何文藻醫師~談美容醫學與整形外科

狐臭手術國際期刊演講  微創狐臭手術 微創狐臭手術-Q&A 何文藻醫師團隊/榮譽榜 狐臭手術國際期刊演講

以下我於雷射醫學會，美容醫學會分享2016年四篇在國際上發表的狐臭相關論文，與各位分享~~~

My name is Jacob Wen-Tsao Ho. I am dermatologist in Taiwan practicing in my own private clinic. Thank you for having me here. I would like to present My new concepts in osmidrosis surgery

Let me briefly introduce you the anatomy of sweat gland. Human has two kind of sweat glands. One is eccrine gland which is everywhere in the body, directly open to the surface and is responsible for the sweat secretion. The other is apocrine gland which is bigger and visible and attached to the follicle located in axillary area and responsible for the malodor. 狐臭，一般來說人的體味大概可以分成兩大類:一個就是汗臭味，一個就是狐臭味。基本上藉著簡單的理學檢查，就可以分辨這兩個味道。一般來說，狐臭有一股特別的味道，在理學檢查的時候，患者通常可以發現有濕耳朵的情形。在生理的結構上，我們的汗腺可以分成兩種:一個就是小汗腺，小汗腺就像毛線球一樣，互相纏繞，最後它的管子會直通到表皮，主要是將汗水排出體外，所以當我們在運動或者是體溫比較高的時候，我們就會藉著小汗腺將汗水排出來，達到調控體溫的作用。小汗腺的分布基本上廣布在全身的表皮上面。另外一個叫做大汗腺，大汗腺又叫做頂漿腺。它的分布只侷限在如腋下或者是跨下等，所以頂漿腺它主要是分泌一種特殊的脂肪酸，這些脂肪酸經過細菌酵素的催化以後，就會產生一股濃郁特殊的臭味，我們簡稱叫狐臭。

Differential diagnosis between hyperhidrosis and osmidrosis ==PE : wet earwax, body malodor 
Treatment included non-invasive antiperpiratant , fragrance, botox, Nd-Yag, Radiofrequency, microwave thermolysis (Miradry), surgical intervention: liposonix , subdermal trimming, liposuction curettage , curettage

I would like to share my 4 article accepted in 2016 by international journals of MJD from Malaysia, dermatologic surgery from US, JPRAS for UK and IJSSP for India. 
2016年的狐臭手術國際期刊如上
1. (馬來西亞期刊)Malay journal of dermatology Genotyping at the SNP rs17822931 can help the clinical diagnosis of body malodor in doubt 
2. (美國期刊)Dermatologic surgery Following Changes in the Axillary Secretions of Two Patients Before and After Bromhidrosis Surgery Using Liquid Chromatography-Mass Spectrometry. Ho WT, Lee LJ, Pan JY. Dermatol Surg. 2016 Sep 28. 
3. (英國期刊)Reply "A comparison of two different sub-dermal trimming techniques for the treatment of axillary osmidrosis". Ho WT. J Plast Reconstr Aesthet Surg. 2016 Jun 16

A 37-year old patient has a chief complaint of over perspiration and body odor for a length of time and has been bothered by it. This is especially during summer or after strenuous exercise. These problems have seriously affected his personal relationships with others and the opposite sex. He had consulted many doctors who then had different diagnosis, from acidity of his sweat and body odor. At times, he would use antiperspirant, which gave some relief. The patient lost confidence because of different diagnosis from different doctors, and he was being bothered by his odor that had caused him to lose his self-esteem. How to do?

According to literature, Yoshiura et al. publised that a SNP, 538G > A (rs17822931), in the ABCC11 gene, can determine the dry or wet type of the earwax. The AA genotype corresponds to dry earwax, and the GA and GG to wet type. The strong association between the wet earwax-related genotypes (GG and GA) and bromhidrosis suggest SNP genotype can be a good marker for the diagnosis of bromhidrosis.

