Surgery for hyperhidrosis has made some great improvements over the years, as doctors are beginning to learn more and more about this condition. However, there are a lot of difficulties that can take place with these surgical procedures, which is why doctors often don’t recommend it unless all other treatment options (antiperspirants, iontophoresis, medications) for excessive have been tried with no success. Sometimes the side effects and the complications that can occur during surgery far outweighs the potential of sweating less.
Sympathetic Nerve Chain
If you’re interested in surgery to stop excessive sweating then it’s important to learn more about your sympathetic nervous system, as the surgical procedures performed to stop hyperhidrosis focus on cutting, clamping, or eliminating a certain part of the sympathetic nerve chain, which is a group of nerves that make up the sympathetic nervous system.
The sympathetic nerve chain can be found running up and down the ribs about 1 inch away from your spine. The building blocks that make up your spine are called the vertebra, and these building blocks are what keeps your sympathetic chain contained.
Ganglion are a group of cells that are located at the end of every vertebral level of the spine, and every ganglions are connected to each other to form the sympathetic chain. Each of these ganglions has a sympathetic nerve branch that comes off of them and travels to sweat glands inside your body.
What Role Does Your Sympathetic Nervous System Play
The sympathetic nervous system is what controls how much your body sweats. It is part of the autonomic nervous system, which is one of the main sets of nerves in our bodies that is responsible for most of our bodily functions that we do unconsciously such as breathing, our heart beat, and sweating.
There are 2 sympathetic chains that makes up the structure of the sympathetic nervous system, and one is positioned on the right of the spine and the other one is positioned on the left. Both chains run down from the neck area to the abdomen.
Doctors still aren’t sure what exactly causes the sympathetic nervous system to begin working improperly and lead to excessive sweating. What they are sure of is that when they remove or eliminate a certain part of the sympathetic chain it will stop the patient from sweating excessively.
How Is Surgery for Hyperhidrosis Performed?
Once again this main nerve (sympathetic chain) of the sympathetic nervous system is a group of nerves that connects to one another to from one structure that is located along your ribs and is positioned 1 inch away from the spine. When surgery is performed for hyperhidrosis the surgeon will cut, clamp, or remove a portion of these nerves along the sympathetic chain at a certain location to interrupt the transmission of nerve impulses that triggers your body to begin sweating.
Back in the day surgical procedures for this condition involved completely removing portions of the sympathetic nerve chain, but these days doctors have realized that taking out one huge chunk of the chain isn’t needed in order for the procedure to be effective (and it will cause less complications).
The area along the sympathetic chain where the surgeon will interrupt the transmission of nerve impulses will depend on what area of the body the hyperhidrosis patient is sweating from uncontrollably.
For example, if the patient is suffering from facial hyperhidrosis the nerves at the highest level of the sympathetic chain will be cut or removed. If the patient is suffering from excessive sweaty armpits the surgeon will cut or remove the nerves located at the lowest area of the sympathetic chain. The nerves found in the center of the sympathetic chain will be cut or clamped by the surgeon to interrupt the transmission of signals through the sympathetic chain to stop the hands from sweating too much.
There are a few different methods the surgeon will use for this procedure such as cutting and dividing a certain area of the chain, removing a very small portion of the sympathetic chain, crushing the chain with a clip, or eliminating a small portion of the chain using electrical cauterization. It doesn’t really matter what method the surgeon uses for the procedure as none seem to be more effective the other.
The most performed sympathetic surgical procedure is ETS, or endoscopic thoracic sympathectomy. The hyperhidrosis patient will placed under general anesthesia and then the surgeon will begin to make small incisions beneath both underarms.
The surgeon will then move the lung by inserting air through the chest cavity. The lung is moved just so the surgeon can get a good look at the sympathetic chain and operate without it getting in the way during the procedure.
Some surgeons who perform this procedure might collapse the lung to get it out of the way during operation. Once the procedure is over the lung will then be inflated again and return to its original position.
With the lung out of the way a video camera small enough to fit through the incision and into the chest cavity will be used to get a good view of the chain. At the very top of the rib cage is where the sympathetic chain is positioned/starts, which is why doctors use R2, R3, R4 and etc to describe the surgical procedure when performing it.
