagic predisposition is thus not indicated in the absence of a concerning medical history. Postoperative bleeding is most commonly precipitated by
a known risk factor, such as the use of anticoagulant medications and complex reconstruction of large surgical defects.2,3 As such, a high level of vigilance is necessitated if a patient develops prolonged bleeding that is not explained by known risk factors and does not respond to standard temporizing measures.2,3 Particularly because AHA is both potentially life-threatening and treatable, dermatologic surgeons should be aware of this disorder as a possible etiology of prolonged postoperative hemorrhage. References 1. Webert KE. Acquired hemophilia A. Semin Thromb Hemost 2012;38:735–41. 2. Alam M, Ibrahim O, Nodzenski M, Strasswimmer JM, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol 2013;149:1378–85. 3. Merritt BG, Lee NY, Brodland DG, Zitelli JA, et al. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol 2012;67:1302–9. 4. Collins PW. Therapeutic challenges in acquired factor VIII deficiency. Hematology Am Soc Hematol Educ Program. 2012;2012:369–74.
S. Tyler Hollmig, MD Department of Dermatology Stanford University Medical Center Palo Alto, California Adam G. Perry, MD Joel Cook, MD Department of Dermatology and Dermatologic Surgery Medical University of South Carolina Charleston, South Carolina
Alternative Continuous Quilting Suture Technique for Preventing Hematoma in Axillary Osmidrosis Axillary osmidrosis is a condition in which excessive unpleasant malodor originates from the axillary apocrine glands.1 For decades, surgical resection of apocrine glands has been the standard treatment; however, occurrence of postoperative hematoma formation beneath the axillary skin sometimes becomes problematic. Bechara and colleagues2 reported that the rate of hematoma after surgical resection was as high as 57%. To prevent hema-
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toma, multiple quilting suture procedures for compressing the axillary skin to the underlying fascia have been proposed.3 Rho and colleagues, in their randomized clinical trial, reported that quilting the axillary skin significantly reduced postoperative hematoma formation.4 However, to accomplish interrupted quilting stitches firmly on both sides of the axillae, the procedure generally takes approximately 10 to 15 minutes. Thus, we here used
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
postoperatively, and the suture is removed 5 to 7 days postoperatively. Results We applied the above-described procedure to 26 axillae of 13 patients. A minor hematoma was found in 2 axillae; however, both hematomas subsided with proper drainage. The postoperative status of the patient in Figure 1 is shown in Figure 2. Discussion Figure 1. Continuous quilting suture in the axilla.
a “continuous” quilting suture technique to shorten the operation time (Figure 1). Surgical Technique After excision of the apocrine glands, the wound is closed without a drain. The continuous quilting suture is started from the most proximal cephalic side of the wound. The suture is continued distally using a 4-0 nonabsorbable thread with a half-circled reverse cutting edge needle. The needle should scoop up not only the skin but also the underlying axillary fascia. Each stitch should be approximately 2-cm long. After reaching the most distal point, the suture is passed vertically (caudally) for 1-2 stitches. Next, the suture is continued back proximally in the same manner to reach the start point, on which both suture ends are tied gently. Care must be taken to avoid forming a large wrinkle on the skin. Tie-over dressing is not applied. The patient is advised to minimize arm movements for at least 3 days
The present procedure is easy to perform and saves surgeons effort compared with the conventional interrupted quilting suture. Practically, it takes less than 4 minutes to accomplish all sutures on both sides. Although the difference in operation time compared with the conventional interrupted technique is only 5 to 10 minutes, the continuous technique should be considered because longer operations are related to elevated complication rates.5 Additionally, the technique also reduces the required number of sutures. Usually, a total of 2 sutures is adequate for both sides. Furthermore, when removing the sutures, it takes only 10 seconds per side, and the patients are less likely to feel pain. Although a minor hematoma occurred in 2 patients, this incidence is not higher than that of previously reported techniques.2 In conclusion, the procedure described here is convenient and timesaving. It may be used as an alternative technique for anchoring the axillary skin to the
Figure 2. (A) Two-month postoperative status. (B) Six-month postoperative status.
