The Feasibility of Treatment for Skin Diseases Using the Ultrasonic Surgical Aspirator

doi:10.4236/mps.2013.32014

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Modern Plastic Surgery, 2013, 3, 71-75

http://dx.doi.org/10.4236/mps.2013.32014 Published Online April 2013 (http://www.scirp.org/journal/mps) 71

The Feasibility of Treatment for Skin Diseases Using the

Ultrasonic Surgical Aspirator

Chihoko Nakahara1, Shiro Niiyama1*, Satoshi Kajiura1, Yoshinori Ito2, Noriyoshi Sumiya2,

Kensei Katsuoka1

1Department of Dermatology, Kitasato University School of Medicine, Sagamihara, Japan; 2Department of Plastic and Reconstruc-

tive Surgery, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Japan.

Email: *[email protected]

Received December 8th, 2012; revised January 10th, 2013; accepted January 18th, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Ultrasound energy liquefies high fluid content tissues, such as epidermis and sweat glands via cavitation, but minimally

affects dermis, blood vessels, and nerves at the same energy level. We have used ultrasonic surgical aspirator to treat

several skin diseases such as Bowen’s disease, wart, prurigo nodularis, and osmidrosis. The ultrasonic surgical aspirator

offers an effective and safe method to treat them with few complications. We expect several other skin diseases could

likely be cured using ultrasonic surgical aspirator by accumulating additional cases.

Keywords: Bowen’s Disease; Osmidrosis; Prurigo Nodularis; Wart

1. Introduction

The ultrasonic surgical aspirator (USA) has long been

used in the fields of renal surgery [1], neurosurgery [2],

and cardiac surgery [3], and is widely available in hosp i-

tal settings. The ultrasonic energy caused cavitation in

high fluid content tissues, such as epidermis and sweat

glands, resulting in liquefaction and subsequent removal

by suction. However, at the same energy level, solid ad-

jacent structures such as dermis, blood vessels, and

nerves were minimally affected [4].

We treat to some skin diseases with this novel and

original method using USA, and the results are sufficient.

Here, we describe the feasibility of treating skin diseases

using USA .

2. Methods and Case Reports

The USA used for this treatment is the Sonopet UST-

2001 (Miwatec Co., Ltd., Kawasaki, Japan). The aspira-

tor is composed of a main unit and a hand piece. The tip

of the hand piece consists of titaniu m, and it has a 2 mm

diameter, 25 kHz frequency, and 300 m maximum os-

cillation. The operator can adjust the level of oscillation

between 0 and 100. The optimal setting will vary de-

pending on the thickness and hardness of the affected

area. Specifically, the thicker and harder the area, the

higher is the setting, and we used settings that fell within

a range of 40 to 80. The area around the tip is irrigated

with physiological saline, which is suctioned away

through the tip itself.

2.1. Patient 1

A 72-year-old female had a 50 × 30 mm, slightly ele-

vated, light red nodule on the neck that had been slowly

growing since its appearance 3 years previously (Figure

1). Beforehand, we examined skin biopsy and it w as con-

firmed that Bowen’s disease, immature keratinization

and irregular acanthosis of the epidermis with clumping

cells. A safety margin was marked approximately 5 mm

from the lesion border. A local infiltration anesthesia was

administered, while waiting for the effect of local anes-

thesia, the ultrasonic aspirator was set up. The ultrasonic

power was set at 70%, the rate of saline irrigation was set

at 40 ml/min, and the suction was 50%. While holding

the handpiece like a pen, the operator lightly pressed the

tip onto the epidermal surface of the region and moved it

around in continuous cir cular, brush-like motions. At the

same time, we cooled the treated area with ice to prevent

the burn. After conf irmation on visual inspectio n that the

lesion had been totally excised, a portion of the wound

was biopsied to confirm the visual findings. Histological

*Corresponding a uthor.

