Frequently Asked Questions

How do I know if I have Hyperhidrosis?
Excessive sweating, also known as hyperhidrosis, is described and defined as sweating above and beyond the physiological needs of the body. A certain amount of sweat is normal and a compulsory part of our ability to regulate our body temperature. It gives us the ability to secrete certain chemicals which have no more use in our bodies.

This site deals specifically with local / focal hyperhidrosis in which the hands and or feet are sweating excessively beyond normal levels. Total body sweating, however, is a separate issue that is beyond the framework of this segment. Total body hyperhidrosis is not cured or treated with surgery. As a rule a thumb total body hyperhidrosis appears later in life (middle age and up) compared to focal hyperhidrosis that starts at a very young age.

Hyperhidrosis diagnosis
Excessive sweating as felt and experienced by the patient is a very subjective matter. To measure this sweating in terms of quantity is a difficult task. It is very easy to talk with a patient who says that their hands are dripping wet, and make a determination because his/her symptoms are clearly defined. Dripping sweat is a physical statement that clearly describes a severe case palmar or plantar hyperhidrosis.

In cases where the description doesn’t describe dripping hands or feet, it ultimately comes down to how much discomfort the patient feels as a result of the symptoms. If the excessive sweating bothers the patient in both a significant social and functional way, then the patient should first start using conservative treatment methods to see if they alleviate the problem. If conservative treatment measures are unsuccessful, then a careful evaluation by an experienced surgeon is mandatory to consider surgery. It is our policy that every patient should try some conservative treatment modalities given by a doctor. It also shows the insurance company that honest attempts were carried out by the patient to help him or her with this problem.

To summarize the above mentioned comments, hyperhidrosis cannot be measured by certain numbers. It is mainly the subjective findings by the patient that should be confirmed with a doctor who is familiar with this subject. It is always recommended for the patient, or his or her parents, to discuss it with a doctor and verify the symptoms and presentation of hyperhidrosis which are very unique. The uniqueness is that the excessive sweating, in the case of palmar hyperhidrosis, appears below the wrist and in the case of plantar hyperhidrosis it is the sweat that appears below the ankle. This simple presentation is the hallmark of the diagnosis. Unfortunately this simple and basic fact is not really understood nor known to many physicians.

The surgeries available now (ETS and ELS), have a proven track record of safety, and high success rates. That being said, evaluation and discussion with an experienced surgeon is a very crucial step.

Hyperhidrosis Questions:
For questions please fill out the form on our contact us page so we can better understand your condition in order to better answer your questions.

• Is the hyperhidrosis surgery right for me?
• Hyperhidrosis Symptoms & Causes

What Are the Chances of Hyperhidrosis Being Cured on Its Own?
Unlike mathematics and other precise disciplines of science, there are many variables in medicine. There are some cases where people with hyperhidrosis have symptoms that go away over time. While this can happen, the chances of this condition spontaneously disappearing in someone with severe hyperhidrosis is very rare.

Patients with a family history of hyperhidrosis have an even lower chance of hyperhidrosis clearing up on its own. This stems from the fact that the hyperhidrosis gene is not a dominant gene, but a recessive one.

The manifestation of hyperhidrosis depends on two genes: one from the father and one from the mother. The balance between these two genes also depends on the rest of the genome. This is why we see varying levels of severity. This is also why, in some families with a genetic history of the condition, not everyone will inherit hyperhidrosis.

In some cases, patients may experience a very severe manifestation of hyperhidrosis in their late teens to their early twenties, but the condition improved over time. This is an exception to the general rule.

In some cases, patients report hyperhidrosis after an accident, operation, or some sort of trauma. In these cases, the condition is not genetically determined. Therefore, the typical rules do not apply to these types of patients.

Are Men or Women More Likely to Have Hyperhidrosis?
Studies have not shown any evidence that this condition is associated with one gender’s genes over the other. Hyperhidrosis is almost equal in terms of distribution between men and women. It does not affect one gender more than the other. Even so, hyperhidrosis is typically more bothersome to women rather than men.

A question that patients should ask themselves is “How much does hyperhidrosis affect my life at on a day-to-day basis?” The answer to this question may vary based on the age of the patient. Patients in their crucial social years of early adult life may find that this condition affects them greatly in social situations, as well as professional ones.

It is at this time that most people become aware of the problem. We often get calls from parents, with children in their early teenage years, who witness the issue even before the children themselves complain of symptoms.

It is important to let these children express themselves and their desire to reduce the symptoms of their condition. Surgical intervention should only be considered after more conservative measures are completed first.

• Can all types of hyperhidrosis (hands, feet, & armpits) be cured with one operation?
• How much does the surgery cost?
• Can hyperhidrosis be corrected?

Disqualifications For Hyperhidrosis Surgery
You are not a candidate for the procedure if you suffer from severe cardio-respiratory illness, pleural disease, or untreated thyroid diseases. Dr. Reisfeld takes the time to personally communicate with people and determine if the surgery is right for them after reviewing their unique situation.

The benefit to this is that you speak directly with Dr. Reisfeld who is an expert in the field, as opposed to staff or personnel who are not.

There are absolute and relative contraindications for this surgery. An absolute contraindication is a situation where no surgical treatment should be attempted. One example is morbid obesity. Excessive weight to height ratio is not only dangerous to the patient but also makes the operation very difficult to perform because of the excessive amount of fat stored within the chest cavity.

There are other examples, such as extensive previous thoracic surgeries. Relative contraindications necessitate a very careful and thorough discussion with the surgeon about previous surgeries before moving forward.

Previous cardiac surgery and previous corrections of certain chest wall deformities are situations when a patient should be aware that the physician may choose not to move forward with the procedure. Such cases that moved forward resulted in successful procedures.

Are There Cases Where Surgery Cannot be Done?
In certain cases, some old scarring can prevent the physician from performing the operation in a safe manner. This type of scarring can be the result of previous pneumonia that was not necessarily clinically obvious.

Chest Trauma can result in internal scarring (adhesions) that can complicate the procedure. Some very unusual anatomical abnormalities can also prevent doing the operation safely. This happens in extremely rare cases.

Call or visit us to discuss your situation directly with Dr. Reisfeld.

Dr. Reisfeld is a board-certified surgeon who performs both the ELS (Feet) and ETS (Hands) procedures. He has focused his career on hyperhidrosis since 1995. He dedicates himself to helping advance the knowledge and the techniques associated with the problem.

He has performed procedures hundreds of times to help people end their suffering from excessive focal hyperhidrosis. At present Dr. Reisfeld is training three other surgeons to incorporate them into the practice of hyperhidrosis sympathetic surgery.

Dr. Reisfeld has authored seven separate peer-reviewed articles on this subject. He dedicates extensive time and research to the advancement of techniques and the overall knowledge of Hyperhidrosis. The goal is to share his knowledge other surgeons from around the world.

Negative Impact of severe hyperhidrosis
There are a few aspects that are being negatively influenced by severe cases of hyperhidrosis. Patients can become, in a negative way, very aware of this physical issue by avoiding full social interaction with people in their lives (family, friends, co-workers, relationship partners). Especially for the younger age group this can cause rejection by others.

Relationships
Hyperhidrosis can have a very negative impact on people’s close relationships. Both men and women are fearful of intimacy because of what they consider a very embarrassing sweating problem. This often times interferes with people’s willingness to enter into relationships. Those who have the procedure report to us how liberated they feel socially after moving beyond the embarrassing situation.

Professionally
Professionally certain tasks which are now the hallmark of life such as computers, phones and essentially numerous electronic devices are severely affected. Anything involving your fingerprint can also be affected (electronic fingerprint access for example). Any profession with common social interactions such as shaking hands can be a big problem.

Affects and dangers of using hands or feet
Patients often report their inability to hold pens, pencils and or papers due to the severe wetness. In terms of danger there is a danger of slipping and falling due to sweaty feet.

As far as we know from the current information we have both from the anatomy as well as the physiological function of the sexual organs those organs and their performance is mainly regulated by the parasympathetic system. The parasympathetic nervous system is part of the autonomic nervous system (involuntary nervous system) which consists of the sympathetic and the parasympathetic system. The parasympathetic innervation to the male and female sexual organs originates in the sacral region which is far below where the lumbar sympathectomy is done. Currently very precise information about interconnection between the sympathetic and the parasympathetic system is not yet available so based upon clinical information the lumbar sympathectomy does not affect sexual performance.

Any surgeon who attempts to perform endoscopic thoracic sympathectomy should be very well versed and experienced with the anatomy and technique in doing the procedure. This experience should include being proctored by an experienced ETS surgeon. Very few contraindications can exist. Amongst them are obesity which makes the exposure of the sympathetic chain within the chest cavity somewhat difficult and hazardous. Other relative contraindications are previous thoracic surgery cases that can produce a lot of scar tissue and adhesions that would prevent easy access to the site where the sympathetic chain is located. It still can be tried but a good surgeon should know the limitations.

As always perspective patients are encouraged to discuss hyperhidrosis with an experienced surgeon.

The typical cases that influence the surgeon with the decision who is really fitting into the surgical treatment of focal hyperhidrosis (hands, armpit and feet) which did not respond to conservative measures are those cases that have severe hand sweating, feet sweating and armpit sweating if they suffer from that site as well.

Often the question is asked to us, “What if I only have armpit sweating and severe foot sweating?” For those surgeons who are familiar with these presentations it poses a relative dilemma when the hands are not a part of these three mentioned above. The technical aspect of doing lumbar sympathectomy for those patients with excessive feet sweating is available providing that the patient first tried conservative treatments and he/she is not extremely overweight and does not have any other associated medical problems. That particular operation will not affect axillary sweating at all. Also the fact that before the operation they did not complain about hand sweating does not mean that in the future after performing lumbar sympathectomy they will not develop also palmar hyperhidrosis (hand sweating). It is somewhat a difficult topic to enlighten all inquiries about this particular combinations of excessive sweating so it is highly recommended that the patient discusses this with an experienced surgeons.

Anecdotally in the past a trial to perform ELS for patients with only plantar hyperhidrosis (feet only sweating) was not as successful as thought to be. Not that there were any technical issue but the physiological outcome was not as we hoped it to be. These particular cases of plantar (foot) sweating only was originally limited to these patients from the East horn of Africa. Those patients did not have any other site of sweating but the feet. Those patients who have severe axillary hyperhidrosis as well as feet sweating it is our belief that they can fit into the grand picture / whole picture of hyperhidrosis and those can be benefitting from ELS to solve their problem but not the armpit problem. Again it should be emphasized that because of the complexity of those questions it is a must for a potential patient to discuss this subject deeply with an experienced surgeon.

With more information that comes as the time goes by. We believe that cases with only plantar sweating and especially if they come later in life (mid 20s onward) are not a good candidate for the ELS procedure. No good explanation is available and because it does not have all the traits of primary focal hyperhidrosis this operation should not be done in those circumstances.

A frequent complaint that we hear from patients who work in the public sector surrounds fingerprinting. Careers such as policing, education or any other governmental agencies require this step.

The accumulation of sweat in the finger-tip area makes it difficult for the person to perform this simple task. It is frustrating when everyone else can do it without hesitation.

Law enforcement candidates complain about its effect on their ability to hold their weapons, as well as writing citations/reports. Many people may view this as something that is insignificant, but for those who live with it daily, it is a serious issue.

There is also the social and psychological components that we need to consider.

Success Rate of ETS (Endoscopic Thoracic Sympathectomy)
Sweaty palms are corrected in over 98% of cases with the ETS procedure. After years of doing the Thoracic Sympathectomy surgery, it is becoming more evident that the success rate for plantar hyperhidrosis (foot sweating) is no more than 30%.

For this reason the lumbar sympathectomy is an emerging option that represents an excellent approach for those patients who did not get any relief with their plantar sweating after the thoracic sympathectomy. It’s also an option for those who consider their plantar sweating a major problem. The success rate of lumbar sympathectomy for excessive foot sweating is about 98%.

How do I know if my sweating is excessive and considered hyperhidrosis?

Simple questions that patients should ask themselves:

● Does my condition bother me socially or functionally?
● Do your hands drip from time to time from the sweating?

If the answers for those two questions are yes, and conservative treatments have not helped then, the available hyperhidrosis surgical procedures as a long and lasting option should be considered by the patient. You should also consult with your doctor or a medical professional in this field.

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How Much Does The Surgery Cost?
Trying to answer this specific question of cost is extremely complicated. Our Los Angeles based staff are experts in this field and are happy to help you understand the process. The most important step is to call our office so the process of verification and knowledge of the patient’s unique coverage can be used to determine cost. The process should include:

● Verification of coverage
● Eligibility (not every insurance company covers this procedure)
● The amount of coverage provided by the insurance company for this procedure
● The above mentioned points are referring to patients who have health coverage. The eligibility and coverage/amount covered will be determined by our office staff.
● For those without health coverage, please refer to the no health coverage section below.
● Quotes will not be given online. Everyone must discuss his/her clinical condition with the surgeon first.
A clinical evaluation needs to be made before a price can be discussed. After a patient is deemed eligible for this procedure, then the financial steps above can be started.

