It is known that a certain segment within the sympathetic chain which is within the chest cavity is responsible for the excessive sweating. Eliminating that segment will cause cessation of the excessive sweating. The elimination can be done with electrocautery, ultrasound dissection, excision or clamping of that segment.

The surgery itself:
The operation is done under general anesthesia and in many places its being done on a outpatient basis. Outpatient basis means that the patient does not have to spend the night in the hospital and in most patients they go home 2 to 3 hours after the procedure was done. Once the patient is asleep the camera is inserted into the chest cavity and the sympathetic chain is identified. Then depending on the technique used the sympathetic chain is either ablated (resected or coagulated) or clamped with titanium clips. Depending on the surgeon the technique varries. The operation is done on each side of the chest in one setting. This is an improvement because in the past it used to be done one side at a time with two separate surgeries being needed. Once the procedure is completed the patient is transfered to the recovery room where and hour to an hour and a half later chest x rays are being taken to make sure that no air or blood are found within cavity. (Hemothorax or Pneumothorax). Pioneer surgeon Dr. Reisfeld based out of Los Angeles at the Center For Hyperhidrosis has an informative site that also shows visitors a walk through of the actual procedure. See his page on hyperhydrosis for more information on the condition.

Over the last 10 years few refinements came about and those are with regard to the scope of the operation as well as to the instruments used to treat hyperhydrosis. Tremendous progress was made with regard to the quality of the pictures as well as the ability to be more precise with regard to the amount of nerve segment that should be dealt with. The traditional and the most time tested approach is to perform T2 sympathectomy. This means that the segment between the second and the third rib is being ablated with whatever preferred method the surgeon uses. This is used to cure hand sweating, facial sweating, and facial blushing. Recently another theory was brought to light by Dr. Lin and Dr. Telerantra with regard to performing the sympathectomy at different levels. This is still a theory which needs more clinical trials to be proven.

At present at the center for hyperhidrosis the surgical approach is to do the clamping method at the level T3 to T4. This particular surgical variant showed to have as good of results as the T2 sympathectomy but with less amount of cases with severe compensatory sweating. Other benefits to this lower sympathectomy level are less interference with heart rate and keeping upper body sweat in tact.

Another finding that came after comparing the different methods of doing the sympathectomy is the almost disappearance of gustatory sweating after performing the T3-T4 sympathectomy. Dr. Reisfeld believes that this happens due to the fact that there is no interference between the sympathetic-para sympathetic relationship which are more closely connected at the upper chest region (T1-T2 area).

Since about 2006 the endoscopic lumbar sympathectomy (ELS) was developed and refined. The need for this operation came from the fact that ETS had very limited success in regards to the elimination of excessive feet sweating. The operation is performed by very few surgeons around the world and the reason for this uniqueness lies in the fact that the lumbar region and its anatomy is unique and not mastered by every surgeon. In this particular procedure the approach to the lumbar sympathetic chain is obtained endoscopically via three small holes on each side of the abdomen. With this approach the cosmetic results are very good. Performance of the ELS procedure is somewhat longer than the ETS procedure and the main reason is that the surgeon must create the space in order to view the sympathetic chain that runs in the lumbar region. The operation itself takes about an hour and a half and is an outpatient procedure, with the patient going home the same day. The operation has a high rate of success (98-99%) with the elimination of feet sweating. Over the last several years the procedure has been further refines with regards to the success rate, safety rate and minimal cosmetic impact. It must be kept in mind that before embarking with this procedure conservative treatment via lotions and pills should be given a trial.