Surgical Treatment

The procedure that gets rid of hyperhidrosis is a fairly straight forward one but with some fairly advance scientific research behind it. Exactly what nerves the surgeons work on defines what area of the body the sweating will stop (and the likelihood of side effects). Carry on reading to discover some interesting facts about the procedure and the likelihood of effectiveness depending on where your excessive sweat is from. Being informed will help you find the right surgeon for the best job, it will prepare you for any potential side effects and will also ensure you will get the results that you want.

 

The updated T2 sympathectomy

The T2 sympathectomy that is done to help treat hyperhidrosis has recently been updated to improve it even more. The reason for this new procedure is to spare the T2 nerve trunk if that is possible. This is due to the fact that the T2 nerve trunk sympathectomy means that you are more likely to suffer from the side effect of severe compensatory sweating. The leading doctors who perform these kind of procedures now recommend that different nerve trunks are clamped because they are thinking of your health post-op. This new procedure is more effective and means that the nerve trunks are clamped rather than destroyed completely.

The different nerves control different parts of the body that are prone to hyperhidrosis, so it is of the utmost importance that the correct nerves are operated upon. You can find out more about this below.

– T1, which is the first thoracic trunk and ganglion controls the sweat in the face, also in the hands and slightly in the underarms also. Interestingly enough, the first ganglion also controls the eyelid and pupil response so this should also be spared during surgery! If it is damaged, this could result in droopy eyelids (Horner’s syndrome.)

– T2, the second trunk, is what the sweat response is controlled by in the hands, face and facial blushing. When this nerve is clamped, it helps to control the sweating and blushing in the face which is what makes it such a popular procedure. It also solves the issue of hand sweating but can make hands overly dry. Although this procedure is popular and effective, there is a higher risk of postoperative compensatory sweating as a result. The severity of CS varies however and a little bit after surgery is completely normal.

– T3, the third thoracic trunk, controls facial and hand sweating.

– T4, the fourth thoracic trunk, controls hand sweating.

– T5, the fifth thoracic trunk, controls underarm sweating.

 

Endoscopic Transthoracic Sympathectomy (ETS):

The first Endoscopic Upper Thoracic Sympathectomy came about in 1954 thanks to an Austrian surgeon. Obviously science keeps improving and developments meant that ETS using smaller instruments could soon be performed to treat the sympathetic nerves using clips and ensure for even more precise procedures.

Evolution over the last 60 years means that the nerves are no longer being cut or destroyed but clamped, this is safer and means less side effects for patients. The procedure using metallic clips is called Endoscopic Transthoracic Sympathetic Blockade (ETB). You might hear the terms ETB and ETS-C when hyperhidrosis is discussed and get confused at the differences but they both mean the exact same thing.

How the procedure takes place

The patient will first go to the operating room and will have a general anaesthetic administered in order to put him/her to sleep. The patient will be laying on their back with their arms extended and temperature probes will be placed on their hands, face and bottoms of feet.

A local anaesthetic will be injected into the underarms after the patient is asleep and a small incision will be made at the fourth rib space. This allows for the lung to then be pushed down and a small endoscope will be inserted into the left side of the chest. As the scope is inserted between the chest space and ribs, it is all visible on a tv screen to allow the surgeon to work precisely and with confidence. The ribs are going to be identified (first, second, third, fourth…) The first rib will usually be covered by muscle and obscured from view but the surgeon will touch this gently with his instrument to confirm its location. The second rib might appear to be the first one because it is the most visible, it curves upwards towards the wall of the chest. The sympathetic nerve trunks that need to be worked on are found along the back wall (at the front of the ribs.) The spinal cord cannot be seen because it’s behind the thoracic vertebral bodies. The nerves are each approximately 3mm in thickness and are like white cords in appearance, covered by chest wall lining which is see through and known as the “pleura”.

