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Ann Thorac Surg 2006;81:1863-1866
© 2006 The Society of Thoracic Surgeons

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Original article: General thoracic

Thoracoscopic Sympathectomy for Isolated Facial Blushing

^a Department of Cardiothoracic Surgery, Odense University Hospital, Odense
^b Department of Cardiothoracic Surgery, Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark

Accepted for publication December 6, 2005.

^_* Address correspondence to Dr Licht, Department of Cardiothoracic Surgery, Odense University Hospital, Sdr Blvd 29, Odense DK-5000, Denmark (Email: licht{at}dadlnet.dk).

Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Facial blushing is one of the most peculiar of human expressions and has become a cardinal symptom of social phobia. The pathophysiology is unclear and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom, but very few surgeons treat patients with isolated facial blushing. The literature is limited, and there are few long-term follow-up studies.

METHODS: A follow-up study by questionnaire in 180 consecutive patients who underwent thoracoscopic sympathectomy for isolated facial blushing at two Danish university hospitals during a 6-year period. Patients routinely underwent T2 sympathectomy at the university hospital in Aarhus (n = 101) and T2-T3 sympathectomy at the university hospital in Odense (n = 79).

RESULTS: The questionnaire was returned by 96% of the patients after a median follow-up time of 20 months. Overall, 90% of the patients had some effect from the operation, and the result was excellent or satisfactory in 75%. There was no significant difference between the two extents of sympathectomy. Compensatory sweating occurred in 88% of all patients and was significantly more frequent after T2-T3 sympathectomy (p = 0.02) Ten percent of our patients regretted the operation because of side effects or no effect of the operation.

CONCLUSIONS: This study demonstrates that thoracoscopic sympathectomy is an effective treatment for isolated facial blushing. The majority of patients achieve an excellent or satisfactory long-term result. Our results suggest that a T2 sympathectomy is superior for patients with isolated facial blushing because side effects are lower compared with a T2-T3 sympathectomy.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Charles Darwin described facial blushing as "the most peculiar and the most human of all expressions" [1], and in the modern era, blushing has become one of the cardinal symptoms of social phobia. The exact nature of this phenomenom is unclear and its prevalence unknown. Thoracoscopic sympathectomy may cure the symptom [2–12], but only a minority of surgeons who perform thoracoscopic sympathectomy treat patients with isolated facial blushing [13]. The literature on sympathectomy for facial blushing is very limited, and there are few long-term follow-up studies. That prompted us to perform a long-term follow-up study of patients who underwent thoracoscopic sympathectomy for isolated facial blushing and investigate whether the extent of sympathectomy has an influence on outcome and side effects.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
From our databases, we identified two groups of consecutive patients who were treated for facial blushing by thoracoscopic sympathectomy at the Department of Cardiothoracic Surgery, Odense University Hospital and Aarhus University Hospital, Denmark, during a 6-year period (January 1999 to December 2004). Objective methods for quantifying blushing before surgery were not applied. The indication for operation was disabling isolated facial blushing as defined by the patient. Only patients with isolated facial blushing were included in this study. Eighty-one patients who also suffered from palmar or axillary hyperhidrosis were excluded from analysis. All patients at Odense University Hospital were treated by a T2-3 sympathectomy, and patients at Aarhus University Hospital underwent a T2 sympathectomy.

All hospital records were retrieved and the following data recorded: symptoms, length of hospital stay, postoperative complications, and duration of the surgical procedure. Questionnaires were mailed to all patients for follow-up, except 1 who had emigrated. In accordance with Danish law, the local Ethics Committee waives review and consent requirements for studies based on questionaires. All patients were asked to mark their disability, both professionally and socially, from their symptoms before surgery (very much, some, or none at all) and to mark the effect they had achieved from the operation on blushing (excellent, satisfactory, some effect, or no effect). Patients were asked to comment on the occurrence and location of any compensatory sweating, defined as excessive sweating after the operation that was considered abnormal. In an attempt to assess the severity of compensatory sweating, all patients were asked if they had to change clothes during the day because of this side effect. Further, patients were asked whether they had developed any gustatory sweating, defined as facial sweating when eating certain foods. Finally, they were asked if they were satisfied with or regretted the operation.

Statistical analysis included independent-samples t test, Mann-Whitney U test, cross-tabulation, relative risk estimates with 95% confidence intervals, and analysis of variance in a linear regression model implemented in the SPSS 10.1 statistical software package (SPSS, Chicago, Illinois). All p values less than 0.05 were considered statistically significant.