Pricing
Pricing varies depending on the type of procedure, and the specific type of coverage from your health insurance provider. Our staff are uniquely trained and experienced in working with insurance companies. They will work closely with you to address any questions or concerns you have.

The procedure is often more affordable than most people think! With the new health care regulations that are being implemented in the U.S., it is extremely important for you to discuss insurance coverage issues with our office staff. Please feel free to call us at (310) 557-3037.

Dealing with the insurance companies
The patients involvement in negotiations with the insurance companies is of utmost importance. Why? Because the patient or their family are the actual customers that can push the insurance company to justify the treatment. As a physician, we are not in the position to discuss any details in regards to eligibility, unless authorization is given to us by the patient to negotiate on their behalf.

Again, this requires active and willing participation by the patient (telephone calls, letters, etc).

No Health Coverage – International
For those patients who have no health coverage or are from out of the country, we can work with you on payment options. It is highly recommended that you contact us. We can discuss the monetary questions you have, and your medical background can be obtained. This will be valuable when discussing your case with Dr. Reisfeld.

Medical insurance is a very unique thing. Blue Shield/Cross in one state via one company may be completely different for someone in another state for another company. There is so much that goes into an insurance policy. Knowledge of these details in many cases is not known by the insurer/patient, which makes it very important to discuss those issues with our expert staff in Beverly Hills, LA.

There are two separate surgical procedures for each type of excessive sweating. Endoscopic thoracic sympathectomy has had a much better success rate for hand sweating vs. foot sweating. Lumbar Sympathectomy procedures have been very effective for excessive foot sweating (plantar hyperhidrosis). The patient should decide which type of sweating is the most bothersome.

Most patients choose to have ETS first. If their hand sweating is not as severe as their foot sweating, then Lumbar Sympathectomy may be the right choice. It is our opinion that ETS should be done first. This is because of the chance that the patient might get some improvement with their foot sweating after doing ETS.

Since endoscopic lumbar sympathectomy (ELS) surgery has a shorter history than ETS, it went through certain refinements, which brought it to the same level of success and safety as ETS. It should be emphasized that very few physicians are doing this procedure, known as ELS, on a routine basis. It behooves the patient to inquire with someone, such as Dr. Reisfeld, who does it on a routine basis.

As always patients must first discuss those issues with their doctor. Dr. Reisfeld is always happy to discuss this with you, as he is one of the only surgeons in the U.S. to be an expert in both procedures.

Unfortunately, the answer is no. Based on our experience and careful evaluations (peer-reviewed studies), we do not believe a single surgery can fix all types of hyperhidrosis. Different procedures are more effective for different types of the condition.

For example, an endoscopic thoracic sympathectomy is extremely helpful for hand sweating. It has shown positive results with armpit sweating. The success of ETS is lower with excessive foot sweating (plantar).

An endoscopic lumbar sympathectomy is very effective for excessive foot sweating. Each type of excessive sweating deserves a different approach to ensure the best possible outcome.

Dr. Reisfeld does not recommend a sympathectomy for facial blushing or facial hyperhidrosis. For more information on this see our facial blushing page.

Many ask: “why should I travel to Los Angeles to see Doctor Rafael Reisfeld?”

When it comes to this important life changing procedure, you want to be in the hands of someone among the world’s leading hyperhidrosis surgeons. Dr. Reisfeld has performed more ETS procedures than any other doctor in the United States. He has dedicated his entire practice to hyperhidrosis, pioneering new techniques, and advancing critical research.

He is the only known surgeon in the world to be an expert at all three major procedures (Hands, Feet, Armpits). This gives him unparalleled expertise in performing these surgeries for each patient. Dr. Reisfeld has authored numerous peer reviewed medical hyperhidrosis papers, the most recent in 2013. He has been featured in newspapers, magazines, and television reports such as CBS, Fox News, Newsweek, and others nationwide.

Dr. Reisfeld takes the time to speak with each and every patient before the surgery instead of staff or personnel who are not experts in this field. We encourage you to contact our office, and take the first step to stopping excessive sweating and start living!

Dr. Rafael Reisfeld is a Board-Certified surgeon, member of the American College of Surgeons, diplomat of the American Board of Surgery, and known worldwide as one of the very best doctors in the field of hyperhidrosis. From the beginning of his involvement with hyperhidrosis, Dr. Reisfeld approached it in a very methodical and compassionate way to help those affected with this condition. Procedures are done at the world class Khalili Center in Beverly Hills, Ca.

At times Dr. Reisfeld gets calls from around the world about sympathectomies done by inexperienced surgeons. It behooves patients to be very thorough and careful about who they choose to do their surgery. Experience and knowledge should be key factors. Unfortunately, in the United States, patients are directed to go to a surgeon in their medical insurance “network.” Those surgeons are not always are familiar with the problem, and as a result, unexpected and or unfortunate life changing results can occur.

We think it is important to understand that the field of the surgical treatment for hyperhidrosis has undergone major changes and improvements over the last two decades. Even though this condition afflicts between 1 and 2 percent of the world’s population, it still remains a very little known subject to the majority of the medical community and patients alike. There is a lot of misinformation out there, making it hard for the average person suffering from hyperhidrosis to get the right advice.

What is the recovery period for the surgery?

For ETS, the recovery period is usually very short. After the hour-long operation, the patient spends about two hours in the recovery room and then goes home. Patients can return to their normal routine within a few days.

Temporary pain related to pressure in the chest can be felt by patients but will be mild to moderate in nature. It is dealt with through the use of oral painkillers. Physical activity is allowed but should be gradually introduced.

See ETS – What to expect after the operation

Lumbar Sympathectomy
The lumbar sympathectomy operation has a longer recovery time. This does not mean the procedure presents any additional risks. Patients stay at the hospital or the surgical facility for about 2-3 hours and then they are released to go back to the hotel or residence.

The lumbar procedure is a far more demanding operation for the doctor and the patient, but the recovery has proven to be relatively easy. Overweight patients pose another degree of difficulty to the surgeon. Make sure you talk with the surgeon extensively about this procedure. Physical activity can be incorporated into the patient’s daily life gradually after the operation.

See ELS – What to expect after the operation
In both procedures (ETS and ELS), the sutures are made from biodegradable material. There is no need for any specific wound care or removal of the sutures.

Axillary Suction Curettage
Axillary suction curettage, together with laser ablation armpit sweat treatment, involves less post-operative pain than the ETS and ELS procedures. There might be some swelling and fluid accumulation, which are temporary.

Patients typically leave the surgical center within a short time after the procedure. Wound care is minimal. Patients are able to return to their normal routines within a short time. Patients have to keep in mind that activities such as raising their arms above their head may pose some discomfort in the short term.

See Axillary Suction Curretage – What to expect after the operation
Regardless of whatever procedure is done, recovery time is a very subjective issue. Some patients return to their normal life activities by the next day, while others will need more time to recuperate. Make sure always to have all of your questions answered by your physician. This will make your recovery smoother for everyone involved.

Disqualifications For Hyperhidrosis Surgery

You are not a candidate for the procedure if you suffer from severe cardio-respiratory illness, pleural disease, or untreated thyroid diseases. Dr. Reisfeld takes the time to personally communicate with people and determine if the surgery is right for them after reviewing their unique situation.

The benefit to this is that you speak directly with Dr. Reisfeld who is an expert in the field, as opposed to staff or personnel who are not.

There are absolute and relative contraindications for this surgery. An absolute contraindication is a situation where no surgical treatment should be attempted. One example is morbid obesity. Excessive weight to height ratio is not only dangerous to the patient but also makes the operation very difficult to perform because of the excessive amount of fat stored within the chest cavity.

There are other examples, such as extensive previous thoracic surgeries. Relative contraindications necessitate a very careful and thorough discussion with the surgeon about previous surgeries before moving forward.

Previous cardiac surgery and previous corrections of certain chest wall deformities are situations when a patient should be aware that the physician may choose not to move forward with the procedure. Such cases that moved forward resulted in successful procedures.

Are There Cases Where Surgery Cannot be Done?
In certain cases, some old scarring can prevent the physician from performing the operation in a safe manner. This type of scarring can be the result of previous pneumonia that was not necessarily clinically obvious.

Chest Trauma can result in internal scarring (adhesions) that can complicate the procedure. Some very unusual anatomical abnormalities can also prevent doing the operation safely. This happens in extremely rare cases.

Call or visit us to discuss your situation directly with Dr. Reisfeld.

What is the age range for patients to have the ETS procedure done?

The age range of patients for which Dr. Reisfeld performs the ETS procedure is between 10 years old and 66 years old. Dr. Reisfeld assesses each patient on a case-by-case basis. Generally speaking, at present the recommendation for younger patients is to wait until they have gained more physiological, physical, and mental maturation.

This means that potential patients should wait until the approximate age of 15 or greater. It is, however, recommended that Dr. Reisfeld be contacted for a more precise assessment. Please see our section on younger age hyperhidrosis.

What is The Age Range Where Patients Can Receive the Sweaty Feet Procedure?

The age range for performing ELS is not yet defined. The body’s physical development, as well as the patient’s mental development, are some of the factors that should be taken into consideration.

The procedure has only been done since about 2005, and there is a need for more information before a proper range can be set. A personal approach should be applied to each case, which makes it important to discuss the unique situation with the surgeon prior to the operation.

It is a known fact that maturation of the sweat glands in the feet can cause excessive feet sweating (plantar hyperhidrosis). This condition happens later in life, usually in the early 20’s. Some younger patients in their teens will also showcase excessive feet sweating on the same level as their hand sweating.

One must keep in mind that the two operations cannot be performed at the same time. We recommend the ETS surgery first, even if the patient insists that both conditions are equally excessive.

There are some cases in which ETS relieved some of the patient’s foot sweating in the beginning, but it is not a guarantee that the reduction will stay for the long-term. As a rule, we wait at least 4 months between the two operations to be certain, at which point we will consider the second operation.

It is recommended that you contact Dr. Reisfeld for a more precise assessment. Every case is unique. Please see our section on younger age hyperhidrosis.

Child Sweating – Young Age Hyperhidrosis:

Excessive hand sweating, also known as palmar hyperhidrosis, can appear at a very young age. Children as young as 6 can have problems with excessive hand sweating, which is often poorly understood by their parents, teachers, and schoolmates. This can very stressful, and creates a lot of functional and social problems in their everyday lives. The surgical solution cannot be considered at a very young age like this. Dr. Reisfeld believes that children suffering from hyperhidrosis should be supported by their families, while they try any conservative measures available.

Even though surgical treatment was offered to children as young as 10 years of age in the past, it was observed that the recurrence rate in younger age groups is higher. Dr. Reisfeld believes that within this age group (10-14 years old), the bodies regeneratives abilities are much more pronounced which would explain the higher rate of recurrence.

During these younger years and time of growth the body has more ways to change. Because of that, Dr. Reisfeld at present limits the surgical treatment to patients who reach mental and physical maturity (Over 14 to 15 years of age).

Also See:
Alternative Hyperhidrosis Treatments

The surgical approach should be reserved for only severe cases once the child enters maturity. This should be determined with your doctor or even better an experienced hyperhidrosis surgeon who understands the topic fully. The decision to perform sympathectomy in younger age groups should NOT be done on an emotional basis. The decision should only be made after careful consideration.

Since Hyperhidrosis is known to be a genetic disorder, the clinical manifestations can come at a very young age. Having hyperhidrosis will cause problems to the affected child, and to their family. Affected children can experience not only embarrassing comments from their peers, but also some misunderstanding from their parents, teachers, and other adult instructors.

This in turn can aggravate the negative impact on the child. Stories about affected children who did not want to go back to school or failed in their classes is something we’ve heard in the past.

The treatment for children affected severely by hyperhidrosis or excessive hand sweating should be discussed with both the family and the child. First, the families should understand the problem by discussing the situation with an appropriate medical care provider. They should understand this is a physiological issue, and not a mental problem with their child.

The affected children, on the other hand, should be supported as much as possible by explaining and re-enforcing the fact that there is nothing wrong with them. The most appropriate time for surgical treatment is not yet determined, but physiologically and mentally matured children could be offered a surgical solution after the age of 14. In the mean time, alternative methods are available.

Teenage Hyperhidrosis
For teenagers, the situation becomes more serious due to the social and functional pressures that are more prevalent at this age. Social interaction becomes much more involved at this age and it can cause anxiety and introversion as well. Teenagers become embarrassed of the effects from the condition, such as their sweaty hands or feet.

The use of electronic devices, which has become an imperative part of our lives, can be a serious problem. Having said that, the impact of severe hyperhidrosis is much more acute in this age group. Teenagers choices or motivation for future professions can also be affected by this condition.

Attempts should be made to treat this with conservative measures as we recommend throughout our website. Teenagers become more mature and a decision should be made with them after careful discussions with an appropriate specialist. Only after a careful discussion can a decision be made.

The vast majority of patients from this age group describe their operation as a life changing step.

Younger / Toddler Hyperhidrosis
Depending on your definition of a toddler, the age can range. Obviously even in the very young age group excessive hand sweating can bother those who suffer from it but more so the parents are very concerned. It is our opinion not to perform the ETS procedure in this very young group because the body has not reached any maturation both physical and mental. My recommendation is to wait until the age group where the patient realizes the gravity of their excessive hand sweating.

Dr. Reisfeld has often been told by patients that they notice a reduction in the amount of sweat from their hands while using alcohol and/or recreational drugs such as marijuana. The likely explanation for this is that these substances cause mental relaxation, which in turn reduces the body’s sympathetic activity. These types of substance trigger this physiological response in the body.

This method is not a solution due to the fact that patients will build a tolerance over time, and will require an increase in the substance to achieve the same effect. Also, these substances can have negative effects on a patient’s health, daily activities, and performance. Chronic usage of marijuana, alcohol, or other recreational chemicals may also cause feelings of paranoia and anxiety, which can cause even more sweating further exacerbating the original condition.

We, in no way, are experts on the usage of recreational drugs and alcohol. However, scientific studies are continuously providing new information on the subject. Many experts agree that these substances, with long term usage, can have a negative impact on a patient’s health. Even though a patient may experience temporary relief from their symptoms in certain social situations, long-term use of these substances is not recommended. The same can be said for prescription medications, mood-altering drugs, etc., they can all have the same negative effects with long term usage.

Some mental health professionals attempt to treat patients with medications for reducing anxiety, as a form of hyperhidrosis treatment. Drawbacks for this type of treatment also include the patients developing a tolerance to the treatment, causing it to be ineffective as time goes on. Dr. Reisfeld often has patients explain that they were treated for hyperhidrosis with different “relaxing medications”. It takes more awareness by health professionals to realize that this is not a psychological disorder, but a physiological disorder.

Is it normal to have sweaty palms?

Constantly sweaty palms are not a normal occurrence. There are situations where your hands will sweat, so it depends on the circumstance. Hand sweating is a normal function of the body under certain circumstances. For example, during heavy physical activity sweaty palms are considered normal.

Excessive hand sweating is defined as sweating that goes beyond the normal physiological needs of the body. This is known medically as Hyperhidrosis. The majority of people have a very mild amount of moisture in their hands. For most people it is unnoticeable.

When the moisture becomes like a shiny film on the hands, it becomes a concern. Advanced cases can get to the point where the hands seem constantly wet. There are also extreme cases in which sweat can drip from the hands.

This requires the person to constantly wipe off their palms. There are different levels of excessive sweating (palmar hyperhidrosis). The severity level is dependent on how much it affects the patient during their daily life.

Defining Hyperhidrosis

The palms of the hands are not a typical place for the body to sweat from. If a person is sweating from his or her palms under normal conditions (non-active, no stress or excitement, normal temperature, social interaction) then they may have hyperhidrosis. Hyperhidrosis is a genetically inherited condition. It causes social and functional problems in everyday life.

Dr. Reisfeld specializes in treating people with this condition. There are a variety of non-surgical treatment options. In cases where surgery is required, the procedure is short and doesn’t require a long recuperation period. There are plenty of options for people with hyperhidrosis.

Is It Normal to Have Sweaty Feet?

Foot sweating can be a normal function of your body under certain circumstances, such as intense physical activity. Excessive foot sweating, however, is defined as sweating that goes beyond the normal physiological needs of your body.

This type of excessive foot sweating is known in the medical community as hyperhidrosis. If a person is sweating from his or her palms under normal conditions (non-active, no stress or excitement, normal temperature, social interaction), then they may have hyperhidrosis. Hyperhidrosis is a genetically inherited condition which causes social and functional problems in everyday life.

As a part of the hyperhidrosis symptoms, sweaty feet and sweaty hands are possible. For many patients, excessive hand sweating is the more bothersome issue. Excessive hand sweating appears earlier than excessive foot sweating in many cases.

This has to do with the maturation of the sweat glands in the feet which are fully developed later in life (mid 20’s). Patients with excessive foot sweating are suffering from it on the same level as those with excessive hand sweating.

As in the case as with excessive hand sweating, the usual conservative measures are not as viable. The lumbar sympathectomy procedure has been used since about 2006. With this operation, one can achieve elimination of excessive foot sweating in up to 98% of the cases.

This operation is not offered for patients who previously had an ETS procedure which was unsuccessful for the feet. It is also not offered for patients where excessive foot sweating is much more of a problem than hand sweating.

Feet Sweating Without Any Sweaty Hand Symptoms
There are cases where patients only experience feet sweating without any hand sweating whatsoever. These cases need to be discussed extensively with the surgeon, in order to determine eligibility for the lumbar sympathectomy procedure.

At this time we are still investigating the mechanism that causes both sweaty hands and feet. It is possible that these cases are caused by something beyond the standard genetic traits.

As always a thorough discussion with a surgeon who is familiar with these issues is essential.

Hyperhidrosis and Genetics

As far as we know, genetics plays a major role in the cause of hyperhidrosis. Numerous studies, based on a large number of cases, have shown a genetic history in more than 50% of the patients with hyperhidrosis. This fact alone is enough of an indication that the basis for this problem is a genetic one. Researchers in China have found the location of the gene that affects this condition. Unfortunately, gene manipulation or gene treatment is still a long way off from being able to be used as a therapeutic measure. Dr. Reisfeld has treated and interviewed thousands of hyperhidrosis patients over the years and has seen this genetic pattern in more than half of his patients. Dr. Reisfeld is one of the most experienced and respected hyperhidrosis surgeons in the world.

The data which includes the 50% + incidence rate is likely to be higher since many people tend to not share, or are unaware of the condition within their family. Hyperhidrosis can be an embarrassing condition, making it more likely to not be talked about. A patient may be unaware that they have an uncle, aunt, or grandparent, etc who suffer from the condition.

Most of the patients who report some family history will more frequently say it is from the mother’s side of the family. We have conducted an informal poll on our website, and the results greatly support this statement. The exact genetic transmission modes are not completely understood due to the fact that gene effects are so complicated. Even with immense progress completed in this field of medicine, professionals are still not completely clear on the gene effects for hyperhidrosis.

The basic fact about the transmission of the gene which is responsible for hyperhidrosis is that many factors are involved in developing a full picture of hyperhidrosis with sweaty dripping hands to the less prominent features.

It should be understood that the full expression of any illness is not simply depending upon one or two factors. We have 23 pairs of chromosomes but the amount of information that they contain is almost incomprehensible, so this is why members of the same family do not always present with the same clinical picture.

Major advances have been made in genetic research. However, due to the benign nature of hyperhidrosis, fewer efforts by drug companies and researchers have been made to solve this issue so far. We hope this changes in the future.

What are the chances I will pass hyperhidrosis onto my children?

Hyperhidrosis is a genetic disorder. More than 50% of the patients who have this condition, have a family history of hyperhidrosis. In those cases where family history is not known, it does not mean that it did not exist in a previous generation (patient did not experience it or see a doctor about it). Hyperhidrosis can skip generations as well.

Also, genetic disorders can also start at any point in a family line. This means that a certain illness can start in a person without there being a family history of it. Not all genes have the same power of transmittance. The gene that affects hyperhidrosis is not a dominant one. Not all children (descendants) will be affected.

The penetration rate is only 25%. So, for example, if you have 4 children then only one is likely to get it. That being said, it does not mean that more children won’t be affected. There is still a lot to be learned about genetic side of hyperhidrosis. Dr. Reisfeld has had cases where identical twins came into his office and only one of the identical twins had hyperhidrosis.

The location of the gene was established a few years back, but knowing the location of the gene has not yet given any therapeutic modality. Hopefully, with the research being done on the human genome, some solutions may be found.

Hyperhidrosis is a subjective issue, therefore it is difficult to quantify. It really is relative to the individual. The most obvious symptom of severe hyperhidrosis is sweat that drips off the hands or feet.

On the other side of the spectrum is mild moisture. In between, there are different levels of excessive hand and feet sweating. It is a matter of how much the condition affects the person’s daily life. Severe cases can affect social interactions, self-confidence, and much more.

Defining Your Severity Level
Mild cases are the ones where moisture appears on the hands and feet throughout the day. in the Touching things like telephones, tables, or desks can leave a mark. Avoidance of social interaction such as handshaking and intimacy are also signs of a higher severity level.

The most severe cases are those who experience dripping sweat. This compounds all the above difficulties. Regardless of your severity, there are solutions to this condition. While surgery is a last resort, it is an option.

Patients also find success in some cases with conservative treatment methods.

Hyperhidrosis and Sleep

Generally speaking focal hyperhidrosis which is hand sweating and or foot sweating does not happen while the subject is asleep. Many will ask why? The answer for that question is that the sympathetic activity goes down while we are asleep. Those patients who suffer from hyperhidrosis will tell you that focal hyperhidrosis in the hands and feet starts after they wake up. Again the physiological explanation for that is that during sleep the overall activity of your body is down. This is a very simplistic way to explain it but we do not have a very good answer as to why it happens in this rhythm. Also a lot of patients who suffer from hyperhidrosis will tell you that drinking excessive amounts of alcohol or using recreational drugs will render their hyperhidrosis to a lower level. Again here the reason for this lies in the fact that by using those substances it reduces the overall activity of the body. We do recommend this as treatment due to obvious reasons.

If I Have Excessive Body Sweating, Does That Mean I Have Hyperhidrosis?

The location of your excessive sweating determines the difference between excessive body sweat and hyperhidrosis. Essentially, hyperhidrosis only occurs in three forms: palmar, plantar and axillary. It manifests in the hands, feet, or face.

Total excessive body sweating happens all over the body. Total body excessive perspiration happens during certain ailments such as:

● High fever
● Cancer
● Obesity
● Diabetes
● An excessive function of the thyroid gland
● Brain tumors
● Neurological symptoms
● Aging processes such as menopause

In those cases, the root of the problem is found by uncovering the underlying problem. In many cases, investigations for a cause may not lead to a specific answer.

The unique presentation of essential hyperhidrosis (palmar, plantar and axillary) is manifested in those specific locations. Many patients will go through endless tests in order to find an exact reason, but find nothing.

The medical community is trying to eliminate other causes of primary hyperhidrosis. In the process, unfortunately, a lot of money and time goes into their research without results. It takes a very simple understanding and knowledge of the problem to diagnose it.

After many years we know that excessive stimulation of the sympathetic nervous system within the chest cavity will cause palmar and axillary hyperhidrosis (hand and armpit sweating). Excessive stimulation of sympathetic ganglia in the lumbar region will cause plantar hyperhidrosis (foot sweating).

What Should I Do if I Think I Have Hyperhidrosis?
If you suspect that hyperhidrosis is to blame for your excessive sweating, we can help. Dr. Reisfeld and his staff are experts in this field. Conservative and surgical treatments are viable ways to relieve the symptoms of this condition.

Is there a connection between hormonal problems and hyperhidrosis?

No there is no connection between the two. That being said, women undergoing menopause will show signs of generalized hyperhidrosis (total body sweat). They commonly experience excessive facial and scalp sweating.

It is a fairly common complaint among this group of patients. Hormonal replacement therapy is a viable treatment for this hormonal imbalance. An Endoscopic thoracic sympathectomy procedure is not advisable for this type of situation.

Can a Thoracic Sympathectomy and a Lumbar Sympathectomy be Done at the Same Time?

So far these two procedures have never been done at the same time. There are a few reasons for this.

1. We do not have the ability to judge the response of the sympathetic system when two locations (thoracic and lumbar) have been at the same time. We do not have any way to ascertain the body’s potential reaction.

2. The Lumbar sympathectomy is a longer and more demanding procedure. Dr. Reisfeld believes the procedures should be done separately.

3. We have very limited clinical experience in doing both a lumbar sympathectomy and a thoracic sympathectomy at the same time. In these cases, a one side thoracic sympathectomy and a lumbar sympathectomy are done on the same day. The other side is done at a later date. The results were positive, but the final clinical recommendation at this point is to not perform both procedures at the same time because we still have some unanswered physiological questions. We need to know how blood pressure and the sympathetic system are affected.

4. A general rule in surgery states that no two elective operations on different parts of the body should be performed at the same time. This rule is based on pure logical considerations and most importantly, patient safety.

5. Until we understand the effects and reactions of the body to these procedures, the surgeries should be separate. If new evidence arises showing a positive reaction to the procedures, it is possible that both could be done at the same time in the future.

What is sympathectomy vs. sympathotomy?

Basically these two definitions relate to the same overall outcome. In both methods the sympathetic chain is rendered inactive due to interruption of the sympathetic chain either by excision or by clamping. Sympathotomy really means interruption the sympathetic chain with clamps which is the method used by Dr. Reisfeld in all of his cases. Basically sympathectomy means doing the operation with clamps compared to excision of a part of the sympathetic chain. When the sympathetic chain is excised then the word sympathectomy is the appropriate word to use.

What is The Best Procedure For My Excessive Foot Sweating?

Excessive foot sweating, or plantar hyperhidrosis, usually manifests together with palmar hyperhidrosis (excessive hand sweating). Solitary foot sweating without excessive hand sweating is also possible but in a very low percentage of cases.

We realized that the thoracic sympathectomy (ETS) doesn’t help with excessive foot sweating. Since 2004, the Lumbar Sympathectomy has proven to be the best option to treat patients with severe plantar hyperhidrosis (excessive foot sweating).

Continued refinements and improvements are constantly discovered. These include technical performance, as well as an understanding of the locations where a lumbar sympathectomy will help.

In some cases, post thoracic sympathectomy compensatory sweating in the buttocks area is also treatable with ELS. The performing surgeon can provide answers to additional questions.

It still behooves patients with foot sweating to try conservative measures before opting for a surgical solution. For more in-depth information please see our foot sweating section.

Are There Any Consequences For Not Treating Hyperhidrosis?

If you attempt conservative methods of treatment and do not experience any positive results, the next step is surgery. Without treatment, hyperhidrosis will continue to affect the individual when it comes to social, personal and functional situations.

As time goes by, surgical treatments are becoming the most effective solution for treating palmar and plantar hyperhidrosis. That being said, the medical communities at large are still behind in their understanding and knowledge of this problem.

Unfortunately, in countries where medical care is not provided, some insurance companies are trying to prevent the treatment. If a patient is willing to continue with his or her condition. that is their choice. The condition won’t go away on its own. Every case is unique and each patient should consult with a physician who is familiar with this problem.

Is It Possible to Correct Hyperhidrosis?

Just to be clear the term hyperhidrosis should be divided into two parts:

1. Focal Hyperhidrosis – In Specific Areas
This type of hyperhidrosis is the type of excessive sweating that is most bothersome to people, especially in their younger years. The condition also affects patients later in their life. Usually, this is specific to the hands and feet. Sometimes the hands, feet, and armpits are affected simultaneously.

For this particular type of hyperhidrosis, the ETS (hand sweating) operations and ELS (foot sweating) operations could provide an extremely successful and reliable solution. These should be performed only if conservative measures did not help.

The operations have a high success rate of 98-99% with a very low recurrence rate. Side effects such as compensatory sweating are a constant byproduct of this operation but fortunately, in most of the cases, the compensatory sweating is vastly preferred over the original condition. Overall, it is mild to moderate at the most.

Facial hyperhidrosis, where excessive sweating is only on the scalp is not recommended for the ETS procedure. To learn more see our facial blushing/sweating page.

2. Generalized Hyperhidrosis – Total Body Hyperhidrosis
In contrast to the term focal hyperhidrosis (hands, feet and armpits), generalized hyperhidrosis denotes a condition where a patient sweats excessively from different parts of the body such as the scalp, face, and body.
The biggest group belongs to older age patients. A major part of this older age group is females who are going through hormonal imbalances (menopause), etc. It represents a difficult task for their physicians, but no surgery is involved.

Besides aging, certain ailments such as diabetes, obesity, cancer, thyroid malfunction, hormonal imbalances, and certain medications can cause generalized hyperhidrosis. In situations like this, it is important to speak with your physician about the nature of the issue.

Does hyperhidrosis get better or worse over time?

As more and more information becomes available about hyperhidrosis, it has become clear that the underlying cause is a genetic one. Clinical studies show that there is a family history present in 50% or more of the cases.

It appears in close relatives (mother, son, father daughter), but it can manifest in other family relatives as well. The genetic mutation can appear without any genetic history in the family. Due to the embarrassing nature of hyperhidrosis, family members often avoid talking about it.

There are instances where a father or a mother notices that their hyperhidrosis gets better over time. This does not mean their child’s hyperhidrosis will have the same positive evolution. Biology is an inexact science. On the other hand, children may have more severe cases of hyperhidrosis compared to their parents.

The majority of cases do not get better over time. Excessive armpit sweating or facial sweating may manifest itself in the early twenties. Sweat glands in different areas of the body also develop and change over time.

What is Primary vs. Secondary Hyperhidrosis?

There might be some confusion when patients hear the terms secondary and primary hyperhidrosis. The term secondary hyperhidrosis denotes a situation where another disease is causing excessive sweating. Diseases like hyperthyroidism, infection, and certain malignant ailments are the primary source of the problem. Once the cause is identified, it can be treated accordingly.

In primary hyperhidrosis, the sole reason for excessive sweating is not related to any other ailment. Instead, it is caused by the genetic disposition that enables hyperhidrosis. It is also important to note that in primary hyperhidrosis cases, the sweating is limited to the palms of the hands and the feet.

Primary hyperhidrosis can also be accompanied by excessive armpit sweating and facial sweating. The surgical treatment for isolated facial hyperhidrosis or axillary hyperhidrosis is still questionable. Therefore, conservative treatments are the primary approach for situations like these.

Will I Have More Hand Sweating After The Lumbar Sympathectomy For My Sweaty Feet?

The answer is no. There are some instances in which patients describe a temporary increase in their hand sweating after a lumbar sympathectomy. These patients received the thoracic sympathectomy for their excessive hand sweating previously.

We do not know what causes this temporary increase in sweat. The length of time where more excessive hand sweating appears is a matter of days not weeks. The body’s nervous system needs time to adjust to the new signals that come after doing a lumbar sympathectomy.

What About Insurance For Hyperhidrosis?

Most insurance companies cover the procedure because it is seen as a medical necessity. We can help you with any insurance concerns. Our office, as a courtesy, will call your insurance carrier to verify benefits in the event that you choose to have the procedure.

Insurance policies are complicated and very difficult to understand. It is necessary to examine each case on an individual basis. In our office, we have useful information about this process. Those who have questions can fax us the front and back of their insurance cards.

Recently, some insurance companies changed their policies surrounding surgical treatment for hyperhidrosis. In those cases, it is important for the patient to involve themselves in the process. Our office is happy to provide you with the necessary information. Please give us a call at (310) 557-3037.

The Present Situation
U.S. Citizens face a lot of uncertainties about health insurance coverage. Until the dust settles we have to continue with the same approach. This means talking with the insurance companies and trying to convince them to cover the procedure.

This process can be a lengthy one and requires the participation of the patients and their families.

Attempts to get authorization from the insurance companies should start with our office calling the insurance company. At times there is a need for the patient/family to get involved with the process. This is due to the fact that the patient or family are the ones insured and must talk to the insurance company directly. This adds a very personal plea that can sway reluctant insurance companies.

The patients (or their families), who own the insurance policies have a stronger influence. Over the years our attempts to discuss the matter with the medical reviewer are not successful. Many of the reviewers have never seen a patient with this condition. They do not have any appreciation of what these patients are going through.

This makes a personal attempt by the patient more effective. Insurance companies claim that the procedure is not within their coverage, but it is time for that to change. This is especially true when you consider that roughly 1 ½% of the population is affected by hyperhidrosis.

Our office is constantly taking steps to educate the review committees. We discuss the failure of all conservative methods and the validity of surgical treatment. It takes a combined effort by the patient and our office to reach a satisfactory solution.

A Brighter Future
As our experience with these insurance issues evolves, we are starting to see more approvals. Insurance companies are recognizing that both ETS and now the Lumbar Sympathectomy is a valid treatment for hyperhidrosis.

The patient, our office, and their family are assisting throughout the appeal process. We and the patients/families demand an independent outside review. Both our office, and the insurance companies, are committed to following through with whatever decision is made.

It is interesting when these cases are reviewed by totally neutral surgeons. We are starting to use those favorable decisions in cases where we have difficulties with the insurance companies.

The takeaway here is that although it may take time to receive authorization from your insurance company you should never give up. More and more cases are being approved, which shows a positive trend towards a change.

What if I do Not Have Health Insurance, What Should I do?

There is a trend among some large insurance companies to exclude hyperhidrosis treatment from their policies. A similar example of this is the trend to exclude patients from getting surgical treatment for excessive obesity.

In our opinion, if a patient makes the effort to first try conservative measures to help their problem with no success then the surgical option should not be excluded from their policy. If a patient finds out that the surgical hyperhidrosis treatment is excluded from their policy, the patient should challenge their health insurance provider.

Many of our patients have successfully challenged their insurance carriers and received authorization to cover the procedure. Please feel free to contact us for more information (310) 557-3037.

More and more procedures are successfully completed as the information available has become more accessible through the Internet and other information mediums. There has been some reluctance from the insurance companies to cover the cost. As for general information, hyperhidrosis is most likely a genetic disorder and not a cosmetic one.

It is recognized by international health organizations as well as the government. Obviously, the insurance industry is trying to limit the number of these operations from a purely financial perspective.

We are working very hard to educate the insurance industry about this disease. This is a physiological ailment and not just a cosmetic or mental problem. Progress is being made in this regard, especially with the number of medical articles and clinical studies written by Dr. Reisfeld and other surgeons.

It is very important for patients to show any evidence that they first tried some sort of conservative treatment such as Drysol, Drionic, Robinul, etc. If insurance companies require documentation, then the patient will be provided with the appropriate forms.

How We Can Help
In every case, our office will call the insurance company for pre-authorization. Some insurance companies will demand certain steps to be taken beforehand. In these cases, we will tell the patients exactly what is needed and guide them through the process.

Some insurance companies will not respect the pre-authorizations they originally gave out. We will do our best to follow up on such issues. Generally speaking, most of the insurance companies will cover this procedure. HMO’s, in almost all cases, do not cover the procedure.

Since the insurance issue has become so important, we would like to re-emphasize that patients first try some conservative approaches to deal with their excessive sweating. Also, it is very helpful and important to keep documentation that shows such measures were taken.

For those patients who are not covered by any kind of medical insurance, there is an inclusive charge that covers the facility fees, anesthesia fees, and the surgical fees.

For more information feel free to contact our office or call our friendly staff with no obligation and we will be happy to help you.

How do I Know if The ETS Procedure is Right For Me?

ETS is a life-changing procedure for thousands of patients. Dr. Reisfeld consults and meets with every interested patient to determine if the procedure is right for him or her. The surgical solution to end hyperhidrosis is both highly effective and extremely safe.

Dr. Reisfeld is the most experienced ETS doctor in the U.S. He takes great pride in what he does and it shows time and time again. He performs this surgery on a daily basis. With one simple procedure, those who suffer from hyperhidrosis can take their lives back. Contact us and we can arrange for you to speak personally with Dr. Reisfeld and ask any specific questions you have.

Where Does The Procedure Occur?

Both procedures happen at cutting-edge medical facilities, or at the hospital. Most of them are done on an outpatient basis, but some, if needed (for insurance, etc.), are done at the hospital. In both scenarios, the ultimate level of medical and surgical care is given.

Patients are able to leave the same day and enjoy a short recovery time after the procedure. Below are some photos that showcase an example of a modern medical facility.

Who Performs Hyperhidrosis Procedures?

Dr. Reisfeld is a board-certified surgeon who performs both the ELS (Feet) and ETS (Hands) procedures. He has focused his career on hyperhidrosis since 1995. He dedicates himself to helping advance the knowledge and the techniques associated with the problem.

He has performed procedures hundreds of times to help people end their suffering from excessive focal hyperhidrosis. At present Dr. Reisfeld is training three other surgeons to incorporate them into the practice of hyperhidrosis sympathetic surgery.

Dr. Reisfeld has authored seven separate peer-reviewed articles on this subject. He dedicates extensive time and research to the advancement of techniques and the overall knowledge of Hyperhidrosis. The goal is to share his knowledge other surgeons from around the world.

What Does T-Level Mean?

The “T” level refers to the corresponding thoracic vertebra level where the sympathectomy occurs. This relates to the rib level. There are some surgeons who use the letter R (R for Rib) to describe the location of the sympathectomy.

Very few surgeons use the letter G to describe the ganglion. Performing the sympathectomy with a clamping method allows the surgeon to locate the exact level. If no clamps are used then it is difficult to ascertain the exact level of the procedure.

It gives the surgeon a way to follow-up. Dr. Reisfeld carefully documents each case to the exact location of where the clamps were applied during ETS.

For lumbar sympathectomy the “L” level corresponds to the level of the lumbar vertebra where the lumbar sympathetic nerve was clamped. Learn more about the lumbar sympathectomy level.

L Level

The L level simply describes the anatomical location where a lumbar sympathectomy procedure is done. For example, if the titanium clips are applied at the L3 level it means that the clips were applied at the level of the third lumbar vertebra.

We human beings have 5 lumbar vertebrae. In the thoracic region (for hand sweating), we have 12 vertebrae. Those levels are used in order to establish a unified approach as to the best level for the sympathectomy.

Why do I have red sweaty hands, is this a common hyperhidrosis symptom?

Patients affected with the hyperhidrosis gene can present this with excessive sweating in their hands, feet, and armpits. This may cause unpleasant and uncomfortable situations where their hands are extremely wet. Another characteristic of this is increased hyper-sympathetic activity, which is a narrowing of the blood vessels in the palms of the hands or feet. The narrowing of the blood vessels can cause clammy hands, as well as slow down the blood flow in the fingers due to the narrowed vessels. This reduced speed of blood flow (not the amount of blood flow) can cause an increase of oxygen consumption in the fingers, which makes the blood appear darker. The darker color (purple or redness) in the patient’s hands is directly caused by this physiological reaction.

With sympathectomy, one can eliminate or reduce the symptoms of hyperhidrosis (wetness of the hands). This will also dilate the blood vessels which helps blood flow to the hands, causing the hands to become warmer and return to a more normal color. This particular change of warming and returning to normal color is not a lifetime guarantee. It can be a long or short term solution, and there are currently no parameters to predict the longevity of this particular change. Patients should keep in mind that the sympathectomy procedure is not advised for clammy or red fingers alone without hyperhidrosis unless it is part of the patient’s hyperhidrosis (excessive hand sweating) condition.

Insurance issues and Sympathectomy for Hyperhidrosis.

Hyperhidrosis is a recognized disease by the International Committees on Diseases Nomenclature. It is also recognized by Medicare as a disease entity. As such, patients deserve medical or surgical treatment for Hyperhidrosis.

Unfortunately, insurance companies created new criteria for the treatment of patients who suffer from severe cases of Palmar Hyperhidrosis. A few of their statements are in need of correction since they (the insurance companies) do not have a full understanding of the problems affecting patients who suffer from the condition.

It is strange that private insurance carriers follow Medicare regulations as they see fit. They cut or reduce benefits for patients and doctors alike, but do not follow Medicare decisions when it comes to the treatment of hyperhidrosis. Learn more about ETS/ELS and insurance coverage.

Demand For The Use of Alternative Methods
Dr. Reisfeld agrees with the requirements of the insurance companies that a potential patient should try some alternative methods (click here). They should do this before they decide to proceed with ETS or Endoscopic Thoractic Sympathectomy for their Hyperhidrosis. However, not all requirements that insurance companies demand show any signs of success. Those measures only offer temporary relief.

Of late, insurance companies’ demands that patients try BOTOX® Cosmetic has become more stringent. They are demanding that patients receive BOTOX® Cosmetic injections for extended periods of time. The treatment most often shows a lack of effectiveness very early on.

Although the FDA has approved the use of BOTOX® Cosmetic for axillary sweating or excessive sweating under the arms, it has NOT been approved for the treatment of sweaty palms or feet (Hyperhidrosis).

Therefore, Dr. Reisfeld feels that the demand to try BOTOX® Cosmetic for the treatment of sweaty hands was put in place by insurance companies without any justification. The extension of BOTOX® Cosmetic as a treatment over long periods of time is even further unjustified.

There are no peer-reviewed medical papers which show that BOTOX® Cosmetic helps in Palmar Hyperhidrosis (which is why the FDA has not approved BOTOX® Cosmetic for the treatment of Palmar Hyperhidrosis). If they do, it is only for a very short period of time. Additionally, it is painful and expensive.

Dr. Reisfeld encourages patients to try conservative means of treatment first. If repeated obstacles are encountered in pursuance of the surgical treatment (ETS), it behooves the patient to go directly to the medical director of the insurance company. They should demand authorization for the procedure.

Pre-existing Conditions
Studies show that about 50% of patients have a family history of Hyperhidrosis. This means that the condition is based on hereditary reasons. Insurance companies do not deny coverage for other diseases to patients on the basis of genetic predisposition. Hyperhidrosis should not be any different.

In Dr. Reisfeld’s records of more than 2500 patients, 51% have a family member who had Hyperhidrosis. The severity of the excessive sweating can be different from one generation to the next.

Experimental procedures
The sympathectomy procedure for palmar hyperhidrosis is an old and established procedure. It has been conducted for the past 70 years. It has been altered and improved upon significantly over the years.

It is not an experimental procedure as some would have you believe. There are numerous peer-reviewed papers and thousands of successful cases. Some insurance companies are using the phrase “it is not in our policy” to allow an endoscopic lumbar sympathectomy for excessive foot sweating.

This is another attempt by insurance companies to not provide services for conditions that can be solved with an operation. The main motivation for this is to save money. Attempts to direct their attention to these new procedures are being met with this typical answer.

What we found is that speaking to the company on the patient’s behalf is often not enough to get an authorization. At this point, it becomes a necessity for the patient to become personally involved with this process.

This means calling the insurance company’s appeal board, supplying them with the appropriate papers (provided by our office), describinig the patient’s suffering, and ultimate receive a positive outcome.

We as providers are limited in our influence over insurance companies. The patient has more power to change the decision.

Is Hyperhidrosis Surgery Right For Me?

This is a very difficult question to answer since we do not have any way to measure the severity of hyperhidrosis. Unfortunately, there are no x-rays, blood tests, or any other objective means by which to determine if a patient is the ideal candidate.

Through discussions that Dr. Reisfeld conducts with the patient, a clinical decision can be made based on several key factors. Every case is unique, which is why Dr. Reisfeld takes time to thoroughly assess each and every case before making clinical decisions.

Since hyperhidrosis is subjective, it affects each person differently. Like any other medical problem, the impact or gravity of the situation affects each patient in a different way. Those with moderate to severe cases of hyperhidrosis suffer enough to persuade them to look for a solution.

As we emphasize within this website, the first step in the process is to talk with someone who understands hyperhidrosis and the available options. From here. you can try some conservative measures first. If conservative measures do not show any signs of helping, then a surgical approach may be necessary.

Any clinical evaluation should be done by the surgeon, even if it is done via telephone. This is a necessary step on the road to recovery. After the clinical evaluation, the next steps include securing insurance coverage, payment, etc.

Patients should receive an evaluation by Dr. Reisfeld before other steps are taken. Dr. Reisfeld is an authority on the topic of hyperhidrosis. He performs an expert evaluation to determine if the surgery is right for you.

Do the Titanium Clips Interfere With Anything?

Titanium clips are entirely safe for the long and short-term. They do not “interfere” with medical examinations such as x-rays, MRI scans, etc. The clips are very small, they will not trigger any safety devices at airports. Titanium as a medical device has been used for many years in different surgical specialties.

The material does not show any signs of rust or decay over long periods of time. It is applied in very delicate locations such as the brain, heart, joints, lungs, etc. The same applies to titanium clips. The chances of the clips extremely low. The safety of this approach is widely recognized.

How secure are the titanium clips?
The clips are very secure. They do not require any follow-up after the surgery. Even so, Dr. Reisfeld does follow up with each and every one of his patients individually in the post-surgery phase. This is a courtesy he provides to ensure his patients are satisfied and happy with their results.

Appointment Scheduling

How do I Schedule an Appointment?
It’s easy! Click here to schedule an appointment. We will send you further information about hyperhidrosis and The Center For Hyperhidrosis. You can also read about what Dr.Reisfeld has done for countless others by viewing our patient testimonials.

Is it Difficult to Schedule a Date For The Surgery?
Scheduling a visit is simple and easy. Since the operation will not require excessive time away from work (usually less than one week), you can schedule the surgery at your convenience.

A consultation and examination with the doctor are required beforehand. Unlike some facilities, Dr. Reisfeld meets with each and every patient before and after the procedure to ensure that the patient is satisfied with their results.

Why Are There Multiple Procedures For Different Types of Hyperhidrosis?

Sympathetic surgery has developed and improved over the last several years. Excessive hand sweating is best treated with the ETS procedure, which can also help with excessive armpit sweating.

Unfortunately, sweaty feet (plantar hyperhidrosis) does not show improvement after an ETS procedure. For sweaty feet, the appropriate procedure is a lumbar sympathectomy. For isolated and excessive armpit sweating, laser ablation of the sweat glands is the treatment of choice.

What Potential Breakthroughs Could We Use to Treat Hyperhidrosis?

With increased technology and a greater awareness of hyperhidrosis, there are two new breakthroughs on the horizon that could revolutionize how we treat this condition.

Oral Medications
The future of oral medication treatment for hyperhidrosis will occur if scientists are able to find a specific medication that will prevent the release of the hormone that triggers sweat (the neurotransmitter Acetyl Choline).

Until such a medication is developed, we are left with less targeted treatment options. This would be the easiest type of treatment to implement, but we will need oral medications that are specifically designed for hyperhidrosis.

Genetic Treatments
This is a very dramatic and very specific type of treatment. Researchers can change the gene that is responsible for this trait. By altering the gene, we can prevent hyperhidrosis entirely. Unfortunately, genetic modification is still in the early stages of development.

More pressing genetic conditions and illnesses will take priority when genetic alteration matures into a viable medical treatment. We hope that one day we can prevent hyperhidrosis entirely by using this method.

Any operation can have the potential for a certain percentage of recurrence in patients. The ETS procedure could potentially result in recurrence. This is true regardless of the method used (clamping, cutting, or excisional).

Recurrences have been reported in medical studies. The statistic ranges between 1 to 4% depending on follow-ups made with the patients. The exact reason for recurrence is not understood. One possibility is re-growth of the nerve or the emergence of new pathways. Pregnancy also has the potential of increasing the recurrence rate.

Potential Factors For Recurrence
During a pregnancy, stem cells from the embryo can affect the re-growth of the sympathetic chain, which can cause a recurrence. There have been cases where symptoms came back during pregnancy and went away again after the child was born.

New pathways could be formed as well. This is due to the ability of sympathetic nerve cells within the spinal cord to assume the role of the sympathetic ganglia that were excluded during a sympathectomy. The sympathetic signals are being re-routed. This is currently a theory that has yet to be proven by research.

Another possible explanation for recurrence (ELS or ETS) is the known anatomical fact that sympathetic nerve cells coming from the spinal cord do not always connect to their anatomical ganglia in the sympathetic trunk.

This means that those original cells in the spinal cord can send connecting fibers up or down the spinal cord to connect to new sympathetic chain ganglia. (Reference – Clinical Autonomic Disorders: Evaluation and Management – Philip A. Low).

To summarize the above-mentioned descriptions it should be understood that the nervous system, both the autonomic and somatic (motoric or sensory), have billions of cells with interconnections. It is very difficult to trace those billions of connections. It brings us to the realization that the ultimate solution will be a genetic one. To completely guarantee a cure for hyperhidrosis, we would need to modify the gene responsible for the condition.

Another observation indicates that patients who are extremely anxious may be more likely to produce neurological transmitters (catecholamines) in their blood. This causes sweating which has nothing to do with the sympathetic chain.

This type of recurrence is almost impossible to predict because it’s dependent on the individual’s social response to anxiety.

The Different Types of Hyperhidrosis Recurrence
It is worth noting that the recurrence rate is a known fact among surgeons who are performing ETS procedures. It is not unique to any particular methods, which is why we have trouble understanding the exact reasons behind recurrence.

If the clamping method is performed at the T3-T4 level, this allows recurrent cases to go back to the T2 level by undergoing the procedure again. In cases where the operation was done at the T2 or T3 level, the second operation is performed between T4 to T5. It is very important for the surgeon to have a report from the first operation in order to make the appropriate decision.

The clamping method does not produce more scarring. As a matter of fact, performing ETS with the clamping method with less cauterization in the area of the sympathectomy causes far less scar formation than the cutting method.

Roughly 10% of patients who are going to have ETS or ELS procedures will experience a short recurrence of sweaty hands or sweaty feet. This will occur for about 3 to 4 days after the operation. It is only temporary and will stop.

Patients who had an ETS procedure and receive ELS may have a recurrence of sweating in their hands after ELS. It should be emphasized that this is rare and for a short time only. There is no exact explanation as to why it happens.

A true technical failure or unsuccessful operation will result in recurrence of the sweating either on the hands or the feet within a few hours to a day after the operation. As always please discuss these potential issues with your surgeon.

Can The Operation be Performed a Second Time?
Yes, a surgeon can go back and repeat the same operation. Each case must be reviewed carefully, as many factors must be considered. A second recurrence is extremely unlikely. Each case has to be discussed with the surgeon before a second attempt is made.

To learn more about what the ETS surgery can do for you, reach out by contacting our office.

Please view our disclaimer.

What Are The Chances of Recurrence After a Sympathectomy?

As with any surgical procedure, a patient can expect a chance of symptoms recurrence. When endoscopic thoracic sympathectomy or lumbar sympathectomy is performed, the surgeon offers a mechanical solution to a physiological-genetic problem.

This can sometimes lead to a small rate of recurrence. The exact reason for the recurrence is not yet defined. The recurrence rate after the operation is between 1-1.5%. If a recurrence happens after a long period of time (more than 1 year), it is thought to be due to the bodies redirection of the nerve signals through different pathways. If this happens, the patient should discuss the matter with his/her surgeon.

On the other hand, if the recurrence happens within a short time, then a technical mistake during the surgery should be considered as the cause. Again this should be discussed with the surgeon. Sometimes there is a mild return of sweating immediately after the operation.

If it is mild and not as excessive as it was prior to the operation, then no further action should be taken. This type of temporary recurrence is normal and will subside after several days.

Another explanation for a recurrence is the fact that very small fibers belonging to the sympathetic nervous system are branching outside of the area that was clamped or resected. There is no way to identify those small fibers.

These tiny fibers (either in the lumbar or thoracic region) can be very hard to identify due to their minuscule size and the sheer number of them present in the human body.

Other topics of interest:

• Sweaty Hands
• Sweaty Feet
• What is ETS – Endoscopic Thoracic Sympathectomy
• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Disqualifications For Hyperhidrosis Surgery

You are not a candidate for the procedure if you suffer from severe cardio-respiratory illness, pleural disease, or untreated thyroid diseases. Dr. Reisfeld takes the time to personally communicate with people and determine if the surgery is right for them after reviewing their unique situation.

The benefit to this is that you speak directly with Dr. Reisfeld who is an expert in the field, as opposed to staff or personnel who are not.

There are absolute and relative contraindications for this surgery. An absolute contraindication is a situation where no surgical treatment should be attempted. One example is morbid obesity. Excessive weight to height ratio is not only dangerous to the patient but also makes the operation very difficult to perform because of the excessive amount of fat stored within the chest cavity.

There are other examples, such as extensive previous thoracic surgeries. Relative contraindications necessitate a very careful and thorough discussion with the surgeon about previous surgeries before moving forward.

Previous cardiac surgery and previous corrections of certain chest wall deformities are situations when a patient should be aware that the physician may choose not to move forward with the procedure. Such cases that moved forward resulted in successful procedures.

Are There Cases Where Surgery Cannot be Done?
In certain cases, some old scarring can prevent the physician from performing the operation in a safe manner. This type of scarring can be the result of previous pneumonia that was not necessarily clinically obvious.

Chest Trauma can result in internal scarring (adhesions) that can complicate the procedure. Some very unusual anatomical abnormalities can also prevent doing the operation safely. This happens in extremely rare cases.

Call or visit us to discuss your situation directly with Dr. Reisfeld.

What about Hand and Armpit Sweating?

Many patients will have a combination of hand and armpit sweating (axillary). When the ETS procedure is done for the hand sweating, about 85% of the patients will see excellent results in regards to their armpit sweating.

This is especially true since Dr. Reisfeld will apply clips on the lower levels of the sympathetic chain. In normal cases, the clamps are on the levels T3 to T4. In cases where axillary hyperhidrosis is very severe a clamp is applied on the T5 level for improved results.

Over the last few years, this method of clamping at the T5 level proved to be very efficient in reducing the amount of axillary sweating.

Dr. Reisfeld is still of the opinion that doing a sympathectomy for armpit sweating only is not recommended. His view is not shared by all surgeons who perform ETS but instead based on his extensive experience and knowledge.

What is The Difference Between Cutting the Nerve Versus Clamping the Nerve?

During the cutting method, the nerve is cut with an electric cautery or with a harmonic scalpel (an ultrasonic device). In the clamping method, titanium clips are applied to the nerve. This ceases the function of that particular nerve segment.

Both methods will result in compensatory sweating (compensatory hydrosis or reflex sweating) but the clipping method allows for the possibility of reversal if the compensatory sweating (compensatory hydrosis or reflex sweating) becomes too severe.

To learn more about reversal see the reversal, click here.

Is The ETS Surgical Procedure Appropriate for Facial Sweating and blushing?

In the early 90’s ETS was thought to be an answer for patients who suffer from facial blushing and or facial hyperhidrosis. The basis for this was the fact that patients who had facial blushing and or hyperhidrosis together with palmar hyperhidrosis (excessive hand sweating) showed an initial improvement of the symptoms in the head region.

That lead to the assumption that ETS would help patients who suffer from facial sweating and or facial hyperhidrosis. It was then adopted by surgeons in Europe and the Far East to offer ETS as a solution for these facial conditions.

As more information came to light, it was shown that patients who had the operation for facial presentations developed more severe side effects in regards to compensatory sweating, gustatory sweating and hair loss.

After reviewing those cases Dr. Reisfeld decided not to offer ETS for those two isolated types of facial hyperhidrosis. The theory is that, while performing ETS for facial problems, the surgeon must be high in the sympathetic chain. This causes less sympathetic ganglia to supply the head region, thus causing severe side effects.

By performing ETS on lower levels of the sympathetic chain (T3 to T4) you allow the head area to get more in-tact sympathetic innervation which helps with the side effects.

What are the Psychological Effects of Living With Hyperhidrosis?

Even though hyperhidrosis is a physiological problem and not a psychological one, patients who suffer from excessive hand sweating are confronted with a variety of social issues. Their ability to engage in simple handshakes and introduce themselves to new people are hampered by this condition.

This causes introversion and results in the person being labeled as a recluse. Other daily activities such as computer use, writing on paper, driving, and use of electronics can be challenging. One issue that we hear repeatedly is the inability to physically interact with loved ones.

Patients are often embarrassed by their condition. Comments like “I never was able to fully develop to the best of my ability” are commonly repeated to us. In order to help in these situations, the patient should first understand this condition and realize that it is something most likely caused by genetics.

The first step is to understand the problem. Second is to try some of the alternative hyperhidrosis treatments. Third, if there is no improvement, then the surgical approach will be considered after a thorough review is carried out with the appropriate medical professionals.

Please keep in mind that hyperhidrosis affects different patients in different ways. Make sure to consult your physician before making any treatment decisions.

Contact Expert Dr. Reisfeld to Learn More

What is The Reversal Operation?

In the event that a patient is not satisfied with the procedure due to some side effects (compensatory sweating), reversal of the operation is possible. For more specific information, see our reversal section.

For those patients who received the cutting method and suffer from severe compensatory sweating, reversal is a possibility that involves a complicated procedure. In this instance, a nerve graft from the ankle is used to bridge the gap in the nerve segment. Over the last two years, Dr. Reisfeld has performed several of these nerve graft reversal operations.

The data that was accumulated from those cases show that at least 60% of the patients will benefit from this procedure in a few ways. Their compensatory sweating decreases and they start sweating in the upper shoulders, neck, and facial areas.

The theory is that once the upper body areas start to sweat the evaporation process causes cooling of the head area. From that location, signals are transmitted to the brain indicating a cooler temperature.

The return of upper body sweating could explain the lessening of compensatory sweating and the ability to better tolerate heat. For this rare and unique procedure, please talk to your surgeon.

Recently, the possibility of using collagen has been requested. Unfortunately, these nerve guides are used mainly in peripheral nerve repair where there is no gap between the cut ends of the nerve. The nerve tube serves as a protective conduit and supposedly enhances axonal regrowth across a nerve gap.

Again, this is only used in peripheral nerve repair. This tube dissolves with time. Other patients ask about the use of Schwann cell cultures which, at present, are in the experimental stage and have not yet been used in any clinical cases.

Dr. Reisfeld only performs the clipping/clamping procedure due to the fact that it is much easier to remove the titanium clips than to perform a nerve graft reversal in the rare event that it is requested. A nerve graft procedure is used for those cases where the cutting method was applied.

Dr. Reisfeld does not perform the cutting method because he believes that the clipping/clamping method is a better choice. Statistical data has not been established for either the clip removal or the nerve graft method.

Experience shows that after a reversal procedure patients will start seeing sweat return on their upper body areas (head and shoulders). As a result, compensatory sweating (compensatory hydrosis or reflex sweating) will be reduced. This process might take up to a year.

With the clipping/clamping method, less nerve tissue is destroyed. With less nerve destroyed one can assume that the recovery after clip removal would be easier and more effective. In either event, it is very important to discuss these issues, should they arise, with your surgeon.

• See our reversal page

Should Patients With Excessive Armpit Sweating Undergo ETS?

For those who only experience excessive armpit sweating, a sympathectomy does not offer the same success rate as it does for hand sweating. For that reason, Dr. Reisfeld does not perform ETS if the only complaint of the patient is excessive armpit sweating.

The armpit contains two types of sweat glands: eccrine and apocrine. The eccrine glands are affected by the sympathectomy while the apocrine glands are not. Those patients who suffer only from armpit sweating should try conservative methods such as drysol, drionic, certain dry, etc.

BOTOX® Cosmetic injections are also a viable option, but the duration can be limited to anywhere from 4 to 9 months. If those methods are not helpful, the best option is to go for laser armpit sweat treatment. In this new and improved procedure, the sweat glands responsible for excessive armpit sweating are destroyed.

It is done through extremely small incisions which allow for quick recovery and less tissue trauma. To learn more visit our armpit sweating page.

Do the Titanium Clips Interfere With Anything?

Titanium clips are entirely safe for the long and short-term. They do not “interfere” with medical examinations such as x-rays, MRI scans, etc. The clips are very small, they will not trigger any safety devices at airports. Titanium as a medical device has been used for many years in different surgical specialties.

The material does not show any signs of rust or decay over long periods of time. It is applied in very delicate locations such as the brain, heart, joints, lungs, etc. The same applies to titanium clips. The chances of the clips extremely low. The safety of this approach is widely recognized.

How secure are the titanium clips?
The clips are very secure. They do not require any follow-up after the surgery. Even so, Dr. Reisfeld does follow up with each and every one of his patients individually in the post-surgery phase. This is a courtesy he provides to ensure his patients are satisfied and happy with their results.

The Difference Between Rosacea and Blushing

Rosacea is a skin condition with symptoms including redness and visible blood vessels in your facial skin. It is also characterized by constant redness around the cheeks. Other symptoms include small, red, or pus-filled bumps. These conditions can flare for weeks or months at a time. In some cases, it is mistaken for acne.

Blushing that is induced sympathetically is characterized by facial redness initiated during certain social or functional situations. This is indicated by short bursts of facial redness that happen in conditions that otherwise will not cause facial redness. Usually, it starts after puberty (20 – 30 years of age).

The Kuntz Nerve Controversey

Over the last few years many questions are being raised about the Kuntz Nerve. “What do you know about the Kuntz Nerve?” and “What do you do with the Kuntz Nerve?” are some common exampes.

It is difficult to explain the controversy surrounding the Kuntz nerve, which causes a lot of confusion among laymen and physicians alike. An understanding of the origin of the sympathetic enervation of the upper limb is important in surgical sympathectomy procedures such as ETS.

During the 1920’s, sympathectomies were performed for a variety of reasons such as elevated blood pressure, circulation problems within the hands, cardiac pain, etc. Most of the above-mentioned reasons were not cured by the surgery. When the sympathectomy was performed for circulation problems in the hands, there was an initial improvement with a warming of the hands and better blood flow but most of those failed after 6 months to a year.

This high failure rate prompted Doctor Kuntz to look for a reason behind the failure. Since one could not perform postmortem examinations on patients, he performed anatomical studies on cats. While doing this anatomical dissection on cats he found some nerve fibers connecting the sympathetic nerve to other nerves within the chest cavity.

Since then the name Kuntz nerve is used. These particular anatomical findings were not found in humans. The reason for the failures when sympathectomy procedures were done for vascular problems is not related to the procedure itself.

The reason for the failure is due to post denervation hypersensitivity (meaning extra sensitivity to circulating chemicals in the blood causing the blood vessels to constrict). Somehow this term Kuntz nerve found its way into modern sympathectomy literature.

Over the last few years there were two anatomical studies done on cadavers trying to solve this issue. In both studies, they found a nerve segment that goes in between the first intercostal nerve and the brachial plexus. The exact function of this nerve segment is unknown.

The intercostal nerves are made of bundles that consist of sensory, motoric, and sympathetic fibers running between the ribs. The brachial plexus is a motoric nerve bundle that innervates the upper extremities and the shoulders.

The exact function of that particular nerve is not known. Moreso the space between the first rib and the intercostal nerve is, generally speaking, an area not touched by ETS surgeons during the procedure. The fact that this area is generally not touched by ETS surgeons makes it less significant in regards to true nature of this elusive nerve.

The mere fact that an anatomical nerve was found does not mean that it has any physiological role in the sympathetic function. Surgeons who claim to see and cut the Kuntz nerve do not even do the dissection in those above-mentioned areas.

The eponym, nerve of Kuntz, should be restricted to descriptions of the intrathoracic branch of the first intercostal nerve. Surgeons who are performing the ETS procedure on a daily basis do not even get to that site. Bleeding problems, as well as severe collateral injuries, restrict the approach to those sites.

In order to expose this elusive nerve one must perform a very delicate dissection with two or three instruments to enable this step. Most of the ETS surgeons who perform this operation do it with one single instrument that does not allow this type of dissection.

Any Connections Between The Kuntz Nerve and Recurrence?
Recently Dr. Reisfeld went back to the anatomy laboratory and performed 6 cadaver studies. This means that 12 separate dissections were done in the upper part of the chest cavity trying to further clarify the issue of the “Kuntz nerve”. Those dissections were completed with the help of 2 experienced Anatomists (University Medical Doctors who teach anatomy in medical school).

No significant nerve connections were found between the second ganglia to the first ganglia. Between the first ganglia and the brachial plexus, some very fine fibers were found but there exact physiological function is not known. This particular area is not approached by any ETS surgeon because of the proximity to a variety of other important structures.

Doctor Reisfeld believes that current clinical and anatomical data do not support the Kuntz nerve as a significant reason for recurrence after a successful ETS procedure. The most likely reason for late recurrence is the creation of alternate pathways within the Spinal cord.

The possibility of a re-growth in the sympathetic chain is a practical possibility since the sympathetic chain has the ability to repair itself. The regrowth can happen if the operation is performed using the cutting method, excision, or ultrasound desiccation. Dr. Reisfeld found that with the clamping method the recurrence rate is even lower than the cutting method.

The above-outlined views about the Kuntz nerve were also supported in 2001. In the international meeting held in Finland, this view was supported by other leading ETS surgeons.

To learn more about what we can do for you contact The Center For Hyperhidrosis by contacting our office.

What is the Recurrence/Failure Rate For Hyperhidrosis Surgery?

Between 1% and 2% of patients will develop a recurrence. The recurrence might manifest itself with mild hand sweating under certain situations such as heavy activity, hot weather, or stressful situations. In those mild cases, a re-operation may not be needed.

In cases where the recurrence is very severe, a second operation is possible. So far, the recurrence rates are equal regardless of the surgical method.

In terms of the failure rate, one must differentiate between early failure (that happens immediately after the operation) and delayed failure (recurrence that can happen within the first 2 years after the operation). Early failure can happen because of technical or anatomical problems. See our recurrence section as well.

Heart Rate Changes After Surgery?

Heart rate changes can happen in a small number of cases. It is possible that a slight reduction in heart rate can occur, but physiologically it has no significance. On the other hand, if a patient is engaged in a heavy exercise, some of them will notice that their maximum heart rate does not reach the same level as before the operation.

Since the procedure was changed from the T2 to the clamping of the T3-T4 levels, there are patients who have not noticed any reduction in their heart rate and in fact, their heart rate went up to 150 – 160 per minute during heavy exercise.

There is no long-term adverse effect on cardiovascular function. To learn more about heart rate changes and sympathectomy please click here. For more information about possible side effects section. Click here

Potential Disqualifications For Sympathectomy Procedures

There are certain situations where a thoracic sympathectomy should not be done because of possible technical problems. Serious cardiac or pulmonary (lung problems), ongoing infection, severe clotting (coagulation problems), cancer, or severe obesity are several reasons not to proceed.

Previous chest surgery or extensive inflammatory diseases in the past may cause severe scar tissue (adhesions) that will prevent exposure of the thoracic sympathetic chain. This is required to perform a safe operation.

In cases like this, an open thoracic sympathectomy is an option, but it is associated with higher amounts of pain, prolonged stays at the hospital, and damage to the lungs so it is not recommended.

Non-Surgical Hyperhidrosis Treatment Options

We wish that every medical condition could be treated with non-surgical methods. In reference to excessive sweating, attempts have been made to treat it with different conservative modalities such as lotions (Drysol), oral medications, electronic devices, BOTOX® Cosmetic injections, etc.

Ultimately, none of the above conservative treatments provide long-lasting solutions. However, that does not make these treatments useless. It is worth using them yourself as every case is different.

Before any decision about surgical intervention is made, one or more of the above modalities should be utilized first. One is advised to keep careful records of those attempts for various reasons, including insurance claims.

This is the common name used for the appearance of sweat in other parts of the body after the sympathectomy is complete. Compensatory sweating, also known as (reflex sweating or compensatory hydrosis), can appear on the lower legs, thighs, abdomen, or the back.

Generally speaking, everything from the nipple line up will be dry after ETS. All patients will get some sort of compensatory sweating (compensatory hydrosis or reflex sweating) which does not necessarily have any correlation to the amount of hand sweating that occurred before the operation.

The majority of patients will experience it on a level that is acceptable to them, which we call mild to moderate. Between 3 to 5% of patients will get it on a severe level. The compensatory sweating (compensatory hydrosis or reflex sweating) is a byproduct of the operation, regardless of the method used.

Can Hyperhidrosis Cause Dehydration?

Generally speaking, the answer is no. There is no change in kidney function, blood concentration, or electrolyte imbalances. The body has strange ways of dealing with excessive sweating. In our own experience over the years, seeing thousands of people suffering from hyperhidrosis, we did not see any cases that had renal (kidney) function problems or anything related to dehydration.

Another common question relating to this is the relationship between hormonal problems and hyperhidrosis. In the aging population, especially among women, there are a lot of complaints about excessive facial/hair sweating that occurs.

This is especially true after menopause. We know that menopause carries with it some hormonal changes which can cause this specific type of sweating but the exact cause is unknown as of yet. Also, the treatment for this type of sweating in the elderly population is not a surgical one.

What is The Reversal Operation?

In the event that a patient is not satisfied with the procedure due to some side effects (compensatory sweating), reversal of the operation is possible. For more specific information, see our reversal section.

For those patients who received the cutting method and suffer from severe compensatory sweating, reversal is a possibility that involves a complicated procedure. In this instance, a nerve graft from the ankle is used to bridge the gap in the nerve segment. Over the last two years, Dr. Reisfeld has performed several of these nerve graft reversal operations.

The data that was accumulated from those cases show that at least 60% of the patients will benefit from this procedure in a few ways. Their compensatory sweating decreases and they start sweating in the upper shoulders, neck, and facial areas.

The theory is that once the upper body areas start to sweat the evaporation process causes cooling of the head area. From that location, signals are transmitted to the brain indicating a cooler temperature.

The return of upper body sweating could explain the lessening of compensatory sweating and the ability to better tolerate heat. For this rare and unique procedure, please talk to your surgeon.

Recently, the possibility of using collagen has been requested. Unfortunately, these nerve guides are used mainly in peripheral nerve repair where there is no gap between the cut ends of the nerve. The nerve tube serves as a protective conduit and supposedly enhances axonal regrowth across a nerve gap.

Again, this is only used in peripheral nerve repair. This tube dissolves with time. Other patients ask about the use of Schwann cell cultures which, at present, are in the experimental stage and have not yet been used in any clinical cases.

Dr. Reisfeld only performs the clipping/clamping procedure due to the fact that it is much easier to remove the titanium clips than to perform a nerve graft reversal in the rare event that it is requested. A nerve graft procedure is used for those cases where the cutting method was applied.

Dr. Reisfeld does not perform the cutting method because he believes that the clipping/clamping method is a better choice. Statistical data has not been established for either the clip removal or the nerve graft method.

Experience shows that after a reversal procedure patients will start seeing sweat return on their upper body areas (head and shoulders). As a result, compensatory sweating (compensatory hydrosis or reflex sweating) will be reduced. This process might take up to a year.

With the clipping/clamping method, less nerve tissue is destroyed. With less nerve destroyed one can assume that the recovery after clip removal would be easier and more effective. In either event, it is very important to discuss these issues, should they arise, with your surgeon.

• See our reversal page

Do the Titanium Clips Interfere With Anything?

Titanium clips are entirely safe for the long and short-term. They do not “interfere” with medical examinations such as x-rays, MRI scans, etc. The clips are very small, they will not trigger any safety devices at airports. Titanium as a medical device has been used for many years in different surgical specialties.

The material does not show any signs of rust or decay over long periods of time. It is applied in very delicate locations such as the brain, heart, joints, lungs, etc. The same applies to titanium clips. The chances of the clips extremely low. The safety of this approach is widely recognized.

How secure are the titanium clips?
The clips are very secure. They do not require any follow-up after the surgery. Even so, Dr. Reisfeld does follow up with each and every one of his patients individually in the post-surgery phase. This is a courtesy he provides to ensure his patients are satisfied and happy with their results.

The Correlation Between Social Phobias Anxiety and ETS

Some patients who suffer from excessive hand sweating are also known to show signs of anxiety and social phobias. This combination of excessive sweating and clinical manifestations are believed to be due to excessive sympathetic discharge.

We know that patients who suffer from hyperhidrosis can experience heart palpitations and the inability and cope with certain social situations. This led some of the ETS surgeons around the world, mainly in Europe, to offer the sympathectomy to patients who suffer only from social phobias and anxieties.

Some of their work was presented at several international meetings, but those findings promoted a healthy discussion about the validity and the success of those treatment modalities to cure them.

In the U.S. and Canada, most of the surgeons who perform ETS did not adopt these approaches as suggested by their European counterparts. Dr. Reisfeld himself feels that because of the uncertainty of these situations, he does not recommend patients to undergo ETS when their only clinical manifestations are those of social phobia or anxiety.

ETS does have a beta-blocking effect. As such, it does provide some relief to patients who suffer from excessive hand sweating and palpitations. Dr. Reisfeld does not believe in performing the operation unless the patient has excessive sweating to signify hyperhidrosis.

Back to Hyperhidrosis Frequently Asked Questions

The Top Reasons to Perform ETS

Dr. Reisfeld has been stating for several years that ETS should be conducted only for sweaty hands and feet. All other issues, including facial blushing, facial sweating, and axillary sweating have not been alleviated properly with an Endoscopic Thoracic Sympathectomy.

Dr. Reisfeld’s claims were recently reinforced by a paper published at the Mayo Clinic Proceedings. He believes that the results of the paper reflect his own vast experience with sympathectomies. As previously stated on this website and others, any patient with severe hand sweating or palmar Hyperhidrosis should first try conservative treatment options. Please see the Alternative Treatment page of the site for further details.

Understanding ETS Controversies
It is interesting to see that a higher number of unhappy patients came from countries where ETS was done for reasons other than severe palmar hyperhidrosis. In those places, facial blushing, facial sweating, and axillary hyperhidrosis were quoted as the main reason for doing the ETS procedure.

Those patients did not see the results they were looking for. They were also are left with bad side effects. This is the reason why Dr. Reisfeld, through his vast experience and research on this topic, maintains his position that ETS should only be done for patients who suffer from severe palmar hyperhidrosis.

It is Dr. Reisfeld’s belief that facial hyperhidrosis and or facial blushing should be treated with medications or other methods, instead of surgery. Axillary hyperhidrosis or armpit sweating should be treated with local measures, such as suction curettage, in order to prevent generalized side effects such as compensatory sweating.

Other topics of interest:

• Sweaty Hands
• What is ETS – Endoscopic Thoracic Sympathectomy
• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Please view our disclaimer.

Hyperhidrosis and Raynaud’s Syndrome

A lot of patients who suffer from excessive hand and foot sweating (palmar and plantar) are mistakenly diagnosed with Raynaud’s syndrome. Patients with palmar or plantar hyperhidrosis may have clammy and discolored fingers or toes because of their hyperhidrosis.

This is not because they suffer from Raynaud’s disease. This can leads to unnecessary treatments such as medications they are not beneficial for hyperhidrosis.

What is Raynaud’s Disease?
This is a condition where some areas of the body, like fingers and toes, feel numb or cold in response to stress. It does not have anything to do with sweating or sweat glands. This disease involves narrow arteries in the skin that limit blood circulation to the affected areas.

Could I Have Raynaud’s Disease and Hyperhidrosis?

Over the years, we have come across several patients who were told that they suffer from Raynaud’s disease as well as hyperhidrosis. This is a common mistake that exposes the patient to unnecessary treatment modalities.

The other problem is that it takes away attention from the real issue, which is hyperhidrosis. A certain amount of patients, on top of their severe palmar hyperhidrosis / plantar hyperhidrosis also have clammy extremities which also are bluish/reddish in color. The explanation for this is overactive sympathetic chain activity.

In order to diagnose Raynaud’s disease, a very simple test is required. This test is called Erythrocytes Sedimentation Rate (ESR). If it is normal, the likelihood that the patient has Raynaud’s is extremely low. Thankfully, it is an extremely simple and cheap test. A person who is suffering from these symptoms should request this test first.

The cold hands and feed (clammy) are also due to the overactive sympathetic chain which causes a narrowing of the blood vessels. If a patient does not have sweaty hands but only clammy extremities with discoloration (bluish, reddish), then a sympathectomy is not recommended for them.

