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Preconditioning and postoperative hyperbaric oxygen therapy to reduce skin flap erosion after osmidrosis surgery

Published:January 14, 2019DOI:https://doi.org/10.1016/j.bjps.2019.01.020
      Osmidrosis surgery is still recognized as one of the best ways to treat body odor,
      • Shin J.Y.
      • Roh S.G.
      • Lee N.H.
      • Yang K.M.
      Osmidrosis treatment approaches: a systematic review and meta-analysis.
      especially the liposuction assisted curettage due to the relatively small incision that does not leave any scars, which, nevertheless, may still cause many complications. One of the most common complications is the erosion of the skin flap, where the necrosis of the flap incision edge is about 4%.
      • Wu W.H.
      Ablation of apocrine glands with the use of a suction-assisted cartilage shaver for treatment of axillary osmidrosis: an analysis of 156 cases.
      Therefore, physicians who perform such surgeries often observe varying degrees of manifestations, some of which are relatively common superficial erosions (Figure 1) and some of which are proportionately deep erosions. Superficial erosions may disappear within a few days to a few weeks and heal completely whereas deep erosion, a kind of skin necrosis, is more likely to occur at the site of the incision. This necrosis easily leads to the appearance of scar tissue. Cutaneous microcirculation exists in the skin flap,
      • Braverman I.M.
      The cutaneous microcirculation.
      which is organized as two horizontal plexuses. One is distributed 1–1.5 mm below the skin surface and the other is distributed between the dermal-subcutaneous junction. Microcirculation refers to the blood circulation in the microvessels between the arterioles and the venules, where the blood and tissue cells exchange substances. The basic function of the microcirculation is to realize the material substitution and transport of oxygen, nutrients and metabolites to the cells various tissues. However, in the process of rotating knife scraping, the continuous friction in the skin flap easily damages the microcirculation, which is especially prone to occur in the pursuit of the complete clearance of the apocrine gland and, thus, leading to the serious damage of the skin flap. The pursuit for better clearance and the well preservation of the microcirculation of the skin flap often put clinicians in a dilemma. To improve this situation, our study aimed to achieve the best of both worlds; that is, to reduce the possibility of erosion or necrosis. Excessive friction or poor healing of the flap can also lead to pigmentation, thus affecting the appearance of the skin in the future. We performed hyperbaric oxygen treatment on 2 Fitzpatrick-skin-type-3 patients in Taiwan before and after osmidrosis surgery. There is a one-person MEDICONET Hyperbaric Oxygen Chamber (O2One H810/H750) in Taiwan which, under the laws and regulations of Taiwan, does not require hyperbaric oxygen specialists. The three patients received hyperbaric oxygen treatment at 1.5 ATA dosages for 45 minutes before the operation, three days post operation following the yarn removal, and five days post operation following the quilting suture removal, respectively. It was later discovered that the recovery of the flaps treated with hyperbaric oxygen was healthier than the earlier observed patients who underwent general surgery with a recovery time of about one week earlier (Figure 2). It is, therefore, believed that the administration of hyperbaric oxygen treatment before surgery has a considerable effect in the improvement of the relative hypoxia of the skin flap during the surgery. This clinical phenomenon is consistent with the findings of many animal experiments mentioned in the literature. It is speculated that HBO preconditioning effectively slows the ischemic reperfusion injury, which is mainly through the regulating factors of apoptosis, the apoptosis signal-regulating kinase 1 and c-Jun N-terminal kinase.
      • Xiao Y.D.
      • Liu Y.Q.
      • Li J.L.
      • Ma X.M.
      • et al.
      Hyperbaric oxygen preconditioning inhibits skin flap apoptosis in a rat ischemia-reperfusion model.
      Despite the small number of subjects in our case, we want to share our observation on the improved healing of the flaps through hyperbaric oxygen treatment. Furthermore, we speculate that it might be helpful in the reduction of the proportion of post-inflammatory hyperpigmentation in the future. We came to this opinion because the inflammation in the previous process is shortened and the healing is rapid, thus pigmentation is reduced. However, these require greater and larger studies to explore the extent of influence of hyperbaric oxygen treatment on skin flap osmidrosis surgery.
      Figure 1.
      Figure 1Relatively common superficial erosions are noted after 7 days of osmidrosis by liposuction assisted curettage.
      Figure 2.
      Figure 2Flap condition on day 7 seemed recovering better after hyperbaric oxygen therapy on before, 3 days and 5 days after surgery.
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        Osmidrosis treatment approaches: a systematic review and meta-analysis.
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