Surgical Techniques
The surgical techniques were identical at the two hospitals except for the pleural drainage during reinflation of the lungs. All patients were operated on in the supine position with abduction of both arms under single-lumen intubated anesthesia. Two ports were made. The first incision (5 mm) was made anteriorly in the axillary hairline. The endotracheal tube was briefly disconnected by the anesthesiologist to deflate the lung when the pleural cavity was entered to avoid damaging the lung parenchyma. A 5-mm blunt-tip trocar was introduced for the use of a 0-degree or 30-degree video-thoracoscope (Olympus Winter & Ibe, Hamburg, Germany). An additional 5-mm trocar was placed posteriorly in the hairline for the introduction of a harmonic scalpel (Ultracision; Ethicon Endo Surgery, Cincinnati, Ohio). The sympathetic chain was identified at the level of the crossing of the second and third costal heads. The parietal pleura was opened, and the sympathetic chain was transected. The incision was extended laterally for approximately 2 cm on the second costa to include any accessory nerve fibers (the nerve of Kuntz). The procedure was performed bilaterally on the second costa (T2) or the second and third costa (T2-T3) depending on local tradition. All procedures were completed by reinflation of the lung while the anesthesiologist ventilated the patient manually, exerting continuous positive pressure for a few seconds to prevent pneumothorax, before a 4-mm chest tube (Aarhus) or the trocar (Odense) was subsequently removed. The surgical wounds were closed with Steri-Strip (3M Health Care, St Paul, Minnesota).

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
The two hospitals were comparable with no significant differences in sex (72% were female), age (median, 37 years; range, 16 to 67), hospital stay (median, 2 days; range, 1 to 5), or postoperative hospital stay (median, 0 days; range, 0 to 2). The median follow-up time of all patients was 20 months (range, 1 to 60). No conversion to open technique was necessary, and there was no operative mortality. One patient from Aarhus had temporary unilateral Horner's syndrome, which resolved after 2 days. None of our patients had hemothorax, but 1 was treated with a chest tube for pneumothorax.

A total of 173 patients answered the questionnaires (96%). Six patients did not return the questionnaire despite a reminder, and the remaining patient never received a questionnaire because she had emigrated. All patients answered the question of social disability from blushing: very much in 162 cases (94%) and some in 11 cases (6%). The question of professional disability was answered by 171 patients: very much in 157 cases (91%), some in 13 cases (8%), and none in 1 patient (1%).

Overall outcome after surgery is shown in Table 1. There was no significantly difference between the two extents of sympathectomy and outcome of the operation (p = 0.29). Four patients had recurrent symptoms after 1 month to 1 year and subsequently underwent reoperation with good results. Compensatory sweating occurred in 153 patients (88%) and was located on the back in 77%, the abdomen in 68%, the lower extremities in 42%, and the chest in 10%. Table 2 demonstrates that compensatory sweating was significantly more frequent after T2-T3 sympathectomy (p = 0.02; relative risk = 1.14; 95% confidence interval: 1.03 to 1.27). Thirty-eight patients (25% of the patients who suffered from compensatory sweating, or 22% of all patients) answered that they often had to change clothes during the day because of this side effect, but there was no significant difference between the two extents of sympathectomy (p = 0.54; relative risk = 0.84; 95% confidence interval: 0.49 to 1.64). Gustatory sweating occurred in 52 patients (30%), with no significant difference between the two groups (p = 0.24). Dry hands were a problem in 26% of our patients, with no significant difference between the two extents of sympathectomy; and mild pain from the portholes was reported by 4 patients after 2 to 20 months. Eighteen patients (10%) regretted the operation because of side effects (n = 1), lack of effect from the operation (n = 7), or both (n = 10). There was no significant association between the extent of sympathectomy and regretting the operation (p = 0.66). Likewise, there was no significant difference in follow-up time between those patients who regretted the operation and those who did not.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

It is possible that the incidence of facial blushing varies with geographical location. For example, it seems to be much lower in Asia, where a Japanese survey showed that facial blushing was the indication for sympathectomy in just 16 of 7,017 procedures [7], but that could also reflect that sympathectomy for isolated facial blushing is rarely used in Japan. In another study, from Taiwan, Kao and colleagues [16] reported that facial hyperhidrosis was seen in just 1 patient for every 40 patients who suffered from palmar hyperhidrosis. Others have reported on thoracoscopic sympathectomy for facial hyperhidrosis [9, 16–20], but facial hyperhidrosis should not be mistaken for facial blushing. Blushing is defined as the reflection of the vasodilatation of cutaneous blood vessels elicited by emotional stimuli [3]. Thoracoscopic sympathectomy for facial blushing was first described in 1985 [2], but it was not until 1998 that a comprehensive study was published from the Swedish Borås group [3, 4]. In their early experience with thoracoscopic sympathectomy for facial hyperhidrosis, they noted that patients were also relieved from attacks of facial blushing. Since then, other papers on thoracoscopic sympathectomy for facial blushing have emerged [5–12,15], but in general, only a minority of the surgeons who perform thoracoscopic sympathectomy treat patients with isolated facial blushing [13].

