INTRODUCTION Treatment of axillary osmidrosis, from the simplest, includes [1-3]Botox injection , antiperspirant, deodorant, 1444nm: [4] [5-6]Nd:YAG yttrium chrome laser, microwave thermolysis , radio frequency, etc. The aforementioned methods are relatively non-invasive treatments. However, total removal of axillary osmidrosis requires a radical surgical procedure to be totally eradicated. The current surgical treatment includes the minimally invasive surgery by performing a subcutaneous incision and using a liposuction-assisted curettage to excise the apocrine gland and the traditional surgery by removing the apocrine glands through a large subcutaneous incision. In the course of operation, the most concerned acute complication is hematoma. When the operation causes trauma in the skin tissue, there will be blood accumulation in the dead space. If the blood accumulates in the dead space and the hemostasis is bad, it is easy for blood to accumulate in the dead space. Because of the presence of blood clot between the skin ap and the subcutaneous tissue, hematoma causes the wound to fail to heal smoothly. In addition, the poor blood ow in the skin ap is usually accompanied by skin necrosis. The blood clot gradually becomes brotic in the later stages and the axillary brosis becomes harder. Hence, the postoperative hematoma is a relatively serious complication for patients. COMMON COMPLICATIONS AFTER THE AXILLARY OSMI DROSIS SURGERY Acute and Subacute Stage Hematoma Hematoma are the most common postoperative complications of axillary osmidrosis surgery. It is possible not to treat contusion. However, with hematoma, there is usually a large accumulation of blood. If not treated well or if not treated in time, it may lead to severe skin necrosis of the ap, wound infection, scar contracture, and delayed healing. Why does hematoma occur? One reason is that the hemostasis in the operation is not thorough enough, electrocautery is not enough to stop the bleeding, the quilting suture fell off and so on. Another possible reason for hematoma is the inappropriate excessive activity of the upper limbs after the surgery. ACUTE AND SUBACUTE STAGE SUBCUTANEOUS EFF USION Because the ap and the tissue does not close up well coupled with an excessive movement of the upper extremities, a subcutaneous uid under the skin forms into subcutaneous effusion. When touched, the skin ap gives an undulating sensation. A pale yellowish serum can be seen with a needle aspiration. The cause of the occurrence of subcutaneous effusion is mainly due to the existence of a cavity between the ap and the subcutaneous tissue at the early stage after the operation. SKIN NECROSIS Skin necrosis is the worst postoperative complication of axillary osmidrosis surgery. It is generally believed that the main reason for this complication is that the aps are trimmed too thin resulting in the destruction of the dermis and the subdermal vascular network. Another reason is understand to be caused by the improper xation of the postoperative STUDY ON NEW MODIFIED TECHNIQUES TO REDUCE HEMATOMA RATE ON OSMIDROSIS SURGERY Original Research Paper Noi-siong, Lau Department Of Dentist, Kang-shuan Dental Clinic, New Taipei City, Taiwan, ROC. X 63GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Dental Science BACKGROUND: The removal of axillary osmidrosis requires a surgical procedure to be totally eradicated. The current surgical treatment includes the minimally invasive surgery by performing a subcutaneous incision and using a liposuction-assisted curettage to excise the apocrine gland and the traditional surgery by removing the apocrine glands through a large subcutaneous incision. The course of operation carries adverse effects such as hematoma, subcutaneous infection, subcutaneous necrosis, etc. The most common and bothersome of which is the subcutaneous hematoma. OBJECTIVE: To reduce the occurrence of subcutaneous hematoma by improving the original surgical method in an innovative and easy way. METHODS: This study intends to use a more innovative and improved method to increase the blood drainage channel. In view of the fact that the occurrence of hematoma is closely related to the skill of the surgeon, we used the same clinician throughout the study to put forth a more reliable research. The research was done on two groups of axillary osmidrosis patients: the rst group, consisting of 28 patients, received the original method of surgery from September 2015 to