Liposuction for axillary hyperhidrosis

Abstract

See related article on page 960 To the Editor: I read with interest the article, “The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: A randomized control trial.”1Ibrahim O. Kakar R. Bolotin D. Nodzenski M. Disphanurat W. Pace N. et al.The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: a randomized control trial.J Am Acad Dermatol. 2013; 69: 88-95Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The study compared liposuction to neuromodulator injections for treatment of axillary hyperhidrosis. I am concerned that the casual reader may get the impression that liposuction is not a valuable treatment for this condition. The inherent weakness of any study such as this, which attempts to compare surgical procedures to simpler injectable techniques, is the variation in surgical technique between operators, as the authors acknowledge. The article omits the earlier dermatologic surgery references to liposuction for hyperhidrosis (a common problem in the digital search age) and those are listed below.2Lillis P. Coleman III, W.P. Liposuction for treatment of axillary hyperhidrosis.Dermatol Clin. 1990; 8: 479-483PubMed Google Scholar, 3Lillis P. Coleman III, W.P. Liposuction for treatment of hyperhidrosis.in: Robbins P. Surgical gems in dermatology. Vol 2. Igaku Shoin, New York1991: 100-102Google Scholar Having performed liposuction for hyperhidrosis for over 2 decades, it is my experience that this is a very technique-sensitive procedure that depends on aggressive scraping of the dermis in addition to removal of subdermal fat. Pathology samples from my procedures have revealed both eccrine and apocrine glands in the aspirate. Failure to produce significant fibrosis allows survival of residual sweat glands and a poorer result. The authors admit that using a less aggressive cannula may have lead to diminished results. Although the reason for this was concern about possible dermal ulceration or skin loss, I have never seen this complication. I commonly see patients a decade or more after this procedure who are still asymptomatic. The very reason that they undergo liposuction is to avoid the recurring expense of neuromodulators. As the authors admit, this study was only 6 months in length, about the length of time expected for neuromodulator benefit to last, so this short time frame does not tell us very much, as presumably even with a less aggressive technique the patients undergoing liposuction will retain their improvement for many years. After 6 years of use, I also have been quite happy with microwave thermolysis, which is less invasive than liposuction, but appears to produce a similar long-lasting result and is probably the new standard of care for this disorder.4Glaser D.A. Coleman III, W.P. Fan L.K. Kaminer M.S. Kilmer S.L. Nossa R. et al.A randomized, blinded clinical evaluation of a novel microwave device for treating axillary hyperhidrosis: the dermatologic reduction in underarm perspiration study.Dermatol Surg. 2012; 38: 185-191Crossref PubMed Scopus (77) Google Scholar The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: A randomized control trialJournal of the American Academy of DermatologyVol. 69Issue 1PreviewBotulinum toxin injections and suction-curettage have been separately shown to be effective in treating axillary hyperhidrosis but have not been compared in the same patients. Full-Text PDF Liposuction for axillary hyperhidrosis: Reconciling trial results and expert opinionJournal of the American Academy of DermatologyVol. 70Issue 2PreviewTo the Editor: We would like to thank Dr Coleman1 for his insightful comments regarding our article and for sharing his expertise in the use of liposuction for treatment of axillary hyperhidrosis. As Dr Coleman notes, and as we have discussed elsewhere,2,3 one of the major challenges of comparative effectiveness studies of procedural interventions is so-called “dose-finding.” That is, selection of the appropriate settings, intensity, and precise surgical technique for each treatment arm is needed to ensure that a fair, apples-to-apples comparison of the procedures is performed. Full-Text PDF