- Is there a more conservative treatment available that does not include surgery?
- 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?
- What about a pre-op consultation?
- What advantages does Micro ETS™ offer?
1. Is there a more conservative treatment available that does not include surgery?
Yes, prescription medications and iontophoresis are conservative treatment modalities that should be tried before considering surgery.
A group of medications (Ditropan, Robinul, Propantheline) known as anticholinergic agents may be effective in reducing excessive sweating. These medications act to block neurotransmission of acetylcholine which has a function in sweat production. These have limited effectiveness as the body can develop a resistance to the medication.
Iontophoresis (Drionic, Hydrex) has been reported to be effective at treating the hands, underarms and feet. If antiperspirants are not effective, iontophoresis may be a good option to explore. More about Iontophoresis:
- Used to treat palmar, axillary, and plantar hyperhidrosis.
- Low intensity electric current (15-18 mA) applied to the palms and/or soles immersed in an electrolyte solution.
- Has to be repeated regularly, initially in 20 minute sessions several times/week, gradually stretching out the interval between treatments to 1-2 weeks. The results vary: many patients (70%), suffering from light to moderate hyperhiderosis, are happy with the method, some may consider it too time-consuming or inefficient and comparably expensive. It is difficult to apply in axillary, and impossible to use in diffuse hyperhidrosis of the face or the trunk/thigh region.
- Side effects include: burning, electric shock, discomfort, tingling, skin irritation (erythema and vesicle formation).
- Sweating returns after cessation.
2. 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.
3. 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. 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)
4. 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.
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.
6. 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.
7. 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.
8. 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.
9. Do insurance companies cover Micro ETS™ surgery?
Our 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.
10. Is Micro ETS™ as effective as other treatment modalities for moderate to severe hyperhidrosis?
Treatment of choice for severe hyperhidrosis because:
Dramatic improvement (extremely high success rate 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.
11. Is Micro ETS™ an approved procedure by the FDA?
Yes, the instruments and equipment are FDA approved.
12. Is “Single Micro Incision” ETS an experimental procedure?
No it 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.
13. How long is the incision?
We 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.
14. Do you participate in insurance plans?
Our office bills your insurance company directly. A deductible may be required up-front in some cases. Visa/Mastercard, American Express & Discover Cards are accepted.
15. 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.
16. Does Micro ETS™ cost $20,000 dollars like some sources are saying?
No, we have negotiated a cash price for those patients whose insurance companies won’t cover the procedure.
17. Is Micro ETS™ effective for facial and scalp hyperhidrosis?
Yes, improvement is seen in facial blushing and for facial and scalp sweating.
18. 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.
19. Is Micro ETS™ effective for excess sweating of the feet?
Hyperhidrosis of the feet improves in 50% of cases. This effect is less predictable.
20. What complications may occur with ETS?
Serious complications from the surgery are unusual.
Sensitive pleurae (chest lining sensitivity) can limit exercise, Horners Syndrome, which is rarely reported, pneumothorax (collapsed lung), bleeding, postop neuralgia and parasthesias, possible hair loss, and bradycardia (slow heart rate) possibly requiring a pacemaker. Other possible complications include, but are not limited to, subcutaneous emphysema, possible conversion to open chest surgery and heat intolerance.
Possible persistence of symptoms can occur if accessory nerve branches are present, duplicate nerve or aberrant nerve tracts are present. Recurrence of symptoms can occur if nerve regeneration occurs (unusual), which could necessitate a need for a redo operation.
21. What contraindications are there to undergoing Micro ETS™?
Prior chest surgery – relative contraindication.
Severe heart or lung disease.
22. What side effects are known after Micro ETS™?
Patients should be aware that compensatory sweating can and does occur.
Compensatory sweating is experienced as excessive sweating on the back, thighs, stomach, axillae, groin and/or lower legs and may range from mild to severe. Reported incidence of developing compensatory sweating in world literature range between 50% to 90% of all patients undergoing the ETS procedure. Of this group, it has been reported that about 5% – 10% of these patients experience severe compensatory sweating. Severe compensatory sweating, or severe compensatory hyperhidrosis, can be very troublesome, especially when it soaks through clothing. This can be more problematic in hot humid climates and can become more of a problem than the original problem treated.
The tolerance of compensatory sweating is patient dependent. Some patients tolerate severe sweating while others do not tolerate even mild compensatory sweating. There are medications that may help lessen the severity of compensatory sweating post operatively.
Overweight patients may experience more compensatory sweating and those who live in hot, humid climates may find it less tolerable. Compensatory sweating is the most common side effect reported by patients regardless of which surgeon is performing Micro ETS.
Gustatory Sweating, which occurs while eating or smelling certain foods, can develop post operatively in about 10 to 20% of the patients.
Phantom sweating occurs in some patients after ETS surgery (feeling the sensations of sweating but not actually sweating) and typically resolves in 1 to 3 weeks after surgery.
23. 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. We use a single1/12th inch (2 millimeter) incision in the axilla. We call this “Micro Single Incision” ETS.
Compare Micro ETS to Clamping
24. What about a pre-op consultation?
For special arrangements, please contact our office staff with any questions. All patients receive a pre-operative preparation packet.
25. Do you collapse the lungs during the surgery?
No, we do 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.
26. What advantages does Micro ETS™ offer?
- Single 1/12th inch axillary incision per side
- Less nerve & chest muscle trauma
- Less post-operative 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 (accessory) nerve cut if present
- Out-patient surgery (discharged the same day)
- No sutures required
- Rapid recovery