cation of mitomycin C, with all radiotherapy treat-

ments completed within 72 hours. Exposure of

surrounding tissue to radiation was minimized

using custom lead cut-outs manufactured

postoperatively.

An antineoplastic agent derived from Streptomyces,

mitomycin C inhibits DNA synthesis by cross-link-

ing strands of the DNA double-helix, preventing

tissue proliferation.4 Historically, mitomycin C has

proven successful in the fields of ophthalmology

and tracheal surgery.5 Early case reports in the use

of resection and adjuvant mitomycin C to treat

keloids were equivocal,1 although the concentra-

tion of mitomycin C used in these early case

reports was low (0.4 mg/mL). Gupta and Narang5,

in a 2010 review, successfully treated 26 pinna

keloids by applying a higher concentration of mito-

mycin C (1 mg/mL) immediately postoperatively

and 3 weeks after surgery. We have also found

success with a higher concentration and staggered

application of mitomycin C.

Conclusion

Keloids are commonly encountered and notoriously

difficult to treat, representing a therapeutic

dilemma. Although many keloid treatment modali-

ties are available, monotherapy has historically

yielded poor results. The authors acknowledge that

the number of patients treated in this series is

small, and the follow-up period is limited; to fur-

ther validate these results, more patients should be

treated with the above protocol, and the follow-up

period should be extended to at least 5 years to

monitor long-term results. Multimodal therapies of

resection with adjuvant radiation and resection

with adjuvant mitomycin C have each shown

moderate success; the authors propose that

combination of these established therapies into a

triple therapy of resection with adjuvant mitomycin

C and radiotherapy needs to be further explored

and may represent a promising treatment algorithm

for this difficult disease.

References

1. Naylor M, Brissett A. Current concepts in the etiology

and treatment of keloids. Facial Plast Surg 2012;28:

50412.

2. Sidle D, Kim H. Keloids: prevention and management. Facial

Plast Surg Clin North Am 2011;19:50515.

3. Kal H, Veen R. Biologically effective doses of postoperative

radiotherapy in the prevention of keloids. Strahlenther Onkol

2005;181:71723.

4. Shridharani SM, Magarakis M, Manson PN, Singh NK, et al.

The emerging role of antineoplastic agents in the treatment of

keloids and hypertrophic scars. Ann Plast Surg 2010;64:35561.

5. Gupta M, Narang T. Role of mitomycin C in reducing keloid

recurrence: patient series and literature review. J Laryngol Otol

2011;125:297300.

MATTHEW WILLETT, MD, MC USN

KENT HANDFIELD, MD, MC USN

JASON MARQUART, MD, MC USA

Walter Reed National Military Medical Center

Bethesda, Maryland

The views expressed in this manuscript are those of the

authors and do not reflect the official policy of the Depart-

ment of Army/Navy/Air Force, Department of Defense, or

U.S. government.

Transient Median and Ulnar Neuropathy Associated with a Microwave Device for Treating Axillary

Hyperhidrosis

Microwave-based devices are recently developed

technology to treat hyperhidrosis by selectively

heating the interface between dermis and subcu-

taneous fat. A few studies using a microwave-

based device for hyperhidrosis13 have

demonstrated significant sweat reduction without

serious complications. We report a case of tran-

sient median and ulnar neuropathy associated

with treatment of hyperhidrosis with the micro-

wave-based device.

LETTERS AND COMMUNICATIONS

DERMATOLOGIC SURGERY482

Case Report

A healthy 32-year-old man received treatment with

a microwave-based device with integrated vacuum

and cooling (miraDry System, Miramar Labs, Sun-

nyvale, CA) for axillary hyperhidrosis. Local injec-

tion of tumescent fluid (mixture of normal saline

100 mL, 0.2 mL epinephrine, 2% lidocaine

10 mL, and sodium bicarbonate 1 mL) was used

for pain management. Approximately 100 mL of

fluid was injected using a 10 mL syringe and 26-G

long needle for treatment of bilateral axillae. The

device has five energy settings. The power is con-

stant across all energy settings, and time is used to

adjust energy levels. Our patient was treated with

the lowest energy level (level 1, 2.4 seconds) in

each axilla. After treatment, he noticed numbness

and weakness in the left first and second fingers.

