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.
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.
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.
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?
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
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.