Effect of optimizing the use of endoscope on the efficiency of microdynamic bromhidrosis removal operation

Bromhidrosis, also known as body odor, is a common disease in life, which often occurs in young adults. The histological basis of bromhidrosis is the hyperplasia of apocrine sweat glands.

surgical method for removing bromhidrosis, 2 which is called: microdynamic bromhidrosis. However, in the blind operation, there are still some cases that partial removal is incomplete lead to recurrence, and the delayed hemostasis to affect the survival of skin flap.
Based on this, our department has carried out endoscope-assisted microdynamic radical axillary osmidrosis, which accurately removes aprocine sweat glands and has a low recurrence rate after operation. Recently, the research team of our center reviewed decades of experience in treating bromhidrosis, in order to explore and summarize a method to ensure the curative effect of the radical operation of bromhidrosis, which can not only ensure the curative effect of operation, but also simplify the operation process and improve the efficiency of operation. By comparing the effects of endoscopic assistance in the whole process of operation and endoscopic exploration after blind rotary cutter suction on the operation time, treatment effect, recurrence rate, and complication rate. The experience is reported as follows.

| Patients
From January 2020 to December 2021, 206 patients with bromhidrosis admitted to the Second Affiliated Hospital of South China University were evaluated for preoperative diagnosis according to the bromhidrosis grade standard of YJPark 3 : Grade 0: odorless; Grade 1: It is only mild when you or others can smell it within 20 cm after intense activity. Grade 2: ordinary daily activities emit obvious odor, which can be smelled within 1.5 m and is moderate; Grade 3: It is severe if you can smell strong smell 1.5 m away without activity. Inclusion criteria: ① Patients with osmidrosis were diagnosed, and the patients were graded as 2 or 3 degrees according to Park and Shin. ② Those who have not received surgical treatment; ③ The patient signed the informed consent form. Exclusion criteria: ① There is ulceration or inflammatory reaction in armpit or whole body; ② Scar constitution; ③ Coagulation dysfunction; ④ Multiple organ dysfunction; ⑤ There are psychological barriers or unrealistic pursuits.

| Instrument
The author uses SPACE® power-assisted rotary cutter(Shanghai Optoelectronic Medical Technology Co. Ltd.) to treat bromhidrosis ( Figure 1). SPACE® consists of inner and outer hollow bushings, the inner bushing head has a zigzag cutter head and the outer protective bushing head has a smooth bevel. During operation, the rotary cutter window faces the skin, and the required rotating speed is set to make the inner sleeve rotate at high speed to cut the subcutaneous tissue, while the outer protective sleeve protects the surrounding tissue. In addition, the negative pressure device is connected to continuously attract the large adipose tissue and hair root fragments under cutting.

| Surgical procedure
The patient took a supine position, with both hands extended 170°,

| Postoperative management
Photographs were taken immediately after operation. Sterile gauze and cotton pad were filled, and elastic bromhidrosis clothes were used to compress the operation area. The separated skin flap was closely attached to the subcutaneous tissue, which kept the shoulder joint braking and abduction, and promoted the survival of the flap and wound healing. Vaseline gauze nails were removed 3-5 days after operation, and elastic bromhidrosis clothes were pressed for 7-10 days.

| Evaluation indicators
1. The average operation time of the two groups was observed.
2. The curative effects of the two groups were compared 3 months after operation. Evaluation criteria of curative effect: ① Cure: reaching grade 0 or grade 1. ② Effective: grade 3 is changed to F I G U R E 2 After the skin is prepared, the first space is marked on the edge of the axillary hair, and the range of 1 and 2 cm outside the first space is marked for the second space and the third space, respectively, and the incision position between the first and second space is about 0.8-1.0 cm long (red short line). If the axillary hair range is large, two incisions should be made on circumstance.

F I G U R E 3
The flap is cutted until the dermis is white.

