Micro ETS™ Surgery Technique.  Hyperhidrosis Surgery, Facial Blushing, Raynaud's Disease Treatment.

Micro ETS™ surgery is a treatment option for;  Hyperhidrosis (facial, scalp, palmar, axillary), facial blushing, vascular disorders (Raynaud's Syndrome), causalgia (RSD), migraine headaches.

Introduction - Hyperhidrosis is present in 0.6 to 1% of the population. The sympathetic nervous system is overactive in these people at inappropriate times (low stress conditions, sitting quietly, cool surroundings, etc) causing excess sweating of the hands, axillae, face, scalp, and sometimes feet.

Today, the treatment of choice for severe hyperhidrosis is ETS. Fortunately today, for patients afflicted with hyperhidrosis, Raynaud's disease, embarrassing blushing, or Causalgia, there are a few surgeons around the world who are experienced with this minimally invasive technique. Many individuals can now be treated surgically with improvement of symptoms from hyperactive sympathetic nerves with minimal cost and morbidity, rather than just receiving repeated life-long treatments which are palliative at best.

ETS developed by applying new state-of-the-art technology to invasive thoracic sympathectomy of the past which has been done for decades. Now, through single-incision ETS, what was once considered to be extremely invasive surgery reserved only for the most severe cases (severe Raynaud's or Causalgia for example), is available to and highly curative for the many individuals today who are plagued by symptoms of over-active sympathetic nerves.

Benefits of "Micro Single Incision" ETS include - ETS ---> curative immediately ---> patients leave the operating room with dry scalp, face, hands, axillae. Single-Micro Incision technique (1/12th Inch Incision) No sutures required. Much less postop pain. High success rate (99.9% for hyperhidrosis palmaris). FDA approved instruments/equipment. Same day surgery (discharged the same day--> lower cost). Not an experimental procedure. Latest technology applied to decades-proven invasive (open) sympathectomy. Precise visual localization and transection of the ganglia of interest.

Less morbidity than by other approaches such as; Through the back. Above the clavicles. A long incision with rib resection. Through 3 or 4 incisions. Rapid return to full functional status usually two to three days for school/work and one week for full physical activities. Improved occupational/professional and social interactions. Sympathetic ganglia are located along both sides of the spine. The removal or destruction of some of these ganglia has been done for decades to treat micro circulation disorders of the hands and feet and hyperhidrosis. Today, Micro ETS is the method of choice to treat severe hyperhidrosis involving the scalp, face, hands, and axillae. Also, it is effective in improving facial blushing which may cause social embarrassment.

Technique - Micro ETS is done in an ambulatory surgical center. Both sides are done at the same time. General anesthesia is required. The lungs are NOT collapsed. Only one micro incision (1/12th inch in length) is made along the outer aspect of the pectoralis major muscle in the axilla (arm pit) in the third intercostal space. A 1/12th inch endoscope is inserted through the Micro chest incision into the thoracic cavity. Identification of the sympathetic nerve and any Kuntz nerve branches is done. One thoracic ganglion level is isolated by cutting the sympathetic nerve precisely as it crosses the second rib. The divided ends are cauterized using a low current to minimize nerve reconnections. For axillary hyperhidrosis two ganglia levels are precisely isolated by cutting the sympathetic nerve and any Kuntz nerve branches as they cross the second, third and, fourth ribs for a T2-T3 sympathectomy. The nerves and ganglia are not removed with this technique. The ganglia are left attached to the spinal cord with preservation of the interganglionic connections. This helps to lessen compensatory sweating and post-op pain.

*DERMABOND® topical skin adhesive is used to close the tiny single incision. Upon completion of the right side, the left side is then done in similar fashion. A chest X-ray is taken and the patient discharged a few hours later with a follow-up exam in the morning. The patient then returns home.
*(DERMABOND® is a registered trademark of Ethicon, Inc., a Johnson & Johnson company)

Normal activities can resume a few days later and full physical activities in one to two weeks. Whether unilateral or bilateral sympathectomy is performed depends on the patient's and surgeon's preoperative plan. Dr. Nielson usually performs bilateral sympathectomies at the same sitting.

Results - Palmar hyperhidrosis is successful in 99.9% of patients. Success is immediate and the patients awaken in the operating room with a dry and warm hand, scalp, face, and axillae. Scalp and Facial blushing subsides and cardiac reactions to stress (increased heart rate) is moderated. Stage fright is substantially reduced. Hyperhidrosis of the feet even improves in many cases, but this effect is less predictable.

Success rates:

Complications - Serious Complications are unusual. Possible perforation of breast implants if present. Sensitive Pleurae (chest lining sensitivity) limiting exercise. Horners Syndrome occurrence rate 0.3%. Heat intolerance. Pneumothorax (collapsed lung), Bleeding, Postop Neuralgia and parasthesias are uncommon. Possible hair loss. Bradycardia (slow heart rate) possibly requiring a pacemaker. Subcutaneous emphysema. Possible conversion to open thoracotomy. Possible recurrence of symptoms. Possible necessity for re-do operations. Treatment failure can occur if Kuntz nerves    are present and are not cut.

Possible Side Effects - Compensatory sweating on the trunk or thighs may occur in 50% of patients. Sweating in these areas is regarded as a minor inconvenience for most patients. Severe compensatory sweating that can soak through clothing may develop in some patients. The tolerance of compensatory sweating is patient dependent. Some tolerate severe sweating while others do not tolerate even mild compensatory sweating. It is difficult to predict pre-operatively. Some medications may help lessen the severity of compensatory sweating post operatively. Overweight patients may experience more compensatory sweating. Phantom sweating, where the patient feels the sensations of sweating but is not actually sweating, typically resolves in 1 to 3 weeks after surgery.

Significant reduction in sweating of the upper chest/back, hands, face/head. Heat Intolerance. Gustatory sweating (increased sweating while smelling or eating) occurs in some patients.

Contraindications

• Prior thoracotomy - relative contraindication.
• Severe cardio-circulatory or pulmonary insufficiency.
• Severe pleural diseases (empyema, pleuritis).
• Untreated hyperthyroidism.

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