He could abduct his arm up to, but not above,

90. He recovered strength in left shoulder abduc-

tion 10 days after treatment, although distal numb-

ness and weakness of his first and second fingers

continued. His finger function did not return until

6 months after the microwave-based device treat-

ment. The rehabilitation department was consulted

for further treatment.

On physical examination, motor strength for

shoulder abduction, elbow flexion and extension,

and wrist dorsiflexion was normal, but wrist volar

flexion strength was grade 4 of 5 on the Medical

Research Council scale, flexion of first and second

fingers was 2 of 5, flexion of other fingers was 4 of

5, and finger abduction was 4 of 5. OK sign was

positive, but Froments sign was negative. Hypoes-

thesia of the median neurotome was evident, and

mild atrophy of the thenar muscles was observed.

Nerve conduction study and electromyography per-

formed to determine the injured area revealed med-

ian neuropathy with moderate partial axonotmesis

and ulnar neuropathy with mild partial

axonotmesis in his left arm. After nerve injuries

were confirmed, he underwent physiotherapy twice

daily, including neuromuscular electrical

stimulation for the flexor muscles in the forearm

and the thenar muscles and strengthening exercise

of the finger flexors.

After 6 months of rehabilitation, his motor power

and sensory deficit improved remarkably, but the

thenar muscles remained atrophic (Figure 1). Sec-

ond finger flexor strength recovered to 4 of 5, and

the other fingers recovered nearly to full strength.

On sensory examination, he demonstrated mild

paresthesia with minimal hypoesthesia of the

median neurotome.

Follow-up electromyography revealed signs of

re-innervation and improved motor unit

recruitment in the median and ulnar nerves. Dener-

vation potentials disappeared, and the interference

pattern increased in the proximal median inner-

vated muscles, including the flexor carpi radialis,

signifying ongoing re-innervation in a proximal-to-

distal direction (Figure 2).

Patients are increasingly seeking treatment that

requires shorter recovery time and less

Figure 1. Thenar muscle of the patients left thumbshowed atrophy after 12 months of treatment with amicrowave-based device for axillary hyperhidrosis.

LETTERS AND COMMUNICATIONS

40 : 4 :APRIL 2014 483

treatment-related discomfort. Because hyperhidro-

sis is not life-threatening, these patients desire

simple treatments with no scars or complications.

Surgical removal of the sweat glands requires

postoperative immobilization and often results in

a scar. Botulinum toxin injection for hyperhidro-

sis has high cost and only 6-month duration of

effect.

Based on our experience, a microwave-based

device for axillary hyperhidrosis is safer than

surgical treatment.3 Only mild procedure-related

adverse events are known, such as vacuum acquisi-

tion marks, edema, and tenderness or altered

sensation in the treatment area; soreness; and dis-

comfort that do not last more than 2 weeks.13

Hong and colleagues2 reported a case of neuropa-

thy after microwave-based device treatment for

axillary hyperhidrosis. They commented that one

subject experienced transient neuropathy of the left

arm with associated muscle weakness that

improved after 6 months. They did not

describe the details of the subject who

experienced neuropathy.

The patient who experienced neuropathy in our

case was a thin, 1.8-m tall man weighing 60 kg,

for low body mass index of 18.5 kg/m2. It can be

assumed that microwave energy penetrated deep

enough to damage some nerve fibers of the bra-

chial plexus. From this case, we suggest that thin

patients with less fat have a higher risk of nerve

damage than normal-weight or obese patients.

Also, we think men are more vulnerable to nerve

injury than women because women have more fat

in the axillary area due to breast tissue. The

median and ulnar nerves are more susceptible to

injury because of their superficial anatomic loca-

tion relative to the radial nerve after branching off

the brachial plexus at the axillary level.