F I G U R E 4
The flap is fixed with about 3-4 oil nails spaced 1 cm apart according to the extent of the operative area. grade 2. ③ Invalid: There is no obvious change before and after treatment.
3. The incidence of postoperative complications, such as hematoma, epidermal abrasion, dermal punctate ulcer, and flap necrosis.

| Statistical analysis
SPSS 26.0 statistical software was used, the measurement data were expressed by (x ± s), the comparison between groups was carried out by t-test, and the counting data were compared by chi-square test, and p < 0.05 showed that the difference was statistically significant.

| RE SULTS
Retrospectively analyzed the patients with axillary osmidrosis from January 2020 to December 2021. A total of 149 patients met the admission criteria, including 84 cases in the whole process of endoscopic treatment group (Group A) and 65 cases in the endoscopic exploration treatment group after negative pressure suction and high-speed rotary cutter (Group B). The average age of the two groups was (29.56 ± 5.98) and (29.63 ± 5.75). There was no significant difference in age and sex between the two groups ( Table 1).
The average operative time of Group A was (85.19 ± 14.71) min, and that of Group B was (63.31 ± 13.71) min, the average time between the two groups was statistically different (t = 9.346, p < 0.05; Table 2). In Group A, 80 cases were cured, four cases were obviously improved but not completely removed, and there were no ineffective patients. In Group B, 62 cases were cured, three cases were obviously improved but not completely removed, and there were no ineffective patients. chi-square test showed that there was no significant difference in curative effect between the two groups (p = 0.967; Table 3). Among 84 patients in Group A, there were one case of hematoma, nine cases of epidermal abrasion, two cases of dermis punctate ulcer, and no flap necrosis occurred. Among the 65 patients in Group B, hematoma occurred in two cases, epidermal abrasion in six cases, dermal punctate ulcer in three cases, and no flap necrosis occurred. There was no significant difference in the incidence of complications between the two groups (p = 0.940).

| DISCUSS ION
Bromhidrosis, also known as body odor, is easy to occur in young people, 4 The main manifestation is the unpleasant smell from the folds of the armpits of the patients. At present, the sweat glands in armpit are divided into eccrine glands, apocrine glands, and apoeccrine glands. The occurrence of bromhidrosis is mainly related to the large number and larger volume of apocrine sweat glands. After secreting viscous liquid containing proteins, lipids, and other components, it is decomposed by bacteria on the skin surface to produce unsaturated fatty acids, resulting in pungent odor. 5 The current treatment of axillary osmidrosis is surgical and nonoperative, such as gold microneedle, 6 laser, and microwave, 7 mainly uses different forms of heat energy to destroy apocrine sweat glands. Injection of botulinum toxin type A 8 inhibits sweat gland secretion by blocking the release of acetylcholine, but it lasts no more than 12 months. 9 Surgical removal of sweat glands is the only way to cure bromhidrosis. The scope of surgical operation mainly depends on range and depth of apocrine sweat glands distribution. 10 Qing 1 found that apocrine sweat glands are basically consistent with the number and range of hair follicles, and its secretory part is mainly distributed in axillary hair area, which can exceed but does not exceed 1.0 cm. The secretory part of apocrine sweat gland is located in the superficial adipose tissue between dermal reticular layer and superficial axillary fascia. 11 Previous studies in our department have also proved this point. 12 We believe that the subcutaneous tissue with a thickness of 4-5 mm under the reticular layer of the dermis, including apocrine sweat glands, should be removed to avoid the recurrence risk caused by insufficient clearance depth in moderate and severe patients. 13 The traditional fusiform skin resection method has a large surgical wound, and too much local tissue removal often leads to incision dehiscence or poor healing, and it will leave a large scar in the patient's armpit, which may also affect the normal activities of the

Postoperative complication Group A Group B
Hematoma 1 2 Epidermal abrasion 9 6 Dermal punctate ulceration 2 3 However, the professional operation of endoscope has a great influence on the operation efficiency. In the long-term practice, we have found two ways to use it: one is to remove bromhidrosis with the help of endoscope in the whole process of operation; The other is endoscope-assisted exploration after blind rotary cutter suction.

| CON CLUS IONS
To sum up, compared with the two methods of endoscopy, we recommend that endoscopy should be used to check the resection of sweat glands after blind suction and stop bleeding in time in the operation area.

FU N D I N G I N FO R M ATI O N
None.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declared that they have no conflicts of interest to this work.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C S S TATEM ENT
The study method and treatment procedure were considered and approved by the ethics committee of University of South China.