Anatomic And Clinic Study Of Apocrine Sweat Glands And Subdermal Vascular Network In Axillary Fossa

BackgroundAxillary osmidrosis is common in plastic and cosmetic surgery. It is not clear to interpret mechanism of axillary osmidrosis. Axillary osmidrosis, commonly called bromhidrosis, can produce a sort of body odor which is repulsive and affect the quality of patients with this disease. Axillary osmidrosis maybe give these mental burden, life stress and even the side-effects on social activities and daily life of bromhidrosis patients.At present, it is certain that allaxillary osmidrosis is close related with apocrine sweat glands in axillary fossa. Histology findings show that axillary osmidrosis patients are different from health adult in apocrine sweat glands morphologic characters. Compared with health adult, there are more numer, deeper localization and bigger diameter of the apocrine sweat glands in axillary osmidrosis.It is tasteless of fresh secretions at first, which are viscous emulsion and contain protein, carbohydrates and lipide, in human apocrine sweat glands. These secretions are transported by apolipoprotein D onto skin's surfaces, and generates typical, acrimony and sharp flavour. Related studies have manifestated that the odors with axillary osmidrosis patients are produced by some substance named E-3-methyl-2-hexenoic acid(E-3M2H), after decomposition of such bacterial as staphylococci and microbacterium.The incidence rate of axillary osmidrosis is 6.41% in China. The radical treatment on axillary osmidrosis is to destroy the secretory portion and ducts of the apocrine sweat glands in axillary region. Surgical treatment on axillary osmidrosis has been proved to be the most effective and rigourous through recently 50 year's experiential summary on the axillary osmidrosis treatment. In order to treat axillary osmidrosis effectively, its cause of disease and pathogenesis should be comprehended. It is necessary to master series knowledge of distribution regularity, histopathology and applied anatomy about the apocrine sweat glands in axillary fossa. Otherwise, the uncorrected measures could be adopted, the treatment on axillary osmidrosis would not obtain satisfactory results, and could result in more harms and distresses on these patients. However, it is controversial for the distribution range and depth of the apocrine sweat glands in axillary fossa. There is not applied anatomy study on the apocrine sweat glands in axillary region in China yet.At present, there is no agreement on distribution range of apocrine sweat gland in tragomaschlia. The majority of scholars agree that the distribution of apocrine sweat glands is similar to that of hair follicle in the axillary osmidrosis and armpit hair area is close-set for apocrine sweat gland. But some scholars disgree this viewpoint. Gang Jian-wu has finished their histology researches about apocrine sweat glands, and deems that there is not positive correlation between the distribution of apocrine sweat gland and hair follicle, the density of armpit hair is not proportional to the degree of osmidrosis, the extent of apocrine sweat glands surpass the edge of armpit hair line 1.0-2.0cm. Li Zhu-mei found that the extent of apocrine sweat glands exceeded the edge of armpit hair line 2.0～3.0cm in osmidrosis surgery. Some doctors thought that the distribution of apocrine sweat glands should surpass the edge of armpit hair line 0.5～1.Ocm. Some believed that apocrine sweat glands distributed most within the armpit hair area, not exceed the edge of armpit hair line 1.0 cm, and there were small quantity of apocrine sweat glands in fluff area.There is also disagreement on depth of the apocrine sweat glands presently. Domestic embryology studies have demonstrated that apocrine sweat glands and sebaceous glands are traceable from embryo bud of primitive epithelium, it is a general viewpoint that apocrine sweat glands are located in fat superficial layers, sometimes in deep part or central region of dermis layer. The distribution, quantity and density of apocrine sweat gland is similar to that of hair follicle. Japanese scholars found in their researches that depth of the apocrine sweat glands were located vertically between 1.7 and 3.7 mm under cuticular layer. Beer has a immunohistochemistry localization experiment on the depth of the apocrine sweat glands of Caucasoid Race, finds out in the end that secretory portion of apocrine sweat glands are located vertically between fat superficial layers, near the dermal reticular layer and not in dermal layers. Some doctor thought that there was some quantity of secretory portion of apocrine sweat glands in deep fat tissue. Lindsay thought in their study that apocrine sweat glands didn't exist in deep fat tissue at all. Some schlor believed that there was a great number of apocrine sweat glands in superficial fascia layers. Yoo deemed that the apocrine sweat glands were located vertically between the deep part of dermal layer and fat superficial layers, had some recurrent rate because