Surgical approaches and techniques in the management of severe hyperhidrosis.

Thoracoscopy has afforded a huge advance for upper thoracic sympathetic procedures compared with prior open procedures. Different clinical syndromes of hyperhidrosis exist and require different forms of treatment. The classic severe palmoplantar pattern of hyperhidrosis will not respond effectively in the long term to any nonoperative treatment and requires sympathectomy for cure. Thoracoscopic sympathectomy is the first-line treatment in these patients. The author's preference is sympathotomy at the second or third rib level, because this method spares the ganglion. It is possible that ganglionectomy or wide extent of sympathectomy will increase the chance of CH, but, conversely, limited "ramicotomy" procedures are often ineffective. T2 sympathectomy has been suggested as possibly being involved with increased CH, but avoiding T2 sympathectomy has been implicated in failure to treat some instances of palmoplantar hyperhidrosis effectively. Axillary and facial hyperhidrosis and facial blushing syndromes are not as universally and overwhelmingly benefited by sympathectomy and these need evaluation on a case-by-case basis. Axillary hyperhidrosis failures with aluminum chloride can be treated with local axillary procedures. Although botulinum type A injection and axillary curettage appear effective in axillary hyperhidrosis, botulinum toxin type A injection has a short duration of efficacy measured in months, whereas the efficacy of curettage appears to be long lasting. Thoracoscopic sympathectomy for axillary hyperhidrosis at levels T3, T4, or T5 is usually, but not always, effective for axillary hyperhidrosis and may result in severe CH.