August 2016; the second group, consisting of 53 patients, received an improved surgical operation, in addition to the original method, from September 2016 to August 2017. In the research, no. 11 blade was used to make a 2-3 mm incision on the axillary ap of 10 patients from the second group after the Quilting Sutures. Tie over bandages are used to reduce the chance of hematoma. RESULTS: The second group of patients received a modied small incision method, showing a reduced occurrence of hematoma from 20% (12/56) in the rst group to 4.7% (5/106) in the second group. In spite of the fact that the sample size in the study is small, the statistics show a signicant difference between the two groups. However, there is no statistical difference found between the two groups with regards to ap ulceration, ap necrosis, and abscess infection. The hematoma statistics show that the new and improved approach is effective and worthy of promotion CONCLUSION: According to the physical principle of capillary action and siphon, exudates and blood are “exuded” from the small incision in the ap through the perforation. The capillary action is the ability of a liquid to ow in a conned space without the aid of an external force such as gravity or even vice versa. The siphon principle is the ow of liquid from a higher level to a lower level. The conclusion of this study is that this new and improved method is effective and worthy of promotion. ABSTRACT KEYWORDS : Wen-tsao, Ho* Department of Dermatology, Ho Wen Tsao skin clinic, New Taipei city, Taiwan *Corresponding Author VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra 64 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS dressing. At the early stage, the necrotic skin appears to be pale. After a week, the necrotic skin forms a black callus. COMPREHENSIVE COMPARISON OF METHODS TO PREVENT HEMATOMA Some of the many ways to solve the problem of hematoma are: QUILTING SUTURES In this study, the skin ap and the subcutaneous tissue are afxed together by means of suture. This article was published in the Journal of Dermatology. The study shows that a nylon line is used to evenly stitch the space between the ap and the subcutaneous tissue. This procedure is called simple suture where the skin ap and subcutaneous tissue are [14,15]stitched up to reduce the dead space . Looking at the data from this study, quilting suture can signicantly reduce the chance of hematoma. Despite that, this method cannot be applied to every operator as the occurrence of hematoma is directly related to the experience of the surgeon and the way the surgery is performed and the method indicated in this paper uses a liposuction-assisted curettage. This study signicantly shows that quilting suture can remarkably reduce the chance of hematoma, the same is true inferentially. FIBRIN Fibrin method was published in an article issued in 2009. The [16-17]study concludes that, whether brin is used or not, there is no statistically signicant difference in the amount of blood ow. Hence, the study concludes that the use of brin after axillary osmidrosis surgery does not reduce the postoperative bleeding and that there is no way to increase its adhesion. TIE OVER BANDAGE [18]Tie over bandage (Fig 1) is used to absorb tissue uid. With the application of external pressure, where the patient clamps the bandage, the skin ap is pressed back to the subcutaneous tissue reducing the dead space and possibility of bleeding. First is to reduce the dead space and the second is to stop bleeding – these two approaches reduce the chance of bleeding. However, there is no particular analysis presented in the literature showing the percentage it can actually reduce the occurrence of hematoma. Fig1 Tie-over bondage is to prevent hematoma DRAIN TUBE This method puts a drain tube in the dead space extracting the blood with the tube. This method is used in most surgical procedures. The disadvantage is that when the drain tube is removed, a gap is left in the area where another amount of time is needed to attach the ap and the subcutaneous tissue. The drain tube is usually removed three days after the surgery. After that, additional time is needed for the wound and the path from the drain tube to heal. In rare cases, the dead space is situated far from the drainage tube and the hematoma could not be extracted because of its location. RESEARCH METHOD In this research, we will be modifying the established methods to reduce the risk of