How is the Skoog procedure for axillary hyperhidrosis performed?

Updated: Feb 12, 2019
  • Author: Richard H S Karpinski, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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Answer

Position the patient supine with the arm abducted approximately 120°. Use routine sterile skin preparation and draping. Consider profuse sweating, which may wet the prepared field, sterile; it ceases when local anesthetic is infiltrated.

Infiltrate the entire hair-bearing area of the axilla with local anesthetic; the author routinely uses a mixture of 0.5% lidocaine with epinephrine and 0.25% bupivacaine and a 25-gauge spinal needle. See the image below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Anesthesia is attained by infiltration of local anesthetic. Image courtesy of Richard H S Karpinski, MD.

Plan the incision with a transverse line following a skin crease across the center of the hair-bearing axillary skin, from the anterior axillary fold to the posterior extent of the hair. In the classic Skoog procedure, staggered-cross incisions are added roughly perpendicular to the transverse limb and extending to the proximal and distal extremes of the hair-bearing area, so that the entire hair-bearing axilla is divided into 4 quadrants. See the image below.

Surgical treatment of axillary hyperhidrosis. Stag Surgical treatment of axillary hyperhidrosis. Staggered-cross incision of a classic Skoog procedure. Image courtesy of Richard H S Karpinski, MD.

In the author's variation of the Skoog procedure, only the single transverse incision is used. Although this makes the dissection substantially more difficult, it produces a less visible scar, a lower risk of flap necrosis, and an easier closure. Wang and others have recommended multiple parallel longitudinal incisions. See the image below.

Surgical treatment of axillary hyperhidrosis. Karp Surgical treatment of axillary hyperhidrosis. Karpinski modification of the classic Skoog procedure incision. Image courtesy of Richard H S Karpinski, MD.

Carry the incisions through the skin and the subcutaneous layer, which in these patients is formed almost entirely by tan-pink sweat glands (color very similar to pancreatic or parotid gland). In thin patients, a fascia layer is usually discernible covering the deep axilla; a cleavage plane just superficial to this facilitates dissection. See the image below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The transverse incision is made, here exposing the subcutaneous sweat glands. Image courtesy of Richard H S Karpinski, MD.

None of the dissection should be deep to the fascia layer. The extent of dissection corresponds roughly to the hair-bearing axilla or to the mapped area if preoperative mapping is used. Reaching the limits of dissection farthest away from the skin incision usually requires use of curved scissors (eg, curved Mayo scissors) and retraction with skin hooks or narrow/deep retractors (eg, mini Deaver). The surgeon also may need to fold or roll the dissected flap on itself as dissection proceeds and may need to change position with relation to the abducted arm (eg, working across the patient's chest or from above the abducted arm). See the images below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Through the rather limited incision, dissection is carried to the entire outlined area. The dissection is deep to the glands but superficial to axillary fascia. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: In the recess of the incision, the shiny and somewhat striated axillary fascia is visible. In conducting the operation, no part of the dissection should violate this fascia. Image courtesy of Richard H S Karpinski, MD.

Meticulous hemostasis with a cautery device is appropriate at this stage, but needs to be limited once gland dissection begins to preserve flap vascularity.

Gland resection is started most easily at the cut edge of the incision and proceeds toward the axillary periphery. Using a fine skin hook, evert the flap over the side or pad of the surgeon's finger and use the convex side of a fine curved scissor (eg, Stevens or Littler scissors) to trim away the glands; the technique is similar to that used for defatting full-thickness skin grafts. With a little practice, removing essentially all of the gland tissue in a sheet without damaging the fine vessels revealed on the underside of the dermis by the resection is possible. The gland color and texture differentiate them from other structures in the operative field and are the most useful determinants of the adequacy of extirpation. See the images below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Once the flaps are elevated and hemostasis is achieved, the flaps are everted and the layer of the glands snipped off the undersurface of the dermis. Here, the upper portion of the flap has been cleared of sweat glands, while the gland lobules are still visible on the lower portion of the flap. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. The Surgical treatment of axillary hyperhidrosis. The carpet of glandular tissue is seen intact on the left side of the skin flap, while the glands have been resected on the right side of the flap, revealing the underside of the dermis. The axillary fascia is visible as a glistening sheet above the skin flap. Image courtesy of Richard H S Karpinski, MD.

The endpoint of gland resection is usually apparent when the carpet of tan gland tissue runs out. However, peripheral "islands" or "peninsulas" of glandular tissue covered by a thin layer of fat may fool the surgeon; missing these small collections of hypertrophic gland tissue is the probable cause of most sweating "recurrences" once the missed tissue becomes reinnervated. To prevent this failure, check the apparent end of hypertrophied gland mass against the axillary hair pattern or against an outline determined by preoperative mapping. Dissecting approximately 1 cm beyond the apparent end of the glandular tissue carpet also may help prevent recurrence without unduly compromising flap circulation. See the image below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Once the skin flaps are cleared of sweat glands, the dermis should be visible along with the bulbs of many hair follicles. Although not seen clearly in this photo, the fine vessels of the subdermal plexus should be visible under magnification as a network of red vessels. The posture of everting the flap over the surgeon's finger to facilitate gland dissection is demonstrated. Image courtesy of Richard H S Karpinski, MD.

Close the incisions with inverted deep dermal absorbable sutures and running skin sutures. Place a drain through a small separate incision at the most inferior extreme of dissection, since without this step a hematoma or seroma often accumulates. See the images below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: At the completion of gland resection, vascularity of the flaps should show no compromise. Hemostasis should be meticulous. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: A drain has been led out through a small incision at the most proximal area dissected. This spot will be the most dependent when the patient is up and about. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The incision has been closed in two layers, and the drain secured with a single suture. The needle end of the drain can be inserted into a Vacutainer red top tube to supply gentle suction once the incision is closed. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. Inci Surgical treatment of axillary hyperhidrosis. Incision is closed and drain is in place. Image courtesy of Richard H S Karpinski, MD.

Place a padded compression dressing over the entire dissected area, hinged at the depth of the axilla: this can be made with fluffed gauze, layers of Kerlix, or other resilient pad, bent into a V. The brachial limb of the V is taped to the upper arm or held in place with an elastic bandage, while the thoracic limb of the V is taped to the chest and may also be held with a halter of Kerlix gauze wrapped across the contralateral trapezius. Commercially-available elastic compression garments can also hold the dressings in place. See the images below.

Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The bandage should be padded and should overlie the entire dissected area. The distal portion can be held in place by wrapping the arm, and the proximal portion needs to be attached to the chest so that the dressing acts like a hinge when the arm is abducted. Image courtesy of Richard H S Karpinski, MD.
Surgical treatment of axillary hyperhidrosis. Modi Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The completed dressing, in this case using a self-adherent stretchy flexible bandage on top of surgical paper tape and Tegaderm. Image courtesy of Richard H S Karpinski, MD.

Postoperative considerations and follow-up care: The drain may be removed in 72 hours. Some kind of padded compression dressing should remain in place for a week. With absorbable deep sutures in place, skin sutures can be removed safely at approximately 1 week. Most patients resume normal nonabducted arm activity as soon as the dressings are removed; exercises that include overhead stretches can be resumed gradually starting 2 weeks after surgery.


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