Aesth Plast Surg

DOI 10.1007/s00266-014-0431-2

I N N OV A T I V E T E C H N I QU E S

AESTHETIC

A Minimally Invasive Procedure for Axillary Osmidrosis:

Subcutaneous Curettage Combined with Trimming Through
a Small Incision
Rongrong Wang Jie Yang Jiaming Sun

Received: 10 May 2014 / Accepted: 7 November 2014

Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract
Background Though minimally invasive procedures
often yield excellent esthetic results for axillary osmidrosis,
the high recurrence rates of malodor limit its further
application. Incomplete removal of the apocrine glands
would lead to recurrence of the axillary bromhidrosis,
while excessive resection of the apocrine glands firmly
attached to the dermis would easily result in local skin
necrosis. Therefore, accurate management of the apocrine
glands is extraordinarily important, particularly with a
limited access. Herein, we would like to introduce an
effective and minimally invasive procedure combining
subcutaneous curettage and trimming for the treatment of
axillary osmidrosis.
Methods A 5-mm incision was marked at the inferior
pole of the central axillary crease. Subcutaneous undermining was done clinging to the axillary superficial fascia.
The whole procedure was performed in the following
sequence of scrapingtrimmingscraping against the
undermined skin flap until the remaining hairs were easily
pulled out.
Results All the wounds healed primarily without significant complications. Out of 300 axillae, 294 (98 %) showed
good to excellent results for malodor elimination. Scars
were invisible in 280 axillae (93.3 %) and slightly visible
in 18 axillae (6 %). The dermatology life quality index
score decreased significantly after the operation.

R. Wang
J. Yang
J. Sun (&)

Department of Plastic Surgery, Wuhan Union Hospital, Tongji
Medical College of Huazhong University of Science and
Technology, Wuhan 430022, Hubei, Peoples Republic of China
e-mail: sunjm1592@126.com

Conclusion The procedure is an efficacious and minimally invasive method for the treatment of axillary
osmidrosis.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Axillary osmidrosis
Minimally invasive
procedures
Subcutaneous trimming
Curettage

Introduction
It has long been a severe psychological burden for patients
who possess axillary malodor, especially for Asian people.
It is generally accepted that osmidrosis is due to the
interaction between bacterial activity and hyper-secretion
of apocrine gland [1].
Current treatments for osmidrosis include antibacterial
products, deodorants, botulinum toxin injections, subcutaneous laser, percutaneous ethanol injections, and various
surgical methods [27]. However, to achieve permanent
resolution of axillary bromhidrosis, surgical eradication of
the apocrine sweat glands is necessary.
A histological study by Byron and associates showed
that the apocrine sweat glands of the axilla extended from
the lower dermis deeply into the subcutaneous fat [7]. As
the reticular dermis is composed of dense irregular connective tissue, technically, removal of the apocrine glands
firmly attached to the lower dermis is relatively more difficult compared with those located subcutaneously.
Incomplete removal of the apocrine glands would lead
to recurrence of the axillary bromhidrosis, while excessive

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Aesth Plast Surg

resection of the apocrine glands firmly attached to the

dermis would easily result in local skin necrosis [8, 9].
Therefore, accurate management of the apocrine glands is
extraordinarily important throughout the whole process,
particularly with a limited access.
Herein, we would like to present a minimal incision
procedure combining subcutaneous curettage and trimming
of the axillary skin flap for the treatment of axillary
osmidrosis.

Patients and Methods

Patients Demography
One hundred fifty-eight patients with primary bilateral
bromhidrosis were treated using this technique between
January 2009 and December 2013 at our department. There
are 52 males and 106 females. The mean SD age was
21.5 5.8 (age range: 1842 years). The mean bodymass-index (BMI) was 20.6. One hundred twenty-three
patients (77.8 %) had a family history of the disease.
Inclusion criteria: (1) patients should meet the diagnostic
criteria of axillary osmidrosis, and (2) no swollen axillary
lymph nodes or local skin inflammation; normal coagulant
activity. Patients with any previous treatment for axillary
bromhidrosis were excluded.
The severity of malodor was determined by the subjective judgment of two independent surgeons. With the
patient sitting quietly for 30 min at room temperature, the
bilateral axillae were exposed. The severity of malodor was
defined as follows. Mild: slight malodor can be detected at
a close distance of 10 cm and no malodor at a distance of
30 cm; moderate: slight malodor at a distance of 30 cm;
severe: strong malodor at or beyond a distance of 30 cm.
All operations were performed on an outpatient basis.
The follow-up period ranged from 6 to 18 months, with an
average of 11.2 months (Table 1).

