Surgery to correct Hyperhidrosis problems should always be a last resort, although results can be good, there are far too many unhappy "endings" out there to make comfortable reading. A successful outcome depends much on the individual's condition, patient expectations, the surgeons skill and the knowledge and communication skills of both patient and doctor. To this end it is imperative that anyone considering surgery reads as much as possible around their condition, takes as much impartial advice as possible, the discussion forums are useful here and finally the choice of surgeon must be based on experience and good patient feed-back.
There are few basics to understand first.
When reading about surgery for Hyperhidrosis, often know as Endoscopic Thoracic Sympathectomy or ETS for short, the terms T1, T2, T3 and T4 are often bandied around this short explanation will help explain their relevance:
The terms "T1", "T2", etc. represent nerve roots exiting from the spinal column below vertebrae T1, T2, etc. respectively. These roots include important motor fibers (to the hand from T1, for instance), sensory fibers (for skin and deep sensation), and autonomic (sympathetic) fibers. These autonomic fibres branch off from the roots a short distance outside the spine and supply structures called the ganglia of the sympathetic chain. Nerve fibres arising from these ganglia supply various structures including skin sweat glands (to cause sweating), skin hair muscles (to cause goose-flesh), the pupil of the eye (to cause dilatation), and the heart (to cause an increased heart rate). The pupil is mainly supplied by fibres arising from root T1, facial sweating by fibres from roots T1 and T2, and the heart and palm sweating by fibres from roots T1 to T4 or so. Removing the sympathetic fibres/ganglia at the T1 level has somewhat undesirable complications, while removing sympathetic fibres/ganglia at lower levels (T2 to T4/5) has been shown to reduce palmar and perhaps facial hyperhidrosis without unacceptable complications, this procedure is called upper thoracic sympathectomy.
Hyperhidrosis is a distressing condition but primarily a cosmetic and social problem. You should agree to choose an invasive and possibly irreversible destructive surgical procedure only after very patient and thoughtful consideration. Although quite safe in good hands, the procedure can have occasional immediate life-threatening complications. Also, in the long term, the outcome may be less than desirable, compensatory hyperhidrosis (excessive sweating elsewhere on the body) and gustatory hyperhydrosis (excessive sweating while eating) are the rule rather than the exception after this surgery.
Surgical procedures for Hyperhidrosis have improved in recent years and the irreversible cutting of nerves can now be replaced with clamping techniques which may be reversible should the CS prove to be too serious. A few surgeons have developed a technique which still involves sectioning or removing the relative nerves and ganglia causing the HH, however, these individuals claim a 100% success rate surgically with a very much reduced rate of side effects as compared to those surgeons using other techniques. The technique below seems impressive for those determined to undergo surgery, however, it is imperative that patients always make their own careful enquiries.
A surgical approach to Hyperhidrosis:
Essential Palmar Hyperhidrosis or excessive sweating of the hands, excessive facial blushing, as well as excessive sweating of the axillae (armpits) and feet, although not life threatening, can lead to significant personal difficulties. Many people with this diagnosis are embarrassed to shake or hold hands; they soak papers at school and often wear gloves or avoid public exposure altogether for fear of embarrassment. They ruin their clothing as well as their shoes. They may be depressed or even considered anti-social.
The true incidence is unknown because many people have never mentioned their symptoms to their doctor. Current studies show that as many as 2 out of 100 people suffer from this condition. The problem often starts in adolescence and there is a tendency for the problem to run in families.
Affected people may have excessive sweating isolated to the hands or feet, or more commonly to both. Occasionally facial sweating or upper lip sweating also occurs. The scalp, armpit and trunk tend to have more normal sweat patterns (i.e. they sweat when you're hot in order to regulate body heat). Palmar sweating or sweating of the hands is not a body heat regulating mechanism and is more often associated with being nervous. Some people experience profuse sweating of the hands just thinking about sweating or personal contact like shaking hands.
Treatments to consider before surgery.
Treatments used currently and in the past include:
Surgery should be a last resort and is only for those that suffer from extreme hyperhidrosis. The treatments listed above suit many people, surgery is offered as a more permanent solution to those that have not experienced relief from more conservative methods.
What is Hyperhidrosis surgery - What is a Sympathectomy?
In the past, surgery to perform a sympathectomy has historically been performed in a number of ways. It can be done through the back with resection of a piece of rib on both sides of the spine. It can be done using a chest incision (thoracotomy) where the chest is opened up, or through an incision in the neck. More recently, a sympathectomy is done via video-assisted (thoracoscopy) techniques. This surgery has also been known as ETS or VATS surgery. Broadly, it is the same surgery, however, the surgeon may employ different techniques. The thoracoscopic technique offers the surgeon easy access to the sympathetic chain with less pain and recovery time. Because it is an out patient surgery, younger patients are now undergoing this surgical technique. The youngest patient on whom we have performed this surgery was nine years of age. What used to require a hospital stay of several days can now be done on an out patient basis. Most patients have the surgery and leave a few hours afterwards. If you are coming in from out of state, however, please plan on setting aside four days. If this is your situation, we'll explain further. This is thoracic surgery. As such, the surgeon would like to make sure that you are healing properly before allowing you to travel on an airplane because of the changes in cabin pressure.