The Feasibility of Treatment for Skin Diseases Using the Ultrasonic Surgical Aspirator

examination of specimens showed elimination of the

epidermis (Figure 2). A steroid and antibiotic ointment

was applied to the wound. The course of recovery was

uneventful, and the wound was totally epithelialized 2

weeks after the procedure. At 14 months after treatment,

no signs of recurrence were observed (Figure 3).

Figure 1. A 50 × 30 mm nodule on the neck.

Figure 2. Histological examination showed elimination of

the epidermis.

Figure 3. At 14 months after treatment, a slight scar was

present but no signs of recurrence.

2.2. Patient 2

A 27-year-old male presented with a 5-year history of

recalcitrant many warts on the sole (Figure 4). Previ-

ously the patient had received treatment with cryotherapy

and 5% imiquimod, however, the treatments were not

effective. A local infiltration anesthesia was ad ministered.

The ultrasonic power was set at 60%, the rate of saline

irrigation was set at 25 ml/min, and the suctio n was 50%.

The thick surface of warts is scraped with a scalpel until

a slight amount of blood oozes out. The operator lightly

pressed the tip onto the warts and moved it around in

continuous circular. Because warts more often recur at

the margin than in the center, it is better to scrape slightly

more widely around warts. Since the epidermis can de-

tach from the dermis when sites that are allowed to come

into contact become white and swell up with fluid, it is

grasped and peeled back with forceps, and the cut away

with scissors. The remaining epidermis is carefully cut

away with the USA. The center often becomes hard, like

a clavus, and that portion is always completely scraped

away. After arresting the bleeding with an electric co-

agulator, steroid and antibiotic ointment is applied, and

the wound is covered with gauze. Epithelializaition usu-

ally occurred in 1 to 2 months and there was no evidence

of recurrence on follow-up at 7 months (Figure 5). His-

tological examination of specimens showed elimination

of the epidermis (Figure 6).

Figure 4. Preoperative appearance of the many warts lo-

cated on the sole.

The Feasibility of Treatment for Skin Diseases Using the Ultrasonic Surgical Aspirator 73

Figure 5. Appearance 7 months after procedure. No scar-

ring or recurrence was present.

Figure 6. Histological examination of specimens showed

elimination of the epidermis.

2.3. Patient 3

A 59-year-old female with prurigo nodularis, had intense

pruritus for one and a half years. She had multiple nod-

ules, several millimeters in diameter, on her whole body

almost. Previously she had received various treatments

with the steroid ointment, topical vitamin D3, narrow-

band UVB, systemic steroid and cyclosporine (3 mg/kg).

However, those treatments were not effective. Conse-

quently, we removed many of the nodules on her right

elbow (Figure 7) as possible using USA. After admini-

stration of local anesthesia, the ultrasonic power was set

Figure 7. Legions of prurigo nodularis on right elbow.

at 60%, the rate of saline irrigation was set at 20 ml/min,

and the suction was 50%. One day after the operation,

the itchy sensation was remarkably alleviated. The

wound was totally epithelialized 2 weeks after the pro-

cedure. Unfortunately, the itchiness on the legion gradu-

ally returned about 4 weeks after the procedure.

2.4. Patient 4

A 23-year-old female with osmidrosis axillae had re-

ceived treatments with various external preparations for

approximately 3 years. However, all these treatments

were ineffective. This patient was placed in a supine po-

sition with her arms abducted from the trunk to approxi-

mately 100˚ to expose the axilla and to avoid injury to

the brachial plexus. Markings were made around the lo-

cation of the axillary hair-bearing area, where the apo-

crine glands are thought to be located. A local infiltration

anesthesia was administered. The ultrasonic power was

set at 60%, the rate of saline irrigation was set at 30

ml/min, and the suction was 50%. A 2 cm incision was

made in the parallel direction of the axillary crease on the

central portion of the hair-bearing axillary area (Figure

8). To maintain neurovascular bu ndles, undermining was

performed parallel to the subdermal plexus with scissors.