狐臭基因檢測，在臨床上，常遇到做過狐臭手術又復發的案例。他們最大的困擾在於自己的味道是純粹汗臭還是真狐臭？
雖然大部分的狐臭患者伴有濕耳朵（耳屎是濕的）現象，但這只能說兩者具相關性卻不能作為診斷的工具。醫學的發展雖然日新月異，針對這類病人，大部分臨床醫師在診斷上卻沿用了最古老直接的方式〜〜聞聞看。雖然很方便但準確度實在不夠精確。所以針對那些無法100%確認自己是否患有狐臭的患者，狐臭基因檢測(SNP rs17822931 in the ABCC11 gene)。

We decided to do a genetic study which was positive for Single nucleotide polymorphism (SNP) rs1782291 with G genotype. Polymerase chain reaction (PCR) amplification with around 300bp product including rs17822931 was performed. Restriction fragment length polymorphism analysis (RFLP) was done with non-template control. The existence of allele A generates a 200bp and 100bp product following BseMII digestion. The AG and AA genotypes of rs17822931 gave three bands and two bands respectively in 2% agarose gel electrophoresis (fig.1) 

Sequencing chromatogram of the sample indicated AG heterozygous 

Although the mutation found in this report is not novel, we would like to emphasize genetic studies can further help in the diagnosis of patients with a strong family history or whose diagnosis is in doubt. 

As many of you know, lots of bromhidrosis surgery studies can be found on the PUBMED. Try doing searches on either osmidrosis or recurrence, you will find quite a lot, talked about relapse rate but few uses objective and quantitative way to define what the recurrence is; is it simply the smell called by one or the others? 
So, that’s the reason behind my study and I would like to share with you all of my findings. 
為什麼我要做這個狐臭手術效果的研究呢?
因為當我們上PUBMED上閱讀關於狐臭手術，您會發現有很多談到關於”復發”比率，簡單用osmidrosis(狐臭)和recurrence(復發)做搜尋，你會發現有很多文章提到recurrence(復發)。可是我們卻很少有一個客觀定量的方式去表明何謂recurrence(復發)，是主觀上有一點點的味道或全然的味道出現稱為復發?或是客觀上被聞到叫復發? 我們也不知道復發的嚴重情形是如何?

This article shown 5% recurrence occurred was mentioned, but we do not know precisely how the author defines it. Is a slight relapse? Or utter relapse? 
這篇提到追蹤復發，但是我們不知道它如何定義狐臭手術的復發

This article referred to comparing the recurrence rate of two procedures, but we do not know how to accurately compare the smell. Based on the above factors, I would like to find a quantitative measurement for surgeons so that each has a scientific communication platform. 這篇都提到兩種術式去比較狐臭手術後的復發率，但是我們不知道它如何精確地去比較兩者的味道。基於上述的因素，我們想要去找的一個科學話定量的方式，讓每位施作狐臭手術醫師有科學化的溝通平台。

Proposed scheme for the release of odoriferous acids by skin bacteria. 這是狐臭氣味的化學結構，圖示被細菌代謝的路徑。

The 2 patients ran on a treadmill for 20 min at room temperature for 3 consecutive days before surgery and 2 months and 6 months after surgery. Factors such as room temperature, mood, and body condition were controlled. The bilateral armpits were washed repeatedly with a total of 5 mL distilled water on each side, and the water and sweat were collected together. The specimens collected on the 3 consecutive days before surgery were combined, leaving three pools for analysis: before, 2 months after, and 6 months after surgery. Surgical satisfaction was also measured. 

