BackgroundThe development of compensatory sweating (CS) following thoracoscopic sympathectomy (TS) for palmar hyperhidrosis (PH) is the major drawback of this procedure. Several techniques were proposed to minimize the occurrence of CS such as changing the level of sympathectomy or conducting it sequentially on both sides with an interval between the two procedures. The aim of this study is to compare sequential T3-T4 TS versus bilateral same-setting T3-T4 TS regarding the development and severity of postoperative compensatory sweating. MethodsThis comparative study included 38 patients (18 males and 20 females) with primary palmar hyperhidrosis between March 2020 and March 2023. Patient’s ages ranged between 5 to 18 years, and they were divided into two groups: group I included 23 patients treated with sequential T3-T4 TS; and group II included 15 patients who underwent bilateral same-setting T3-T4 TS. Both groups were compared with regard to patient characteristics, operative details, and postoperative outcomes. ResultsThere were no significant sex or age distribution differences among both groups. The mean cumulative operative time was significantly longer in group I (38 versus 27 min). There was no statistically significant difference in the rate of compensatory sweating between groups I and II (6/23 [26%] vs 5/15 [33%], respectively; p = 0.77). No over-dryness or recurrence occurred in any patient in either group. ConclusionSequential TS does not seem to have superior results when compared to bilateral same-setting TS regarding the development of compensatory sweating. Conducting bilateral same-setting TS is both safe and feasible with shorter operative time, hospital stay, and overall cost. Level of EvidenceIV