Primary axillary hyperhidrosis treatment : a prospective and comparative study between liposuction and laserlipolysis Tratamento

Introduction: Hyperhidrosis is a common disease characterized by excessive sweating. Several treatment options are described as axillary liposuction and laserlipolysis. Objective: To compare the effectiveness of two treatment methods for axillary hyperhidrosis – one exclusively surgical (liposuction) and the other employing invasive laser therapy (laserlipolysis) – using a prospective, comparative study with a one-year follow up. Methods: Liposuction was carried out in the right axilla, while laser lipolysis was performed in the left axilla. The evaluation was conducted using the starch-iodine test, comparative histological analysis and patient self-assessment questionnaires. Results: Twelve patients took part in the study. The starch-iodine test indicated decreased sweating in all patients within one year after the procedures, while the histological analyses showed absence or reduction of the secreting ducts and acini on both sides and in all cases. After one year of follow-up, the patient’s satisfaction index measured by the questionnaires remained positive in all cases, with 75% asserting maximum satisfaction, and 25% reporting difference between the sides (better results were described in the right hand side axilla). Conclusions: Both techniques showed similar effectiveness after one year of follow-up. Laserlipolysis had a lower frequency of postoperative complications.


INTRODUCTION
Hyperhidrosis is a common condition characterized by excessive sweating.It can manifest in one or more areas: axillae, palms, face, scalp, soles, and groin. 1 Excessive production of sweat -more than necessary to regulate the body's temperaturecan significantly influence the affected patients' quality of life, possibly leading to depression or social isolation.Hyperhidrosis can be classified as primary, secondary, generalized (whole body) or focal (specific body sites). 1,2rimary axillary hyperhidrosis (PAH) is idiopathic and focal.In addition to affecting the patients' quality of life, it can also lead to a variety of complications, such as bacterial or fungi overgrowth, muscle cramps, eczematous dermatitis, and other dermatological conditions. 3. Cases should be evaluated on an individual basis in light of the severity, the picture's extension, and advantages and disadvantages of each method.Conservative treatments should be given priority. 1he liposuction of eccrine glands is a procedure aimed at aspirating the axillary region's glands, and is performed under local tumescent anesthesia.][3][4] The present paper describes a prospective, comparative and monocentric study aimed at comparing the effectiveness of two approaches for treating axillary hyperhidrosis: an exclusively surgical method (liposuction) and another based on invasive laser therapy (laserlipolysis).

Patient selection
Twelve patients bearing primary axillary hyperhidrosis who underwent prior treatment with topical antiperspirant and botulinum toxin type A injections were selected.Only patients who had similar intensity of hyperhidrosis in both axillae (verified by the starch-iodine test) were included.The study complied with the Declaration of Helsinki's ethical principles.
The group's epidemiological analysis was conducted based on the following factors: age, gender, and complications during and after surgery.

Exclusion criteria
Patients with conditions that could stimulate hyperhidrosis, those who used drugs that stimulated sweating, or who had undergone thoracic sympathectomy or another surgical method to treat hyperhidrosis were excluded.

Hyperhidrosis quantification test
The starch-iodine test comprises the application of iodine solution in the sweating area, followed by drying and subsequent spraying of starch on the same zone.The combination of starch and iodine with sweat lends a dark blue color to the region.This test was performed before, 30 days after, and one year after the procedure.The difference between the sides received the following classification: No = It has neither improved nor worsened In case of improvement: Similar = Similar sweating on both sides Right = Less sweating on the right Left = Less sweating on the left 2. Histological analysis Histology was performed on both axillae after biopsy with 5mm punch in the axillary cavities (intersection of the horizontal and vertical middle axillary lines) before the procedure and 30 days later.The objective was to identify the area with the greatest number of glands (acini and ducts) in a fixed observation field.

Satisfaction questionnaires
The patients answered a questionnaire about their degree of satisfaction with the procedures 1 week, 30 days and 1 year after the procedures were performed, using the ratings below: -2 = My sweating has worsened and I would not undergo the procedure again -1 = My sweating has worsened, but I would like to undergo the procedure again 0 = My sweating has not changed + 1 = My sweating has improved, but I would like to sweat any less +2 = I am completely satisfied 4. Questions about the difference in the results obtained for each side The patients answered a second questionnaire 1 week, 30 days and 1 year after the procedure, aimed at subjectively quantifying the difference between the sides, using the following ratings: No = It has neither improved nor worsened In case of improvement: Similar = Similar results on both sides Right = Better results in the right axilla Left = Better results in the left axilla

Statistical analysis for the assessment of the difference in outcomes using diverse techniques
The statistical analysis of this correlated paired sample was performed based on the results obtained with starch-iodine test, using Microsoft Excel's McNemar test with continuity correction, and a 5% significance level (alpha = 0.05 for the rejection of the null hypothesis) and with degree of freedom = 1.According to the formula below, the number of failures is "a" -which denotes the failure in transitioning from the absen-Surg Cosmet Dermatol 2016;8(4):296-300.ce of difference in the intensities of sweating between the two sides, into the presence of difference in the intensity of sweating between the two sides -and the number of successes is "d" -which denotes the absence of asymmetry in the intensity of sweating between the sides, meaning the sweating in the two sides are equal: The analysis was performed aiming at comparing the statistical evidence -if they existed at all -for the difference in the ratings attributed to the intensity of sweating between the sides after 1 year of follow-up.The study's null hypothesis (Ho) was "both procedures lead to the same outcome".
• Liposuction is performed with a 2.5mm gauge, two--hole cannula, with the lumen facing up.
• Laserlipolysis is performed with the Delight ® device (Industra Technologies, São Paulo, Brasil), with 6,000 J of accumulated energy, set on continuous mode, potency at 6W, using the 915nm wavelength.Aspiration was not performed after the laser was applied .

