Frequently Asked Hyperhidrosis - Sweaty Hands, Facial Sweating, Blushing Face, Surgery Questions & Answers

1. What advantages does Micro ETS offer over other surgical techniques?
2. Is clamping as effective as cutting the sympathetic nerve at the T2 level?
3. Do clamps have any side effects associated with their placement in the chest?
4. Is ETS efficacy and the chance of developing more intense compensatory sweating that different between surgical techniques?
5. 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?
6. What is the importance of Kuntz nerves and what exactly are they responsible for?
7. Why is it important not to remove or injure any sympathetic ganglia?
8. Why have people come to you to have redo Micro ETS surgery?
9. Do insurance companies cover Micro ETS surgery?
10. Is Micro ETS as effective as other treatment modalities for moderate to severe hyperhidrosis?
11. Is Micro ETS an approved procedure by the FDA?
12. Is "Single Micro Incision" ETS an experimental procedure?
13. How long is the incision?
14. Do you participate in insurance plans?
15. Do the symptoms associated with hyperhidrosis recur once Micro ETS has been performed?
16. Does Micro ETS cost $10,000 to $20,000 dollars like some sources are saying?
17. Is Micro ETS effective for facial and scalp hyperhidrosis?
18. Does improvement of symptoms take a long time once Micro ETS is performed?
19. Is Micro ETS effective for excess sweating of the feet?
20. What complications may occur with ETS?
21. What contraindications are there to undergoing Micro ETS?
22. What side effects are possible after Micro ETS?
23. Do surgeons who perform Micro ETS use the same technique?
24. How experienced is Dr. Nielson as an ETS surgeon?
25. What about a pre-op consultation?
26. If my only concern is underarm sweat and odor, is there a treatment other than ETS?
27. What is SDLA® and what area of sweating does it treat?
28. Does Dr. Nielson collapse the lungs during the surgery?
    

• 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

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.

Compare Micro ETS to Clamping

nflammation of the tissue, a neuroma, surrounding the nerve clamped can develop as the body reacts to the placement of a foreign object.  Foreign body reactions to clamps may cause pain, recurrent symptoms and/or new symptoms to develop.
(CLICK IMAGE AT LEFT TO ENLARGE.  ROLL MOUSE OVER ENLARGED PICTURE TO VIEW CLAMPS AND RESULTING NEUROMA)

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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.

5.   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.

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 individualswith 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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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.

Click to Enlarge

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.

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.

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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Yes, the instruments and equipment are FDA approved.

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.

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.

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.

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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No, I have negotiated a cash price for those patients whose insurance companies won't cover the procedure.

Yes, improvement is seen in 95% for facial blushing and 98% for facial and scalp sweating.

No, success is immediate and the patient awakens in the operating room with dry and warm hands, face, and axillae.

Hyperhidrosis of the feet improves in 50% of cases. This effect is less predictable.

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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.
Death

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).

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

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Dr. Nielson’s Micro ETS technique is less invasive because the T2 ganglion is not disturbed in any way. He has found over the years that by sparing the ganglia, side effects may be less likely.

Compensatory sweating is the most common side effect reported by many 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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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.

Compare Micro ETS to Clamping

Dr. Nielson has performed over 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. 

25.   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.

A NEW technique is now being offered by Dr. Nielson called Sub-Dermal Laser Ablation (SDLA). The technique is used only for underarm sweating and has a fast recovery time.  Learn More

SDLA® is only for underarm sweating and odor problems.  It is a minimally invasive laser technique that only requires local anesthesia, is performed in Dr. Nielson's office and has low risks and side effects associated with it. 
Learn More

28.   Does Dr. Nielson collapse the lungs during the surgery?

No, Dr. Nielson does not collapse the lungs. Doing so causes trauma to the airway and lungs.  A patient is able to go home the next day because lungs are not deflated.

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Please contact us for more information on hyperhidrosis by calling 1-877-837-9379 toll free or submit a questionnaire.