Hyperhidrosis,
Micro ETS Surgery Questions & Answers
Do
you have a question about hyperhidrosis or Dr.
Nielson's Micro
ETS technique? Check out our list of questions that Dr. Nielson
is frequently asked. If you don't see your question send it to
us at info@etsus.com
- What
advantages does Micro ETS offer over other surgical techniques?
- Is clamping as effective as cutting the sympathetic nerve at the
T2 level?
- Do clamps have any side effects associated with their placement in
the chest?
- Is ETS efficacy and the chance of developing more intense compensatory
sweating that different between surgical
techniques?
- Does dividing only one sympathetic nerve level (the T2 level) and
not removing any length of nerve nor the nearby ganglion
lead to less compensatory sweating?
- What is the importance of Kuntz nerves and what exactly are they
responsible for?
- Why is it important not to remove or injure any sympathetic ganglia?
- Why have people come to you to have redo Micro ETS surgery?
- Do
insurance companies cover Micro ETS surgery?
- Is
Micro ETS as effective as other treatment modalities for moderate
to severe hyperhidrosis?
- Is
Micro ETS an approved procedure by the FDA?
- Is "Single
Micro Incision" ETS an experimental procedure?
- How long is the incision?
- Do you participate in insurance plans?
- Do
the symptoms associated with hyperhidrosis recur once Micro ETS
has been performed?
- Does
Micro ETS cost $10,000 to $20,000 dollars like some sources are
saying?
- Is
Micro ETS effective for facial and scalp hyperhidrosis?
- Does improvement of symptoms take a long time once Micro ETS is
performed?
- Is
Micro ETS effective for excess sweating of the feet?
- What
complications may occur with ETS?
- What
contraindications are there to undergoing Micro ETS?
- What side effects are possible after Micro ETS?
- Do
surgeons who perform Micro ETS use the same technique?
- How experienced is Dr. Nielson as an ETS surgeon?
- What about a pre-op consultation?
What
advantages does Micro ETS™ offer?
- Single 1/12th inch axillary incision per side
- Less intercostal nerve & chest muscle trauma
- Less post-op pain
- Lungs are NOT collapsed
- Precise cut of sympathetic nerve that is much
less painful
- Nerve & ganglia are not removed
- Surrounding tissue is not disturbed
- T2 level cut only (T2/T3 for severe axillary sweating)
- Kuntz nerve cut if present
- Out-patient surgery (discharged the same day)
- No sutures required
- Rapid recovery
Is
clamping as effective as cutting the sympathetic nerve at the
T2 level?
It depends on:
a) if any Kuntz nerve  are
present (if so they need to be addressed too) and
b) whether the metal
clamp stays fully across the nerve and doesn't become
dislodged.
Do
clamps have any side effects associated with their placement
in the chest?
Inflammation of the tissue, a neuroma, surrounding
the nerve clamped can develop as the body reacts to the placement
of a foreign object. (CLICK CLAMP AND NEUROMA (TEXT
TO THE RIGHT) TO SHOW ON PHOTO)
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Is
ETS efficacy and the chance of developing more intense compensatory sweating
that
different between surgical techniques?
When comparing efficacy of one ETS technique to
another it is important to look at:
a) whether the Kuntz nerves are dealt with when present
b) how the nerve is found and then divided (by dissecting the surrounding
tissue away from the nerve just to find it can lead to more postop
pain and may increase the chance of developing Horner's syndrome)
c) whether only the T2 level is divided or clamped rather than
multiple levels
d) the number of incisions, but just as important is the size of
the incision (intercostal space between patients can vary in width,
with the risk of developing chronic neuralgia (pain and numbness)
greater the larger the instrument that is used. Small females for
instance, have a narrower intercostal space making the risk of
developing chronic chest wall neuralgia greater the larger the
instrument that is used and if more than one incision per side
is used.
Does
dividing only one sympathetic nerve level (the T2 level) and not removing
any length of nerve nor the nearby ganglion lead to less compensatory
sweating?
Yes. When comparing ETS techniques, it is important
to look at:
a) whether the nerve is precisely cut and not handled as it is looked
for
b) not disturbing the nearby ganglion
c) not removing nerve with ganglia attached
d) not having many levels cut as this may lead to more intense compensatory
sweating
e) making sure that any Kuntz nerves present
crossing the second rib are divided or clamped, otherwise persistent
or even recurrence of symptoms may occur.
What
is the importance of Kuntz nerves and what exactly are they responsible
for?
Kuntz
Nerves Stats - Kuntz nerves are small nerve branches
from the sympathetic nerve trunk most commonly arising at or
around the T2 level. Sometimes they are present at the T3 and
T4 levels as well. They bypass the level they are at and therefore
can continue to carry nerve signals past a severed or clamped
sympathetic nerve trunk. Kuntz nerves are
present in approximately 50% of individuals with one report being
as high as 63%. In my experience, Kuntz nerves are present in
at least 80-90% of individuals. I've found as many as seven small
Kuntz branches in one patient. If these small nerve branches
are not cut where they cross the second rib, then persistent
hyperhidrosis and/or Raynauds' symptoms can occur. Return of
symptoms after a sympathectomy even can be interpreted as "nerve
regeneration or reconnection" several months after surgery.
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Why
is it important not to remove or injure any sympathetic ganglia?