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
underlying fascia to prevent hematoma and has the potential to be used in any surgical treatment of axillary osmidrosis. References 1. Huang YH, Yang CH, Chen YH, Chen CH, et al. Reduction in osmidrosis using a suction-assisted cartilage shaver improves the quality of life. Dermatol Surg 2010;36:1573–7. 2. Bechara FG, Sand M, Sand D, Altmeyer P, et al. Surgical treatment of axillary hyperhidrosis: a study comparing liposuction cannulas with a suction-curettage cannula. Ann Plast Surg 2006;56: 654–7. 3. Tung TC, Wei FC. Excision of subcutaneous tissue for the treatment of axillary osmidrosis. Br J Plast Surg 1997;50:61–6. 4. Rho NK, Shin JH, Jung CW, Park BS, et al. Effect of quilting sutures on hematoma formation after liposuction with dermal curettage for treatment of axillary hyperhidrosis: a randomized clinical trial. Dermatol Surg 2008;34:1010–5.
1060
5. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg 2007;119: 1060–4.
Yusuke Shimizu, MD, PhD Tomohisa Nagasao, MD, PhD Kazuo Kishi, MD, PhD Department of Plastic and Reconstructive Surgery Keio University School of Medicine Tokyo, Japan Toru Asou, MD Department of Plastic Surgery Tokyo Cosmetic Surgery Clinic Tokyo, Japan
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
Treatment options for AHA include bypassing agents, which circumvent factor VIII in activating the coagulant pathway, and immunosuppressant medications. The bypassing agents include both recombinant activated factor VII and the activated prothrombin complex concentrate anti-inhibitor coagulant complex.4 These drugs are the treatment of choice for active, potentially fatal bleeding, but may be associated with an increased risk of thrombosis. Immunosuppressants are used to lower factor VIII inhibitor titers. These medications thereby have the ability to both treat active bleeding that is mild and to prevent recurrent bleeding episodes from occurring. First-line immunosuppressants include systemic corticosteroids alone or with the addition of cyclophosphamide. Resistant cases occasionally require concomitant rituximab, azathioprine, calcineurin inhibitors, or other agents.4 Although immunosuppression is commonly withdrawn after normalization of factor VIII function, approximately 10% to 20% of patients relapse and may require longterm therapy. Surgical interventions for disorders that are not life-threatening should be postponed until the coagulopathy is resolved.1,4 Mohs micrographic surgery is performed with a highdegree of safety and is well tolerated by patients.3 Active bleeding after MMS is relatively rare, with a rate of 0.1% reported by a recent prospective multicenter study.2 Preoperative laboratory work-up to evaluate for a hemorrhagic predisposition is thus not indicated in the absence of a concerning medical history. Postoperative bleeding is most commonly precipitated by
a known risk factor, such as the use of anticoagulant medications and complex reconstruction of large surgical defects.2,3 As such, a high level of vigilance is necessitated if a patient develops prolonged bleeding that is not explained by known risk factors and does not respond to standard temporizing measures.2,3 Particularly because AHA is both potentially life-threatening and treatable, dermatologic surgeons should be aware of this disorder as a possible etiology of prolonged postoperative hemorrhage. References 1. Webert KE. Acquired hemophilia A. Semin Thromb Hemost 2012;38:735–41. 2. Alam M, Ibrahim O, Nodzenski M, Strasswimmer JM, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol 2013;149:1378–85. 3. Merritt BG, Lee NY, Brodland DG, Zitelli JA, et al. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol 2012;67:1302–9. 4. Collins PW. Therapeutic challenges in acquired factor VIII deficiency. Hematology Am Soc Hematol Educ Program. 2012;2012:369–74.
