AXILLARY SKIN EXCISION (SKOOG)

Information booklet

Introduction

Everyone sweats when it is hot or when they are emotionally

stressed. However, hyperhidrosis is a condition where people
sweat more than normal or at times when most people would not.

Hyperhidrosis can be localised (i.e. occurring in just one part or

the body) or generalised (i.e. all over the body).

When sweating occurs only in the under arm region (axilla)

some people may choose to undergo an operation to remove
sweat glands from the skin in the axilla.
Local excision of sweat glands is an effective method of reducing sweating localised to the axilla.
However, Dr Bond will have explained that it is only one of several treatments available and has both
advantages and disadvantages. In particular, it is a surgical procedure involving an anaesthetic and a
cut whereas there are non-surgical treatments available. You should consider carefully if it is the right
procedure for you.

There are three broad groups of axillary sweat gland removal operations:

1. Complete removal of all the skin under the arm pit. This is the most effective technique but is
very uncomfortable, takes many weeks to heal and leaves far too great a scar to be acceptable
except in very rare cases.
2. At the opposite extreme is subcutaneous tumescent liposuction. This is done though a
keyhole scar and heals quickly but the reduction in sweating maybe inadequate and returns in
many cases.
3. The Skoog Procedure is a good compromise between these two extremes. It is the choice of
many surgeons, including Dr Bond and is explained below. The scars are noticeable with this
procedure but it is effective in making sure the glands are removed. It reduces sweating by
approximately 60% of the preoperative state with a good long term effect.

The Skoog Operation

The Skoog procedure involves excision (removal) of one or more small ellipses of skin in the arm pit,
about 2cm wide by 5cm long. The remaining skin is retracted to expose the glands on the underside of
the skin. The glands are surgically removed using fine scissors under magnification. The wound is then
closed and pressure applied for several days.

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What to Expect and How to Prepare

It is vital that you have not taken any anticoagulant medications for at least a week (eg, Warfarin,
aspirin, Copidegrel, ibuprofen, high-dose vitamin E, ginkgo, ginger, garlic, dong quai). Please let Dr
Bond know if you have.

Before arriving, a shower with regular soap or antibacterial soap (eg, chlorhexidine) on the morning of
surgery is an appropriate precaution. Please avoid using antiperspirants on the morning of the
procedure.

There is no need to abstain from shaving under arms if you normally do so. If you do not, they will be
shaved the morning of the operation as it makes peri - operative care of the wound easier for both you
and the nurses. A single dose of intravenous antibiotics at the commencement of the operation is given
as a precaution.

The operation is carried out under general anesthetic (asleep) but local anesthetic is also used to
make the operation site more comfortable when you wake up. The underarm area is infiltrated
(injected) with a solution containing saline and local anaesthesia that assists with the surgery and
reduction of post-operative pain.

Between one and three parallel incisions are made with a transverse line following a skin crease
across the center of the hair-bearing arm-pit skin, from the front to back of the extent of the hair area.

Small pieces of skin are removed and the rest of the skin is folded over to allow sweat glands to be
removed under direct vision. Great care is taken to avoid bleeding.

The wounds are closed with dissolvable sutures in most cases but occasionally stitches are used that
require removal one week after the surgery. A drain (small tube) is left protruding from the skin to
reduce the chance that fluid accumulates under the skin. A padded compression dressing is placed
over the entire area, and held in place with an elastic bandage.

After the Operation

Immediately after your surgery, you will spend approximately half an hour in the recovery room whilst
you wake up and will then be returned to your bed on the ward.

It is normal to remain in hospital for the next 24 hours. On the day after the operation Dr Bond will
review the wound and the drain. Usually the drain is taken out after 24 hours but may occasionally stay
in place for several days. Even if the drain does have to stay in place it is usually possible to go home
and return to the ward for removal a few days later.

Occasionally, it may be necessary to stay in longer than 24 hours, depending on the extent of the
surgery. A padded compression dressing remains in place for a week. If non-dissolvable sutures have
been used, they can be removed at approximately one week after the surgery.

Most patients resume normal arm activity as soon as the dressings are removed; exercises that
include overhead stretches can be resumed gradually starting two weeks after surgery.

The following things are to be expected to some extent after the operation:

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 1. Pain- Some pain will occur after the operation which should ease
after a few days. It should be well controlled by analgesia that will
be provided before discharge from Hospital.

2. Visible scar- Between one and three parallel scars will be present
in the arm pit region. These can be quite red and raised for
several months after the surgery but gradually fade.

3. Restricted movement- A feeling of limitation to movement due to tightness of the skin. This
improves once the dressings are removed but may last for several weeks. Gentle stretching is
commenced at two weeks

4. Swelling- It is common to have a small amount of swelling in the under arm region which
resolves over a couple of weeks.

The following are not expected but can occur in a small number of cases

1. Haematoma formation requiring drainage- Great care is taken to stop all bleeding during the
operation, a tube drain is left in place after the operation and a compression bandage is applied
to the wound. Despite these precautions in some cases fluid can still collect under the skin
(haematoma). Although this will usually go away by itself, it may occasionally require a further
surgical procedure to drain the fluid.

2. Skin necrosis- The operation requires that the skin is thinned out. Furthermore, the skin is often
weakened by long term exposure to moisture from hyperhidrosis. Occasionally after the
operation the skin can breakdown to leave an open wound at the site of surgery. Although this is
rare using modern techniques it is a very important complication as it can delay healing from the
operation for many weeks, result in a poor scar appearance and occasionally requires re-
admission to hospital for dressings.

3. Wound infection- For similar reasons to above, infection can occur in the wound. Again, this is
uncommon. It may require antibiotics if it occurred.

4. Keloid (raised and red) scar formation- Some people are particularly prone to formation of keloid
scars. If you know you are one, you should discuss it with Dr Bond. It is not an absolute
contraindication to surgery but should be born in mind when deciding about the procedure.

Longer term outcomes

1. Failure to reduce sweating- The average degree of reduction of sweating after a skoog
procedure is around 60-70%. It is not possible (or desirable) to remove all sweating and most
people are pleased with this result. However, occasionally, the objective decrease is less. If
sweating remains a problem, alternative techniques for its management may have to be
considered.

2. Return of sweating after 6-9 months- It is not uncommon for some degree of return of sweating
to occur as new nerves regrow in the skin at around 6 months to a year. But this is usually only
a small amount and may not be noticed at all.

3. Compensatory sweating- In some cases, treating sweating in one region of the body may result
in increased or new sweating in another area. This is very uncommon after axillary skin
excision.
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