of the difficulty of removing cleanly.There are disputes for subdermal vascular network (SVN) in axillary fossa could be reserved when removing apocrine sweat glands by the means-of trimming with scissors. There are few and un-detailed study on protecting skin blood supply while cleaning apocrine sweat glands.However, protecting blood supply in axillary region is very important for the operation of axillary osmidrosis to prevent skin necrosis. The anatomical study of the axillary subdermal vascular network architecture has not been reported now yet.For this reason, it is very necessary to develop the anatomy study of the apocrine sweat glands and the subdermal vascular network architecture in axillary region. We carry out our study including such contents as:distribution regularity of apocrine sweat glands, the subdermal vascular network architecture in axillary region and histopathology observation both macrographically and microscopically. At the same time, we will explore the morphologic feature of the apocrine sweat glands of different degree axillary osmidrosis, arterial architecture and venous return of the subdermal vascular network skin flap in axillary region, in order to supply with anatomic and histological basis of the axillary osmidrosis's treatment.It is our purpose to develop a new operation technique to treat on axillary osmidrosis according to our study and research outcomes. This new operation should obtain better results and little complication than conventional operation, which is axillary furrow incision, visual trimming with scissor and radical treatment on axillary osmidrosis. The new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. We named this new technique as "retainning the pedicle subdermal vascular networks branches and trimming with scissor" methods. It is cheap, convenient, efficient and maneuverable method which should be popularized.Chapter 1 Anatomic Basis of Apocrine Sweat Glands in Axillary FossaObjective To investigate the distribution range and depth of the apocrine sweat glands of the axillary osmidrosis, in order to supply with applied anatomy basis of removing apocrine sweat glands to treat axillary osmidrosis.Methods From September 2010 to November 2010,2 biopsy samples (with axillary osmidrosis),8 biopsy samples (normal, without axillary osmidrosis), were employed into the applied anatomy study in axillary fossa, to explore the characteristics including and the distribution, density, structure and function of the apocrine sweat glands, and its relationship with other skin tissues. Investigate the distribution range and depth of the apocrine sweat glands of the axillary fossa, to find a sort of better methods removing apocrine sweat glands in axillary fossa by imitation of operation. Some tissues sample were tooken, Paraffin Embedding, slicing, HE dyeing and observating with optical microscope.Reults Superficial fascia was a integrated membrane structure in axillary region. Deep fat tissue under superficial fascia manifested yellow macrobead fat between health adult and osmidrosis cadaver. As far as superficial fat tissues were considered, there were yellow microaggregate fat in health adult, but pitchy millet-like granules which proved to be secretory portion by use of pathological section in axillary osmidrosis cadaver. There is no apocrine sweat gland in normal skin.The apocrine sweat glands were devided into secretory portion and duct. The depth of the apocrine sweat glands were located vertically at superficial fat tissues between the dermal reticular layer and superficial fascia layers which were not dissected away easily. Secretory portions distributed most within the armpit hair area, exceeded the edge of armpit hair line 0.5cm, not surpass the edge of armpit hair line 1.0 cm. Under the bottom, the apocrine sweat glands bond with superficial fascia very tightly. Secretory portion could be removed cleanly without harms to reticular layer of dermas.Conclusion Secretory portion of apocrine sweat glands can be seen clearly with naked eye, it is pitchy millet-like granules on axillary osmidrosis corpse. Secretory portions distribute most within the armpit hair area,exceed the edge of armpit hair line 0.5cm, not surpass the edge of armpit hair line 1.0 cm. The depth of the apocrine sweat glands locate vertically at superficial fat tissues between the dermal reticular layer and superficial fascia layers which are not dissected away easily. Trimming under dermals layer, the secretory portion of apocrine sweat glands could be removed cleanly without harms to reticular layer of dermas. Chapter 2 Morphology Study of Apocrine Sweat Glands in Axillary FossaObjectiveTo investigate the morphologic feature of human apocrine sweat glands and sebaceous glands in axillary osmidrosis patients. And explore the role and importance of apocrine sweat glands in the pathogenesis of axillary osmidrosis.Methods From October 2008 to December 2010,39 patients with axillary osmidrosis were devided into three groups according to the degree of the odors with