Compensatory Hyperhidrosis After Sympathectomy: Level of Resection Versus Location of Hyperhidrosis

Abstract

Dewey and colleagues [1Dewey T.M. Hebert M.A. Hill S.L. Prince S.L. Mack M.J. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis.Ann Thorac Surg. 2006; 81: 1227-1233Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar] and Reisfeld [2Reisfeld R. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis (letter).Ann Thorac Surg. 2007; 83: 358-359Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] suggested that including T2 in the sympathectomy level increases the incidence of severe compensatory hyperhidrosis (CH) and dissatisfaction rates. But in Dewey and colleagues’ [1Dewey T.M. Hebert M.A. Hill S.L. Prince S.L. Mack M.J. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis.Ann Thorac Surg. 2006; 81: 1227-1233Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar] report and Reisfeld’s [2Reisfeld R. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis (letter).Ann Thorac Surg. 2007; 83: 358-359Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] letter, T2 sympathectomy was done for facial sweating and blushing. Because the level of sympathectomy was always decided by the location of the primary hyperhidrosis, the latter may well explain the risk of increased CH and patient dissatisfaction. Dewey and colleagues [1Dewey T.M. Hebert M.A. Hill S.L. Prince S.L. Mack M.J. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis.Ann Thorac Surg. 2006; 81: 1227-1233Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar] noted increased dissatisfaction and severe CH in patients undergoing T2 sympathectomy, except those T2 sympathectomy patients who also underwent the procedure for palmar hyperhidrosis. In our experience [3Baumgartner F.J. Toh Y. Severe hyperhidrosis: clinical features and current thoracoscopic surgical management.Ann Thorac Surg. 2003; 76: 1878-1883Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar], T2-3 sympathectomy led to a low incidence of severe CH, but the vast majority of our patients had palmar hyperhidrosis, and none had primarily facial hyperhidrosis or blushing. Several criteria seem to reliably predict which patients will have good results after T2-3 sympathectomy [4Baumgartner F. Compensatory hyperhidrosis after thoracoscopic sympathectomy (letter).Ann Thorac Surg. 2005; 80 (author reply 1161): 1161Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] (ie, massive palmar sweating approximating plantar sweating with onset either in early childhood or puberty, and exacerbation with ordinary hand lotion). Reisfeld [2Reisfeld R. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis (letter).Ann Thorac Surg. 2007; 83: 358-359Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] commented that the rates of dissatisfaction and severe CH for patients with only facial or axillary hyperhidrosis or blushing are too high and suggests that sympathectomy not be done for these patients. All these issues together suggest that patient dissatisfaction is less related to T2 sympathectomy than it is to the facial and axillary location of the primary hyperhidrosis. If the results of sympathectomy for palmar hyperhidrosis are excellent and for other locations they are less, then should sympathectomies even be done for axillary or facial hyperhidrosis and blushing? There are many patients with severe symptoms limited to the face and axilla whose lives have been significantly improved with surgical sympathectomy. What needs to be taken seriously, however, is that surgery for facial and axillary blushing and hyperhidrosis is trickier than for typical palmoplantar hyperhidrosis and has an increased rate of patient dissatisfaction. An extensive discussion of risks is crucial, as is an estimate of the patient’s psychological stability. The patient’s perception of the sweating problem before and after the operation is even more likely to be important than the quantitative level of compensatory sweating. Proper patient selection is the key. Confounding variables with regard to surgical sympathectomy (ie, location of hyperhidrosis, sympathectomy level, clamp vs cut vs resect, and role of medical management) lead to divergent conclusions from different studies, not all of which are well thought out. The importance of prospective, randomized trials to scientifically address these issues is apparent. However it also remains apparent that sympathectomy for severe palmar hyperhidrosis (whether at the T2 or T3 level) results in excellent outcomes and satisfaction in the overwhelming majority of patients.