hematoma. RESEARCH OBJECTS Patients with osmidrosis who agreed to have surgery at our clinic in Taiwan were divided into two groups: 28 in the rst group and 53 in the second group, with a total of 81 persons. GROUPING OF THE EXPERIMENTAL OBJECTS This research compared and analyzed retrospectively the records of the rst group of patients who received the axillary osmidrosis surgery from September 2015 to September 2016 with the second group of patients who received improved axillary osmidrosis surgery from September 2016 to September 2017. Among the 28 patients from the rst group of objects, those who received the surgery from September 2015 to September 2016, were found mild to moderate side effects, especially hematoma. Consequently, this study modied the surgical approach to reduce the risk of hematoma. On that account, the surgeries performed to the 53 patients of the second group of objects after September 2016 employed additional new modications. METHODS AND PROCEDURES ESTABLISHED PROCEDURES FOR GROUP ONE PATIENTS After removing the apocrine sweat gland, the wound is stitched together by quilting sutures with bondage gauzed secured on it. MODIFIED PROCEDURES FOR GROUP TWO PATIENTS After the removal of the apocrine sweat gland, approximately ten or more 2-3 mm incision was made in between quilting sutures on the axillary ap of the second group objects with the use of No. 11 blade. Tie over bandage gauze was in the same manner secured on the wound to reduce the chance of hematoma, as seen in Fig. 2. All patients underwent subcutaneous removal of the apocrine glands. The bilateral armpits were sterilized then injected with swelling agent anesthesia on the pre-marked area of the axillary producing a “peau d'orange” effect on the covered tissue. The formula used for the swelling agent anesthesia solution is composed of 500 ml saline, 20ml 2% lidocaine, 1ml 1:1000 epinephrine and 12.5 ml sodium bicarbonate. A 1-1.5cm long incision was made in the center of the creased axillary and the apocrine gland was removed through the incision with the use of a pair of scissors. This process is repeated throughout the axillary until the whole area basically becomes a thin ap. The surgical process starts with the sterilization of the armpit. It is followed by the inltration of anesthesia and the swelling agent, the proportion of which is 500 ml of saline, 20 ml sodium bicarbonate solution and 1 ml epinephrine; about 50-100 c.c. is used on each side. A No. 10 hollow needle is used, matched with a No. 27 needle, to inject the solution between the skin ap and the dermis to hold the skin open. After the inltration, a No. 15 blade is used to make a small incision, about 3-4 mm, at the middle of the armpit. An IRIS scissor is then used to separate the skin ap from the subcutaneous tissue. After the separation, a rotating knife is used to scrape off all the apocrine glands. The excision of the apocrine glands is done one by one through minimally invasive holes. The incision is closed with Quilting Sutures. Finally, a tie over bandage, about the size of a st, is used to press against the skin ap and the dermis and is fastened with sutures. After the Quilting Sutures, a No. 11 blade is used on the group 2 patients to make approximately ten 2-3mm incision on the skin ap. Afterward, the tie over bandage is used to reduce the chance of hematoma. The patients were asked to return three days after the surgery. VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra During the rst visit, the xed suture is cut and the tie over bandage is removed. In this study, we can see that on the third day, the color of the blood on the tie over bandage turned brown or black, not a bright red color, only a few wounds have bright red color, telling us that removing the tie over bandage on the third day, as intended in this study, is reasonable. The brown or black color refers to oxidation, which means that there is no occurrence of bleeding. Fig. 2 After the Quilting Sutures, a No. 11 blade is used on the group 2 patients to make approximately ten 2-3mm incision on the skin ap. POST-OPERATIVE MANAGEMENT The tie over bandage was removed 3 days after the operation (Fig. 3). The removal of the suture was set 7 days after the surgery and the removal of the wound suture was set 14 days after the surgery. Fig 3 Blood absorbed by bondage gauzes 3 days after removal. POST-OPERATIVE EVALUATION Possible complications include hematoma, seroma, skin ulceration, infection