axillary osmidrosis:25 cases in severe group,11 cases in mezzo group,3 cases in mild group. Observed both macrographically and microscopically by using of operation and histopathology methods, to compare the characteristics, the distribution, density and structure between the apocrine sweat glands and sebaceous glands in axillary osmidrosis patients. To investigate the relationship between size, lumen number of glands, the rate of secretory active phase, and the degree of axillary osmidrosis.Results Through pathological section, white prominence-like granules were proved to be compomers of sebaceous glands and hair follicle, and pink millet-like granules were also proved to be secretory portion of apocrine sweat glands. There were statistical difference (P< 0.05) among three groups on such index as trans diameter and long diameter of secretory portion of apocrine sweat glands, lumen number of glands and active phase rate of apocrine sweat glands. There was also statistical difference between compomers of hair follicle and sebaceous glands, and secretory portion of apocrine sweat glands (P< 0.01).As far as white prominence-like granules were considered, There was statistical difference only between severe osmidrosis group and mild osmidrosis group (P< 0.05)Conclusion White prominence-like granules are compomers of sebaceous glands and hair follicle, and pink millet-like granules are secretory portion of apocrine sweat glands. The distribution range of compomers of hair follicle and sebaceous glands are wider than that of secretory portion of apocrine sweat glands. But the depth of secretory portion of apocrine sweat glands is deeper than that of sebaceous glands. Sebaceous glands have vigorous secretion in axillary osmidrosis patients. There are such secretory periods as active phase and in- active phase in the human apocrine sweat glands.The degree of osmidrosis is related with size, number and active phase rate of apocrine sweat glands. Apocrine sweat glands play very important role in mechanism, development and treatment of axillary osmidrosis.Chapter 3 Anatomy and Histopathology Observation of Apocrine Sweat Glands in Axillary FossaObjective To investigate the distribution range and depth of the apocrine sweat glands of the axillary fossa,in order to supply with anatomic and histological basis of the treatment of axillary osmidrosis.Methods From December 2008 to October 2010,2 biopsy samples (with axillary osmidrosis),8 biopsy samples (normal, without axillary osmidrosis), were employed into the axillary anatomy study; and 25 patients with severe axillary osmidrosis were observed both macrographically and microscopically by using of operation and histopathology methods, to compare the skin character and the distribution, density, structure and function of the apocrine sweat glands.Results The apocrine sweat glands were divided into secretary portion and duct. The secretary portion were located vertically between the dermal reticular layer and superficial fascia layers which were not dissected away easily distributed most within the armpit hair area,not surpass the edge of armpit hair line 1.0 cm. Ducts could not been removed away completely.Conclusion The apocrine sweat gland is divided into secretary portion and duct. The secretory portions are located vertically in superficial fat tissue between the dermal reticular layer and superficial fascia layers which could not be dissected away easily. It is very important that secretory portions become ducts under reticular layer of dermis. The secretory portions of apocrine sweat glands distribute most within the armpit hair area,not surpass the edge of armpit hair line 1.0 cm. Ducts could not been removed away completely. In order to treat axillary osmidrosis effectively, the secretary portion should be removed away through cutting off the tissues between the dermal reticular layer and superficial fascia layers; the ducts of apocrine sweat glands should be deal with removing hair follicle from the dermal reticular layer to superficial fascia layers.Chapter 4 Anatomic Basis of the Subdermal Vascular Network in Axillary FossaObjective:To investigate the anatomic basis and clinical signifance of subdermal vascular network(SVN) in axillary fossa.Methods:From September 2010 to December 2010,16 sides of adult upper fresh specimens were perfused red emulsion into brachial artery, the distribution of blood vessels of subdermal vascular network in axillary fossa was anatomically observed. And vascular distribution in axillary fossa was examed on 6 cases cast specimens.Results:Subdermal vascular networks formed between the dermal reticular layer and superficial fascia,were orignited from the cutaneous arteries through axillary deep fascia,which appeared as the shape of tree branches. Superficial fascia vascular network did not participate in the formation of subdermal vascular network(SVN). Fat tissue under dermis should be retained vertically about 2.5～3.5 mm in order to protect the subdermal vascular network(SVN) in axillary fossa.The density