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Ann Thorac Surg 2007;83:358-359
© 2007 The Society of Thoracic Surgeons
The Center for Hyperhidrosis at The Beverly Hills Center for Special Surgery, 1125 South Beverly Drive, Suite 500, Los Angeles, CA 90035
(Email: dr_reisfeld{at}sweaty-palms.com).
I read with interest the article by Dewey and colleagues [1] regarding thoracoscopic sympathectomy for hyperhidrosis. After performing more than 2,000 endoscopic thoracic sympathectomy (ETS) procedures for hyperhidrosis, I believe that the only indication at present for performing ETS is severe palmar hyperhidrosis. Contrary to earlier publications recommending ETS for facial hyperhidrosis, facial blushing, and axillary hyperhidrosis (eg, [2]), my experience has been that patients presenting with only facial symptoms have a lower "cure" rate, higher rate of severe compensatory sweating, lower rate of satisfaction, and are more likely to request a reversal of the procedure [3, 4]. To get good results for facial sweating or facial blushing, the T2 segment must be eliminated. However, eliminating T2 seems to result in greater compensatory sweating than if a sympathectomy is performed at nerve level T3 [5]. I have compared data from 618 patients with clamping ETS at the T2–T3 level to 656 patients in whom the T3–T4 level was used (Reisfeld R, unpublished manuscript, 2005). The T3–T4 group had a higher rate of satisfaction and a lower rate of severe compensatory sweating than the T2–T3 group, with both differences achieving statistical significance. Dewey and colleagues [1] similarly report that compensatory sweating is significantly more likely to be severe in patients who had T2 ganglia excised, and the most satisfied patients at follow-up were those who did not have resection of T2. They included the T2 level in the sympathectomy in those patients who had facial symptoms. Unfortunately, many surgeons still offer ETS for patients with facial hyperhidrosis or facial blushing as the sole clinical manifestation.
I also suggest that axillary sweating alone as the presenting clinical picture should be dealt with by suction curettage and not ETS. As a referral surgeon, I receive a considerable number of letters, e-mails, and consultation visits from patients who were unhappy with the results of their ETS procedures performed elsewhere. The vast majority of these unsatisfied patients underwent the procedure for reasons other than palmar hyperhidrosis, with about 82% that were done for facial sweating, facial blushing, or axillary sweating alone.
Finally, a "Discussion" to the article mentions the Kuntz nerve, and many articles regarding ETS for hyperhidrosis also mention it. However, looking at the original article by Kuntz, he writes about nerve fibers connecting the first and second sympathetic ganglia and the brachial plexus in cats [6]. His initial studies were done to investigate the high failure rate of sympathectomies performed for vascular problems. The fibers that he described are not actually in the ETS field. I believe that coagulating some fibers found lateral to the main trunk may cause more side effects because those fibers are somatic (ie, sensory and motoric).
In conclusion, we should use ETS only for patients with severe palmar hyperhidrosis. This would greatly decrease the number of unhappy patients, with the further practical consequence of producing less likely litigation.
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  F. Baumgartner and J. Konecny Compensatory Hyperhidrosis After Sympathectomy: Level of Resection Versus Location of Hyperhidrosis Ann. Thorac. Surg., October 1, 2007; 84(4): 1422 - 1422. [Full Text] [PDF]
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