If the patient is a thin man, we recommend using

a lower energy level to avoid nerve injury. It is

also recommended that physicians monitor patient

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1..199

110000ms 22mVV1.200

1.211

11.2222

1.222223

10000mms 1000VV11.244

1.199966

11.119977

1.1198

1.111999

10000mmss 200VV1111..2000

1.1196

11.19977

11.11988

1..1999

100ms 500V11.220000

(A) (B)(((

(C))C(C)CCC (D)((D)

Figure 2. Motor unit recruitment during effortful volition by needle electromyography. (A) Flexor carpi radialis at6 months. (B) Abductor pollicis brevis at 6 months. (C) Flexor carpi radialis, at 12 months. (D) Abductor pollicis brevis at12 months after treatment with microwave-based device.

LETTERS AND COMMUNICATIONS

DERMATOLOGIC SURGERY484

hand and finger sensation during the procedure.

Although the target zone of action of a micro-

wave-based device is known to be independent of

skin thickness, as shown in a porcine model,4 the

thickness of the skin and subcutaneous fat seems

to influence the treatment depth of this device. In

patients with little subcutaneous fat, microwaves

penetrate deep enough to influence some nerves

that branch from the brachial plexus in the

axilla.

This case demonstrates that patients may develop

nerve injury even when using the lowest energy

level. Even in this case with nerve injury, the

long-term benefits of improved hyperhidrosis may

outweigh such adverse effects as weakness of the

left hand that recovered after 12 months. Also, the

patient improved, neurologically and functionally,

with intensive physiotherapy after 6 months of

persistent weakness and numbness. Based on this

observation, we recommend prompt and intensive

rehabilitation to accelerate recovery if neural

damage occurs unexpectedly. Moreover, more

caution is needed when treating thin male

patients.

References

1. Glaser DA, Coleman WP 3rd, Fan LK, Kaminer MS, et al. A

randonmized, blinded clinical evaluation of a novel microwave

device for treating axillary hyperhidrosis: the dermatologic

reduction in underarm perspiration study. Dermatol Surg

2012;38:18591.

2. Hong HC, Lupin M, OShaughnessy KF. Clinical evaluation of a

microwave device for treating axillary hyperhidrosis. Dermatol

Surg 2012;38:72835.

3. Lee SJ, Chan KY, Suh DH, Song KY, et al. The efficacy of a

microwave device for treating axillary hyperhidrosis and

osmidrosis in Asians: a preliminary study. J Cosmet Laser Ther

2013;15:2559.

4. Johnson JE, OShaughnessy KF, Kim S. Microwave thermolysis

of sweat glands. Lasers Surg Med 2012;44:205.

DONG-HYE SUH, MD

SANG-JUN LEE, MD

Department of Dermatology

Arumdaun Nara Dermatologic Clinic

Seoul, Korea

KEEWON KIM, MD

Department of Rehabilitation Medicine

Seoul National University

Seoul, Korea

HWA JUNG RYU, MD, PHD

Department of Dermatology

Korea University College of Medicine

Seoul, Korea

The authors have indicated no significant interest with com-

mercial supporters.

Sudden Visual Loss and Multiple Cerebral Infarction After Autologous Fat Injection into the Glabella

Soft tissue augmentation is a cosmetic procedure

that dermatologists commonly performed, but side

effects, including skin infections, necrosis, and

rarely, vascular occlusion, have been reported.

Retinal artery obstruction after autologous fat

injection is a devastating disease involving sudden

visual loss and, very rarely, cerebral infarction. We

report a case of retinal artery occlusion with multi-

ple cerebral infarctions caused by an autologous

fat injection into the glabellar area.

Case Report

A 31-year-old woman presented to our hospital

with sudden visual loss and arm weakness.

Twenty-four hours before the onset of these symp-

toms, she had received an autologous fat injection

in her glabella area to correct a cosmetic problem

performed under general anesthesia by a local

general practitioner. After she recovered from the

general anesthesia, the patient reported vision loss

LETTERS AND COMMUNICATIONS

40 : 4 :APRIL 2014 485