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Tanaka et al. Plast Aesthet Res 2020;7:17 I http://dx.doi.org/10.20517/2347-9264.2020.12 Page 3 of 10

excision or SACS closed curettage at Showa University Hospital or affiliated private clinics. Patients who
had previously undergone other surgical treatments for AO were excluded from this study. Prior to surgery,
[1]
the odor level of each patient was determined by a previously described gauze test . The scale ranged from
Level 1 (no odor) to Level 5 (severe odor), and patients with Levels 3 (moderate) to 5 were considered
suitable for surgical treatments. The treatment option was chosen by each patient and his/her family instead
of by the operating surgeon. Surgical procedures for more than 90% of patients were performed by a single
surgeon (D.M.), and the other procedures were performed by surgeons under his supervision.

SACS system closed curettage
Patients lay in the supine position, with their arms abducted 90°-120°. The region of hair-bearing skin plus
a 5-mm margin was delineated and 30-40 mL of a solution of 0.25% lidocaine with 1:200,000 epinephrine
was injected for local anesthesia. A 5-mm skin incision was made at either the medial or lateral edge of the
marked skin. Suction of the marked area was first performed by a conventional liposuction cannula (3-mm
diameter) inserted through the incision, and the subdermal layer containing the sweat glands (mainly
apocrine glands) was removed by the SACS system (TPS; Stryker, Kalamazoo, MI, USA), equipped with an
electric shaver (Formula; Stryker). This system is normally used for endoscopic arthroplasty in orthopedic
surgery. It is composed of an outer cannula equipped with a grid that safely removes apocrine glands, and an
inner cannula equipped with a serrated blade that strongly oscillates to remove apocrine glands [Figure 1].
The shaver was also connected to a vacuum pump (S200; Kakinuma Medical Inc., Tokyo, Japan) by a
suction tube, which immediately removed the tissues containing the apocrine glands and discarded them
into a container. After the subdermal tissues of the entire marked area were evenly excised, 2-6 quilting
sutures (depending on the size of operated area) were used to anchor the loosened skin to the underlying
fascia, and a drainage tube was inserted to extend through the skin incision. Compression by tie-over
dressings and elastic bandages was applied for 3-5 days postoperatively. Anchoring sutures and sutures
closing the incision were removed one week after surgery. The patient was allowed to perform full range-
of-motion of the shoulder two weeks postoperatively.

Open excision
The operating position, local anesthesia, and operating area for conventional open excision were the same as
[22]
for patients undergoing SACS curettage. According to a previously reported technique , a small elliptical
section of skin (3-6 cm long) in the center of the hair-bearing region was removed. The axillary skin was
undermined from the incision both medially and laterally above the fascia. A skin hook was used to turn
over the undermined skin, and the layer mainly containing the apocrine glands was identified [Figure 2].
Subdermal tissues containing the apocrine glands were pruned evenly from the center up to the edge of the
marked area by dissecting scissors, and bleeding was controlled by electrocauterization. Following wound
closure with 5/0 nylon sutures, 2-6 quilting sutures were used to anchor the skin flap to the underlying
fascia, and a drainage tube was inserted to extend from the edge of the incision. Compression was achieved
using tie-over dressings and elastic bandages, which were applied for 5-7 days postoperatively. Quilting
sutures were removed one week after surgery, and incision sutures were removed between two and three
weeks after surgery. The patient was usually allowed to perform full range-of-motion of the shoulder four
weeks postoperatively.

Data assessments
Safety was assessed according to the occurrence of acute moderate-to-severe adverse events, which
included hematoma, seroma, and delayed wound healing. The events were assessed for each axilla. When
more than two adverse events occurred in the same axilla (e.g., skin necrosis plus wound infection), the
major event was used to determine the overall rate of occurrence for patients undergoing either closed or
open surgery. Mild adverse events such as erosion, contact dermatitis due to dressing tape, and transient
erythema were excluded from the assessment.