The operator lightly pressed the tip onto the undersurface

of the axillary skin and moved it around in continuous

circular. Effective removal of apocrine glands was dem-

onstrated by the appearance of hair follicles and dermis.

Histological examination of specimens showed elimina-

tion of the apocrine glands (Figures 9 and 10). Wounds

The Feasibility of Treatment for Skin Diseases Using the Ultrasonic Surgical Aspirator

Figure 8. Insert the handpiece through the incision.

Figure 9. Before ultrasonic aspiration. Normal axillary skin

architecture showing apocrine glands.

Figure 10. After ultrasonic aspiration. The apocrine glands

have been removed.

were closed with sutures followed by coverage with

compressive bandages for 3 days. Sutures were removed

usually approximately 10 days after surgery, and active

shoulder movements were prohibited for 2 weeks post-

operatively. Two weeks postoperatively the patient’s os-

midrosis axillae were evaluated as no malodorousness.

3. Discussion

The ultrasonic energy caused cavitation in high fluid

content tissues such as epidermis and sweat glands. The

cavitation is followed by blasting and liquefaction. As

such, ultrasound energy is more effective within epider-

mis and sweat glands, since these tissues are less dense

as compared to more cohesive tissues such as dermis,

blood vessels, and nerves. Therefore, it offers the advan-

tages of fairly effortless removal of epidermis and sweat

glands, with less bleeding due to minimal destruction of

more solid tissue such as blood vessels [4].

Lesions from Bowen’s disease are often small and

usually can be easily treated by surgical excision and

direct closure. However, for patients with lesions that are

large and/or located in joint areas, or in surgically prob-

lematic areas such as the ears, nose, eyelids, and mucous

membranes, surgical excision can become complicated

with skin grafting, immobilization of a joint, the use of a

general anesthesia, and/or hospitalization sometimes re-

quired. All of these factors should be avoided, if at all

possible, particularly because most patients with Bo-

wen’s disease are elderly, and any one of these circum-

stances can trigger a decline in general health and well

being. Although other nonsurgical options are available,

the most widespread being cryotherapy and 5-fluoro-

uracil ointment, the USA offers an option that is effectiv e

and inexpensive with few complications.

Because there is currently no cure for human papillo-

maviruses (HPV) infection, traditional treatment modali-

ties have focused on the destruction of infected tissue

through a variety of techniques. These include salicylic

acid, podophyllin, b leomycin, cryotherapy, laser therapy,

and surgery [5]. Recently, immunomodulatory com-

pounds with antiviral properties have been investigated

in HPV therapy. However, such as salicylic acid may

cause local irritation and desquamation; bleomycin and

imiquimod may offer several side-effects; cryotherapy

and laser therapy are painful and may lead to scarring,

whereas surgical removal of warts causes localized reac-

tions such as pain, scarring, bleeding, and secondary in-

fections can occur [5]. Moreover, a skin graft or flap-

formation surgery may be needed, depending on the size

and location of the warts. However, the USA offers an

option that is very simple, safe, and effective method.

Prurigo nodularis is a benign chronic dermatosis that is

often difficult to treat successfully. Topical or intrale-

sional glucocorticoids are the treatment of choice. Other

topical treatments such as topical vitamin D3, and topical

capsaicin have also been reported. Oral treatments such

as cyclosporine and thalidomide have been shown to

improve frequently. However, many therapeutic modali-

ties have been used but frequent relapses are common. In

our case, one day after using USA, the severe itchiness

improved considerably, even the nodules had not com-

The Feasibility of Treatment for Skin Diseases Using the Ultrasonic Surgical Aspirator

pletely disappeared. This clinical effect of USA on pru-

rigo nodularis is similar to that of cryotherapy. The con-

tinued absence of pruritus after cryotherapy may be due

to sensory nerve damage and impairment of nerve regen-

eration. Other effects of cryosurgery on the dermis in-

clude marked edema, distortion of cells, and a decrease

in capillary circulation with resultant extravasation of

erythrocytes [6]. We expect that USA may be effective

via the same mechanism as that of cryotherapy.

