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Hyperhidrosis FAQWhat is it?Hyperhidrosis is an involuntary sweating response generated by the sympathetic nervous system. The body uses sweating as a means to regulate our own body temperature in response to changes in generated body heat or environment. Besides the environmental changes, which can make us, sweat, hormonal or emotional stimuli can cause sweating. There are two types of sweat glands are primarily responsible for sweating and temperature regulation. There are 4-5 million exocrine glands in the body and approximately one-third of them are in the palms. The feedback system that regulates sweating is located in the sympathetic chain and runs along the posterior chest parallel to vertebral column. What are the symptoms?The symptoms of hyperhidrosis represent excessive sweating which may or may not be related to temperature, emotional response or activity. The incidence of this disease is approximately 0.5-1% of the population. It is important to determine whether hyperhidrosis is primary or secondary. Primary hyperhidrosis refers to sweating that is excessive with no known cause and unrelated to any other medical condition. This may be in response to emotional stimuli such as public speaking or situations, which make one apprehensive or anxious. Secondary hyperhidrosis is sweating that occurs due to underlying conditions or diseases such as hyperthyroidism or medications. Another cause of secondary hyperhidrosis can be diabetes, which results in a dysfunction of the autonomic nervous system. Hyperhidrosis can occur at multiple sites including the hands, the feet, the axilla and less likely in the groin and buttocks. What are the concerns?Hyperhidrosis can result in emotional and social embarrassment and in children can result in developmental delay in social skills because of concerns of ridicule or avoidance of personal relationships. This disease tends to become most prevalent in the years during puberty and remain stable after that age. Although hyperhidrosis is not a dangerous disease, it can significantly affect a person's ability to interact with other people and result in situational avoidance and emotional development delay. What are the treatment options?There are two basic treatment options: medical therapy or surgical therapy. MedicineTopical remedies reduce the amount of sweating but must be applied two to four times per day. Most patients prior to surgery will have tried this remedy. The lotions can cause chapping and cracking of the hands and has a wide range of effectiveness. Oral medications such as anti-cholinergic drugs are groups of medicines, which inhibit the autonomic nervous systems from firing and results in the inability to sweat. There are significant side effects that occur with these medications, such as dry mouth, dry eyes, and GI dysfunction, and for these reasons have not gained significant popularity. Iontophoresis is a technique, which uses ionic transfer to interrupt the sympathetic chain but must be used daily for many hours and can be somewhat uncomfortable. The result is transient. Patients frequently find this an unacceptable method of treatment. SurgeryThoracic sympathectomy has been performed for may years to treat many different diseases. This procedure was used to increase blood flow to the hand in-patients who have reflux sympathetic dystrophy. This disease causes intense vasoconstriction, which is also under the control of the sympathetic nervous system and can result in tissue loss of the finders. Originally this operation was performed by making a large incision in the chest called a thoracotomy with approximately a 3% risk of long term pain syndromes. In order to save the finders, this was an acceptable complication. When we are talking about simply relieving excessive sweating on the hands and both sides are required to be operated on, this was an unacceptable complication and a relatively large operation for a small problem. Another approach was to perform an axillary thoracotomy, although much more cosmetically appealing and less invasive, it was not without significant risk, such as postoperative pain syndrome, and a significant recovery time. In the early 1990's, thoracoscopic surgery was developed and resulted in major advances for minimally invasive techniques performed on the chest. This is similar to other endoscopic surgical techniques such as laparoscopic surgery used in general surgery or arthroscopic surgery used in orthopedic surgery. In 1993, we started performing thoracoscopic sympathectomies, which required a 2-3 day hospital stay and one side was operated on at a time. In 1994, because of better anestheti8c and surgical technbiques, bilateral sympathectomies were performed, however, the patient was still admitted for 2-3 days. In 1997, with the development of new instrumentation and more experience, patients were able to have a bilateral thoracoscopic sympathectomy and these patients were now being operated upon on an outpatient basis. Surgical AnatomyThe sympathetic chain within the chest accounts for different functions at different levels and it is important to recognize the patient's symptoms prior to performing this procedure. The T1 ganglion also called the stellate ganglion controls not only the sweating over the face but also the eyelid and pupil. If the T1 nerve root is destroyed the result can be a Horner's syndrome which is a cosmetic deformity resulting in the eyelid lowering to the level of the pupil instead of at the top of the iris, smaller pupil on the same side and back of sweating on the same side of the face. This is an acceptable complication for those patients with reflex sympathetic dystrophy to improve blood flow to their hand, however, unacceptable in those patients with hyperhidrosis. The T2 nerve root controls the palms on either side and the T4 nerve root controls the axilla and armpit. The procedure routinely involves removal of the T2-T4 nerve root thereby markedly limiting the risk of a Horner's syndrome since the procedure is not carried out above the second rib. We believe that removing the nerve root is better than simply electrocauterization at the present time since nerves tend to regenerate and the recurrence rate is significantly higher with just electrocautery of the nerve root rather than removal. Although "clip technology" is developing for reversal of this procedure, it has not been shown to be beneficial and the results are not as satisfying at the present time. Surgical TechniqueThe procedure involves three, 3 mm incisions (see figure 2) on each side with removal of the sympathetic chain from T2-T4 and the procedure is repeated on the opposite side. Typically, no chest tubes are placed and the patient can be discharged approximately four hours after the procedure if there are no complications. Please see the Section on Prognosis for possible complications. The wounds are closed with either suture or glue. At the present time, we are using surgical glue, which gives an excellent cosmetic result. Evaluation and TestingA thorough medical history is required of all patients undergoing thoracoscopic sympathectomy. Patients must completely abstain from smoking for a minimum of two weeks prior to their surgery. Depending upon age, all that is required is a chest x-ray preoperatively. If the patient is over the age of 45 we also obtain an electrocardiogram. This will require a clinic visit preoperatively to discuss the procedure, take an adequate history and physical, and obtain the necessary laboratory evaluations. You will then be admitted the morning of the procedure and discharged that same day. You will be given a return clinic visit appointment with us for approximately two weeks later for your postoperative evaluation. No follow-up care should be required after this. Expected Hospital CourseSince 1997, we have been performing bilateral thoracoscopic sympathectomy as outpatient procedures. The operating time is approximately 1-1 l/2 hours with additional three hour stay in the recovery room followed by a chest x-ray and discharge the same day. Results of TreatmentSince the results are immediate in most patients, patients will notice a difference when they awaken in the recovery room. Because of narcotis, which are used during the operative procedure, it is difficult to determine whether a Horner's syndrome is present or not since narcotics cause papillary constriction. The best long-term results for hyperhidrosis are associated with removal of the chain from T2-T4. PrognosisOur experience has been excellent. We have had no patients return with hyperhidrosis. We have performed more than 200 procedures. ComplicationsComplications include but are not limited to:
How to contact us?Please telephone the following number to schedule a clinic appointment: (734) 936-4973 It may be necessary for us to obtain pre-approval from your insurance company. Most insurance companies have approved this procedure, especially when it is being done on an outpatient basis. |
