Subdermal Coagulation Treatment of Axillary Bromhidrosis by 1,444 nm Nd:YAG Laser: A Comparison with Surgical Treatment
A 25-year-old female presented with malodor in both axillae aggravated since adolescence. She had no medical history, but a maternal family history of axillary bromhidrosis was present. On examination, wet earwax in both ears was noted. Serious hyperhidrosis was diagnosed based on the clinical findings.\nWe decided to treat the left axilla with the 1,444 nm Nd:YAG laser (Accusculpt™; Lutronic Corp., Seoul, Korea), and the right axilla with a modified Inaba's method and compared the effectiveness and complications of each modality.\nBoth axillary areas were anesthetized with 24 ml of 0.5% lidocaine mixed with 1:100,000 epinephrine. As the 1,444 nm Nd:YAG laser is highly absorbed by water which becomes heat energy, tumescent anesthesia was not used to avoid unwanted thermal damage via heated tumescence.\nLaser irradiation areas of 10×5 cm in size were marked on the left axilla. Apocrine glands in the subcutaneous and dermal layers were destroyed by irradiating 1,254 J of laser at 1,444 nm with 175 mJ of pulse energy at a pulse rate of 40 Hz (power 7 W) using a fiber type internal probe via 18-G needle puncture sites (). The amount of energy applied was based on the surface temperature elevation and the extent of fat dissolution assessed by the operator's hands. No liposuction was performed. The 18-G needle puncture sites were not sutured, and the operative area was not compressed.\nModified Inaba's surgery was performed on the right side. After local anesthesia, a 2-cm long single incision line was made, and subdermal dissection was done. Subdermal apocrine glands were manually shaved with a modified Inaba's shaver, and a compression dressing was applied to avoid hematoma or seroma formation.\nThe patient revisited our hospital on postoperative days 3 and 10 and after 6 and 12 months. Relatively less ecchymosis and scars were observed on the left axilla treated with the laser (). The right and left axillae, including acute complications, were compared at long-term follow-up (). Other than a serious bruise in the right axilla lasting about 2 weeks and a mild bruise in the left axilla lasting less than 1 week, no major complications were noted. Pain score was measured on a scale of 0 to 10, and the patient experienced no pain in the left axilla. However, the patient experienced moderate to severe pain (7 to 8 out of 10) with activity limitations on the modified Inaba's operation side. As the postoperative compression dressing had to be applied for 2 weeks, activity limitations continued for 2 weeks on the right side. Additionally, postoperative pain continued for 7 to 10 days. The remnant malodor in the left axilla was deemed 'tolerable' (scale 3) and the right axilla was deemed 'none' (scale 0). After the 1 year follow-up, the remaining odor was <10% to 15% compared with the initial grade. Other complications, such as restriction of movement and pain, were completely cleared. The patient's level of satisfaction with the left, laser treated side, was generally high in terms of quality of life.\nHistological examinations were also done on the subcutaneous fat layer of the laser-irradiated side immediately after the procedure and at 6 months postoperatively (). Immediately after the procedure, the exam showed ablated adipose tissue and apocrine glands. The 6 month histologic examination showed more ablated apocrine glands than previously, which resulted in decrease in malodor.