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Gharagozloo. Mini-invasive Surg 2020;4:14 I http://dx.doi.org/10.20517/2574-1225.2019.55 Page 5 of 10

Table 1. Hyperhidrosis disease severity scale
A Sweating is never noticeable and never interferes with daily activities
B Sweating is tolerable and sometimes interferes with daily activities
C Sweating is barely tolerable and frequently interferes with daily activities
D Sweating is intolerable and always interferes with daily activities

indication was axillary and palmar hyperhidrosis. Mean operative time was 67 ± 13 min for unilateral RSS.
There was no conversion to thoracotomy. The mean increase in ipsilateral palmar temperature was 1.2 ± 0.3 °C.
Median hospital stay was three days (range 1-4 days). Chest tube was removed on the first postoperative
day (POD#1) in 43/47 (92%) patients and the second postoperative day (POD#2) in 4/47 (8%) patients.
There were no bleeding complications. Complications included transient heart block after sympathectomy
on the second side in 1/47 (2%) and transient partial Horner’s syndrome that resolved in two weeks in 1/47
(2%). There was no permanent Horner’s syndrome.

Whereas all patients had a score of D preoperatively, at a mean follow up of 28 ± 6 months, 46/47
patients had a score of A. The overall sustained resolution of hyperhidrosis was 98%. In one patient (2%),
hyperhidrosis recurred in the first operated side after three months.

Compensatory hyperhidrosis was seen in 19/47 (40%) patients after selective dorsal sympathectomy of
the dominant upper extremity. The contralateral selective dorsal sympathectomy was delayed until the
resolution of the transient compensatory hyperhidrosis, which occurred within four weeks in all patients.
Transient compensatory hyperhidrosis was seen in 21/47 (45%) after selective dorsal sympathectomy of the
contralateral upper extremity. This resolved in 46/47 patients within five weeks after the procedure. At a
mean follow up of 28 ± 6 months, 46/47 (98%) patients were free of sustained compensatory hyperhidrosis.
One patient (2%) experienced compensatory hyperhidrosis affecting the anterior abdomen and lower chest.
There was no gustatory sweating in this group of patients.

DISCUSSION
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, surgical procedures achieve symptomatic relief but are associated with compensatory
hyperhidrosis in 50%-97% of patients [30-33] . Compensatory hyperhidrosis, which occurs on the trunk
and lower extremities following sympathectomy and gustatory hyperhidrosis and refers to facial
sweating associated with eating or olfactory sensation of hot spicy food, is a significant complication
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 [34-40] . However, the results have
[41]
been inconsistent 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-T4 ganglia
[42]
for axillary sweating, Lin and associates showed successful sympathectomy in 99% of patients . However,
compensatory hyperhidrosis was noted in 88% of patients. From these studies, a number of conclusions
can be reached: (1) longer extent of dorsal thoracic sympathectomy 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