of subdermal vascular network (SVN) varied from place to place. There was statistical difference in the density of SVN between midaxillary line, postorior axillary line and anterior axillary line (P<0.05). Large cutaneous artery of thoracodorsal artery originated from 8 cm under axillary furrow.Conclusion:Fat tissue under dermis should be retained vertically about 2.5-3.5 mm in order to protect the subdermal vascular network(SVN) in axillary fossa. Superficial fascia vascular network did not participate in the formation of subdermal vascular network (SVN). These areas of midaxillary line and postorior axillary line should be choosed as the donor sites of dermal vascular plexus free skin graft in clinic. Large cutaneous artery of thoracodorsal artery originate from 8 cm under axillary furrow.The characteristics of subdermal vascular network in axillary fossa play important role in the clinic application.Chapter 5 Radical Treatment on Axillary Osmidrosis with the Method of "Retainning the Pedicle's Subdermal Vascular Network Branches and Trimming with Scissor"Objective:To investigate how to protect the skin blood supply maximatily when removing the axillary apocrine sweat glands for radical treatment on osmidrosis.Methods:From July 2009 to March 2011,215 cases of axillary osmidrosis treated by operation of removing apocrine sweat glands were analyzed retrospectively.215 patients were divided into two groups:115 patients treated with new technique--trimming with reservation of pedicle subdermal vascular network branches,100 patients treated with common technique--trimming with axillary central furrow incision. The clinic outcomes, complications, disadvantage and advantage of the two group patients were analyzed and compared.Results:Follow-up time was 6 months to 2 years after operation. Two techniques had attained satisfactory clinic outcomes. (1) the time of unfolding bandage:the former was 2 d, the latter was 5 d. (2) disconnecting time:the former was 7 d, the latter was 10 d. (3) the time of skin color recovery:the-former was 7～14 d, the latter was 14～21 d. (4) hematoma:he former was7(6.1%), the latter was 12(12.0%).(5) Wound late healing:the former was10(8.7%), the latter was 18(18.0%). (6) Skin necosis:the former was 0(0.0%), the latter was 6(6.0%). (7) Recovery:the former was 113(98.3%), the latter was 97(97.0%). Compared with common technique, new technique had better clinic outcomes and less complications.There are some thickness of secretory portions of apocrine sweat glands usually under subdermal vascular network(SVN) in axillary fossa.While removing apocrine sweat glands in axillary region,it depended on operation positions whether SVN could be retained. It was impossible to reserve SVN in axillary central part. However, SVN could be retained in axillary periphery sites, for the reason of thicker branches of SVN and scarce apocrine sweat glands.Conclusion:The methods of "retainning the pedicle subdermal vascular networks branches and trimming with scissor", make the best of anatomic basis knowledges of the apocrine sweat glands and SVN in axillary fossa. The incision of new technique ensures precisely stoping bleeding and effective removing apocrine sweat glands. Compared with common technique, the new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. It is very valuable for the operation of treating osmidrosis to retain the pedicle subdermal vascular networks branches and remove the axillary apocrine sweat glands.The new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. This method deserves clinic application because of more skin blood supply being protected effectively and less operation complications.SummaryWe firstly propose that 2 biopsy samples (with axillary osmidrosis) be used in the applied anatomic study of the apocrine sweat glands in axillary fossa. it is very necessary to develop the anatomy study of the apocrine sweat glands and the subdermal vascular network architecture in axillary region. We carry out our study including such contents as:distribution regularity of apocrine sweat glands, the subdermal vascular network architecture in axillary region and histopathology observation both macrographically and microscopically. At the same time, we will explore the morphologic feature of the apocrine sweat glands of different degree axillary osmidrosis, arterial architecture and venous return of the subdermal vascular network skin flap in axillary region, in order to supply with anatomic and histological basis of the axillary osmidrosis treatment.It is our purpose to develop new operation technique to treat on axillary osmidrosis according to our study and research outcomes. This new operation should obtain better results and little complication than conventional operation, which is armpit fold mini-incision, visual trimming with scissor and radical treatment on axillary osmidrosis. The new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. We name this new technique as "retaining the pedicle subdermal vascular networks branches and trimming with