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the nerve is interrupted, and how the chain is interrupted, along with systematic pre- and postoperative
assessments of sweating pattern, intensity and quality of life. This report suggested that the highest success
rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis.
R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary,
palmar, axillary and pedal and axillary only hyperhidrosis, interruptions at R4 and R5 are recommended.
The top of R3 is best for craniofacial hyperhidrosis.

EXTENT OF SYMPATHECTOMY
The success of dorsal thoracic sympathectomy is judged by: (1) High rate of relief of hyperhidrosis; (2) low
rate of recurrence; and (3) low rate of compensatory hyperhidrosis and gustatory hyperhidrosis.

Invariably, the surgical procedures achieve symptomatic relief but are associated with compensatory
hyperhidrosis in 50%-97% of patients [53-56] . Compensatory hyperhidrosis that occurs on the trunk and lower
extremities following sympathectomy and gustatory hyperhidrosis, which refers to facial sweating associated
with eating or olfactory sensation of hot spicy food, are significant complications of sympathectomy.
As a result, several studies have attempted to determine whether limiting the extent of sympathectomy
can impact the incidence of these two complications [57-64] . However, the results have been inconsistent,
[65]
and randomized trials have not been performed. In 2000, Furlan et al. reviewed published series after
sympathectomy. They reported a compensatory hyperhidrosis rate of 52.3%, gustatory hyperhidrosis rate
of 32.3%, phantom hyperhidrosis of 38.6%, and Horner’s syndrome in 2.4% of patients. In 2200 patients
undergoing ablation of T2 ganglion for palmar sweating and T3-4 ganglia for axillary sweating, Lin and
[66]
associates showed successful sympathectomy in 99% of patients . However, compensatory hyperhidrosis
was noted in 88% of patients. It is important to note that the rate of compensatory hyperhidrosis depends
on the rigor by which compensatory hyperhidrosis is defined. If compensatory hyperhidrosis is defined as
“any increased amount of new sweating”, as has been defined in many of the aforementioned studies, the
rate of compensatory hyperhidrosis is very high. On the other hand, if some new compensatory sweating
is tolerated by the patient and compensatory sweating is defined as “sweating that cannot be tolerated”, the
rate of compensatory hyperhidrosis will be much lower. The latter scenario is consistent with the experience
of many surgeons. However, for the purpose of clarity and comparison of different surgical techniques, it is
best to define compensatory in the most rigorous manner.

From these studies, a number of conclusions can be reached: (1) longer extent of dorsal thoracic sympath-
ectomy is associated with greater risk of compensatory hyperhidrosis; (2) the severity of compensatory
hyperhidrosis is decreased with staging of dorsal sympathectomy with unilateral sympathectomy
accomplished a few weeks apart versus bilateral sympathectomy at the same setting; (3) the extent of
compensatory hyperhidrosis is decreased with selective ramicotomy; and (4) incidence of Horner’s
syndrome is lower with transthoracic approach when sympathectomy is performed by dissection versus
diathermy of the T2 ganglion or when sympathectomy is limited to below the T2 ganglion.

[18]
[20]
Landmark studies by Wittmoser and later by Friedel have determined the ideal extent of sympath-
ectomy.
It has been postulated that limiting the extent of sympathectomy or sympathicotomy may decrease the
rate of compensatory hyperhidrosis. The thoracic sympathetic chain is composed of both nerve bodies of
the second sympathetic neuron as well as postganglionic axons from nerve bodies from other levels that
travel within the chain. Microscopic examination of what macroscopically appears as a ganglion in the
sympathetic chain reveals a combination of nerve bodies as well as communicating axons from other nerve
bodies that travel up and down the chain. Based on this understanding, division of a single macroscopic
ganglion does not result solely in the removal of the nerve bodies to that specific level, but in addition,