Hyperhidrosis
This is excessive sweating over part or all of the body. People normally sweat to keep their skin moist and to control their body temperature. Excessive sweating is commonly on the hands, face and underarms (axilla).

Facial Blushing
Facial blushing is a common condition affecting many people. It can be due to many diseases. Primary facial blushing comes from activation of the sympathetic nervous system in the brain. A signal passes out to the sympathetic nerves and a blush occurs on the face and upper chest and is associated with a flushing feeling in the face. Redness can occur on the face, neck, upper chest and upper back. It can spread onto the arms. Sympathetic nerves control the diameter of the blood vessels and when stimulated the vessels open up and the skin becomes red. Stress, embarrassment, heat and exercise therefore affect blushing. Some drugs including alcohol also cause blushing. Treatments consist of recognising that stress is often the major problem and having a psychologist look at stress and anxiety management techniques. If there is one specific event that is stressful, avoidance may be appropriate. Some medications interfere with transmission of the signal through the sympathetic nervous system (Propanol or Clonidine which are blood pressure tablets; Zoloft, Efexor or Aropax which are Serotonin antagonists). Drugs have a variable effect but can be very useful in the short term and the can allow a period of control for reflection on whether further treatment is required. Cosmetics can be placed on the face to hide blushing. Laser treatment to the face has been tried, but tends to be a very temporary benefit. A sympathectomy involves cutting the sympathetic nerves in the upper chest on each side to try and abolish blushing.

Sympathectomy
Sympathectomy has been performed for decades for hyperhidrosis especially of the hands, palmar hyperhidrosis). The usual approach was via an incision above the collarbone and the operation was highly effective. This incision and other incisions (under the arm or in the back) are largely obsolete due to the new operation of Endoscopic Thoracic Sympathectomy (ETS).

Endoscopic Thoracic Sympathectomy
This is a “keyhole” surgery operation where small instruments are introduced through the chest wall. The lung is partly collapsed and there is then an airspace through which the instruments can pass above the lung and below the blood vessels and nerves to the arm to the inside of the chest wall at the back where the sympathetic chain lies. Parts of the sympathetic chain can then be removed or clipped or divided by diathermy. All of these give similar results. Clips have recently become mentioned on the internet as a couple of overseas web sites indicate the clips can be removed if the patient isn’t satisfied. They may well be removed, but it is not at all certain if the nerve will ever recover. When to remove them is not clear. Patients should not consider this a reversible operation. Surgeons vary in their belief as to which of these techniques is best.

Advantages of Endoscopic Thoracic Sympathectomy (ETS)

• Smaller incision (more cosmetically acceptable).
• Less post operative pain.
• Reasonably short operating time.
• Ability to do two sides in one procedure.
• Rapid return to work.

Disadvantages of Endoscopic Thoracic Sympathectomy (ETS)
The need to collapse both lungs, hence patients who have lung disease or smoke or even older patients whose lungs are more resistant to collapse (reduced lung compliance) may not be suitable for this operation. Patients with severe coexisting cardiac disease may also not be suitable.

What if I don’t want surgery?
You should consider consulting a specialist – this may be a psychologist, dermatologist or vascular physician, depending on which approach you and your general practitioner decide is best. Many patients come initially to the surgeon and they want a permanent effective cure. Surgery is appropriate for selected cases only for very severe facial blushing after trying prior treatments and after the patient has been informed of the complications and thought about the implications of surgery.

Who does the surgery?
There are quite a number of specialist surgeons, mostly vascular surgeons and some thoracic surgeons, who perform sympathectomy for hyperhidrosis. Few perform the surgery for facial blushing. This is in recognition of three factors:

1. The surgery is technically challenging.
2. The end point of surgery is very subjective, i.e. the patients assessment as to how surgery has helped them manage socially by inhibiting blushing.
3. Compensatory sweating is frequent and can distress the patient. A small number of patients present with this and have personality issues which are the main issue rather than the result of the effects of facial blushing (it is very difficult to decide which).
4. The current medicolegal climate and medical indemnity insurance crisis. This means that a successful sympathectomy with a patient satisfaction of less than 100% can be argued to be a failure by the patient of their representative. This situation has lead to formal complaints and litigation against some surgeons.