scissor" methods. It is cheap, convenient, efficient and maneuverable method which should be popularized.Our experiments proved that the apocrine sweat glands are devided into secretory portion and duct, secretory portion transfer into duct at the dermal reticular layer. The depth of the apocrine sweat glands are located vertically in superficial fascia between the dermal reticular layer and superficial fascia layers which are not dissected away easily.The apocrine sweat glands in axillary fossa distribut most within the armpit hair area,not surpass the edge of armpit hair line 1.0 cm. Ducts could not been removed away completely. The secretory portion of the apocrine sweat glands in axillar form a integrated, tough and firm membrane structure which could not be easy erased away. Under the bottom, the apocrine sweat glands bond with superficial fascia very tightly.In order to treat axillary osmidrosis effectively, the secretory portion should be romoved away through cutting off the tissues between the dermal reticular layer and superficial fascia layers; the ducts of apocrine sweat glands should be deal with removing hair follicle from the dermal reticular layer to superficial fascia layers.White prominence-like granules are compomers of sebaceous glands and hair follicle, and pink millet-like granules are secretory portion of apocrine sweat glands. The distribution range of compomers of hair follicle and sebaceous glands are wider than that of secretory portion of apocrine sweat glands.But the depth of secretory portion of apocrine sweat glands is deeper than that of sebaceous glands. Sebaceous glands have vigorous secretion in axillary osmidrosis patients.There are such secretory periods as active phase and in-active phase in the human apocrine sweat glands.The degree of osmidrosis is related with size, number and active phase rate of apocrine sweat glands. Apocrine sweat glands play very important role in mechanism, development and treatment of axillary osmidrosis.Subdermal vascular networks formed between the dermal reticular layer and superficial fascia,were orignited from the cutaneous arteries through axillary deep fascia,which appeared as the shape of tree branches. Fat tissue under dermis should be retained vertically about 2.5-3.5 mm in order to protect the subdermal vascular network(SVN) in axillary fossa.The density of subdermal vascular network (SVN) varied from place to place. Superficial fascia vascular network did not participate in the formation of subdermal vascular network(SVN). These areas of midaxillary line and postorior axillary line should be choosed as the donor sites of dermal vascular plexus free skin graft in clinic. Larger cutaneous artery of thoracodorsal artery originate from 8 cm under axillary furrow.The characteristics of subdermal vascular network in axillary fossa play important role in the clinic application.There are some secretory portions of apocrine sweat glands usually under subdermal vascular network(SVN) in axillary fossa.While removing apocrine sweat glands in axillary region,it depended on operation positions whether SVN could be retained. It was impossible to reserve SVN in axillary central part. However, SVN could be retained in axillary periphery site, for the reason of thicker branches of SVN and scarce apocrine sweat glands.The methods of "retainning the pedicle subdermal vascular networks branches and trimming with scissor", make the best of anatomic basis knowledges of the apocrine sweat glands and SVN in axillary fossa. The incision of new technique ensures precisely stoping bleeding and effective removing apocrine sweat glands.Compared with common technique, the new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. It is very valuable for the operation of treating osmidrosis to retain the pedicle subdermal vascular networks branches and remove the axillary apocrine sweat glands.The new operation technique could attain the aim of protecting skin blood supply effectively and ensuring satisfaction of removing apocrin sweat glands. This method deserves clinic application because of more skin blood supply being protected effectively and less operation complications.There are these insufficiencies in our research such as:Firstly, because sex factors influence couldn't be eliminated, it is wrong for statistical significance of superficial and deep fat ascribed to effects between axillary osmidrosis cadaver and no axillary osmidrosis cadaver.Secondly, the live odor degree could not be distinguished in axillary osmidrosis cadaver, we know no cause of difference in the size of apocrine sweat glands between our and other researches.Thirdly, axillary osmidrosis cadavers in our study is limited, maybe be the reason of incidence rate and cadaver factors which result in it is not easy to find axillary osmidrosis cadavers.Fourthly, in order to investigate the distribution range and depth of the apocrine sweat glands of the axillary osmidrosis, such general Marker as CD15,CD44和S-100, could be used into immunohistochemistry localization experiment.