The Surgical Treatment of Axillary Hyperhidrosis Ph.H. SABATIER A N D A.J. PICAUD
Surgical removal o f the gland-bearing skin o f the axillae as a reasonable management o f axillary hyperhidrosis is described The principlef according to the techniques o f Skoog, is to peel back, not excise, the hairy zone o f the axillary skin and to resect all the hyperfunctioning glan dular layer on the deeper face o f the dermis without damaging the dermal vascularization.
E x c e s s i v e s w e a t i n g from the armpits can be a distress that may disturb the psyche and social life o f afflicted persons, especially young women who are nervous and emotional. The discomfort o f wetness, odor and staining of garments is made all the worse to bear because there is no good topical or internal medicaments to abate the condition. There is, however, an effective surgical treat ment which we recount below. The armpits contain eccrine and apocrine sweat glands in abundance, and it is notorious that these structures are stimulated to secrete their products not only under the influence o f am biant high tem perature, but by psychic factors. Since there are no topical agents that are good enough nor internal medicaments that are selectively effective, surgical excision of the glandbearing skin of the axillae becomes a reasonable management o f axillary hyperhidrosis. In 1963 Hurley and Shelley suggested and practiced removal o f much o f the skin of the axillae by elliptical excisions. Their operation improves the condition but suffers from not D r. S a b a tie r is a n a tte n d in g p la stic s u rg e o n , C .H .U ., 0 6 N ic e F ra n c e . D r. P ic a u d is a p la s tic s u rg e o n , 0 6 N ic e , F r a n c e . A d d re ss r e p r in t re q u e s ts to D r. S a b a tie r, 11 r u e L o n g c h a m p , 06 N ice, F r a n c e .
being always completely controlling. Removal of too little skin may leave too many sweat glands and removal of enough or too much may result in scars that are disturbing of normal movement of the arms. At about the same time, Skoog and Thyresson, and subsequently others, devised operative techniques by S- or Z-plasties that better preserved skin and vasculature while largely ridding the axillae of sweat and apocrine glands. Their principle is to peel back (not excise) axillary skin along lines o f incision and resect only the lower part of the gland-bearing dermis and hypoderm. TECHNIQUE OF OPERATION Under general anesthesia in a hospital or under local anesthesia in a well-equipped office surgery, the patient is placed in the supine position with the arm abducted at an angle not exceeding 120 degrees in relation to the thorax in order not to injure the fifth and sixth cervical nerves by stretching them too much over the head of the humerus. The lines of incision are then traced out with a skin pencil according to Fig. 1. It is to be noted that the incision in the vault of the axilla is longest and that those at right angles to it are m ade about one centimeter from the distal ends of it. The undermining and peeling back of the skin is then done with curved scissors in the plane
J. Dermatol. Surg. 2:4 Septem ber 1976
331
1. The lines o f incision traced out with a skin pencil.
F IG U R E
between the axillary fascia over the cellular subcuta neous tissue. Bleeding controlled, the four freed flaps are then turned back, held by skin hooks and deprived of glands recognizable by their lobules o f gray color. Curved scissors again are used in resecting grossly this subdermal glandular layer. The procedure is much like that of taking a full-thickness skin graft. Magnifying glasses enable one to identify outlying and skipped glands which may be destroyed by fine electrocoagula tion. Care is taken in all of this not to injure subcuta neous blood vessels o f importance. The gland-bearing subcutaneous tissue removed, the flaps are repositioned and sutured with interrupted stitches o f a nonabsorbable material. Strategically placed drains are inserted to conduct away serous or sanguineous discharge. A pressure dressing is applied in a manner not to restrict a certain am ount o f movement of the arm and shoulder. The dressing is changed on the third day postoperatively and the drains are then removed. Sutures are removed on the fifteenth day and bandaging is then dispensed with. Healing proceeds as pictured in Figs. 2 and 3. In the course o f time, the lines of incision become obscured as creases covered by axillary hair. C O N C L U S IO N
Properly performed by not cutting too close to epider mis, not injuring blood supply and by preventing hem a toma formation be hemostasis and drains, no contrac tures result and normal functional mobility is achieved. A certain amount of glandular function resumes since it cannot be expected, nor is it desirable, that every gland be removed. The ideal is to remove enough to end the disability of hyperhidrosis. Improvement can almost always be attained and utter failure can result only from leaving too many glandular structures. Experience and good techniques are the keys to success.
F IG U R E 2.
Healing at 15 days postoperatively.
F IG U R E 3.
Close-up view o f Figure 2.
G E N E R A L R EFERENC ES Skoog, T., and Thyresson, N. Hyperhidrosis o f the axillae. A method o f surgical treatment. Acta C hir. Scand. 124:531-338, 1962. Hurley, H.J., and Shelley, W.B. A simple surgical approach to the management o f axillary hyperhidrosis. J A M A 186:109, 1963. Hurley, H.J., and Shelley, W.B. A x illa ry hyperhidrosis. C linical features and local surgical management. Br. J. Derm atol. 78:127-140, 1966. Skoog, T., and Thyresson, N. The surgical treatm ent o f axillary hyperhidrosis. Br. J. Dermatol. 78:551, 1966. Preaux, M J . Le traitm ent chirurgical de l'hyperhidrose axillaire. Bull. Soc. Fr. Dermatol. Syphil. 74:730-733, 1967. Bretteville-Jensen, G. Radical sweat gland ablation fo r axilla ry hyper hidrosis. Br. J. Plast. Surg. 26:158-162, 1973. Shaw, M .H . A serious com plication ó f an operation fo r axillary hyperhidrosis. Br. J. Plast. Surg. 27:196-197, 1974. Skoog, T. Plastic Surgery. New Methods and Refinements. Stockholm, A lm quist and W iksell, 1974.