Surgical Technique
With the patient in a supine position, the axillae were
exposed with the upper arms abducted slightly above the
shoulder level. Bilateral axillary hair was shaved. Short
(24 mm) axillary hairs were left as indicators. The area
was marked 0.51 cm beyond the hair-bearing area for
dissection. A 5-mm incision was marked at the inferior
pole of the central axillary crease as the access (Fig. 1). For
patients who have longer axis of the hair-bearing area, an
additional incision could be marked in parallel with the
original incision. The operating field was routinely prepared with Povidone-iodine, and then the draping was
done. Local anesthesia was given using 0.5 % lidocaine
with 1:200,000 epinephrine. The incision was made
through the axillary skin down to the subcutaneous fat
tissue using a No. 11 blade along the marked incision.
Subcutaneous undermining was performed clinging to the
superficial fascia with a pair of ophthalmic scissors
(Fig. 2). A 4 9 7 mm fenestrated cup curette was used to

Fig. 1 A 5-mm incision was marked at the inferior pole of the central
axillary crease as the access. As for patients who have longer axis of
the hair-bearing area, an additional incision could be marked in
parallel with the original incision

Table 1 Demographics of patients

Variables

Value

Number of patients

158

Age range, (mean SD)

1842, (21.5 5.8)

Female

106

Male

56

BMI, (mean SD)

17.327.4, (20.6 3.8)

Family history

123

Combined hyperhidrosis
Follow-up time, (mean SD)

56
618, (11.2 4.1)

123

Fig. 2 Subcutaneous undermining was performed clinging to the

superficial fascia with a pair of ophthalmic scissors

Aesth Plast Surg

scrape back and forth against the undermined flap to

remove the apocrine sweat glands. Apparent tissue resistance can be felt at the tip of the curette. Slow but
numerous stroke movements were continued until no more
tissue block was drained out through the incision site. The
mixture contained the destroyed sweat glands, adipose
tissue, and other skin appendages (Figs. 3, 4). Then the
residual tissue attaching to the dermis was resected blindly
using a pair of ophthalmic scissors. With the blunt tips
facing down, the flap was elevated by the scissors. The
pulp of the index finger of the non-dominant hand was used
to press the axillary flap against the scissors to assist in
efficient trimming (Fig. 5). Next, the area was scraped
again gently to remove the residual tissue that was not
completely detached. No more resistance could be felt at
the tip of the curette (Figs. 6, 7). The axillary hairs were
easily pulled out at the time. Last, the subdermal pocket
was irrigated repeatedly with normal saline to remove tissues remaining in the subdermal pocket. Pressure was

Fig. 3 Scrape back and forth against the undermined flap using a
4 9 7 mm fenestrated cup curette to remove the apocrine sweat
glands

Fig. 4 The drained mixture contained the destroyed sweat glands,

adipose tissue, and other skin appendages

maintained in the area for 35 min to achieve adequate

hemostasis. No drainage was placed. The incision was
closed with 50 nylon followed by bulky compressive

Fig. 5 Blind trimming with the ophthalmic scissors. With the blunt
tips facing down, the flap was elevated by the scissors. The pulp of the
index finger was used to press the axillary flap against the scissors to
assist in efficient trimming

Fig. 6 Secondary scraping against the axillary flap to remove the

residual tissue that is not completely detached

Fig. 7 The smooth underlying surface of the axillary skin flap

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Aesth Plast Surg

and no significant change. The postoperative scar was

assessed as invisible, slightly visible, conspicuous, and
very conspicuous, respectively. The patient satisfaction
level was evaluated in a 5-tier system: very satisfied, satisfied, neutral, dissatisfied, and very dissatisfied.
Dermatology Life Quality Index

Fig. 8 The right axillary fossa 7 days postoperatively

The quality of life was assessed using the DLQI, which

includes a 10-item questionnaire to evaluate the effects of
skin problems on daily life activities. Each question has
four different responses: not at all, a little, a lot,
and very much with corresponding scores of 0, 1, 2, and
3, respectively. Total scores range from 0 to 30, with
higher scores indicating greater impairment. The quality of
life was evaluated preoperatively and 6 months postoperatively [9].
Statistics
The collected data for pre- and 6-month postoperative
DQLI scores were analyzed using 2-sided paired nonparametric tests, with statistical significance at the 95 %
confidence level. The analyses were conducted with SPSS
version 13.0 (SPSS Inc., Chicago, IL, U.S.A).