A scalpel is used to move the capillaries in the pleura slightly, exposing the nerves. Titanium clips are then applied to whatever nerves need treatment. The nerve ganglions are not disturbed in any way during this process and the entire process on the left side only takes about 5 minutes. The same is done on the right side of the body, no stitches are required as Steri Strips is what is used to close the wounds. The entire procedure takes about 15 minutes and afterwards, the patient is taken to the recovery room where they immediately get an x-ray. Most patients will come around very quickly and be able to leave the hospital 2-4 hours later providing they are feeling OK and have brought somebody with them. No numbness is needed on the sympathetic nervous system because it controls sweating and does not touch any of the muscle functions.

How effective is a sympathectomy for hand sweating?

During this new and innovative technique, the 2nd sympathetic nerve trunks are spared and just the 4th and 5th are clamped. For those who have the procedure, 98% will see a result in terms of their hand and underarm sweating disappearing and no severe compensatory sweating afterwards. Research has also shown that the hands will not become “bone dry” like they do often with the standard T2 sympathectomy, so this is an extra advantage.

How effective is a sympathectomy for axillary (armpit) sweating?

With the recent updates for procedures that treat hyperhidrosis, what is now recommended for armpit sweating is titanium clamps being fitted to the T4 and T5 nerve trunks. The treatment completely gets rid of excessive armpit sweat in 98% of cases compared to the previous T2 sympathectomy which only had a 60% success rate. The side effect of CS is not known to be overly common with the new method is used but was very common with a T2 sympathectomy. The face and head are responsible for 44% of heat loss from the body and once the T2 trunk has been clamped or cut, the heat has to be released somewhere so it’s usually just moved around. The sweating is therefore shifted to the groin, buttocks and legs. One more option that is available for armpit sweating is a mini liposuction procedure on the underarms by an experienced plastic surgeon.

How effective is a sympathectomy for face and scalp sweating?

An ETB procedure for facial sweating is around 95% effective. When the T2 and T3 nerve trunks are clamped, this increases the success rate to 98%. An added and possibly unexpected benefit is after this procedure takes place, greasy facial problems/blotchy skin complexion improves. When the scalp sweating diminishes – this allows the hair to grow longer, thicker and healthier than ever before.

How effective is a sympathectomy for facial blushing?

For those who have an ETS procedure to help cure their facial blushing, there is around an 85% success rate, for the remaining 15% of people, intense blushing will return. It is recommended that clamps are applied to T4 and T5 clamps to get rid of facial blushing. This fails in 15% of cases as the T1 nerve has more control over the issue than the T2 nerve. Despite this slight downfall, the T1 nerve should not be disturbed because it will leave to droopy eyelids and paralysis of the eyelid muscles. Clamping of the T2 nerve trunks gives you more of a chance of developing compensatory sweating but unfortunately, there is little that can be done for this.

How effective is a sympathectomy for feet sweating?

For many of those who suffer from hand sweating, they have excessive sweating on their feet too. Only around 50% of those who have an ETS procedure for their hand sweat, will also see results with their foot sweating. This procedure is not really recommended if you suffer from hyperhidrosis of the feet. If you DO wake up with dry feet after the surgery has taken place, you might find that the condition returns anywhere from a week to several years later. A lumbar sympathectomy is the best procedure to get rid of foot sweating but it is known to cause some horrible side effects including ejaculation issues in men and urinary incontinence in women.

 

Post Surgery

About three hours after your hyperhidrosis surgery, patients will usually be able to leave hospital if they wish to do so. It’s worth noting however that patients who come to the hospital alone, will need to stay overnight just for some extra observations as their health is of the utmost importance. If you bring a family member with you, you can choose to leave whenever you wish providing that you seem to be recovering well.

On the day after you have had your surgery, you can remove any band aids and also take a shower as you normally would. There will be no stitches, only Steri strips and these can be removed by yourself between the fifth and seventh day.

