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.
Received December 8th, 2012; revised January 10th, 2013; accepted January 18th, 2013
Copyright © 2013 Chihoko Nakahara et al. This is an open access article distributed under the Creative Commons Attribution Li-
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
72
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
74
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
75
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