Perhaps you might ask why use 5cc of distilled water to rinse the armpits 
If pre-surgery is x, and post-generate y, the molecule concentration before surgery is x/5cc; same thing goes for post-surgery (y/5cc). Which means the proportion is still divided between x and y. 
It wouldn’t matter much water used, as long as the same amount of the water use for pre and post operation; more flushing water used, the more we can ignore the sweat volume effect. 或許你會問為何用5cc蒸餾水去沖洗腋下，如果術前是x，術後產生y，術前的味道分子濃度 x/5cc，術前的味道分子濃度 y/5cc，兩者相除比例仍為x/y
不因為你用多少水有影響，只要術前術後等量即可，而且沖洗的水體積越多，越能夠忽略流汗體積的效應。

We aimed to evaluate these physiological changes in patients Using Liquid Chromatography-Mass Spectrometry. Apocrine gland secretions contain many odorous fatty acids, including linear saturated, linear unsaturated, and branched unsaturated C6-C11 acids.1, 2 Here, we measured (E)-3-methyl-2-hexenoic acid (3M2H), a C7 branched unsaturated fatty acid found in human apocrine gland secretions that has a particularly strong stench, especially in Caucasians and Asians 

~~~~~the 3M2H change on the 1st patient. 
Pre-OP: 223,796 (two hundred twenty-three thousands, seven hundred and ninety-six) caps 
2 months after the surgery, dropped down to 3,069 (three thousand and sixty-nine) caps, a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up a little to 13,154 (thirteen thousand one hundred and fifty four) caps; slight increase from four month ago. 
~~~~the HMHA change on the 1st patient. 
Pre-OP: 658,062 (six hundred fifty-eight thousands and sixty-two) caps 
2 months after the surgery, dropped down to 9,284 (ninety-two hundred and eighty-four) caps, a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up to 41,544 (forty-one thousand five hundred and forty-four) caps; an increase of 3.5% from four month ago. 
~~~~ the 3M3SH change on the 1st patient. 
Pre-OP: 102,965 (one hundred and two thousands, nine hundred and sixty-five) caps 
2 months after the surgery, dropped down to 1,367 (thirteen thousand and sixty-seven) caps, a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up a little to 5,352 (five thousand three hundred and fifty two) caps; slight increase from four month ago. 
質譜儀下的狐臭分子變化
這是第一位患者的3M2H變化，術前223796 cps ，術後兩個月 3069 cps (和術前比降低了98%)，術後6個月 13154 cps(和術前比降低了94%)，六個月比兩個月有微微的回升
HMHA變化，術前658062 cps ，術後兩個月 9284cps (和術前比降低了98%)，術後6個月 41544 cps(和術前比降低了93%)；六個月比兩個月有微微的回升
患者的3M3SH變化，術前102695 cps ，術後兩個月 1367 cps (和術前比降低了98%)，術後6個月 5352 cps(和術前比降低了94%)；六個月比兩個月有微微的回升

the 2nd patient. 
Pre-OP: 229,932 (two hunThis is the 3M2H change on the 2nd patient. 
Pre-OP: 53,976 (fifty-three thousands, nine hundred and seventy-six) caps 
2 months after the surgery, dropped down to 864 (eight hundred and sixty-four) caps; a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up a little to 6,271 (sixty-two hundred and seventy-one) caps; a decrees of 88% compare to pre-op. 
the HMHA change on dred twenty-nine thousand, nine hundred and seventy-six) caps 
2 months after the surgery, dropped down to 4,810 (forty-eight hundred and ten) caps; a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up a little to 35,604 (thirty-five thousand, six hundred and four) caps; a decrees of 86% compare to pre-op.
This is the 3M3SH change on the 2nd patient. 
Pre-OP: 6,451 (six thousands, four hundred and fifty-one) caps 
2 months after the surgery, dropped down to 67 (sixty-seven) caps; a decrees of 98% compare to pre-op. 
But, six month after the surgery, the number went up a little to 550 (five hundred and fifty) caps; a decrees of 91% compare to pre-op. 
質譜儀下的狐臭分子變化
患者的3M2H變化，術前53976 cps ，術後兩個月 864cps (和術前比降低了98%)，術後6個月 6271 cps(和術前比降低了88%)，六個月比兩個月有微微的回升；