S. Tyler Hollmig, MD Department of Dermatology Stanford University Medical Center Palo Alto, California Adam G. Perry, MD Joel Cook, MD Department of Dermatology and Dermatologic Surgery Medical University of South Carolina Charleston, South Carolina
Alternative Continuous Quilting Suture Technique for Preventing Hematoma in Axillary Osmidrosis Axillary osmidrosis is a condition in which excessive unpleasant malodor originates from the axillary apocrine glands.1 For decades, surgical resection of apocrine glands has been the standard treatment; however, occurrence of postoperative hematoma formation beneath the axillary skin sometimes becomes problematic. Bechara and colleagues2 reported that the rate of hematoma after surgical resection was as high as 57%. To prevent hema-
1058
toma, multiple quilting suture procedures for compressing the axillary skin to the underlying fascia have been proposed.3 Rho and colleagues, in their randomized clinical trial, reported that quilting the axillary skin significantly reduced postoperative hematoma formation.4 However, to accomplish interrupted quilting stitches firmly on both sides of the axillae, the procedure generally takes approximately 10 to 15 minutes. Thus, we here used
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
postoperatively, and the suture is removed 5 to 7 days postoperatively. Results We applied the above-described procedure to 26 axillae of 13 patients. A minor hematoma was found in 2 axillae; however, both hematomas subsided with proper drainage. The postoperative status of the patient in Figure 1 is shown in Figure 2. Discussion Figure 1. Continuous quilting suture in the axilla.
a “continuous” quilting suture technique to shorten the operation time (Figure 1). Surgical Technique After excision of the apocrine glands, the wound is closed without a drain. The continuous quilting suture is started from the most proximal cephalic side of the wound. The suture is continued distally using a 4-0 nonabsorbable thread with a half-circled reverse cutting edge needle. The needle should scoop up not only the skin but also the underlying axillary fascia. Each stitch should be approximately 2-cm long. After reaching the most distal point, the suture is passed vertically (caudally) for 1-2 stitches. Next, the suture is continued back proximally in the same manner to reach the start point, on which both suture ends are tied gently. Care must be taken to avoid forming a large wrinkle on the skin. Tie-over dressing is not applied. The patient is advised to minimize arm movements for at least 3 days
The present procedure is easy to perform and saves surgeons effort compared with the conventional interrupted quilting suture. Practically, it takes less than 4 minutes to accomplish all sutures on both sides. Although the difference in operation time compared with the conventional interrupted technique is only 5 to 10 minutes, the continuous technique should be considered because longer operations are related to elevated complication rates.5 Additionally, the technique also reduces the required number of sutures. Usually, a total of 2 sutures is adequate for both sides. Furthermore, when removing the sutures, it takes only 10 seconds per side, and the patients are less likely to feel pain. Although a minor hematoma occurred in 2 patients, this incidence is not higher than that of previously reported techniques.2 In conclusion, the procedure described here is convenient and timesaving. It may be used as an alternative technique for anchoring the axillary skin to the
Figure 2. (A) Two-month postoperative status. (B) Six-month postoperative status.
40:9:SEPTEMBER 2014
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
underlying fascia to prevent hematoma and has the potential to be used in any surgical treatment of axillary osmidrosis. References 1. Huang YH, Yang CH, Chen YH, Chen CH, et al. Reduction in osmidrosis using a suction-assisted cartilage shaver improves the quality of life. Dermatol Surg 2010;36:1573–7. 2. Bechara FG, Sand M, Sand D, Altmeyer P, et al. Surgical treatment of axillary hyperhidrosis: a study comparing liposuction cannulas with a suction-curettage cannula. Ann Plast Surg 2006;56: 654–7. 3. Tung TC, Wei FC. Excision of subcutaneous tissue for the treatment of axillary osmidrosis. Br J Plast Surg 1997;50:61–6. 4. Rho NK, Shin JH, Jung CW, Park BS, et al. Effect of quilting sutures on hematoma formation after liposuction with dermal curettage for treatment of axillary hyperhidrosis: a randomized clinical trial. Dermatol Surg 2008;34:1010–5.
1060
5. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg 2007;119: 1060–4.
Yusuke Shimizu, MD, PhD Tomohisa Nagasao, MD, PhD Kazuo Kishi, MD, PhD Department of Plastic and Reconstructive Surgery Keio University School of Medicine Tokyo, Japan Toru Asou, MD Department of Plastic Surgery Tokyo Cosmetic Surgery Clinic Tokyo, Japan
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