and delay in wound healing. Recording of data lasted for 2 weeks for both group 1 and group 2 patients. EXPERIMENTAL RESULTS Calculation formula and signicance analysis, where t is statistical value: The equation of the degree of freedom is: V = subnumber – 1 T TEST PROCEDURE: The t value of the required statistics is calculated. This study selected different statistical calculation methods for different types of problems. a. To decide the degree of difference between the average of a small sample and the average of its population, the statistical value t is calculated as follows: b. To evaluate the degree of difference between the two groups of samples and their average, the formula for calculating the statistical value t is as follows: This study compares the obtained t value with the theoretical t value and further deduce the probability of occurrence. Judgment is made based on the relationship between the t values given in Table 1 and the signicance of the difference. Table 1 The T and P value denitions RESULT An independent sample T test was used to analyze the results of the two groups of data on hematoma, seroma, infection, skin surface ulceration, and skin necrosis. The results of the analysis are shown in Table 2. Table 2 shows that hematoma has a signicant value of p<0.05, indicating that there was a signicant difference in the postoperative occurrence of hematoma. The mean value for the rst group of data, calculated as 0.21, is greater than the mean value of the second group of data, computed as 0.05. Therefore, it can be said the surgical method on the second group of patients yields a better result than the surgical method on the rst group of patients in terms of hematoma complication. The value of signicance for the seroma, infection, skin surface ulceration and necrosis were greater than 0.05 denoting that there was no signicant difference in the postoperative occurrence of complications in the form of seroma, infection, ulceration and necrosis. That is, the two surgical methods conducted on the two groups of patients does not improve nor does it increase the occurrence of complications such as seroma, infection, ulceration, and necrosis. To sum up, the result of the surgical method on the second group is better that of the rst group. Table 2 Analysis of outcomes between A-B surgical techniques DISCUSSION Many doctors use different methods to reduce the risk of hematoma, seroma, and so on with the use of suture, bandages, tissue glue, and drainage tubes. In this study, we can see that the second group of patients, who received a more improved surgical method, showed a reduced occurrence of hematoma at 4.7% (5/106) as compared to the rst group at 20% (12/56). It is interesting to note that the occurrence of hematoma on the right side for both groups of patients is slightly higher. The postoperative complications of the two groups of patients were not related to their profession/activity, age, sex and smoking history. The research encouraged patients with smoking history to quit smoking. It is suspected that those with smoking X 65GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra t P Value Signicance of difference t ≧t(df)0.01 P≦0.01 Difference is very signicant t ≧ t(df)0.05 P≦0.05 Difference is signicant t 0.05 Difference is insignicant Item Group N Mean value Standard deviation t p Hematoma Group 1 12/56 0.21 0.41 2.829 .006 Group 2 5/106 0.05 0.21 Seroma Group 1 1/56 0.02 0.13 1.000 .322 Group 2 0/106 0.00 0.00 Septic infection Group 1 2/56 0.04 0.19 1.000 .326 Group 2 0/106 0.00 0.00 Skin ulceration Group 1 20/56 0.36 0.49 0.501 .618 Group 2 3/106 0.30 0.46 Delayed healing Group 1 11/56 0.18 0.39 1.001 .322 Group 2 9/106 0.09 0.29 Skin necrosis Group 1 2/56 0.04 0.19 0.460 .647 Group 2 2/106 0.02 0.14 VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra history have more problems but found no increased risk. The new surgical approach appeared to have greatly improved hematoma complications but yielded no positive effect on other complications such as infection, ulceration and delayed healing. During the study, once hematoma occurred, no matter in which group, the blood clot is cut and drained. Patients are requested to return to the clinic every day until the bleeding stops. Prophylactic antibiotics are also given. CONCLUSION The method used here is capillary action or wicking. Capillary action is the ability of a liquid to ow in a narrow space without the aid of, or even