If you are wondering when you can return to work, well it’s completely up to you. If you only have a light duty job, you can return as soon as you feel able to do so, whether this be 1 – 5 days after surgery. Heavy duty work however should be put on hold until at least 10 days later for the benefit of your own health. Everyone feels better in their own time, we’re all different and all have different reactions to surgery. Most people will be able to continue driving around two days post surgery and you are encouraged to walk around and take the stairs just one day after. The sooner you get back up on your feet, the more “yourself” you will feel so make an effort to carry on as normal as soon as possible.

 

Side effects

Although this surgery is as safe as can be, there are some side effects as there is with any surgery so it’s important that you are aware of these. The risks of ETS surgery are low but nevertheless, you can find out what they are below.

Compensatory Hyperhidrosis

This is the most common side effect of ETS surgery and it’s not unusual for most patients to experience this. It can occur no matter what type of procedure you have gone through. Compensatory hyperhidrosis is basically a condition where the excessive sweating is initially shifted instead of going away completely. In this case, it is usually moved from the armpits, hands, feet or face to the back, chest, abdomen, buttocks, groin and backs of the thighs. This happens because the brain is desperately trying to get rid of the excess body heat and has nothing else to do with it but distribute it elsewhere on the body.

It was previously thought that this side effect would only happen if just the T2 nerve was clamped but more serious compensatory sweating would occur when T2, T3 or T2 + T3 is cut or clamped. This is because T2 + T3 are responsible for heat and sweat loss in the head and neck, eliminating a massive 44% of body heat! The new technique that has been implemented however is set to eliminate this side effect with some patients, depending on the type of hyperhidrosis that they suffer from. Clamping T2 + T3 glands however is ESSENTIAL for those who suffer with sweating or blushing. Clamping of T4 or T4 & T5 will lead to mild compensatory sweating in most cases and 1 in 20 will experience a more severe case of the side effect.

The symptoms of compensatory hyperhidrosis might be there all day long or just occasionally, it’s dependent on the individual. If you have mild CS, you will sweat on your buttocks, groin, legs or trunk but it will not be obvious or show through your clothes which is a relief to most. Some people will just tolerate this and some will use medication to help fight the issue. The hands or feet sweating and facial blushing is the biggest problem for those with hyperhidrosis, so they don’t see the side effect of compensatory hyperhidrosis as a HUGE deal providing that it has less severe consequences.

More severe compensatory sweating can, of course, be frustrating and harder to deal with. It usually involves sweating profusely below and between the breasts, the lower chest, the abdomen, groin and thighs. It’s a very uncomfortable feeling and for those who go through it, they might feel that it was worse than before and even regret their decision for the sympathectomy. Removal of the clamps is an option for these people and while it won’t reverse the operation completely, it gives the sufferers of severe CS the biggest chance. Once the nerve is cut, it’s usually irreversible so really think things through before you make a treatment choice.

It’s not known what groups of people are most likely to suffer from severe compensatory sweating as it’s thought to be pretty random. However, sympathectomy of the T2 or the T3 nerves is what usually causes the extreme side effect. Depending on how severe the CS you get is, determines if you can deal with it or you come to regret the procedure completely. CS can happen almost immediately after the operation or many years later.

For those who have an extreme case of the mentioned side effect, there is something that can be attempted in order to cure it. The titanium clip that was applied during the ETB procedure can be removed and although reversal does not always work this, it’s a possibility and more likely than if you had the nerve cut for example. If your severe compensatory hydrosis happened after a sympathectomy, there is another option out there. It involves transplanting a skin nerve into the lower leg where the nerve was removed or cut. It is a complicated procedure and will only be available if you have a severe case of CS. The sympathetic nerve should be clamped not cut because it’s much easier to reverse the procedure if need be.

There are some medications out there which can give you some relief from compensatory sweating, the best ones being Robinul Forte and Ditropan. Visit your physician and they will likely know what you are best prescribed with.

Robinul Forte would be the first route of treatment to go down. It should only be used when absolutely necessary because it can cause body dryness. Some of the other side effects of this medication include headaches and constipation. Taking the medication around three hours before a meal is the best way to use Robinul Forte.

