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Re: Botox for a Lifetime or Tumescent Axillary Liposuction and Curettage: Once

To the Editor:
There continues to be widespread interest and use of Botox for axillary hyperhidrosis. I find this most remarkable, expensive, and wasteful. Tsai and Lin recently reviewed the treatment options for axillary osmidrosis (and hyperhidrosis) with considerable clarity. However, suction curettage after tumescent anesthetic distention of the axillary vault has proven remarkably advantageous, safe, and generally curative. The availability of aggressive curettage instrumentation has only increased the efficaciousness of the procedure. Why would one sentence a patient to a lifetime of medical expense when a single surgical intervention has every reasonable expectation of being curative and is even less uncomfortable and distressing than the multiple needle injection technique of Botox administration? I cannot fathom such an economic and painful disservice to our patients suffering with this unpleasant entity.
     I again refer the readership to previous commentary on the remarkable success of the Cassio cannula available from Brazil. (Figures 1 and 2). This cannula has proven its efficacy and superiority in a number of international settings, with all witnesses convinced. On some occasions, I have demonstrated it immediately after others had completed their work using other instrumentation with significant harvesting of residual glands obvious.

Figure 1. Lateral view. revealing elevation of sharpened scraping surface. Curettings drawn into suction opening proximal to the scraping protrusion (when attached to machine).
Figure 2. Ventral view of curved, blunted, spatula cannula design allowing noncutting forward movement and elevation of axillary flap. Large aspiration aperture is evident.

     If the individual rendering care for axillary hyperhidrosis is incapable of himself/herself of performing the preferred surgical intervention, then it would seem proper to send the patient on to someone who can do so. The referral physician must necessarily be aggressive to the undersurface of the dermis. One should not hesitate to aggressively currete the subdermis in fear of minor scarring consequences, provided only the patient is forewarned and elects the more aggressive and curative approach. Removal of the glands remains primary in the patients' minds, and so should it be in ours. Cost, nuisance, necessity of repeated painful injections, and time expended all favor the single adequate surgical approach over any presently available pharmaceutical drug.

Inaugural International Chair of Dermatologic Surgery
(International Society of Dermatologic Surgery)
University of California, San Francisco
(Dermatologic Surgery)
Stanford University Medical Center
Stanford, California