Page 176 - Read Online

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

Figure 3. Examples of postoperative complications: A: hematoma after open excision; B: wound dehiscence after open excision; and C:
seroma after closed curettage by the suction-assisted cartilage shaver system

the outcomes of microwave coagulation, suction curettage, and laser coagulation. They concluded that
microwave coagulation and suction curettage were superior to laser coagulation, but the complication rate
of suction curettage was much higher than the rates of the other two procedures. In the English-language
literature, however, no studies have compared the two major surgical treatments (suction curettage and
conventional open surgery). We believe that our study was meaningful because we compared the outcomes
of these two procedures, 90% of which were performed by a single surgeon.

SACS system
To our knowledge, only one comparative observation of the efficacy of curettage by the SACS system
[15]
versus AO treatment by open excision has been published in Japanese . The seven other English-language
reports on AO treatment by closed-curettage SACS [2,14,16-20] were uncontrolled clinical observations or case
series, as listed in Table 2. During early SACS procedures, the tip of the outer cannula was open, which
often accidentally perforated the axillary skin during the procedure [14,15] . Therefore, curettage by SACS
was performed under endoscopy. Later, most surgeons modified the procedure and used an outer cannula
tip equipped with a grid, so that the apocrine glands could be safely removed while skin perforation and
damage to the subdermal plexus were avoided [Figure 1A]. There are two different types of inner cannula
tips, consisting of smooth or serrated blades. Most surgeons, including our group, have preferred the latter
type of tip, because it more thoroughly removes the apocrine glands.

As shown in Table 2, the complication rate for the SACS system in our study (10.4%) was relatively higher
than the rate in previous studies (0%-7.7%). The higher rate might be because we extensively undermined
the hair-bearing skin plus a 5-mm margin to remove the apocrine glands thoroughly. A few authors spared
[18]
fibrous cords and perforating vessels during curettage by the SACS system. Chern et al. preserved
fibrovascular bands and found a single adverse event involving 1 of 60 axillae. There were no recurrences.
They found, however, that the mean efficacy rate was relatively low, since excellent results were obtained
[19]
from only 67% of patients. Similarly, Hsu and Wang preserved the subcutaneous fibrous septa, and did
not observe any adverse events. However, 3 of 19 (15.8%) patients developed recurrence and underwent
revision surgery. We concluded that the greater is the number of preserved fibrovascular bands, the greater
is the number of remaining apocrine glands around the bands.

Complications
Among the acute adverse events seen in this study, only the incidence of seroma in the patients undergoing
SACS closed curettage was higher than the incidence in the patients undergoing open surgery (2.7% vs. 0.3%).
Interestingly, in patients undergoing abdominoplasty, the incidence of seromas in the patients undergoing
abdominoplasty combined with closed liposuction is higher than in patients undergoing conventional
open abdominoplasty . A seroma results from the rupture of lymph vessels, but the associated factors
[25]