Home > Q&A
1. What is Hyperhidrosis?
    Sweating is a normal physiological response to heat, while hyperhidrosis is defined as the sweating amount being more than for normal physiological response to environmental temperature, especially when the sweating areas are restricted to face, hands, armpits or feet, and disturb people’s normal social life or learning.

2. Should Hyperhidrosis be treated? Is there age-limit to undergo sympathetic surgery?
    Hyperhidrosis is a benign disorder with no harm to health. Treatment is considered only when it disturbs people’s normal social life or learning. In my experiences, the youngest patient was a three year-old little girl; the oldest was a 79 year-old farmer. There is no age-limit to undergo sympathetic surgery. Early surgical treatment is not recommended unless withdrawal behavior is found on small child with hyperhidrosis. Surgical treatment is indicated only when hyperhidrosis becomes worse and disturbs social life and learning after adolescence.

3. Besides of sweating problem, is there any other indication in sympathetic surgery?    
    Of course, in addition to treatment of hyperhidrosis, there are many other indications in sympathetic surgery.
Indications in sympathetic surgery
Hyperhidrosis Migraine
Facial blushing (Erythrophobia) Vibration disorder
Angina Alcoholism
Causalgia Asthma
Upper abdominal cancer pain Social phobia and Psychic disorders
Hypertension Parkinsonism
Arrhythmia Raynaud’s syndrome
Rhinitis Others

4. Is there any possible side effect or complication in sympathetic surgery?
    Except the most famous side effect of reflex (compensatory) sweating, actually there are a few subjective feeling of side effects mentioned without clinical evidence to support them.
Mentioned postoperative side effects
#Reflex sweating Decreased physical capacity
Reduced blood supply Over sensitive to stress/sound
Cold hands and feet Photophobia
Loss of libido Weight gain
*Horner’s syndrome Reduce pulse reaction
Shortness of breath Chronic fatigue or lack of energy
Delayed reaction Mental delay
Depression Headache
Tinnitus Double vision
Irritable colon syndrome Paresthesia of hands and feet
Asymmetric sweating of body Others
# Gustatory sweating is also a kind of reflex sweating.
*Horner’s syndrome is a surgical complication, not side effect.

5. Is there any objective data used to choice of better surgical candidates in treatment of hyperhidrosis?
    Yes, there are. Table 3: Surgical Index of Hyperhidrosis
Influent factors *Grades of disturbance
None Light Moderate Troubling Intolerable
Handling article or working 1 2 3 4 5
With people in public 1 2 3 4 5
Professional activities 1 2 3 4 5
Doing work or Studying 1 2 3 4 5
In closed or hot environment 1 2 3 4 5
Engaging in sports or hobbies 1 2 3 4 5
With family 1 2 3 4 5
Feeling nervous and anxious 1 2 3 4 5
Embarrassment in personal life 1 2 3 4 5
Depressed for it 1 2 3 4 5
*grades < 20: sympathetic surgery is not recommended 20 < *grades < 40: good surgical candidates *grades > 40: be aware of possibility of very nervous patient High incidence of Delayed Sweating Phenomenon (DSP) in grades > 40.

6. What is Delayed Sweating Phenomenon (DSP)?
    About 5.0% of Hyperhidrosis palmaris et axillaris experienced return of severe and massive hand or armpit sweating on the fourth day after sympathetic procedure, then complete and permanent cure of hand or armpit sweating follows. Rare case has DSP one week after operation. Most DSP lasts half day only but as long as one or two days are possible.

7. Besides surgical method, is there conservative method used to treat Hyperhidrosis? 
    Only surgical method guarantees permanent cure. Conservative managements can be tried with deodorants or Ionophoresis with only temporary effect. Botox injection is not recommended for its limited effect and commercially overemphasized. Besides, it is also too expensive and painful to achieve its effect.
8. How many surgical methods are used to treat Hyperhidrosis?
    There are Endoscopic and conventional open methods to treat Hyperhidrosis. Endoscopic method has completely taken the place of conventional open methods in the world now. Strereotactic cauterization is nearly abandoned for less therapeutic effect and higher recurrent rate.
9. Is there difference between ETSC/ESB (Endoscopic Thoracic Sympathetic Block by Clamping) and ETS (Endoscopic Thoracic Sympathectomy or sympathicotomy)?

    Any procedure that can interrupt sympathetic tone to hands is the rationale to cure Hyperhidrosis. Cutting or burning sympathetic nerve is conventionally used to treat Hyperhidrosis in ETS. Clamping sympathetic nervous trunk with titanium clip instead of cutting or burning is used in reversible ETSC/ESB. Return of original condition is possible by removal of clip in ETSC/ESB.
    ETSC/ESB is performed through two small incisions made in each armpit under general anesthesia. Ganglions are clamped by titanium clips instead of cutting or burning sympathetic nervous trunk. It takes less than 20 minutes to finish the whole procedures of ETSC/ESB. Patient usually feels chest or back pain after waking up from anesthesia. Normal activity can be resumed on the next day. No operation scar is visible. Reversal procedures can be easily performed by removal of the clips. ETSC/ESB has been clinically used by many surgeons in the world now.

10. Is ETSC/ESB safe?
    ETSC/ESB is a very safe and mature surgical procedure. Dr. Lin has performed Endoscopic sympathetic procedures to treat different sympathetic disorders on more than 7000 cases since 1989, which included more than 200 patients from more than 30 countries all over the world.
11.What kind of Anesthesia is recommended for ETSC/ESB?
    General anesthesia is the only choice for sympathetic surgery. Local anesthesia is not recommended for its poor anesthetic quality and inhuman.

12.What is the main reason for patient’s regret and then reversal is requested?
    Reflex sweating (compensatory sweating) after sympathetic surgery is the main reason for patient’s regret. Without exception, a certain percentage of patients could not tolerate reflex sweating and would like to receive reversal procedure. Reflex sweating happens not only on Hyperhidrotic patients but also on other sympathetic disorders even without sweating disorder. Postoperative sweating phenomenon is a reflex reaction, not compensation. Its mechanism has been first found out by Dr. Lin.
13. What is the golden time for reversal? Is it difficult for reversal?
    The golden time is within three months after ETSC/ESB. Clips can be removed without difficulty by endoscopy. Effective response of reversal procedure usually appears within three months. The latent period of return of sympathetic tone varies from case by case. It usually takes six moths or more to get recovery. No improvement is possible if the reversal procedure is performed late.
14. Is there any way to treat reflex (compensatory) sweating when it happened after sympathetic procedure?
    It is very difficult to treat reflex sweating whenever it is triggered. Only a few of such patients can be luckily controlled by anticholinergic medicines.
    Reconstruction of sympathetic nervous trunk is the only way to return the continuity of sympathetic tone, but the surgical results are still very dissatisfied with people who underwent reconstructive surgery in the world. Dr. Lin has designed a new reconstructive technique of sympathetic nerve that can be performed totally by endoscopic method. This all new reconstructive method is “Intercostal Nervous Grafting” (ICNG). ICNG is the first choice in sympathetic reconstructive procedure in the world now. Intercostal nerves instead of sural nerve are used to a donor graft in ICNG.
    Prevention of side effect before operation is much more important than postoperative management. ETSC/ESB possesses preoperative prevention character in sympathetic surgery.
15. What are the advantages and disadvantages between ICNG and SNG?
(I) Advantages of intercostal nervous graft (ICNG):
    a) From the viewpoint of Human Anatomy:
    1) There are a dozen of intercostal nerves (ICN) communicating with sympathetic nervous trunk and ganglions in each thoracic cavity, which are composed of large amount of sympathetic nervous fibers. In addition, the size of ICN usually accords with the size of sympathetic nervous trunk. Its location and size become the first choice in reconstructive surgery of sympathetic nervous trunk. Dr. Lin emphasized that ICN is a Gift from God for sympathetic nervous reconstruction.
    On the contrary, there is only one sural nerve in each ankle; its location is so far from thoracic cavity. The sizes of sural nerves are so various and so far to accord with the size of sympathetic nervous trunk.
    2) The length of nervous graft:
The length of intercostal nervous graft can be taken as long as clinical necessity, while the length of sural nervous graft is limited for the sake of its length, location and less survival rate.
    3) Factors influencing graft survival: Blood supply is the most important influencing factor to guarantee survival of graft. Micro-vascular circulation of ICN is completely preserved when ICNG is prepared as a rotation flap for reconstruction. It is impossible to preserve vascular circulation of sural nervous graft when it is removed from ankle. Tissue fluid is the only but very unreliable factor to support sural nervous survival.
    b) From the viewpoint of human physiology:
    Though two main neuro-transmitters, Acetylcholine and Noradrenaline, are the same among different nervous fibers, different nervous functions are determined by different co-neurotransmitters in different nervous systems. Nervous fibers have similar or the same co-neurotransmitters in the same nervous system. The role of nervous graft should not only bridge the gap between cut nerves but also return transmission of neuro-transmitters and co-transmitters. Tissue histology reveals that intercostal nerves are composed of large amounts of sympathetic nervous fibers. The more similarities between donor and recipient, the better operative results are anticipated. Intercostal nerve is more similar with sympathetic nervous trunk than sural nerve between their compositions. Only anatomic bridge between the gaps is not enough to guarantee return of normal transmission of neuro-transmitters. Only ICNG preserves its physiologic function in whole process of sympathetic reconstructive surgery.
    c) Surgical technique:
Sympathetic reconstruction with intercostal nervous graft can be performed totally by one stage of endoscopic method. It takes 3 - 4 hours to complete whole procedures of ICNG. Two-stage operation is necessary on sural nervous grafting, which includes endoscopic preparation of intra-thoracic surgical field and removal of sural nerve from ankle area by open method. More than 6 hours are necessary for SNG.
(II) Disadvantages of Intercostal nervous graft:
    A few possible disadvantages are found in ICNG. Temporary chest tight or pain, small area of numbness in armpit or anterior chest wall is normally encountered after ICNG. But, they usually disappear in a month.
    Permanent numbness of both small toe areas cannot be avoided after SNG.
Intercostal nervous graft (ICNG) Sural nervous graft (SNG)
Location Intra-thoracic cavity Ankle
Size Similar with sympathetic nerve Various
Graft character Rotation graft Free graft
Choice of graft Multiple choices Single choice
Role of graft Bypass and self-release of neuro-transmitters A bridge only without physiologic function
Micro-vascular circulation Preserved Destroyed
Histology Composed of 50% or more sympathetic nervous fibers Fewer sympathetic nervous fibers, sensory function only
Physiology Yes No
Neuro-transmitters and co-transmitters The same or similar, self-release None
Operation time 3.0 – 4.0 hrs > 6.0 hrs
Surgical results Very fast Longer duration of waiting for surgical results
Duration of observation Between one and three months From six months to three years

(Left): body surface of intercostal innervation, overlaps of innervated areas are found.
(Right): intercostal nerves in intrathoracic cavity.

Procedures of ICNG

16. Is recurrence possible after ETSC/ESB?
    Recurrent rate is less than 1.0%. Incomplete surgical procedure is the main cause of recurrence when it happened within three months after operation. Nervous regeneration is considered the main cause of recurrence when sweating returns more than three months after operation.
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