The surgeon will use a special instrument to clamp, burn, or cut the R3 to R4 area of the sympathetic chain to stop excessive sweating. The surgeon will perform the procedure on one side and then do the same thing on the opposite side.
The specific location the surgeon places the clamps to interrupt the sympathetic nerve chain will be determined by where the patient experiences hyperhidrosis. The best results for palmar hyperhidrosis is surgery performed around the R3-R4 levels. For facial sweating the best results involve interrupting the very top of R3. Interrupting the sympathetic chain at R4 and R5 levels give the best results for underarm sweating and foot sweating.
Many surgeons believe lowering the level of the sympathetic surgery to R3 and R4 levels will decrease the amount of compensatory sweating the patient experiences after the procedure. Most professionals that perform ETS strongly believe that cutting around the R2 section of the sympathetic chain will cause much more compensatory sweating.
Any uncontrollable sweating experienced due to ETS surgery is referred to compensatory sweating. Pretty much every hyperhidrosis patient that goes through with this surgical procedure will experience some type of compensatory sweating in various parts of their body.
This compensatory sweating is supposed to be only temporary and will eventually stop after 4 to 7 days. This compensatory sweating can sometimes be even more severe than the original excessive sweating, and if it doesn’t stop then might indicate a failed operation.
As far as clamping, burning, or cutting the sympathetic nerve chain the clamping procedure is often recommended. When you cut or burn the chain there is no chance of reversal, but with the clamping method reversal is possible since the patient can always have the clamps removed. However, even with the clamping procedure there is a chance that the the sympathetic nerve won’t regenerate.
What To Expect After Surgery is Completed
After the ETS procedure is complete you will be told it’s best you stay in the hospital for a while so doctors can observe you. You will get the chance to return to your house that very same day of the operation, but the surgeon will want to keep an eye on you for a while first to see how you’re doing. You will experience some pain and maybe some difficulty breathing after the surgery is done, and you’ll be given some medication to help with pain until it is gone. Everyone is different, but the pain usually lasts a week to 2 weeks.
The most common side effect you will experience after surgery is compensatory sweaing. Since one or more areas of your body releases very little to no sweat at all your body will make up for this lack of sweating in other areas of your body.
Another common side effect is a reduced heart rate (especially while you’re exercising). The surgeon is required to let you know that your heart rate will get reduced after the operation and your athletic ability will be affected. Doctors normally warn patients that if they are an athlete that they shouldn’t get this ETS procedure done. After the procedure you will find yourself running out of breath very easily and getting fatigued quickly.
You will still be able to do physical activities, but you just won’t be able to do it at the same capacity as you did before the ETS operation. There are a number of other side effects that can occur after this operation such as Horner’s syndrome and gustatory sweating, but these side effects are rare.
Cost of This Operation
You better have really good insurance if you’re interested in this operation. Just the consultation alone can cost up to $800. The full amount for this procedure varies from surgeon to surgeon and will depend on what you need done. However, the average cost for ETS is in the $35,000 to $50,000 range!
If you have good health insurance though you may only have to cover around $2,000 (might be a little more or less depending on your insurance) of that amount. Make sure you pre-authorize the operation to be sure that your health insurance will cover it.
Other Types of Sympathectomy
Another surgical procedure used to treat hyperhidoris is endoscopic lumbar sympathectomy or ELS. This surgical procedure is mainly used for patients who suffer from excessive underarm sweating. Axillary suction currettage or the use of a laser to burn the sweat glands is performed (sometimes both).
In this operation the surgeon will make 3 small incisions on the abdomen. A specially designed instrument will then be placed into the incisions and the sympathetic chain that runs down the lumbar vertebrae will be found. The chain at the level underneath the second lumbar vetebra is clamped. A laser beam will also be used to separate and get rid of as much of the sweat glands as possible.
At the end of the day it is your decision to go through with this surgery or not. Just remember that there’s no going back once you have gotten it done. Your nervous system is what we’re talking about here, and there is literallly a million different things that could go wrong.
Also, keep in mind that for about 90% of the HH patients that have surgery performed experience compensatory sweating, and it can turn out to be even worse or just as severe as the sweating you experience right now with your original hyperhidrosis. Always try non-surgical methods first before deciding to go under the knife.