The present study has a high response rate of 96%, which strengthens the credibility of our results. Possible reasons for the high response rate are that Denmark has a free public health care system and most patients are willing to participate in follow-up studies. In addition, patients who have not emigrated are easily located by means of their social security numbers. Our results demonstrate that isolated facial blushing is disabling both professionally and socially to almost all patients who seek surgical treatment. Our results also demonstrate that thoracoscopic sympathectomy is quite effective for treating patients with isolated facial blushing. Table 1 shows that the majority reported an excellent or satisfactory result from the operation. Overall, 90% of our patients achieved some effect from the operation, a figure that is comparable with previous studies [2–5, 10].

There is no consensus on the extent of sympathectomy for isolated facial blushing. Some surgeons perform a T2 [5, 9, 11], a T1-T3 [4], a T2-T3 [2], a T2-T4 [12], or a T2-T5 sympathectomy [8, 10]. We have always used a T2 or a T2-T3 sympathectomy depending on local tradition, and the present study demonstrates that there was no significant difference between these two extents of sympathectomy. Theoretically, it may be argued that a true difference between the two extents of sympathectomy could be masked by selection bias because none of the patients was randomly assigned to treatment. All patients underwent a T2 procedure at one hospital and a T2-T3 procedure at the other hospital, depending on local tradition. However, the two patient populations were very homogenous: all were Caucasian with no significant difference in age or sex, and all lived in the same geographical area and answered the same questionaire. In addition, the surgical equipment and techniques were identical except for the pleural drainage. Consequently, we do not suspect that we have overlooked any true difference between the two extents of sympathectomy, but ultimately a prospective randomized trial may be necessary.

Facial blushing is a benign condition, and we believe that it is very important to discuss possible side effects with the patient before surgery. In particular, we emphasize that compensatory sweating is a permanent side effect after sympathectomy, although the reported incidence varies considerably. Most authors describe it in 30% to 70% of patients who were treated by thoracoscopic sympathectomy for primary hyperhidrosis. There are no published data on the incidence of compensatory sweating after sympathectomy for isolated facial blushing, but the present study demonstrates that this is also very common. It occurred in 88% of our patients, and in 25% of these, it was so severe that they often had to change clothes during the day. As seen in Table 2, the incidence of compensatory sweating was significantly higher after a T2-T3 procedure. Considering there was no significant difference in the effect of the operation between the two extents of sympathectomy, we consequently believe that a T2 sympathectomy is superior for patients with isolated facial blushing.

Criticism has been raised about surgical treatment for facial blushing because there is very little evidence that the patients most likely to pursue surgical treatment for facial blushing actually blush more readily and intensely than other people [21]. It has been pointed out that facial blood flow during acute embarrassment seems to be unrelated to ratings of the self-reported frequency of blushing [22]. On the other hand, self-consciousness and fear of blushing correlate well with subjective estimates of blushing frequency and intensity [22]. It has therefore been suggested that if the source of the patient's problem is anxiety about blushing rather than blushing per se, anxiety would be a more appropriate target for treatment than permanently eliminating the normal regulation of facial blood flow and sweating [21].

We agree that it is only reasonable to ask if one should treat facial blushing by thoracoscopic sympathectomy. Our results indicate that it is effective, but obviously patients should undergo a meticulous and critical selection. Firstly, the type of blushing that is likely to benefit from sympathectomy is mediated by the sympathetic nerves and is the uncontrollable, rapidly developing blush that is typically elicited by receiving attention from other people [3]. Secondly, blushing must be of major concern to the patient—enough to tolerate a substantial amount of compensatory sweating after the operation. We emphasize that 10% regret the operation, and this figure is always mentioned to our patients before surgery. However, we also mention that the majority of our patients were satisfied with their operation and would even recommend it to others. Many questionaires were returned with an additional note that the operation had changed their life completely for the better and that they only wished they had undergone surgery years before. Even though the vast majority of our patients continued to have an excellent or satisfactory result after a median follow-up time of 20 months, it may be speculated that, with time, some patients tend to focus on their present side effects and forget the discomfort of blushing that previously led them to undergo thoracoscopic sympathectomy. If so, one would expect that patients who regretted the operation had a significantly longer follow-up time, and that was not the case.

In conclusion, the present study demonstrates good results of thoracoscopic sympathectomy for isolated facial blushing. Side effects are frequent, but most patients are satisfied with the operation. We recommend a T2 sympathectomy for isolated facial blushing rather than a T2-T3 sympathectomy because there are fewer side effects. Randomized studies on sympathectomy for facial blushing are needed, and until we have these results, the present and other follow-up studies provide the only information for thoracic surgeons and their patients.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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