Introduction

Axillary bromhidrosis (osmidrosis) is characterized by persistent, unpleasant body odor, primarily attributed to the bacterial conversion of precursors present in apocrine secretions into volatile odorous compounds. ¹, ² Although the condition is frequently associated with sweating, the determining factor underlying the odor involves the interaction between the apocrine substrate and the cutaneous microbiota. ²

Clinically, onset after puberty is common, coinciding with the functional maturation of the apocrine glands. ³ In many patients, the condition persists for years and may lead to social limitations, embarrassment, social withdrawal, and impaired self-esteem. In continuity with the Kataoka's previously published observations in the RBCP, ¹, ⁴ the psychosocial burden was considered a relevant component of the treatment protocol, justifying systematic preoperative psychological evaluation.

Reported treatments include clinical measures (targeted hygiene, antiseptics, topical antibiotics in selected cases, and hair removal ³), as well as interventional approaches. These include open excisional techniques ¹, ³ (potentially effective but associated with greater scar-related and functional morbidity) and closed or minimally invasive techniques, such as suction curettage, ⁵ shaver-assisted techniques, ¹⁰, ¹¹ superficial liposuction, ⁵, ⁶ interstitial lasers (1,444-nm Nd), ¹², ¹³ and microwave thermolysis. ¹⁴, ¹⁵ Reviews and meta-analyses suggest that closed techniques may provide a favorable balance between efficacy and morbidity despite methodological heterogeneity and variations in the definition of recurrence. ¹⁶, ¹⁷

In this context, a novel technique was developed combining superficial liposuction (mechanical reduction of the glandular substrate) with adjunctive thermolysis (Orlight laser), using continuous thermographic monitoring and an objective thermal endpoint (≤39 °C) to improve reproducibility and safety.

Objectives

Materials and Methods

Study design and ethical considerations: prospective observational case series conducted at Hospital Ruben Berta, São Paulo, Brazil. The study protocol was submitted to and approved by the institutional Research Ethics Committee. All patients signed a free and informed consent form.

Study population and clinical criteria: the study included 38 patients with axillary bromhidrosis refractory to clinical management and associated with social and/or functional impairment. The study population comprised 20 male and 18 female patients, aged 18 to 52 years (mean age: 31 years). Symptom onset occurred predominantly between 12 and 15 years of age (approximate mean within this interval, based on patient history).

Psychological assessment: all patients underwent preoperative evaluation by a psychologist and completed a structured questionnaire documenting psychosocial impact and alignment of therapeutic expectations. Follow-up or referral was offered when needed.

Outcomes: (i) odor intensity measured using a 0-10 numerical rating scale (preoperative and postoperative); (ii) overall patient satisfaction (routine postoperative assessment at the institution, reported as >80%); (iii) mild recurrence of odor at 12 months; and (iv) adverse events, including seroma, hematoma, localized fibrosis, and transient paresthesia.

Statistical analysis: continuous variables were presented as means. Proportions were reported with 95% confidence intervals (95% CI) calculated using the Wilson method. For outcomes with zero observed cases, the conservative upper limit based on the "rule of three" (3/n) was also reported to provide context for the uncertainty associated with a finite sample size. No p-values were calculated for the preoperative versus postoperative change in odor intensity because measures of dispersion (SD/IQR) or individual paired data were unavailable.

Surgical Technique

Fig. 1 - Starch-iodine (Minor) test and surgical marking.

Fig. 1 - Starch-iodine (Minor) test and surgical marking.

Fig. 2 - Thermographic monitoring screen

Fig. 2 - Thermographic monitoring screen

Results

Mean odor intensity decreased from 8 to 2 (0-10 scale), representing an absolute reduction of 6 points and a relative reduction of 75%.

Overall patient satisfaction was reported as greater than 80%. Three patients (7.9%) experienced transient paresthesia, which was resolved completely within one month. Four patients (10.5%) developed localized fibrosis, which was managed with lymphatic drainage without the need for surgical reintervention.

Discussion

The present prospective series describes a proprietary technique for the treatment of axillary bromhidrosis that combines mechanical reduction of the glandular substrate (superficial liposuction in the dermal-subcutaneous plane) ⁵, ⁶ with adjunctive thermolysis (Orlight laser), ¹², ¹³ using continuous thermographic monitoring and an objective thermal endpoint (maximum skin temperature ≤39°C). This technical approach addresses a recurring challenge in literature: achieving efficacy comparable to that of more aggressive techniques while maintaining low morbidity and rapid recovery. ¹³

In terms of efficacy, the mean odor intensity decreased from 8 to 2 on a 0-10 scale, representing an absolute reduction of 6 points and a relative reduction of 75%. Although formal statistical inference (p-value) was not possible because measures of dispersion were unavailable, the magnitude of the observed change is clinically relevant and consistent with meaningful functional and social improvement. The literature on closed techniques reports substantial methodological heterogeneity, including differences in odor and satisfaction scales, units of analysis (per axilla versus per patient), and definitions of recurrence, ¹⁶, ¹⁷ requiring caution when making direct comparisons. In this context, reporting relative effects together with 95% confidence intervals provides greater transparency.

