Prone Positioning in Large-Volume Liposuction

Sir: Axillary bromidrosis is a combination of hyperhidrosis and osmidrosis1 and is a distressing condition that poses significant social embarrassment in almost all countries worldwide. However, the definite cause of bromidrosis has not yet been determined. To summarize the possible causes, an English literature search from 1975 to June of 2007 was performed for articles with references to bromidrosis. In conclusion, axillary sweat glands may play the most important role in the cause of bromidrosis. In addition, axillary microorganisms, hormones, and inherent causes also contribute to bromidrosis. First, osmidrosis is characterized by excessive odor that originates in apocrine glands, whereas hyperhidrosis is a condition of excessive sweating from eccrine glands.1 Reasonable removal of axillary sweat glands has achieved a satisfactory outcome for most patients. A bewildering multitude of surgical methods has been reported to date, which can be classified into three classic types: (1) a method that removes only subcutaneous cellular tissue without removing skin, (2) a method that removes skin and subcutaneous cellular tissue en bloc, and (3) a method that partially removes skin and cellular tissue en bloc and removes the subcutaneous cellular tissue of the adjacent area. It is thus evident that the definite location of axillary sweat glands has not yet been determined. Also, it is important to identify where the three types of sweat glands are in the axillae. As histologic findings suggest, eccrine glands are dominant in the dermis, but most apocrine glands are located in subcutaneous tissue. In recent publications, it has been a trend to carry out a prospective histologic study on axillary biopsy specimens by means of various immunohisto-chemical markers beyond routine stains. The popular markers include CD15, CD44, human milk fat globulin-1, and S-100 (Table 1).Table 1: Immunohistochemical Markers of Axillary Sweat GlandsNext, it is believed that the malodor is composed of E-3-methyl-2-hexenoic acid, which is liberated from nonodorous apocrine secretions by axillary microorganisms. Zeng et al.2 reported that in the apocrine gland secretions, E-3-methyl-2-hexenoic acid was carried to the skin surface bound to two proteins, the structures of which structures are shown in Figure 1. Leyden et al.3 claimed that although there were some types of microorganisms residing in axillary flora, including Micrococcaceae, aerobic diphtheroids, and propionibacteria, only diphtheroids generated typical body odor.Fig. 1.: Structures of the two proteins on which E-3-methyl-2-hexenoic acid was carried to the skin surface.Furthermore, apocrine glands of human axillae are a major source of odorous signals and pheromones, which do not function until puberty. According to Beier et al.,4 androgen receptors were located in the nuclei of apocrine secretory epithelium and estrogen receptor β was located in the nuclei of apocrine secretory epithelium and in cytoplasm, and apocrine glands lacked estrogen receptor α. In addition, most of the patients have family members who also suffer bromidrosis. An autosomal dominant inheritance pattern was proposed in one study.5 Guang-Yu Mao Song-Lin Yang, M.D. Jiang-Hong Zheng, M.M. Department of Plastic Surgery Shanghai No. 6 People’s Hospital Shanghai Jiao Tong University Shanghai, People’s Republic of China