in opposition to, external forces like gravity. [19-20]The siphon principle is the ow of liquid from a higher level to a lower level. The second group of patients received a modied punctured method that showed the reduced occurrence of hematoma with 20% (12/56) from group 1 patients decreasing to 4.7% (5/106) from group 2 patients. Regardless of the small sample size of the study group, the statistics show a signicant difference between the two groups. However, there was no statistical difference between the two groups with regards to skin ulceration, skin necrosis, and abscess infection. The conclusion of this study is that this new and improved method is effective and worthy of promotion. REFERENCE: 1. An JS, Hyun Won C, Si Han J, Park HS, Seo KK. Comparison of onabotulinumtoxinA and rimabotulinumtoxinB for the treatment of axillary hyperhidrosis. Dermatol Surg. 2015 Aug;41(8):960-7. 2. Jeong JH, Hong JM, Pak CS, Kim JH, Heo CY. Treatment of axillary osmidrosis using a laser with a 1,444-nm wavelength. Dermatol Surg. 2014 Aug;40(8):851-7. 3. Sánchez-Carpintero I, Martín-Gorgojo A, Ruiz-Rodríguez R. Microwave Treatment for Axillary Hyperhidrosis and Bromhidrosis. Actas Dermosiliogr. 2017 Mar 8. 4. Hsu TH, Chen YT, Tu YK, et al. A systematic review of microwave-based therapy for axillary hyperhidrosis. J Cosmet Laser Ther. 2017 Mar 10:1-8 5. Toyoda Y, Gomi T, Nakagawa H, et al. Diagnosis of Human Axillary Osmidrosis by Genotyping of the Human ABCC11 Gene: Clinical Practice and Basic Scientic Evidence. Biomed Res Int. 2016;2016:7670483. 6. Shi LL, Sargen MR, Chen SC, et al. Effective local anesthesia for onabotulinumtoxin A injections to treat hyperhidrosis associated with traumatic amputation. Dermatol Online J. 2016 Jun 15;22(6) 7. de Almeida AR, Montagner S. Botulinum toxin for axillary hyperhidrosis. Dermatol Clin. 2014 Oct;32(4):495-504. 8. Ren Y, Liu W, Chen J, et al. A missense variant of the ABCC11 gene is associated with Axillary Osmidrosis susceptibility and clinical phenotypes in the Chinese Han Population.Sci Rep. 2017 May 9;7:46335 9. Sun Y, Long J, Wang Y. Correlation between ABCC11 gene single nucleotide polymorphism and the incidence of axillary osmidrosis in Chinese Han population].Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2013 Nov;38(11):1141-5. 10. Ho WT, Wang HY, Pan JY. Genotyping for SNP rs17822931 in ABCC11 gene can help in the diagnosis of body malodour. Malaysia journal of dermatology 2016 Jul Vol 36 11. Toyoda Y, Takada T, Gomi T, Nakagawa H, Ishikawa T, Suzuki H. Clinical and Molecular Evidence of ABCC11 Protein Expression in Axillary Apocrine Glands of Patients with Axillary Osmidrosis. Int J Mol Sci. 2017 Feb 15;18(2). pii: E417. 12. Caroprese A, Gabbanini S, Beltramini C, et al. HS-SPME-GC-MS analysis of body odor to test the efcacy of foot deodorant formulations. Skin Res Technol. 2009 Nov;15(4):503-10. 13. Ho WT, Lee LJ, Pan JY. Following Changes in the Axillary Secretions of Two Patients Before and After Bromhidrosis Surgery Using Liquid Chromatography-Mass Spectrometry. Dermatol Surg. 2017 Mar;43(3):459- 462. 14. Miyamoto E, Hayashi A, Komoto M, et al. "Sea anemone-shaped xation": a feasible tie-over technique for axillary osmidrosis. J Plast Reconstr Aesthet Surg. 2012 ;65:e202-203. 15. Rho NK1, Shin JH, Jung CW, et al. Effect of quilting sutures on hematoma formation after liposuction with dermal curettage for treatment of axillary hyperhidrosis: a randomized clinical trial. Dermatol Surg. 2008 ;34:1010-5 5. Shimizu Y, Nagasao T, Kishi K, et al. Alternative continuous quilting suture technique for preventing hematoma in axillary osmidrosis. Dermatol Surg. 2014;40:1058-106 16. Sajid MS1, Hutson KH, Rapisarda IF, et al. Fibrin glue instillation under skin aps to prevent seroma-related morbidity following breast and axillary surgery. Cochrane Database Syst Rev. 2013 May 31;(5):CD009557. 17. Lim DW, Park J, You YC, Yang WY, Lee W. The Effectiveness of Fibrin Glue Using in Dermal Shaving at Osmidrosis. J Korean Soc Aesthetic Plast Surg. 2005 Mar;11(1):93-98. Korean. 18. Miyamoto E, Hayashi A, Komoto M, et al. "Sea anemone-shaped xation": a feasible tie-over technique for axillary osmidrosis. J Plast Reconstr Aesthet Surg. 2012 ;65:e202-203. 19. Wikipedia: https://en.wikipedia.org/wiki/Capillary_action, accessed Nov. 22, 2015. 20. Hughes, Stephen W. A practical example of a siphon at work. Physics Education 2010. 66 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS