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Learn about Hyperhydrosis
Thorascopic Sympathectomy
Meet the Surgical Team
Advances in ETS Surgery



Sweating is a natural body function needed for the regulation of body-temperature. There are five million sweat glands throughout the body and about two-thirds of these glands are situated in the hands. The secretion of sweat is controlled by the sympathetic or (vegetative) nervous system. In approximately 1% of the population, the nerves are over-stimulated and sweat is produced far greater than needed to keep a constant temperature. This condition is referred to as Hyperhydrosis. Excessive sweating may be episodic or continuous. Profuse sweating may be caused by warm weather, emotional stress, or for no reason at all.

Hyperhydrosis may be part of an underlying medical condition (secondary Hyperhydrosis ) or may be of unknown cause (primary Hyperhydrosis). In general, secondary Hyperhydrosis involves the entire body. Diseases or medical conditions which cause secondary Hyperhydrosis include hyperthyroidism, endocrine treatment for malignant diseases, psychiatric disorders, obesity and menopause. Primary Hyperhydrosis, or sweating without known cause is also termed idiopathic or essential Hyperhydrosis. This is a much more common condition than secondary Hyperhydrosis and may occur in one or several locations of the body. The hands, feet and armpits are the most common locations. The condition usually starts during adolescence and is lifelong. Nervousness and anxiety can precipitate excessive sweating.

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FACIAL Hyperhydrosis

Facial sweat may be so profuse that it causes the person to be insecure or anxious. The person may appear overly nervous when this is not the case. Patients may also experience excessive facial blushing.

PALMER Hyperhydrosis

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Sweaty hands is usually the most distressing manifestation of primary Hyperhydrosis. The amount of hand sweating varies from moisture to dripping. Many patients report that their hands also feel cold. Because our hands are exposed in social and professional settings, many patients with Hyperhydrosis are self conscious and may avoid social contact. They may be reluctant to shake hands, handle paperwork, etc . Patients have even been embarrassed to hold the hands of those they love.


Axillary Hyperhydrosis, or excessive sweating in the armpits can cause embarrassing wet marks on shirts. Plantar hyperhydrosis refers to excessive sweating of the feet and is a known cause of foot odor. Less commonly, patient may have excessive sweating of the trunk or thighs.

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In secondary Hyperhydrosis, the underlying medical condition should be treated first. For example, patients with hyperthyroidism should have treatment directed at their endocrine disease. Those patient’s with psychiatric diseases such as anxiety disorders should seek psychiatric care. Treatment options for primary hyperhydrosis include antiperspirants, iontophoresis, drugs and botulinum toxin injections and surgery.


It is the simplest treatment and is usually recommended first. The most effective agent is aluminum chloride. This treatment often works for patients with light to moderate Hyperhydrosis.


Iontophoresis is a "second line" treatment if antiperspirants fail. This treatment consists of applying low intensity electric current to the hands or feet immersed in an electrolyte solution. The procedure has to be repeated regularly several times a week. The results vary, but many patients find it to be too time consuming and expensive. It is difficult or impossible to treat axillary or facial hyperhydrosis with this method.


Various drugs may affect sweating, but generally are not recommended for the treatment of hyperhydrosis because of side affects including dry mouth, blurred vision and sedation.


Botulinum toxin is a poison that interferes with nerve conduction. This toxin is produced by the bacteria Chlostridium Botolinum and works by interfering with the effect of the neuro-transmitter substance acethylcholine at the nerve synapses. In low doses, the toxin may be injected in the face or neck to paralyze local muscles to prevent wrinkles or treat muscular spasms. It may also be used to treat hyperhydrosis by paralyzing the sympathetic nerves that cause sweating by injecting the toxin in the axilla or hands. It works well for axillary and palmar Hyperhydrosis. The treatment is temporary and has to be repeated two or more times a year. Over time this treatment may become cost prohibitive.

Many patients report that the injections are painful. With time, repeated injections may become less effective in treating the hyperhydrosis in some patients. The reason for this is not clear. It has been hypothesized that some patients produce antibodies to the botulism toxin that renders the toxin ineffective.

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SURGERY (Thorascopic Sympathectomy)

Sympathectomy is a procedure to cut the nerves that transmit the signals to the sweat glands. The nerves that trigger sweating in the hands, face, and feet are located in the chest cavity where they exit the spinal cord. In the past, an open chest procedure was required to cut these nerves. Many patients preferred to live with their symptoms because of the magnitude of surgery required to treat the condition. Advances in endoscopic surgery now permit surgeons to cut these nerves with small scopes inserted into the chest through incisions under the armpits, similar to that used in arthroscopic knee surgery. This procedure is termed Endoscopic Thorascopic sympathectomy


Endoscopic thoracic sympathectomy cures hyperhydrosis. Surgery is performed by inserting a miniature camera and instruments into the chest through small incisions similar to those used for knee arthroscopy.

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The neurosurgeon cuts the sympathetic nerves of the T-2 ganglion with magnification and illumination provided by the camera.

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The surgery lasts an hour. The procedure is performed on an out-patient basis and most patients return to work and regular physical activity within one week. The endoscopic technique is very safe and is curative in 98% of patients.

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Jim Avery, M.D. (board certified cardiovascular surgeon), Bruce McCormack, (board certified neurosurgeon), Charlotte Moore Ph.D, (board eligible neurophysiologist)

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Dr. McCormack pioneered the use of intraoperative nerve monitoring to improve the safety of ETS surgery. The results have been presented at National Neurosurgery and Neurophysiology Meetings. Prior to the surgical procedure, monitors are placed on areas of the body typically affected by hyperhydrosis. These areas include the face, hands, armpits and feet. The monitors measure impedance changes in the skin similar to a lie detector test (Figure 1 and Figure 2).

During the procedure, Dr. McCormack uses the magnification and illumination of the endoscope to visually identify the sympathetic ganglion from T1-T4. Dr. McCormack then uses a micro-nerve stimulator to sequentially stimulate each sympathetic ganglion. Impedance changes in various body areas are measured during the nerve stimulation and recorded by the neurophysiologist (Figure 3).

Dr. McCormack also identifies the sympathetic nerves to the pupil and eyelid by having the neurophysiologist check pupil reaction during nerve testing. These nerves are usually at T1 and are protected to avoid a Horner’s syndrome (figure 4).

With the nerve stimulation data, Dr. McCormack then cuts only those nerves that innervate sweat glands in the areas affected with hyperhydrosis. For example, a patient with palmar hyperhydrosis, T2 and T3 ganglion may individually, or both be involved. The intraoperative nerve testing precisely defines which ganglion has to be cut and avoids injury to the ganglion not involved. This is important because post-operative compensatory sweating problems increase with the number of ganglion cut.

Nerve testing is a valuable technique that improves the safety of the ETS procedure by minimizing complications of compensatory sweating and Horner’s syndrome.

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