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Clinicians who perform hyperhidrosis operation use various techniques to decrease the risk of post-operative haematoma and seroma, including tie-over dressings, fibrin glue, drainage tubes and quilting sutures. Tie-over dressings compress the dissected flap towards the subcutaneous tissue to prevent dead space.
Although the risk depends on the technique used and the individual surgeon, it is impressive that quilting sutures considerably decreased the incidence of axillary haematoma from 28.1% to 4.9% in their study. Modified quilting sutures are also an option.
During the hyperhidrosis operation, we involved subdermal trimming by making one or two small incisions. Before reviewing the literature, the most common and best way to prevent haematoma after hyperhidrosis operation at our clinic was a drainage tube (Penrose drain) combined with tie-over dressings after apocrine gland removal. The drainage tube was believed to promote blood drainage to lower the risk of haematoma and seroma. However, a small risk of drainage tract formation, delayed wound recovery and residual dead spaces in areas unconnected to the drainage tube was sometimes observed in our practice. Although the haematoma rate was low, we did not know the exact rate, and the placement of a Penrose drain delayed wound recovery and increased the frequency of follow-up, which were troublesome to surgeons.
Therefore, we began performing a technique reported in the literature that uses quilting sutures rather than a drainage tube to prevent haematoma. As mentioned in the literature, there is still a risk of haematoma with this technique. After performing an observational case series, we found that the haematoma had a particular presentation: single or multiple, not large, and confined to spaces between the quilting sutures. As the fluid of the haematoma had no definite shape and it was confined to spaces between the sutures, its pressure was applied in all directions. Consequently, the skin flap, which was flexible, bulged.
To resolve this problem, we developed a simple modification to the established technique. A no. 15 blade was used to make 3-mm long incisions between the sutures immediately after they were quilted (Figure 1A). During each incision, the flap was pulled up to avoid injuring the subcutaneous tissue with the blade, which can cause further bleeding. We observed significant transudate and fresh blood flowing from the holes immediately after puncturing the skin. Tie-over dressings were scheduled for removal 3 days post-operatively. Dressings were orange-brown to black instead of reddish, indicating that active bleeding occurred mainly in the first 1–2 days. The representative patient was advised to minimise his arm movements for the first 3 days post-operatively, and the wound was checked daily for 7 days. The quilting sutures and incision site sutures were removed at 4 and 7 days post-operatively, respectively.
We shared our experience because we have performed more than 100 axillary lymph node dissections using this modified technique, and no haematoma has developed thus far. Figure 1B shows the skin flap with the most ecchymosis at 3 days post-operatively. Once the dressings were removed, most of the punctured incisions healed without any scarring. Thus, we can deduce that bandage removal at 3 days post-operatively is the most effective strategy.
Although we performed this modified technique in a series of 100 patients and did not observe haematoma, we did perform a retrospective study or not yet encounter the complication. We believe that this modified procedure will be of great benefit to other surgeons and clinics.
Conflict of interest statement
“Sea anemone-shaped fixation”: a feasible tie-over technique for axillary osmidrosis.