The cause of osmidrosis has been the topic of several

papers, it is generally agreed that the odour originates

from bacterial decomposition of sweat secreted from

apocrine glands. To treat severe cases, various types of

surgical methods have been introduced [7]. Of these

procedures, manual shaving had the lowest recurrence

rate for malodor. CO2 laser vaporization had results

similar to manual shaving except for a clinically higher

recurrence rate. Liposuction had advantages such as

small invisible scars and the least number of surgical

complications, but it had a high rate of dissatisfaction in

postoperative malodor. Therefore, removal of subcuta-

neous apocine glands by manual subdermal shaving is

the effective method. However, many problems with

wound healing were reported: hematoma, seroma, skin

necrosis, and severe scarring. The use of ultrasonic aspi-

rator allowed us to remove apocrine glands with scar less,

and the USA offers a safe and effective method.

Even though the USA offers a safer way to treat of

skin diseases, it still should be used with care to avoid

potential complications such as skin necrosis via a ther-

mal effect. Burns can occur if the operator presses too

hard or the device is allowed to remain stationary. How-

ever, this problem can be avoided simply by moving the

hand piece tip across the region with small, uninterrupted,

brush-like strokes. In our department, the treated area is

cooled by ice or irrigation with saline maintained at 4˚C

throughout the operation. Topical steroids are applied to

the affected area for a few days postoperatively to pre-

vent burn.

4. Acknowledgements

The authors gratefully thank Dr. Shinsaku Aiba and Mr.

Satoshi Kohira for his critical cooperation in preparing

this article.

REFERENCES

[1] R. T. Chopp, B. B. Shah and J. C. Addonizio, “Use of

Ultrasonic Surgical Aspirator in Renal Surgery,” Urology,

Vol. 22, No. 2, 1983, pp. 157-159.

doi:10.1016/0090-4295(83)90499-5

[2] E. S. Flamm, J. Ransohoff, D. Wuchinich and A. Broad-

win, “Preliminary Experience with Ultrasonic Aspiration

in Neurosurgery,” Neurosurgery, Vol. 2, No. 2, 1978, pp.

240-245. doi:10.1227/00006123-197805000-00010

[3] H. Suma, H. Fukumoto and A. Takeuchi, “Application of

Ultrasonic Aspirator for Dissection of the Internal Mam-

mary Ar tery in Coronary Ar tery Bypass Graft in g,” Annals

of Thoracic Surgery, Vol. 43, No. 6, 1987, pp. 676-677.

doi:10.1016/S0003-4975(10)60251-2

[4] Y. Ito, S. Kondo, N. Sumiya, M. Yoshii, K. Otani and M.

Wako, “Dermabrasion Using an Ultrasonic Surgical As-

pirator,” Plastic and Reconstructive Surgery, Vol. 97, No.

5, 1996, pp. 1034-1039.

doi:10.1097/00006534-199604001-00024

[5] A. Rivera and S. K. Tyring, “Therapy of Cutaneous Hu-

man Papillomavirus Infections,” Dermatologic Therapy,

Vol. 17, No. 6, 2004, pp. 441-448.

doi:10.1111/j.1396-0296.2004.04047.x

[6] T. P. Waldinger, R. C. Wong, W. B. Taylor and J. J.

Voorhees, “Cryotherapy Improves Prurigo Nodularis,” Ar-

chives of Dermatology, Vol. 120, No. 12, 1984, pp. 1598-

1600. doi:10.1001/archderm.1984.01650480060020

[7] Y. J. Park and M. S. Shin, “What Is the Best Method for

Treating Osmidrosis?” Annals of Plastic Surgery, Vol. 47,

No. 3, 2001, pp. 303-309.

doi:10.1097/00000637-200109000-00014