How is our technique different?
What makes Dr. Richard Fischel's technique so special is his success rate and history.
Most surgeons either use electrocautery to "burn" the nerve, or they "clip" or "cut" the nerve. When one "burns" the nerve there is the risk that heat will run up and/or down the sympathetic nerve chain that can result in unwanted side effects such as Horner's Syndrome (Droopy Eye) or compensatory sweating (where other areas of the body overcompensate). When one "clips" or "cuts" the nerve there is no guarantee that the nerve won't grow back resulting in a reoccurrence of hyperhidrosis or that the body once again will have compensatory sweating.
With respect to what we deem resection to be: resection is the actual removal of the sympathetic nerve chain with the ganglion at the specific T level(s) along with the efferent and afferent branches. The portion of the sympathetic nerve that is removed at the T-2/T-3 specifically targets the hyperactive sweating of the hands and face, 70% of the patients also experience dryness or some degree of improvement for the feet. It is not a separate surgery, and it is NOT done for people who suffer with only foot sweating. The cold clammy feeling of the hands is definitely resolved, as many of our patients have come to us with a diagnosis of Raynauds Syndrome, and leave with warm and dry hands. Also, for the excessive armpit sweating, if during the same surgery, Dr. Fischel also removes the nerve root at the T-4 level.
Why?
Dr. Fischel "resects" the nerve ganglia thereby reducing the chance of compensatory sweating. Additionally, Dr. Fischel uses a Harmonic scalpel that produces no heat. It is believed, at this time, by removing the afferent and efferent branches along with the ganglion removes any possibility for the nerves to overcompensate to find an alternate route for sweat. Just clipping or cutting the nerve permits the nerve that has just been traumatized to overreact. There has been some talk about the Kuntz nerve. With respect to the Kuntz nerve branch, this is actually a nerve that runs parallel to the sympathetic chain at the level of the second ganglion where the "Ramus Communicantes" falls in between the second and third head of the rib. We DO divide this nerve at the T2/T3 level when we remove the Ramus Communicantes. It has been our experience that it is the actual removal of this portion of the nerve that has given this technique its superior results. As a side note -- the surgery has no impact on mobility as the sympathetic chain has no relation to the motor nerves. Recovery depends on the individual. This is out patient surgery and most patients leave the hospital or clinic the same day. They return to their normal activities.
What is your success rate?
Due to the new HIPAA requirements, we will need prior patients' written permission before we can provide you with the name and phone number of past patients who have expressed a willingness to share their experience with the surgery. What are the risks?
As for the risks; the biggest concern for all, is the compensatory sweating.
Compensation may be problematic or just a re-routing done by the body. While Dr. Fischel's technique has diminished the percentage of patients who get this, there remains the 2%-3% of those who need further treatment to try to resolve this, and even those that do, to date our experience has shown that the problematic aspect of the sweating gradually goes away as the body adjusts. There are 20% who have noted a mild difference in their trunk or leg area, but remain happy that the hand problem has been resolved. The published results of problematic compensatory sweating using either a clip or electrocautery or cutting of the nerve are between 50%-90%. Dr. Fischel's published results show a 2-3% problematic compensatory sweating risk.
Another risk, again, is Horner's syndrome (Droopy Eye), but we have addressed why this risk is very low with the method that Dr. Fischel uses.
To our knowledge, no other thoracic surgeon, or general surgeon for that matter, is using Dr. Fischel's technique.
Is this a new technique?
To our knowledge, no other thoracic surgeon, or general surgeon for that matter, in the United States is using Dr. Fischel's technique. This technique has a twenty-five year history and is not new. There is, however, one other surgeon, Dr. Peter M. Wragg of Australia, who performs this surgery in this fashion as well. His results over the last twenty years are synonymous with Dr. Fischel's. The reason no other surgeon is using this technique isn't because it's unconventional, but the "cutting out" of the nerve and branches versus just "clipping" or "cutting" is more difficult to do thoracascopically; i.e., using very small incisions with a video camera. Dr. Fischel is a Thoracic Surgery Specialist and nationally and internationally renowned for his surgical skills and abilities. He was on the June 2001 cover of Surgical Rounds, a national journal that heralds the "state of the art" in surgical techniques, and recently again received recognition as one of "America's Top Thoracic Surgeons".
Advanced-Antiperspirant.com
http://www.advanced-antiperspirant.com/
Stop-Excessive-Sweating.com
http://www.stop-excessive-sweating.com/