The main surgical treatment is endoscopic thoracic sympathicotomy (or sympathectomy), a surgical procedure where a lighted telescope is inserted through the armpit, into the chest cavity, and the sympathetic nerves (the T2 level sympathetic nerve) to the face and upper arm are cut, crushed or destroyed at the sympathetic ganglia near the spine (Kao M-C, et al, Endoscopic sympathectomy treatment for craniofacial hyperhidrosis, Arch. Surgery 1996 131:1091-1094). This procedure, known as ETS, will not usually help people with hyperhidrosis of the underarms, feet, or body, but may be very helpful or even curative for hand or facial hyperhidrosis, and may help relieve facial blushing. Because it is an unusual operation, not many surgeons are familiar with it, but there are surgeons who have extensive experience with this procedure.

It is performed in an operating room equipped with a video laparoscope, and performed under general anesthesia. Two separate surgical procedures, one on the right and another one the left side, have to be done (usually at the same time) in order for it to work on both sides of the body. The patient can often go home the same day, and is expected to have a full recovery from the surgery in about 1 week. There are complications such as the development of pneumothorax (excessive air in the chest cavity, outside of the lungs) or Horner's syndrome in around 1% of cases, as well as bleeding, infection and injury to the surrounding tissues, but these are fairly rare side effects. Published reports show 68-87% satisfactory control of patient's sweating problems (Rex LO, et al, The Boras experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing, Eur. J. Surg. 1998, Suppl 580: 23-26 and Sayeed RA, et al, Quality of life after transthoracic endoscopic sympathectomy for upper limb hyperhidrosis, Eur. J. Surg. 1998, Suppl 580:39-42). One major problem with this surgery is that it often (around 80% of the time) causes people to sweat elsewhere, in order to provide the needed cooling effect for their entire body. By eliminating the sweating of the face and arm, many patients develop compensatory sweating elsewhere, which may be bothersome, and has been reported to be severe in some cases. In addition, this surgical procedure is permanent, so that if one is bothered by the compensatory sweating, there may be no other treatment to use other than medication or antiperspirants to control that new symptom. If one is considering ETS, one should seek to obtain multiple medical opinions prior to the surgery, especially from a physician who DOES NOT perform this procedure. Many insurance companies will not cover this procedure which can cost between $5,000 and $10,000.

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