It has recently been discovered that taking Ditropan in low doses can be very effective on severe cases of compensatory sweating. Another medication that might work is Probantheline Bromide.

Horner’s Syndrome

Another possible side effect to EBS is something that is known as Horner’s syndrome, which is ptosis (a droopy eyelid), meiosis (a constricted pupil) and anhydrosis (absence of sweating). Nasal congestion could also be part of the condition. It is a temporary condition in the circumstances that the clip from the procedure is removed. If the nerve has been cut or removed, the symptoms of Horner’s syndrome will be permanent. A skilled plastic surgeon can treat the physical changes from Horner’s syndrome but your health will likely never be the same again.

Brachial Plexus Injury:

This is a very rare condition but it does happen occasionally after hyperhidrosis surgery. It is when injury to the spinal nerve causes pain, muscle weakness and even paralysis in one arm. It’s very hard to treat brachial plexus injury so it’s lucky that it is so unusual.

Hemothorax:

This condition is where there is bleeding present in the chest cavity. This is usually due to bleeding from an artery found underneath the ribs. This is not a common side effect, in fact it happens to under 1% of patients.

Pneumothorax:

With this condition, the lungs struggle to fully expand but usually this would only happen if the patient has had previous problems with their lungs.

Gustatory Sweating

This side effect of the surgery causes the patient to sweat after they have eaten or smelt food. It’s similar to what you might experience after eating something particularly hot. Approximately 10% of patients will experience gustatory sweating. If it does happen to you, it’s usually years after the ETB or ETS procedure has taken place. Robinul Forte usually treats this quite easily.

Neuritis:

Neuritis is basically pain between the shoulder blades and it develops in some patients who have had the surgical procedure. It is due to inflammation of the nerves and treatment is usually easy using anti inflammatory medication.

Rib pain:

Where the endoscope is inserted between the ribs can sometimes bring rib pain as a post-op side effect. This is usually due to the pressure on the ribs and will subside itself in 95% of cases. You might also experience some soreness on/around the breastbone for the same reason. This can scarily feel like someone standing on your chest but don’t panic, it’s normal and will go away.

Back pain

Around one week after the operation, you might feel pain in your back between your ribs. This is due to inflammation underneath the nerves. You will usually feel a dull ache during night-time but again this is easy to treat using medication.

Reduced heart rate

For those who have a T2 sympathectomy, 10% of those will experience a 10% decrease in their heart rate. It is worth noting that this never occurs after a T4 – T5 sympathectomy. A slower heart rate might sound scary but It’s fine and will have no major impact on your general health as long as you have no other heart conditions. Although the heart rate will reduce, the amount of blood being pumped around your body will be the same. That being said, if you are an elite athlete, you should avoid a T2 sympathectomy for this very reason.

Dry facial skin

After you have had ETS or ESB surgery, you might experience facial dryness or more issues regarding your complexion. This is usually not severe and will not impact your life in a major way but some patients might also experience dandruff after the procedure. An unexpected benefit of this is that those who suffer from acne, might find that it goes away thanks to this side effect! No sweating AND clearer skin? This sounds like a benefit rather than a side effect!

 

Things to consider post-surgery

Although the surgery is quick, there are some things you need to put in place to enhance your recovery time even more and make sure you return to your normal state of health as soon as possible.

Tingling

Many sufferers of hyperhidrosis will experience a tingling feeling in their hands before they begin to sweat. Even after surgery, many will experience the same. It’s strange but the awareness of such tingling feeling will go away with most patients after the sweating eases, even if it still exists.

Pleuritis and Neuritis: These conditions have been mentioned previously because it’s important that you consider these before surgery. These are quite common occurrences with patients and result in pain/inflammation of ribs at the front and back. Either of these or both in conjunction with each other can occur after surgery. Your doctor will usually prescribe you with medication to deal with these and luckily, they are easily treatable and disappear in no time at all.