Results of Surgery
In young patients bilateral sympathectomy with an overnight stay in hospital is usual. In other patients, staged procedures or one or two nights in hospital may be needed. The operation is highly effective for palmar and facial sweating (patient satisfaction 95%) moderately successful for axillary sweating (patient satisfaction 80-90%), and reasonably successful for facial blushing (patient satisfaction 70-100%).

It is usual to excise the second (T2) thoracic ganglion as it controls the sympathetic outflow to the head, neck, hands, arms and sometimes the underarms. If axillary sweating is the primary problem it may be necessary to excise the third (T3) thoracic ganglion as well to produce dryness on the trunk several centimetres lower. If the sympathectomy has been performed you might wonder why patient satisfaction isn’t 100%. This is because patients can still sweat in a very hot environment and when drinking alcohol. Patients can also blush in relation to heat and alcohol and some drugs. Patients present with a physical problem (sweating or blushing) which is causing a social problem (embarrassment at work etc). The treatment offered is a physical treatment (sympathectomy) but in fact the patient wants a solution to the social problem. Some patients will accept occasional blushing and sweating with severe provocation and others will not. Patient satisfaction can also be diminished if the patient develops compensatory hyperhidrosis.

Results of Sympathectomy for facial blushing specifically
60-70% of patients have a satisfactory result, i.e. no blushing or diminished blushing. Diminished means less duration and less intensity. Another 10-20% have a moderate response. About 5% have no improvement at all in blushing and the cause for this is not certain. Patients who are looking for a good reduction in blushing will be pleased and those who want total abolition of blushing will not find this operation helpful.

Compensatory Hyperhidrosis/sweating (CS)
When a sympathectomy is performed it is likely there will be increased sweating below the level of the sympathectomy. This effect is unpredictable and not every patient has it. If it does occur it can last for weeks or months. There is literature to suggest it may be permanent but our overwhelming experience has been that it usually improves in 6-12 months. Compensatory sweating is unpredictable but it seems to be worse in patients who have lower body sweating beforehand or in those patients in whom a lot of the sympathetic chain is removed (e.g. if T2 and T3 ganglia are taken for axillary hyperhidrosis). The unpredictable nature of compensatory sweating is well illustrated by several patients of this practice who had severe hand and foot sweating who have undergone bilateral T2 sympathectomy with dramatic improvement in both hands and feet. More usually patients have had a dramatic improvement in the hands with some moderate increase in sweating in the feet and hence their satisfaction rating is somewhat less than 100%. Treatment of compensatory sweating can consist of tablets such as Atrobel, topical anti-perspirants (Mitchum or Driclor), and alterations of clothing to suit. Hand dryness is invariable (many patients with primary facial blushing will have clammy, sweaty hands). Hand dryness is treated with hand cream. If the patient is not sweaty beforehand than the compensatory sweating can be disconcerting, It is important to think carefully about this before surgery.

The risks of surgery
Requirements of surgery are general anaesthesia and hospital admission. A fit young person undergoing general anaesthesia may die from unforeseen problems (drug allergies, blood clots). Local problems such as injury to the lung and blood vessels and nerves to the arm and injury to the major blood vessels leading from the neck down to the heart can be avoided by careful technique. There are numerous small arteries and veins adjacent to the sympathetic chain and on occasions these may require diathermy or even insertion of a metal clip. This is why the patient would have been told that a bilateral sympathectomy will be performed only if surgery is satisfactory on the first side. If there are any difficulties on the first side we have found it prudent to stop and do the second side at a later stage.

Specific complications of surgery
Compensatory lower limb hyperhidrosis.