Fig. 3 - Orlight laser

Fig. 3 - Orlight laser

The 12-month rate of mild recurrence was 13.2% (95% CI, 5.8%-27.2%). The width of the 95% confidence interval reflects the sample size while at the same time explicitly acknowledging the remaining uncertainty. Although the point estimate is favorable, the confidence interval does not exclude moderate recurrence rates in larger samples. Nevertheless, this finding is consistent with the range reported for minimally invasive techniques, ⁸, ¹⁶, ¹⁷ and the mild nature of the recurrence, without the need for reoperation, suggests sustained clinical control in most patients.

Regarding safety, no cases of seroma or hematoma were observed. In small case series, reporting a rate of 0% without a confidence interval may create a false impression of certainty; therefore, the conservative upper limit estimated using the rule of three (approximately 7.9%) was also reported, reinforcing methodological rigor. Transient paresthesia occurred in 7.9% of patients (95% CI, 2.7%-20.8%) and resolved completely within 1 month, a finding consistent with manipulation of the superficial axillary plane. Localized fibrosis occurred in 10.5% of patients (95% CI, 4.2%-24.1%) and was managed conservatively without sequelae.

Fig. 4 - Reduction in mean odor intensity (0-10 scale)

Fig. 4 - Reduction in mean odor intensity (0-10 scale)

The main technical feature of this protocol is continuous thermographic monitoring, establishing a maximum skin temperature of 39 °C as the safety endpoint. Interstitial procedures based on thermal energy depend on heat distribution within the subcutaneous tissue and its dissipation to the dermis. Thermal peaks and exposure time are key determinants of dermal injury and the risk of necrosis or burns. The use of real-time thermography provides objective and potentially reproducible monitoring, reducing operator variability and minimizing the occurrence of clinically undetected hot spots during laser application.

Another relevant methodological aspect was systematic psychological assessment. Bromhidrosis is a condition in which the degree of social and psychological distress may be disproportionate to physical findings. Therefore, preoperative evaluation by a psychologist and the use of a structured questionnaire may serve as strategies for patient selection, expectation management, and documentation of disease impact, all of which directly influence subjective outcomes such as patient satisfaction and perceived improvement. This approach is consistent with evidence regarding the emotional burden of the condition and with one of the authors' previously published clinical experience in the RBCP. ⁴

Fig. 5 - Odor recurrence at 1 2 months

Fig. 5 - Odor recurrence at 1 2 months

Fig. 6 - Adverse events observed in the series (n = 38)

Fig. 6 - Adverse events observed in the series (n = 38)

Table 1 - Sample characteristic

Table 2 - Outcomes and adverse events with 95% confidence intervals (95% CI)

Regarding its place within the therapeutic algorithm, the proposed technique may be considered a minimally invasive alternative for moderate to severe bromhidrosis, particularly in patients seeking minimal scarring, rapid recovery, and reduced risk of thermal injury. The combined mechanical-thermal approach aims to reduce residual glandular tissue ("islands") remaining after superficial liposuction, while thermographic monitoring provides an objective mechanism for controlling and standardizing the thermal endpoint. Future studies should incorporate additional objective and standardized outcome measures, such as validated quality-of-life instruments and microbiological or biochemical assessments, when appropriate. Measures of dispersion (standard deviation [SD]/inter-quartile range[IQR])shouldalsobereportedtoallow formal paired inferential analysis and estimation of effect size.

Concerning limitations, this study is a case series without a control group. Odor intensity was reported as mean preoperative and postoperative values without measures of dispersion or distribution (SD/IQR), precluding inferential statistical testing and calculation of a standardized effect size. Patient satisfaction was reported as greater than 80% without the exact proportion. Nevertheless, the standardized surgical technique and the minimum follow-up of 12 months strengthen the descriptive analysis and allow clinical interpretation of the efficacy and safety profile.

Conclusion

Laser-assisted superficial axillary liposuction using the Orlight laser with continuous thermographic monitoring (≤39 °C) proved to be a reproducible and safe technique in this prospective series of 38 patients, resulting in a substantial reduction in odor intensity (75%), overall patient satisfaction exceeding 80%, and a low frequency of adverse events, with no cases of seroma or hematoma. The 12-month rate of mild recurrence was 13.2% (95% CI, 5.8%-27.2%).

Future comparative studies using standardized outcome measures and paired analyses may further strengthen the evidence.