Dry hands

Your hands are going to be really dry after surgery, so having some products nearby that can help you with this is important. Hand lotion and moisturizer can help to keep your hands moist, so packing some in your hospital bag and carrying them nearby after the procedure is going to be useful for you.

Emotional relief

Many assume that after surgery and with the knowledge that their hyperhidrosis is nearly gone for good, they are going to feel much better emotionally and usually this is the case. However, the operation itself can be an emotional experience due to the anaesthesia and the worry that you might have experienced beforehand. About half of patients wake up crying in fact so having loved ones nearby who can help you emotionally is important. After a week or so, you will usually start to get a boost in confidence due to the lack of sweating or blushing and you will start to feel like yourself again, but some patients do take longer.

Many people who have had the surgical procedure, will have a recurring dream within the first month after the operation that can be quite distressing. These dreams usually consist of the hyperhidrosis being back and worse than ever. Many describe the dream as them being drenched in sweat and those around them laughing about it, with little they can do to ease their discomfort. This is thought to happen because of the fear of the sweating returning, patients are not yet fully convinced that it’s gone for good so the anxiety is projected into their dreams.

Despite the things that need to be thought about, the end result of hyperhidrosis surgery is definitely worth it for the majority of patients. There is such an improved quality of life for those who have had the surgery and seen the results that they wanted. They will love the things that most people take for granted including opening a door handle, turning a steering wheel without getting it wet and inserting contact lenses safely. Former patients have been quoted saying that their lives have literally been transformed because of the procedure.

 

Surgical options

If secondary hyperhidrosis is experienced in a mild form, most sufferers just deal with it or go through a nonsurgical option as treatment. Many people get to the point where they can no longer deal with it emotionally or physically, so they decide to move forward with surgery. Previous surgeries required quite a lot of recovery time and were pretty exhausting but there are now more options out there. Recent endoscopic techniques now allow for a sympathectomy procedure with minimum discomfort or inconvenience to patients. They also promise a better result and a quicker recovery time.

Removal of Axillary Sweat Glands

If you only suffer from hyperhidrosis under your arms and do not experience excessive sweating in any other areas of your body, removal of your axillary sweat glands might be an effective solution for you. This would be performed by a qualified surgeon and afterwards a large compression dressing is applied under the armpits to ensure the fluid filled sac does not appear and to secure the flap to the tissue. You can find out more information about this innovative technique from a plastic surgeon with experience with sweat gland removal. Something else that has recently been developed and is set to be effective for some is lipo-suction of the axillary sweat glands although you might want to stay away from this method until more research has been conducted.

Thoracic Sympathectomy:

This surgery has been around since the late 1800’s and it could treat many conditions including epilepsy, angina pectoris, hypertension and goiter. It is no longer performed for any of these conditions however except for rare types of angina pectoris. It is quite interesting that a sympathectomy can save arms and legs lacking in blood circulation and on the road to amputation. It was discovered that the same side of the body where the procedure was done was dryer and less sweaty than the other. Despite this, it was not until the late 1940’s that it was realized that a sympathectomy procedure is possibly the best treatment for hyperhidrosis.

There have been many different surgical approaches over the years including a midline procedure (across the back and down the spine), para-median (through the back and lateral to the spine) and transverse (through the back but in the opposite direction to the other methods.) All these would be performed by the best neurosurgeons with years of experience. Thoracic surgeons use other methods for the procedure including transthoracic (a large chest incision), transaxillary (through the armpits) and anterior transthoracic approaches (through the front of the chest using a large incision).

Sympathetic blockage is a procedure that is used for hyperhidrosis that works really well for most patients. Specific nerve trunks will be clamped which blocks the signal from the brain to the hands/feet/armpits.etc. that causes excessive sweating. This shows that the nerves in the chest are not the cause of the hyperhidrosis but rather the nerve SIGNALS that send the sweat response. In the cases of those who sweat in the hands, scalp, underarms, face and the facial blushing, the nerves that control these are found in the chest and they spread out like spider webs to each location.