What is the best procedure to eradicate fox odor? Which one is safer and more effective? The procedure that our team is performing extensively and believes is currently the most popular is the small incision parietal sweat gland excision. This procedure has been used by us for twelve years for the treatment of axillary odor, especially recurrent axillary odor, so let’s talk about the pros and cons of this procedure. The basic principle of small-incision parietal sweat gland excision (hereinafter referred to as small-incision surgery) is to remove the top-secreting sweat glands in the axilla on a large scale to remove the pathological basis for the production of metabolic products from the sweat glands. Since the parietal sweat glands are vertically distributed in the mid-dermis, deep dermis, and superficial subcutaneous fascia, often spanning 1 cm vertically, and in severe cases the axillary hair distribution is long and wide, even spanning 20 cm longitudinally, wide excision is imperative. Although the surgical target is the secretory and ductal parts of the parietal sweat glands, the resection level also includes subcutaneous fat in the superficial fascial layer, skin appendages, hair follicles, small sweat glands, some sebaceous glands, and the subcutaneous vascular network. Therefore, the procedure has the effect of stopping sweating in the armpit for simple hyperhidrosis and removing armpit hair for female patients who need to remove armpit hair, which are two other advantages of the procedure. Patients who suffer from hyperhidrosis and have luxuriant axillary hair can also benefit from this procedure. For more than a decade, the specialists in our department who are interested in the treatment of axillary odor have come up with too many improvements and have ingeniously adopted no less than 20 new treatments. The patient’s subjective experience has gone from being painful and uncomfortable like having a child to now commonly seeing patients drifting off to sleep during the procedure. The collective wisdom of physicians has resulted in a more humane approach to treatment that reflects a patient-centered philosophy. Even though doctors want to achieve the best level of healing for every patient they treat, the harsh reality still needs to be faced. There are risks associated with surgery: flap necrosis, hematoma, delayed wound healing, odor residue, and unsightly wounds. How to avoid the risks as much as possible and perform the surgery safely depends on the physician’s adequate surgical experience and clinical practical skills, intraoperative resilience and understanding of the surgery. Fine operating techniques, rational operating steps, and standardized procedures are necessary to ensure a perfect surgical outcome. To cope with flap necrosis, it is most critical that the surgical operation must be maintained with gentle movements and low intensity under low tension. Vigorous pulling of the skin is strictly prohibited. The vigorous pulling action leads to occlusion and embolization of the arterial vessels due to damage to the elastic muscle layer of the micro-artery under the skin, which subsequently leads to skin necrosis and dissolution. There is a saying that the surgeon’s hand is like a woman’s hand, which speaks of strict control of the force, and the entire operation is performed without violence or even with a large pulling force, with a good prognosis of minimal tissue damage. For this reason, we have designed a standardized intraoperative procedure to avoid excessive force damage to the flap. The procedure may seem easy, but the easier it is, the better the surgeon’s skills are. The most common cause of wound hematoma is inappropriate postoperative upper limb movement, which pulls the fresh wound and causes the new granulation tissue to rupture and bleed, and once a small hematoma is formed, it will push and pull the flap to separate from the base, producing a chain effect that further increases the subcutaneous bleeding range and forms a huge hematoma, which is more difficult to handle subsequently. Therefore, it is important to protect the bilateral shoulder joints in a fixed position according to the doctor’s instructions! The trouble was that I needed help to eat and go to the bathroom for two days until the pressure gauze was removed from the wound. The natural advantage of a small incision is to stop bleeding under direct vision, which is not yet possible with a minimally invasive mini-incision. The probability of postoperative wound rebleeding and hematoma is significantly lower in cases with direct visual hemostasis than in surgery under blinded vision. We chose a 1.5 cm mini-incision after a comparison of a large number of cases. Individual cases with excellent skin texture and particularly good elasticity have been successfully operated under an incision of only 1 cm in length. The combined advantages provide a better base for smooth wound healing. Delayed wound healing refers to cases where continued wound dressing is required more than 2 weeks after surgery. As the excision disrupts some of the subdermal blood vessels, the preserved epidermis and dermis experience ischemic changes, and narrow islands of small pieces of necrosis and epidermal surface peeling can be seen as a natural process. The probability of large skin necrosis after surgery has been discussed and improved for more than 10 years and has been reduced to only about 0.3%. For cases that require a change of medication for a period of time after surgery, we have designed several medication regimens to facilitate the return of foreign patients to the local area for continued treatment. The residual odor is the most unwanted postoperative problem for the operator, and we have done the most research in this area. The first thing to clarify is that sweat gland tissue, like neuronal cells, has a non-regenerative quality. According to the pathology of the excised skin specimens, we found that the axillary sweat glands are not only distributed at the level of the axillary hair follicles, but that the secretory part of the axillary sweat gland is still present in its deeper part. What is the opinion of patients with postoperative recurrence, is it that the first excision was not complete and the residual sweat glands are acting again? Or is it a regeneration of the sweat glands after excision? What we know now is that it is not enough excision that is the cause. The root cause is a fear on the part of both the patient and the surgeon of a catastrophic outcome due to poor postoperative recovery. It may also be that the patient is not prepared for the limited time of the surgery. Or maybe the doctor does not pay enough attention to the patient’s problem and does not want to spend enough time and effort. Sooner or later, the remnants of the dacryocystis gland may produce an odor, and reoperation may still be possible but more difficult. Excessive excision is also detrimental to healing. If too