RESULTS
Twelve patients (8 men, 4 women) with primary axillary hyperhidrosis who underwent previous treatment with antiperspirants or topical botulinum toxin type A injection were selected.The mean age was 24 years (min = 17, max = 39) with a mean of 22 years.
The indices of patient satisfaction with the outcomes of the procedures carried out can be seen in Table 1.Seven days after the procedure, 41.6% of the patients described absence of change in the amount of sweating, while 58.4% reported some degree of improvement.Thirty days after all patients described some degree improvement, with 83.3% reporting being completely satisfied.At the end of 1 year of follow-up, the satisfaction index remained positive in all patients, with 75% reporting maximum satisfaction.
An individual patient self-assessment questionnaire and the starch-iodine test were applied, aimed at studying the differences between the outcomes obtained with each of the procedures performed.The self-assessment results are shown in Table 2.After 1 week, 66.6% described the presence of differences between the sides, with 62.5% reporting a greater decrease in sweating on the left.After 30 days, 91.6% of the study patients reported a similar decrease in sweating in the two sides.After 1 year of follow up, 25% reported the presence of differences between the sides, with the right presenting the best results.
The starch-iodine test evidenced a decrease in sweating in all cases, both at 30 days and after 1 year of follow-up (Table 3).At 30 days, only one case presented differences between the sides, with the right showing a greater decrease in sweating.At 1 year, three patients showed differences between the sides, with the right presenting greater decrease in sweating.The McNemar  test with continuity correction for assessing the difference in the intensity of sweating between the two sides was of 1,333, with p = 0.2482.For a p-value greater than a (significance level) Ho is accepted and H1, rejected.As a result, there is no significant difference between the two procedure types regarding the cause and effect of the difference in the results obtained for the intensity in sweating.The histologies performed before and 30 days after the procedure showed absence or decrease of the secretory ducts and acini on both sides (Figure 1A and 1B: right axilla, 2A and 2B: left axilla).
There was absence of intercurrences during the procedures.Postoperative intercurrences can be seen in Table 4. Four patients experienced pain only on the right side, 6 had pain in both sides and none reported pain only on the left side, with a maximum duration of 10 days, being well controlled with ketorolac trometamol.Local hematoma was observed on the right side in all cases, and in the left side in 5 cases.Regression took place in up to 10 days, with the use of a gel containing allantoin and sodium heparin.Temporary paresthesia was reported on the right side in 3 cases, with improvement of symptoms in roughly 90 days with prednisone and Vitamin B1.Skin erosion was reported only in 1 case, in the right side, with improvement in 30 days using silicone gel.

DISCUSSION
Primary axillary hyperhidrosis affects about 3% of the population in the USA and implies significant emotional and psychosocial consequences.Unlike secondary hyperhidrosis, PAH is not associated with any identifiable underlying condition. 1,3The limited understanding about the precise pathophysiological mechanism means that its treatment is varied, with varying responses for each therapeutic modality. 2The present study evaluated the liposuction of eccrine glands, comparing it with 915nm diode laser assisted axillary laserlipolysis.The starch-iodine test demonstrated the presence of decreased sweating in all cases, both at 30 days and after 1 year of follow-up.The histological studies performed before the procedure and 30 days after showed absence or decrease of secretory ducts and acini in both sides.These outcomes are in line with the literature.Leclere 7 described reduced sweating in all evaluated therapeutic modalities, demonstrated by the decrease in the dark areas in the starch-iodine test in all studied groups: 975nm diode laser, association of 924/975nm lasers, isolated curettage, and curettage combined with the association of 924/975nm lasers.That article concluded that the group that underwent last treatment modality had a more significant decrease in sweating. 7.6 Laserlipolysis' safety and effectiveness are recognized in the reviewed

CONCLUSIONS
This study evidenced satisfactory outcomes during the 1 year follow up after the performances of liposuction and laserlipolysis procedures for the treatment of axillary hyperhidrosis refractory to clinical treatment with antiperspirants and botulinum toxin type A. Both techniques showed similar effectiveness at the end of the case's follow up, nevertheless axillary laserlipolysis can be considered a good alternative in the treatment of axillary hyperhidrosis due to the lower frequency of post-operative complications associated to it in the present study.Yet, further studies and more comprehensive patient follow-ups are required in order to confirm this paper's conclusions.l

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Figure 1: A. Right axilla before the treatment with an eccrine sweat gland unit comprising four secretory acini and one excretory duct

Table 4 : Intercurrences in the postoperative period
6,88Caplin 8 demonstrated the 1.064nm Nd:YAG laser's efficacy using the starch-iodine test and patient satisfaction scales after 1 year of follow-up. Heconcluded that it is an effective therapy, with lower levels of adverse effects, 8 a finding that was also observed in the present study.