Results
Fig. 9 The right axillary fossa 14 days postoperatively

dressings. The dressings were changed on the second

postoperative day and every 3 days thereafter. Sutures
were removed 7 days postoperatively. Patients were
advised to restrict shoulder movement for approximately
2 weeks postoperatively (Figs. 8, 9). Postoperative oral
antibiotics were not routinely administered.
Evaluation
Patients were asked to estimate the effect of the operation
6 months after surgery. A detailed record of postoperative
complications, malodor elimination, reduced hair growth,
scar formation, and patient satisfaction was obtained for
every patient. The degree of axillary malodor elimination
was evaluated as excellent (no odor occurs after intense
exercise), good (mild odor occurs after intense exercise),
fair (mild odor occurs after daily activity or moderate odor
occurs after intense exercise), and poor (moderate to severe
odor occurs after daily activity). Recurrence was considered when the outcome was worse than fair. The level of
hair growth reduction was divided into four categories:
significantly reduced, moderately reduced, mildly reduced,

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All the wounds (158 cases with 316 axillae) healed primarily without significant complications like skin necrosis,
wound dehiscence, or inflammation. The follow-up duration ranged from 6 to 18 months. Of all the 158 cases, 93
patients came back to our clinic for a follow-up visit, 57
received a telephone follow-up, and 8 patients were lost to
follow up 6 months postoperatively. Table 2 includes the
postoperative complications and patient subjective assessments obtained 6 months after the surgery. The most
common postoperative complication was skin ecchymosis
(19 axillae, 6.3 %), which spontaneously faded away
within 2 weeks. Three cases of hematoma (1.3 %) occurred, two of which were males. The two cases in males both
occurred on the right side, while the one case in a female
occurred bilaterally. After aspiration and proper pressure
dressing, the wound healed primarily. As for malodor
elimination, 294 axillae (98 %) showed excellent to good
results. The other three cases (2 %) who had poor to fair
results received a re-operation in the same manner, and all
of them showed excellent results afterwards. Hair growth
was reduced significantly in 214 axillae (71.3 %) and
moderately in 81 axillae (27 %). There was no hyperpigmentation, hypertrophy, or atrophy of scars. Scars were
invisible in 280 axillae (93.3 %) and slightly visible in 18

Aesth Plast Surg

Table 2 Postoperative evaluation of patients
Variables

Table 3 Median DQLI scores before and 6 months after the surgery
N (%)

Preoperative

6 months
postoperatively

9 (416)

0 (03)a

0a

0a

1
2

0
0a

Question 5

0a

Question 6

0a

0a

Postoperative complications
Ecchymosis

19/300 (6.3)

Median DQLI score (range)

Hematoma

4/300 (1.3)

Clinical symptoms

Skin necrosis

Question 1

Wound dehiscence

Self-conscious

Wound infection

Question 2
Daily activities

Malodor elimination
Excellent

264/300 (88)

Good

30/300 (10)

Fair

5/300 (1.7)

Poor
Reduced hair growth

214/300 (71.3)

Moderate

81/300 (27)

Mild

4/300 (1.4)

No significant

1/300 (0.3)

Work or study
Question 7
Personal relationship
Question 8
Sexual relationship

Scar formation
Invisible

280/300 (93.3)

Slightly visible

18/300 (6)

Very conspicuous

Leisure

1/300 (0.3)

Significant

Conspicuous

Question 3
Question 4

Question 9
Treatment
Question 10

3/300 (1)
0

DLQI dermatology life quality index

a

Patient satisfaction
Very satisfied

128/150 (85.3)

Satisfied

18/150 (12)

Neutral

3/150 (2)

Dissatisfied

1/150 (0.7)

Very dissatisfied

axillae (6 %), which was totally acceptable. Overall patient

satisfaction rates were high, and 146 patients (97.3 %)
were very satisfied or satisfied with the final outcome.
The median DQLI score was 9 (range: 416) before the
operation and decreased to 0 (range: 03) 6 months postoperatively. The relative reduction of impairment was
78.6 % (range: 66.7100 %, P \ 0.05). Subscores of
questions 1, 2, 4, 5, 6, and 7 significantly decreased after
the procedure (P \ 0.05). Subscores of the remaining
questions showed no significant decrease (P [ 0.05)
(Table 3).