Sympathectomy by removing a segment of nerve along
with the attached ganglia can lead to more intense compensatory sweating
and more postoperative pain as well. The ganglia are interconnected
from one level to another and disturbing any of these connections
can interfere with the modulatory effects they have on the entire
sympathetic nerve chain.
Why
have people come to you to have a redo with Micro ETS™ surgery?
Some individuals have come to me with persistent symptoms
(sweating for example) after having had ETS surgery performed by
someone else. I have treated them with redo ETS successfully and
discharged them the same day despite undergoing a redo procedure.
I have found the cause(s) to be hidden sympathetic nerve/ganglia
under thick tissue making it easy to have been missed the first time,
and intact Kuntz sympathetic nerves crossing the second and/or third
rib(s)! Partial nerve
regeneration has also been found in many redo surgeries
by Dr. Nielson.
Do
insurance companies cover Micro ETS™ surgery?
My office staff personally speaks with each insurance
company helping them to see why hyperhidrosis really is a medical
condition impairing one's life in many ways and not just a cosmetic
nuisance.
Is
Micro ETS™ as effective as other treatment modalities for moderate
to severe hyperhidrosis?
Treatment of choice for
severe hyperhidrosis because:
Dramatic improvement (98 to 100% improvement for
palmar involvement for example)
Less expensive treatment than life-long medical treatments, and/or
other surgical or radiological approaches.
Extremely low complication rate and morbidity (NOT all techniques
are the same!)
Rapid return to full functional status.
1 to 3 days for school/work
2 weeks for full physical activities.
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Is
Micro ETS™ an approved procedure by the FDA?
Yes, the instruments and equipment are FDA approved.
Is "Single
Micro Incision" ETS an experimental procedure?
No, my "Micro Single Incision" ETS technique
evolved by applying new state-of-the-art technology to invasive thoracic
sympathectomy of the past which has been done for decades. Now, through
single "Micro 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
curative for the many individuals today who are plagued by symptoms
of over-active sympathetic nerves with very low post-op morbidity.
How
long is the incision?
I only make a single
1/12th inch (2 millimeter) incision in the axilla (armpit).
Working through this micro incision usually affords my patients
much less post-op discomfort . No sutures are needed. The scar
produced is extremely small and almost painless. Both the right
and left sides are done at the same time.
Do
you participate in insurance plans?
My hyperhidrosis office bills your insurance company
directly. A deductible is required up-front in many cases. Visa/Mastercard,
American Express & Discover Cards are accepted.
Do
the symptoms associated with hyperhidrosis recur once Micro ETS™ has been performed?
No, except in a few cases.
Recurrence is possible if:
1) Kuntz nerves are missed during surgery (parallel
nerves which bypass the sympathetic ganglia).
2) Incomplete division of the sympathetic nerve chain.
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Does
Micro ETS™ cost $10,000 to $20,000 dollars like some sources are
saying?
No, I have negotiated a cash price for those patients
whose insurance companies won't cover the procedure.
Is
Micro ETS™ effective for facial and scalp hyperhidrosis?
Yes, improvement is seen in 95% for facial blushing
and 98% for facial and scalp sweating.
Does
improvement of symptoms take a long time once Micro ETS™ is performed?
No, success is immediate and the patient awakens in
the operating room with dry and warm hands, face, and axillae.
Is
Micro ETS™ effective for excess sweating of the feet?
Hyperhidrosis of the feet improves in 50% of cases.
This effect is less predictable.
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What
complications may occur with ETS?
Serious Complications are unusual
Possible perforation of breast implants if present
Sensitive Pleurae (chest lining sensitivity) limiting exercise
Horners Syndrome occurrence rate 0.3% (None of Dr.
Nielson's patients
have developed this complication !) Can occur if stellate ganglion
is injured or if the sympathetic nerve is handled.
Heat intolerance
Pneumothorax (collapsed lung, small amount of air or carbon dioxide
around the lung which is reabsorbed spontaneously and requires no
further treatment usually).
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
Gustatory sweating (increased sweating while smelling or eating)
occurs in some patients.
Treatment failure.
Possible causes:
Missed Kuntz nerves (sympathetic
nerve branches which leave the main nerve trunk and bypass the
ganglia crossing a distance away from the main nerve trunk).
What
contraindications are there to undergoing Micro ETS™?
Prior thoracotomy - relative contraindication.
Severe cardio-circulatory or pulmonary insufficiency.
Severe pleural diseases (empyema, pleuritis).
Untreated hyperthyroidism.
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What
side effects are possible after Micro ETS™?
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
Facial hyperpyrexia or facial blushing
Numbness of the skin (intercostal nerve injury)
Possible failure to improve symptoms
Possible regeneration of the nerve
Infection
Dry face, dry mouth, dry eyes
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Do
surgeons who perform Micro ETS™ use the same technique?
No! A few surgeons use only one (1")
incision per side while others use 2 to 4 incisions per side.
I use a single 1/12th inch (2 millimeter) incision in
the axilla. I call this "Micro Single Incision" ETS.
How
experienced is Dr. Nielson as an ETS surgeon?
Dr. Nielson has performed
close to 6000 procedures with
his 1/12th inch microsingle
incision ETS technique. Few other surgeons have performed
as many truely minimally invasive surgeries making Dr. Nielson perhaps
the most experienced minimally invasive ETS surgeon in the world.
What
about a pre-op consultation?
For special arrangements, please contact Dr.
Nielson's office staff with any questions. All patients receive a pre-operative
consultation with Dr. Nielson.
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