患者的HMHA變化，術前229932cps ，術後兩個月 4810 cps (和術前比降低了98%)，術後6個月 35604 cps(和術前比降低了86%)，六個月比兩個月有微微的回升
3M3SH變化，術前6451 cps，術後兩個月 67cps (和術前比降低了98%)，術後6個月550cps(和術前比降低了91%)，六個月比兩個月有微微的回升

LC-MS/MS can be used to evaluate bromhidrosis and the effects of surgery and is useful for assessing possible relapse. 質譜儀下的狐臭分子變化
質譜儀測量狐臭分子在術前術後的相對差異，可以做為一個好的量測方式。

the subdermal trimming technique illustrated in the original literature . 4–5-cm incision was made in the central pole of the crease and a subcutaneous pocket was then created. The elevated axillary flap was turned over with the fingertips; then, the trimming was performed under direct vision by using a scissor. 

1. Although this technique caused lower recurrence rate and lesser complications in my clinical practice, a 4-5 cm linear scar was the main postoperative complaint, though not obvious in some cases. This may be because intervention through the narrow incision to open a pocket to clear the apocrine glands is difficult; although the skin is malleable, it has limitations and some places may still be inaccessible.

2. This may be because intervention through the narrow incision to open a pocket to clear the apocrine glands is difficult; although the skin is malleable, it has limitations and some places may still be inaccessible.
3.In order to decrease the scar length and sustain the clearance rate, I had an idea to modify the surgery by using two narrower incisions. We made two 1-1.5 cm incisions between the three aliquot boundaries of the armpit. Two subcutaneous pockets were made through both incisions and merged into a bigger pocket and glandular and subcutaneous tissues attaching to the dermis were removed carefully using only a scissors and direct vision. In this way, we could approach further from both openings and overcome the problem of insufficient ductility, with insignificant scarring. 
傳統手術會留下一個比較大的切口或者是藉由一個小的切口做一個皮下剪除頂漿腺的動作減少疤痕，但相對擴清率會下降，本篇藉由兩個小的微創切口去減少長疤痕組織，並增加擴清率。

we have observed high recurrences in our patients, such as with previous liposuction for accessory breast or trans-axillary breast augmentation, although these kinds of patients only occupied few in our bromhidrosis surgeries. We are curious about it and suspect the apocrine glands and superficial fascia complex are destroyed and not intact on the side of the skin flap after iris scissor dissection. This is why some of the glands are instead separated and attached toward the side of the subcutaneous tissues.
We could deduce that the previous axillary surgery may destroy the superficial fascia complex and make the plane disoriented. The apocrine glands not easily seen on the side of subcutaneous tissue after dissection is found abundant on the ones who had undergone axillary surgery before. Although many surgeons are aware of the importance of clearing the apocrine glands from the skin flap to reduce the risk of malodour recurrence, glands located in the subcutaneous tissue are easily neglected in patients who have previously undergone axillary surgery and these glands may also make a minor contribution to recurrence. Therefore, surgeons must consider the presence of apocrine glands both on the skin flap and on the subcutaneous adipose in order to achieve the best outcomes. However, we do not recommend that operators take an unnecessary amount of tissue, as this might increase the risk of hematoma and subsequent skin necrosis. Instead, we suggest that they remove the suspected glands in the subcutaneous adipose after careful inspection. 
臨床的操作上，我們會發現因為復發重做手術，或以前做過抽脂副乳，經腋下隆乳患者來做手術，原先的apocrine gland - superficial complex被破壞掉了，再加上當時手術後會有纖維化的表現，再用鈍剪分離時，臨床的觀察皮下組織那一側會有一些粉紅色的組織，我們將其中一些組織剪除送化驗，可以發現裡面夾雜很多的頂漿腺體。因此上述的情況可以視為頂漿腺殘存的高風險狀況。