Discussion
It is generally believed that the secretion of the apocrine
glands and the activity of bacteria create the characteristic
malodor of axillary osmidrosis. The apocrine glands of
osmidrosis patients are both hypertrophic and hyperplastic,
which has been confirmed by the published studies [10,
11]. To achieve permanent resolution of axillary

Statistically significant, P \ 0.05

bromhidrosis, efficient removal and destruction of the

axillary apocrine glands should be guaranteed [8]. Surgical
procedures tend to provide a more definite treatment for
solving this problem.
An optimal operative procedure for axillary osmidrosis
should include the following features: minimal axillary
scar, rapid wound healing, fewer complications, a shorter
convalescent period, and a low recurrence rate [7]. Or it
needs to generate a both esthetically and functionally
pleasing result.
Basically, three types of surgical methods can be identified for the treatment of osmidrosis. Type 1, only subcutaneous tissue is removed and not the skin. Type 2, skin
and subcutaneous tissue are removed en bloc. Type 3, the
skin and subcutaneous tissue are partially removed en bloc,
as well as the subcutaneous tissue of the adjacent area [12].
The latter two methods have gradually been abandoned for
the unsightly scarring and partial function disorders. Type
1 tends to be the most reasonable method for being both
safe and efficient for the treatment of axillary osmidrosis
[13].
Various minimally invasive procedures have been proposed, including mechanical liposuction, curettage, suction-assisted cartilage shaver, scissors trimming, and many
combined techniques [6, 7, 10, 1317], many of which
have shown highly promising results. All of those

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successfully performed operations have one thing in common; they manage to remove the residual apocrine sweat
glands firmly attached to the dermis.
Liu developed a minimally invasive surgical subsection
method for axillary osmidrosis. The glandular tissue was
removed by manual excision with scissors through a 1-cm
incision. The whole procedure was performed blindly.
The method showed a very high percentage of good results,
which was confirmed by the histological examinations. But
thorough trimming using scissors alone blindly may result
in tearing of the skin. Further, for long lesions, a single
incision may not be enough to reach all the sweat glands
[16]. Li described a procedure combining tumescent liposuction with subcutaneous pruning. Long-term follow-up
showed a high satisfaction rate as well. However, the
access incision was designed on the superior pole of the
center crease. Though the incidence rate of hematoma was
0 in their series, either for an esthetic or therapeutic view,
we believe that an incision designed on the inferior pole is
more advantageous [17]. Liu and associates excised the
central apocrine glands using scissors supplemented with
scraping against the marginal glands to treat osmidrosis.
Trimming performed under direct vision insured a more
radial removal of the apocrine glands while compromising
the appearance of scars [18].
Herein, we design a new method to combine subcutaneous curettage and trimming together to treat osmidrosis
through a limited incision. Subcutaneous curettage allows a
wide range of scraping toward the apocrine glands, while
mild to moderate curettage tends to result in incomplete
removal of the apocrine glands and aggressive curettage
may lead to scar formation. Thus, after a moderate curettage, we detach the residual glands using a pair of ophthalmic scissors. The pulp of the index finger of the nondominant hand is used to press the axillary flap against the
scissors to assist in efficient detachment. There is no need
to drag or evert the skin flap. Lastly, scratch gently to
remove the sweat glands that are not completely off. Sharp
pruning combined with blunt scraping ensures a more
radical elimination of the apocrine glands while avoiding
excess mechanical injury to the skin flap. The whole procedure is followed through a scrapingtrimmingscraping sequence. If the remaining hairs are not easily pulled
out after the secondary scraping, the trimmingscraping
procedure can be repeated.
The technique holds many distinct advantages: (a) It
allows permanent elimination of axillary malodor compared to those non-surgical methods. (b) The postoperative
scars are almost invisible and much more esthetically
pleasing than those of open surgeries. (c) It is applied with
the most basic surgical tools. The ophthalmic scissors and
fenestrated cup curette are the main tools we need.
(d) Compared to those curettage-only methods, it allows

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more radical elimination of the apocrine glands. Combined