Horner’s Syndrome: a syndrome of a slightly drooping eyelid and a small pupil associated with some blurring of vision in that eye. This is because the sympathetic nerve to that eye has been damaged. These nerves reside in the stellate ganglion which is between the first and second rib, i.e. just above the second (T2) ganglion. It is important to divide the sympathetic chain at the second rib without pulling on the stellate ganglion and without burning near it. These can either cause permanent or temporary Horner Syndrome. The reported incidence of this in sympathectomy has been 1% (this has been our experience) although there are specific techniques to minimise the risk of Horner Syndrome and in a number of situations a temporary Horner Syndrome may not be a significant problem if a sympathectomy can be accomplished.

Preparations for Surgery

How to have surgery
Discuss the matter with your general practitioner who will refer you to Mr Self. Phone for an initial consultation (9429 1176). If you have any questions, the secretaries in the office can often answer most of the preliminary general enquiries. Please feel free to bring your partner or family a family member/friend to the appointment. After this appointment some patients will book for surgery and others will treat the appointment as an information session. We will explore your medical suitability for surgery at the initial consultation (which takes about 30 minutes). We will discuss your symptoms, your physical suitability for ETS surgery, the desirability of undergoing ETS surgery, any other relevant treatment options. A letter will be sent to your referring doctor and you for you to consider your options.

Fitness for the procedure
It is important to not smoke tobacco for 3 months before surgery and to not have a cold or sore throat within several weeks of the procedure. Other medical illnesses may impact on the decision to operate.

Costs of Surgery
Sympathectomy is an operation listed in the Commonwealth Benefits Schedule so a rebate applies through Medicare or your private health insurance. Additional costs apply. It is our practice policy to provide cost estimates for any patient wishing to proceed to surgery.

Staff Involved in Endoscopic Thoracic Sympathectomy (ETS)
Mr Self has a limited number of anaesthetists and assistants for this operation. Specific instruments are required. Specifically trained operation theatre nursing staff are utilised. Operations are currently performed at Epworth Hospital. Other doctors may be involved for patients wishing ETS who have other medical illnesses or who are older in age. This means it may take several weeks from your initial consultation to arrange surgery. I think this is preferable given the possible complications of sympathectomy, the permanent nature of the changes, and the magnitude of the surgery.

Other Treatment Options
It is our practice not to recommend sympathectomy unless we believe the patient will have a high level of satisfaction after surgery. We continue to see many patients who are physically suitable for the operation but the operation is not desirable for other reasons. Patients with hyperhidrosis may find relief from routine antiperspirants, Mitchum roll-on, Odaban or Driclor – the latter two being available without prescription from your local chemist. Some patients with facial blushing benefit from drug therapy – Propranolol, Clonidine, Efexor and Zoloft. Botox injections have a limited role but can be used for temporary relief especially for axillary hyperhidrosis. We have not used them for palmar or plantar hyperhidrosis to date. In some patients anxiety management has helped facial flushing and significant weight loss has helped hyperhidrosis and avoided surgery.

Information
All information disclosed by telephone, in writing, or in person is treated in strictest confidence. A letter is sent to the referring doctor which is routine recommended medical practice. We will request an emergency notification number, but in certain circumstances, it is not necessary to notify family. Permanent partners or spouses will need to be aware of the procedure before the surgery.

Follow-up
All patients will have a chest x-ray prior to surgery, on the afternoon after surgery. A chest x-ray will then usually be requested 3 weeks after surgery followed by a post operative review consultation at 4 weeks after surgery. It is imperative that you attend this consultation to ensure an adequate recovery.

Internet
There are a number of Internet sites devoted to sympathectomy. Key search words are hyperhidrosis, facial blushing, ETS, Sympathectomy. Please remember that most of the Internet sites are located overseas and are commercially orientated. There are a number of chat lines which provide useful information but once again this is not edited in any way.

Further information
This page provides general information and is an introduction to the topic. None of it is supposed to be specific medical advice. If any information could be improved or if you have any additional information, we would be grateful for your input.

GREG SELF
Vascular Surgeon