University of California San Francisco

Principles of Surgical Treatment for Hyperhidrosis

1. Removal of Sweat Glands

This approach involves surgical procedures aimed at completely removing or significantly damaging the sweat glands. These methods are typically used to treat axillary hyperhidrosis (excessive sweating of the armpits).

  • Procedure: Various techniques are employed to remove or damage the sweat glands in the targeted area.
  • Effect: The results are localized to the area where the surgery is performed.
  • Recovery: The trauma from surgery is generally more significant than sympathetic surgery, resulting in a longer healing process.

2. Paralyzing the Sweat Glands (Sympathetic Surgery)

This method involves blocking or dividing the nerve that activates the sweat glands, rendering them unable to produce and excrete sweat.

  • Procedure: Sympathetic surgery is minimally invasive, involving small incisions and leading to minimal trauma and fast recovery.
  • Effect: The impact is usually not localized and can cover a larger surface area of the body. This may result in compensatory sweating in other regions as a counter-reaction. However, newer techniques aim to minimize these side effects.
  • Applications: This approach is suitable for treating regions where direct sweat gland removal is not feasible, such as the face, hands, and feet.

Considerations on Choosing a Surgical Procedure for Palmar Hyperhidrosis

Over the past 25 years, critical evaluation of various surgical methods for treating palmar hyperhidrosis has led to a preference for certain techniques over others. This evaluation, based on common sense and clinical results rather than controlled studies, highlights the evolution and refinement of surgical approaches.

Traditional Approach: T2 Sympathectomy

Historically, surgery for palmar hyperhidrosis involved dividing the sympathetic chain over the 2nd and 3rd rib, often referred to as “T2 Sympathectomy.” However, this term is misleading because the T2 ganglion remains intact, with only the interganglionic segments above and below it being transected. Despite its widespread use, this method has several shortcomings:

  1. Risk of Horner’s Syndrome: Using the 2nd rib as a landmark can be unreliable. In some individuals, the stellate ganglion extends over the front of the 2nd rib and, in rare cases, even to its lower edge. Cutting or clamping the nerve on the second rib can result in Horner’s syndrome, especially if a coagulating current is used due to uncontrollable heat propagation.
  2. Impact on Craniofacial Sweat Glands: Interrupting the T1-2 interganglionic segment denervates most craniofacial sweat glands and disrupts autonomic afferents that relay surface temperature information from facial skin to brain stem thermoregulatory centers. This disruption may contribute to compensatory sweating.

Optimized Approach: T3 Method

These findings led to the development of the T3 method, designed to achieve optimal results with minimal side effects. This technique involves precisely targeting the T3 ganglion by carefully identifying the path of the white ramus communicans that branches off the intercostal nerve and connects to the ganglion. Additionally, to prevent other nerve injuries, it is essential to detach the T3 ganglion using cutting mode cautery rather than coagulation mode. (put link for the T3 paper that we published.) https://www.sciencedirect.com/science/article/pii/S2772993124004601?via%3Dihub

Conclusion

Based on years of experience and analysis, the T3 method is advocated for its effectiveness in reducing compensatory hyperhidrosis and achieving long-term success in treating palmar hyperhidrosis.