Hyperhidrosis

Surgical Anatomy

Department of Cardiothoracic Surgery
Peer Review Status: Internally Peer Reviewed

Surgical Anatomy
The sympathetic chain within the chest accounts for different functions at different levels and it is important to recognize the patient's symptoms prior to performing this procedure. The T1 ganglion also called the stellate ganglion controls not only the sweating over the face but also the eyelid and pupil. If the T1 nerve root is destroyed the result can be a Horner's syndrome which is a cosmetic deformity resulting in the eyelid lowering to the level of the pupil instead of at the top of the iris, smaller pupil on the same side and back of sweating on the same side of the face. This is an acceptable complication for those patients with reflex sympathetic dystrophy to improve blood flow to their hand, however, unacceptable in those patients with hyperhidrosis. The T2 nerve root controls the palms on either side and the T4 nerve root controls the axilla and armpit. The procedure routinely involves removal of the T2-T4 nerve root thereby markedly limiting the risk of a Horner's syndrome since the procedure is not carried out above the second rib. We believe that removing the nerve root is better than simply electrocauterization at the present time since nerves tend to regenerate and the recurrence rate is significantly higher with just electrocautery of the nerve root rather than removal. Although "clip technology" is developing for reversal of this procedure, it has not been shown to be beneficial and the results are not as satisfying at the present time.

Surgical Technique
The procedure involves three, 3 mm incisions (see figure 2) on each side with removal of the sympathetic chain from T2-T4 and the procedure is repeated on the opposite side. Typically, no chest tubes are placed and the patient can be discharged approximately four hours after the procedure if there are no complications. Please see the Section on Prognosis for possible complications. The wounds are closed with either suture or glue. At the present time, we are using surgical glue, which gives an excellent cosmetic result.