much is removed, the subcutaneous vascular network will be damaged too much and the blood supply to the skin will be destroyed, so the probability of skin necrosis will increase, but the efficacy will be more accurate because the skin necrosis will fall off in large pieces; if not enough is removed, the skin will heal smoothly and the skin will be more beautiful, but it will be easy to recur in the short term and the surgical effect will not be guaranteed. The balance between the two is in the hands of the doctor, and the only way to master it slowly is to experience and summarize the cases. Patients vary greatly in height, fatness, and thinness, weighing different body types, different medication experiences, and even different surgical, laser, and freezing experiences. It is a test for the doctor to treat them differently. It is a great responsibility of the doctor to remove enough flaps and to take into account the vitality of the flap as much as possible to ensure that most of the flap survives. Patients also need to be more understanding and not cause additional concerns for the doctor, such as claiming that their original skin is “flawless” if the wound is not healing well. Patients with good compliance tend to have a better chance of recovering well, and since they trust their doctors and know about the disease, they should stop and leave the rest to their doctors. The following is a comparison of small incision surgery and mini-incision scratch type surgery: Due to the poor anatomical positioning of minimally invasive or mini-incision scratch type surgery removal, scratch type surgery efficacy is also generally at a disadvantage. It is often only indicated for patients with mild underarm odor and symptoms that do not affect daily life. The sweat glands at the surgical site are not clearly distinguishable to the naked eye, so why does the small incision surgery have advantages that scratch surgery cannot surpass? The reason is the high accuracy of the surgical level positioning of the surgery under direct vision. We know that the axilla is a special anatomical part of the human body. It is a sunken structure and is the site of the arteries, veins, lymphatic vessels and the motor and sensory nerves that innervate the upper extremities. Because of the importance of the axillary anatomy to the upper extremity, the anatomical separation operation of axillary surgery is performed from deep to superficial as much as possible. Any action such as incision and separation pointing to important structures such as deep large blood vessels is to be avoided. The rebound incision for abscess incision and drainage is based on this principle, and it is only by making an invasive operation such as an incision toward the avascular zone that major accidents can be avoided. However, the mini-incision is difficult to reach the deep level of the superficial fascia or, if it is reached, it cannot always be maintained at this level because the overall structure of the axilla is curved, making it very easy for any non-direct vision operation to wander outside the reasonable level. The result is predictably low excision efficiency, i.e., far from the clearance efficiency of direct vision excision. Excision under direct vision sacrifices the length of the skin incision, and the complete subcutaneous incision of the skin up to the deep surface of the superficial fascia via a 1.5 cm long incision can not only be found at this level with the help of the naked eye, but the expansion from the opened level to the sides is also clear and intuitive with the cooperation of certain experience. The final result of the surgery is directly and positively related to the high rate of removal. We believe that the clearance rate that can be achieved by a specialized physician with specialized training is over 95% or even 98%. However, in principle, it is not possible to achieve a complete clearance of 100%, which is due to the characteristics of the distribution of sweat glands. The treatment of axillary odor can be satisfactory only if enough sweat glands in the axillary hair layer and the ducts of the secretory part of the axillary sweat glands injected into the hair follicles are removed. In the majority of patients followed up in the clinic, recurrence after minimally invasive mini-incisional scraping comes from the fact that the secretory ducts have been removed, but the secretory sweat glands, which are hidden at 1 cm from the skin surface and even beyond the depth of the hair follicle, have not been reached at all. The destruction of the ducts in the superficial layer of the axillary fascia is often surprisingly effective in the short term, and some patients are completely odor-free for a short period of time, usually about six months, but once the regenerative sweat ducts regenerate and the secretory sweat glands become active and produce metabolic products, the odor begins to reappear. Again, this is not a recurrence, but an incomplete removal. So why not do a thorough scraping to the deeper tissue? The reason is still the level problem, the unpredictable risk increases exponentially when the scraping operation is done to the deeper part, once the surgical operation causes collateral damage, the consequence is vascular and nerve damage, there may be abnormal sensation, numbness, movement disorders, and to put it more seriously, uncontrolled bleeding from the aorta, death is a matter of minutes. The trade-off is often the result of doing scraping and suction type surgery can only remove a portion of the large Han gland, the removal rate is lower than small incision surgery, and the medium to long term results are not ideal. Finally, there is the issue of appearance. As an invasive treatment, small incision surgery provides a way to eradicate fox odor. In order to achieve a more aesthetic result, we apply cosmetic suturing techniques, special sutures for cosmetic surgery, full-thickness skin slice in situ grafting techniques and other plastic surgery techniques during surgery. Although most of the patients recovered well and most of the wound scars were not obvious after one year, the wound was sometimes not very aesthetic and the incidence was about 5%. This is a drawback of the procedure that cannot be overcome at this time. If you require a completely invisible postoperative scar, this procedure will not meet your expectations for the time being. In order to obtain a high clearance rate and perfect hemostasis, the skin incision is temporarily set at 1.5 cm! However, please understand that we cannot guarantee that the scar is not visible before surgery. It’s not that the doctor is not willing to solve the problem, but it’s just that you can’t have both the fish and the bear’s paw. We look forward to the early release of the new product under our trial, which can solve the problem of hemostasis and hide the incision while obtaining a stable removal rate. We hope to find a better treatment for fox odor soon!