Surgical removal o f the gland-bearing skin o f the axillae as a reasonable management o f axillary hyperhidrosis is described The principlef according to the techniques o f Skoog, is to peel back, not excise, the hairy zone o f the axillary skin and to resect all the hyperfunctioning glan dular layer on the deeper face o f the dermis without damaging the dermal vascularization.
E x c e s s i v e s w e a t i n g from the armpits can be a distress that may disturb the psyche and social life o f afflicted persons, especially young women who are nervous and emotional. The discomfort o f wetness, odor and staining of garments is made all the worse to bear because there is no good topical or internal medicaments to abate the condition. There is, however, an effective surgical treat ment which we recount below. The armpits contain eccrine and apocrine sweat glands in abundance, and it is notorious that these structures are stimulated to secrete their products not only under the influence o f am biant high tem perature, but by psychic factors. Since there are no topical agents that are good enough nor internal medicaments that are selectively effective, surgical excision of the glandbearing skin of the axillae becomes a reasonable management o f axillary hyperhidrosis. In 1963 Hurley and Shelley suggested and practiced removal o f much o f the skin of the axillae by elliptical excisions. Their operation improves the condition but suffers from not D r. S a b a tie r is a n a tte n d in g p la stic s u rg e o n , C .H .U ., 0 6 N ic e F ra n c e . D r. P ic a u d is a p la s tic s u rg e o n , 0 6 N ic e , F r a n c e . A d d re ss r e p r in t re q u e s ts to D r. S a b a tie r, 11 r u e L o n g c h a m p , 06 N ice, F r a n c e .
being always completely controlling. Removal of too little skin may leave too many sweat glands and removal of enough or too much may result in scars that are disturbing of normal movement of the arms. At about the same time, Skoog and Thyresson, and subsequently others, devised operative techniques by S- or Z-plasties that better preserved skin and vasculature while largely ridding the axillae of sweat and apocrine glands. Their principle is to peel back (not excise) axillary skin along lines o f incision and resect only the lower part of the gland-bearing dermis and hypoderm. TECHNIQUE OF OPERATION Under general anesthesia in a hospital or under local anesthesia in a well-equipped office surgery, the patient is placed in the supine position with the arm abducted at an angle not exceeding 120 degrees in relation to the thorax in order not to injure the fifth and sixth cervical nerves by stretching them too much over the head of the humerus. The lines of incision are then traced out with a skin pencil according to Fig. 1. It is to be noted that the incision in the vault of the axilla is longest and that those at right angles to it are m ade about one centimeter from the distal ends of it. The undermining and peeling back of the skin is then done with curved scissors in the plane
J. Dermatol. Surg. 2:4 Septem ber 1976
331
1. The lines o f incision traced out with a skin pencil.
F IG U R E
between the axillary fascia over the cellular subcuta neous tissue. Bleeding controlled, the four freed flaps are then turned back, held by skin hooks and deprived of glands recognizable by their lobules o f gray color. Curved scissors again are used in resecting grossly this subdermal glandular layer. The procedure is much like that of taking a full-thickness skin graft. Magnifying glasses enable one to identify outlying and skipped glands which may be destroyed by fine electrocoagula tion. Care is taken in all of this not to injure subcuta neous blood vessels o f importance. The gland-bearing subcutaneous tissue removed, the flaps are repositioned and sutured with interrupted stitches o f a nonabsorbable material. Strategically placed drains are inserted to conduct away serous or sanguineous discharge. A pressure dressing is applied in a manner not to restrict a certain am ount o f movement of the arm and shoulder. The dressing is changed on the third day postoperatively and the drains are then removed. Sutures are removed on the fifteenth day and bandaging is then dispensed with. Healing proceeds as pictured in Figs. 2 and 3. In the course o f time, the lines of incision become obscured as creases covered by axillary hair. C O N C L U S IO N
Properly performed by not cutting too close to epider mis, not injuring blood supply and by preventing hem a toma formation be hemostasis and drains, no contrac tures result and normal functional mobility is achieved. A certain amount of glandular function resumes since it cannot be expected, nor is it desirable, that every gland be removed. The ideal is to remove enough to end the disability of hyperhidrosis. Improvement can almost always be attained and utter failure can result only from leaving too many glandular structures. Experience and good techniques are the keys to success.
F IG U R E 2.
Healing at 15 days postoperatively.
F IG U R E 3.
Close-up view o f Figure 2.
G E N E R A L R EFERENC ES Skoog, T., and Thyresson, N. Hyperhidrosis o f the axillae. A method o f surgical treatment. Acta C hir. Scand. 124:531-338, 1962. Hurley, H.J., and Shelley, W.B. A simple surgical approach to the management o f axillary hyperhidrosis. J A M A 186:109, 1963. Hurley, H.J., and Shelley, W.B. A x illa ry hyperhidrosis. C linical features and local surgical management. Br. J. Derm atol. 78:127-140, 1966. Skoog, T., and Thyresson, N. The surgical treatm ent o f axillary hyperhidrosis. Br. J. Dermatol. 78:551, 1966. Preaux, M J . Le traitm ent chirurgical de l'hyperhidrose axillaire. Bull. Soc. Fr. Dermatol. Syphil. 74:730-733, 1967. Bretteville-Jensen, G. Radical sweat gland ablation fo r axilla ry hyper hidrosis. Br. J. Plast. Surg. 26:158-162, 1973. Shaw, M .H . A serious com plication ó f an operation fo r axillary hyperhidrosis. Br. J. Plast. Surg. 27:196-197, 1974. Skoog, T. Plastic Surgery. New Methods and Refinements. Stockholm, A lm quist and W iksell, 1974.
