Sirs: we have read the article by Dr. Reisfeld with a great interest [3]. It is addressing a very important problem concerning the level of clamping the sympathetic trunk in hyperhidrosis patients. The question concerning safety of T2–T3 clamping versus effectiveness of T3–T4 clamping seems to be one of the most essential nowadays. We would like to congratulate the authors with such a large cohort of patients and such good results. Nevertheless, there are some issues we would like to comment upon. Reisfeld has based his evaluation of the compensatory hyperhidrosis on the subjective opinion of the patients, collected during standard telephone interview [3]. We believe that this method may have introduced a possible bias that may challenge the validity of his conclusions. At our institute we apply preoperative and follow-up evaluations, including not only the subjective opinion of the patient but also gravimetry and vapometry in order to have an objective indication of the patient’s condition [2]. IN addition, we use a standard stress stimulus to standardize the conditions of the examination. Despite the long distance the patients sometimes have to cover to visit our institution, we insist on regular follow-up visits 3, 6, 12 months after the operation and subsequently every year. This procedure enables us to withdraw reliable conclusions, especially in the patients that suffered from moderate (between 100–200 mg/min) palmar hyperhidrosis before the operation and afterwards do not perceive the operation as having yielded a positive result. Our evaluation also involves the abdominal and lumbar regions (that should serve as negative control) and, therefore, gives us additional information on possibly underlying concomitant diseases, especially psychological problems associated with palmar hyperhidrosis [4]. These patients, despite the success of sympathectomy, nevertheless still suffer from excessive sweating associated with their mental condition. In these patients, additional psychological intervention might be beneficial. Special attention is needed for patients in whom the ratio between the intensity of palmar hyperhidrosis versus abdo-lumbar background is below 10:1. There is also the issue of expectation of those patients who believe that the surgery will revolutionize their whole life. Those inadequate expectations may subsequently lead to postoperative depression and exacerbation of the significance of the surgery-induced problems such as compensatory hyperhidrosis [1]. This would create a reactive attitude and reported over-incidence of the severe compensatory hyperhidrosis. Adequate preoperative informative support should therefore include information on all possible complications and risks with a special emphasis on compensatory hyperhidrosis, especially if the patients do not have the opportunity to discuss their problems with the surgeon during regular followups. Lack of such a support may even create adverse attitudes towards sympathectomy in general, as can be observed in some Internet discussion panels run by patients affected by compensatory hyperhidrosis [5]. Finally, close and regular follow-up also allows patients to benefit from the expertise of the sympathetic surgeons in terms of treatment of compensatory hyperhidrosis and additional support, including psychological and/ or botox therapies. Those benefits are unachievable via standard telephone interview. To summarize, we would like to congratulate Dr Reisfeld for his outstanding work and results. His findings are very important as they provide strong support in favor of T3–T4 sympathectomy by clamping in localized hyperhidrosis with very low incidence of compensatory hyperhidrosis. Nevertheless, we think that an additional, more objective, quantitative evaluation and strict follow-up rules might bring even more to the understanding of the impact of this remarkable problem.