trimming allows more accurate removal of the residual
glands and reduces the incidence of skin necrosis to a large
extent. Compared to trimming-only methods, the combined
curettage treats broader areas of apocrine glands and can
greatly reduce the risk of skin tearing.
Besides, several key points should be noted during the
operation: (1) Incision design. Besides the routinely
designed inferior incision, never hesitate to add extra
incisions (which should be parallel to the skin crease) for
those patients with larger lesions. Non-continuous minimal
scars tend to be more esthetically pleasing than those long
incisions produced by open surgeries. (2) Trimming. During the trimming procedure, the axillary skin flap should be
elevated by the scissors to avoid damage to the underlying
well-known vessels and nerves. Rely on the sense of touch
of the pulp of the index finger and feel the thickness of the
managed skin flap. The residual apocrine glands should be
trimmed evenly as much as possible. (3) Secondary
curettage. After sequential scraping and trimming, the
axillary skin flap is super thin. Try not to scrape against the
same site aggressively. Otherwise, the skin flap circulation
could be compromised. (4) Irrigation. After the final
scraping, the subdermal pocket is thoroughly irrigated to
wash away the detached tissue block to prevent regeneration of those residual glandular tissues. (5) Pressure
dressing. For that the relative position of the axillary skin
flaps and subcutaneous fat tissue changes from the supine
position to an erect stance, the axillary skin should never be
anchored to the underlying fascia to avoid displacement of
the axillary skin. The gauze pieces (15 cm 9 20 cm, 10
pieces) are fluffed and bound together to form a gauze ball,
which fits the axillary fossa perfectly. Then a routine figure-of-8 bandage is applied to maintain firm pressure under
each arm.
The most serious complication in our practice was
hematoma. As there were no well-known vessels at such an
anatomical plane, though complete hemostasis under direct
vision is almost impossible through a limited incision,
hemostasis can basically be achieved through pressure
dressing and shoulder-arms limitations. Two cases of local
hematoma (males) both occurred on the right side and were
found on the second postoperative day. Needle aspiration
was conducted, followed by pressure bandages. The wound
healed eventually. The other case of hematoma happened
to a female patient (Fig. 10). She came back to our clinic
through an emergency ambulance service on the very
evening of the surgery. Serious errhysis was found on both
sides. Oddly, there was not any obvious bleeding spot, and
the blood seemed to be in a totally uncoagulated state. She
was not in her menstruation period or taking any anticoagulant medicines. After careful inquiry, we found that she
had had pigeon soup supplemented with Dang Gui

Aesth Plast Surg

Fig. 10 Extensive errhysis of the axillae after intake of pigeon soup

supplemented with Dang Gui (Chinese angelica) and red dates (Color
figure online)

(Chinese angelica) and red dates immediately after the

operation. Out of all the ingredients, Dang Gui has been
demonstrated to possess the function of promoting blood
circulation and removing blood stasis [19]. The other
ingredients had been considered to assist in improving
blood circulation by ordinary Chinese people since long
before. Then, bilateral hematomas were removed and
intravenous hemostatics were given. No more hematoma
was formed at wound dressing changes 1 day later. Ultimately, the wound healed in time. After this, we instructed
our patients that No herbs can be taken only after detailed
consultation with the doctor.
In our series, the recurrence rate of axillary osmidrosis
was 2 %. Recurrence usually occurred at the periphery of
the axilla. We reached the above conclusion partly from the
observed phenomenon that obviously denser hair existed at
the peripheral area in those recurrent patients. Partly for
that the recurrent malodor was successfully eliminated
after re-operation of the area with denser hair. However,
for practical difficulties, we did not perform histological
examination. There was minimal to no scarring in the long
run. As for hair reduction, all female patients were glad to
have the axillary hair removed or significantly reduced.
While for the male patients, a detailed clarification was
needed preoperatively.
For those skilled and experienced plastic surgeons, the
above technique is relatively easy to master. Even though, it
is more difficult to operate blindly than under direct vision,
especially for those new practitioners. At the beginning of
the learning curve, there might be more unexpected outcomes, for instance, hematoma due to uneven dissection
and loose postoperative dressings, skin necrosis or wound
dehiscence because of aggressive scratching, skin tearing as
a consequence of poor trimming, and of course malodor
recurrence due to incomplete removal of the sweat glands.
Thus, one should be fully aware of the regional anatomy

and skillful at the open surgeries prior to performing the

limited incision procedures. Also, indications for this
technique need to be followed: (a) Patients request permanent elimination of axillary malodor; (b) Patients who are
very conscious of scars, they would rather undergo a reoperation than to have unsightly postoperative scars;
(c) The operator should have a good command of the regular open surgeries for axillary bromhidrosis; (d) No
inflammation exists in the local area, and normal coagulant
activity is present; (e) For those male patients who possess
severe underarm malodor, the wide open resection approach
is usually suggested.
The dermatology life quality index was adopted to
measure the impact of axillary osmidrosis on the quality of
life of our patients. A median DLQI score was 9 before the
operation, compared with 0 postoperatively. The difference
is statistically significant. The procedure has a positive
effect on improving patients quality of life in the aspects
of clinical symptoms, self-conscious, daily activities, leisure, work, and study.
The high satisfaction rates, low recurrence rates, and
decreased DLQI score all indicate the effectiveness of this
procedure. Further, randomized control trials are needed in
the future to compare the presented technique with the
other surgical methods in all aspects.
In conclusion, subcutaneous curettage combined with
trimming is an efficacious and minimally invasive method
for the treatment of axillary osmidrosis. It is worth being
adopted in the clinical practice.
Conflict of interest The authors declare that they have no conflicts
of interest to disclose.

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