The only reason nowadays for a thoracic or lumbar sympathectomy is an extreme level of hyperhidrosis in the extremities. With the sympathectomies, the patient will feel a warming of the extremities and the discoloration will disappear.

The aforementioned improvements are not long lasting. The warming effect and the improvement of the discoloration are temporary. As far as the excessive sweating is concerned, there are lifelong improvements with high success rates. The recurrence rate is in the range of about 1%.

What to expect after each of the three main procedures:

Learn more about the recovery period for each of the main surgical procedures Dr. Reisfeld performs for excessive sweating of the hands, feet and armpits.

• Endoscopic Thoracic Sympathectomy Recovery (Hands)
• Lumbar Sympathectomy Recovery (Feet)
• Axillary Procedure Recovery (Armpit)

Other topics of interest:

• Details of the surgery
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Please view our disclaimer.

Are Warts Related to Hyperhidrosis?

There have been patients who notice warts on their fingers. It is a very small percentage of hyperhidrosis patients. There is a slight possibility that the wet condition of the skin promotes the growth of these warts.

We have noted a reduction in both the number and size of warts after completion of the ETS procedure. We are unable to make any definitive observations from the small number of cases where we’ve seen warts appear. There is certainly a possibility that the two are correlated, but until we are able to observe more cases, there is no certain answer to this question.

Robotic Surgery For Hyperhidrosis?

Discussions regarding the use of robotic devices when performing thoracic or lumbar sympathectomies are ongoing. In a thoracic sympathectomy (ETS) robots offer no practical role. The setup of a robotic surgical device takes a long time before the surgery can begin.

During this setup, a human surgeon can complete ETS for both sides. The incisions needed for a robotic approach are larger. In Dr. Reisfeld’s opinion, the motivations to try this approach are mainly financial. Since the mid-1990’s we are able to achieve extremely high success rates coupled with excellent safety records using a non-robotic approach.

Robotic surgery is a newer technique that should only be used in certain cases where endoscopic surgery cannot achieve the same level of success and safety. That being said, Dr. Reisfeld’s opinion is that robotic surgery for hyperhidrosis (ETS, ELS) is unnecessary. Plantar hyperhidrosis (foot sweating treatment) can be treated in a very safe and efficient manner with excellent results using an endoscopic lumbar sympathectomy,

In this time of rising healthcare costs, keeping the price down is very important. Using robotic surgery, the total price can be 2-3 times as much. Recently, It has become possible to utilize a robotic tool to complete the procedure with one incision.

This incision is larger than the 1-3 small incisions used in the ETS or ELS procedures. A larger incision increases pain, results in a bigger scar, and also carries the possibility of hernia formation when the procedure is done for a lumbar sympathectomy.

Pros of robotic surgery
For this particular surgery, Dr. Reisfeld believes there are no advantages over an endoscopic surgery.

Cons of robotic surgery

• Unnecessary. It increases the cost of the surgery
• Requires a larger incision
• The entire procedure takes longer
• A more complex procedure sometimes requires more surgeons

Axillary Excessive Sweating Treatment: After the Procedure

Here are the things you can expect after you’ve completed treatment for your hyperhidrosis:

Pain Levels
You should expect a certain amount of pain which is localized to the armpit area. Generally speaking, it is not severe and is manageable with oral medications that will be prescribed to you. The pain threshold is different from person-to-person, but it is safe to say that the pain levels are generally tolerable. One should expect the pain to decrease a few days after the operation.

Recommend Activity
It is recommended that your physical activity is kept to a minimum for the first few days. You can gradually increase activity back to normal levels. For strenuous physical activity (jogging, basketball, working out) one should listen to his/her body.

There are no rigid rules. No muscles have been cut in this operation, so the healing process should be fast. Dr. Reisfeld will explain how you should use padding in the armpit area to help with the healing process and to reduce the amount of swelling in the area.

Incisions
The incisions are very small (2mm). No sutures are used and those holes will close on their own within a short time.

Showers and baths
You can take a shower or bath the day after the procedure. The bandages can be removed and new ones can be applied (your decision). Most of the time, patients are comfortable with replacing their band-aids for a few days. Use of soap or skin lotions is fine.

Food
You can feel free to return to your normal diet immediately after the procedure.

This is intended as a general guide. Please call Dr. Reisfeld with any concerns or questions. You are also welcome to e-mail us with questions and or pictures illustrating your concern. We love to hear back from our patients, so please consider writing a testimonial for us.

Can I Use Deodorant after an Axillary Laser Ablation or Axillary Suction Curettage?
Yes, deodorants can be used after the operation. Since no operation can eliminate underarm sweating completely, the deodorant is used to control any minimal perspiration and aid with normal body odor.

Body Piercings and Hyperhidrosis Procedures

Body Piercings, depending on their location, may interfere with the operation. In these cases, the piercings can be removed temporarily while the procedure is completed.

After the operation, they can be put back. You should discuss things like this with the surgeon prior to the procedure. Please do not hesitate to ask any questions you may have.

Does Obesity Have Anything to do With Hyperhidrosis?

The answer is no. Obesity is a combination of Western lifestyle, diet, and genetics. We know that hyperhidrosis is the result of a genetic trait. Any patient can be genetically predisposed to different illnesses.

Studies have shown that more than 50% of patients with hyperhidrosis have a family history of the condition. We are aware of the gene responsible for hyperhidrosis. However, manipulating this gene is not possible with current technology.

Patients who are excessively obese can pose two additional problems. First, an operation on obese patients is more difficult. This is due to the fact that fatty tissue surrounds many of the nerves.

Second, obese patients have a bigger body surface area and hands that contain additional sweat glands. Their chance of having severe compensatory sweating is higher.

Does Being Skinny Have Anything to do With Hyperhidrosis?
No, there are patients who are skinny and suffer from hyperhidrosis. At the same time, a lot of patients who have a normal height-weight ratio are thin. There is no evidence that hyperhidrosis causes any kind of hypermetabolic effect, in which patients could potentially lose weight because of their excessive sweating.

Other topics of interest:

• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Please view our disclaimer.

Does Obesity Have Anything to do With Hyperhidrosis?

The answer is no. Obesity is a combination of Western lifestyle, diet, and genetics. We know that hyperhidrosis is the result of a genetic trait. Any patient can be genetically predisposed to different illnesses.

Studies have shown that more than 50% of patients with hyperhidrosis have a family history of the condition. We are aware of the gene responsible for hyperhidrosis. However, manipulating this gene is not possible with current technology.

Patients who are excessively obese can pose two additional problems. First, an operation on obese patients is more difficult. This is due to the fact that fatty tissue surrounds many of the nerves.

Second, obese patients have a bigger body surface area and hands that contain additional sweat glands. Their chance of having severe compensatory sweating is higher.

Does Being Skinny Have Anything to do With Hyperhidrosis?
No, there are patients who are skinny and suffer from hyperhidrosis. At the same time, a lot of patients who have a normal height-weight ratio are thin. There is no evidence that hyperhidrosis causes any kind of hypermetabolic effect, in which patients could potentially lose weight because of their excessive sweating.

Other topics of interest:

• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Please view our disclaimer.

A Surgical Solution for Excessive Foot Sweating

A Lumbar sympathectomy is done under general anesthesia. It involves 3 small cuts for the endoscopic approach into the retro-peritoneal area. Once the surgeon is there, a space is developed and the sympathetic chain at the lumbar region is located. At this point, it is either excised or clamped at the levels L3-L4. This particular procedure is done on both sides. The operation takes about an hour to perform and in contrast to the endoscopic thoracic sympathectomy, the patient should stay over at the hospital for one day.

As more experience is gained by the doctor, a lumbar sympathectomy can be performed on an outpatient basis. In a typical case like this, if the operation starts early in the morning and the anatomical relations are displayed easily, the resulting discomfort can be brought down to a minimum. This enables the patient to leave the hospital later that day.

Many more cases must be done in order to establish a definitive pattern, which would allow us to do the majority of these cases on an outpatient basis. There are a few sensory nerves located close to the lumbar sympathetic chain. It is very important to avoid them, but even if the nerve is damaged, the result can be some numbness in the inner thigh region. Fortunately, this is temporary.

The current success rate is approximately 97-98%. Possible side effects include bleeding, pain, discomfort.

Even though retrograde ejaculation has not been proven to be a problem in Lumbar Sympathectomy procedures, it is worth discussing.

Potential patients for Lumbar Sympathectomy should be aware of the fact that sometimes, in very rare cases, due to technical difficulties there might be a need to change the operation. The procedure would change from an endoscopically assisted Lumbar Sympathectomy, to an open Lumbar Sympathectomy.

This will involve incisions on both sides measuring about two inches in size. The added discomfort or pain is very well tolerated by patients in situations where the operation had to be converted. The scarring is minimal as well.

It is important to keep in mind that this is a technical difficulty that can arise. Prior to the surgery, the patient is given the very clear choice to allow conversion from an endoscopically assisted to an open lumbar sympathectomy. The reason this is offered is to allow for more approaches to successfully complete the procedure.

The current method being used to perform ELS gives us better opportunities to examine the sympathetic chain. Obviously different centers use different approaches, but in comparing the methods, we found out that our current method gives an ability to examine the sympathetic chain over a longer segment. This enables us to make sure that all sympathetic fibers below the lumbar vertebra #2 are clamped for the best results.

It is a known fact that all sympathetic fibers below the lumbar vertebra #2 run to the feet. If the lumbar sympathectomy is done in a lower level (ie 3 or 4), one might miss some very fine fibers that run to the feet. This could result in a less successful outcome.

Clinical Results Thus Far (500 + Cases):
The clinical experience accumulated since 2008 shows that the lumbar sympathectomy is a very effective method for treating severe plantar (sweaty feet) hyperhidrosis. Most of our patients previously had ETS performed with zero results. As time goes by more people with primary plantar hyperhidrosis are having lumbar sympathectomy performed as well.

The success rate is about 97-98%, and side effects such as increased compensatory sweating, pain, discomfort, and scars are minimal. Retrograde ejaculation (male patients), sexual dysfunction, or hypotension has not occurred in any of Dr. Reisfeld’s 500+ lumbar sympathectomy cases. Dr. Reisfeld continues to work hard to further develop and improve this procedure. No other surgeon comes close to this level of experience.

In ETS cases, at about 3 to 4 days after the lumbar sympathectomy, another bout of sweating occurs. As we learned from previous ETS cases, this is a short bout of sweating and it stops in a few hours or up to a day later. So far no increase in compensatory sweating has been noted after the lumbar sympathectomy procedure. Some patients will have an initial increase in their compensatory sweating, compared to what they had after the procedure.

The ELS procedure will cause fluctuation in the amount of compensatory sweating, but in the long run, these changes will go back to normal. This is why the time interval between ETS and ELS should be at least 6 months. On the other hand, patients who experience any level of compensatory sweating after an ETS procedure should expect that level to stay. Keep in mind ETS is a separate procedure from the lumbar sympathectomy. Learn more about ETS.

Some patients who previously had ETS done, and later underwent lumbar sympathectomy experience hand sweating. This a temporary occurrence and will resolve itself in a short time.

So far, information about compensatory sweating in patients who had only lumbar sympathectomy done is not yet available. This is due to the small number of cases where only the lumbar sympathectomy was performed. In the small amount of cases where only lumbar sympathectomy procedures were done, compensatory sweating was mild. It is still too premature to draw any definite conclusions.

In regards to the recurrence rate after an endoscopic lumbar sympathectomy, the numbers are not yet in. There are rare reports of some limited-partial recurrence. This can be the result of abnormal branches that are supplying the feet with sympathetic innervation. Again, those observations were made in a very small number of cases, and more time will be needed to define the exact reason for this limited recurrence.

Related Studies:
In 2013 Dr. Reisfeld published another important study in regards to the treatment of severe plantar hyperhidrosis. Dr. Reisfeld is proud to be one of the few surgeons who has invested his time and effort to study and advance this subject. View this study.

In a paper published in December 2009, there is a description with results with in regards to the surgical treatment of plantar-feet hyperhidrosis. Across 90 patients, the procedure had a high success rate and overall satisfaction. For a brief summary of this paper see -> Endoscopic lumbar sympathectomy for plantar hyperhidrosis.

In a separate study about (Endoscopic sympathectomy for palmar and plantar hyperhidrosis: results in 107 patients), published in 2000. French surgeons performed 78 lumbar sympathectomies. Their results are similar to those published in the previous paper, as well as by Dr. Reisfeld in his published/peer reviewed paper on ELS. The French authors performed ELS only on women.

The History of The Lumbar Sympathectomy
Lumbar Sympathectomy is a procedure that used to be performed for patients with vascular insufficiency (blood supply problems – to lower legs). The idea was that by doing a sympathectomy, the vaso constrictive influence of the sympathetic chain on the blood vessels would be abolished. Therefore, the blood vessels would be open and provide a better blood supply to the legs.

This was done for many elderly patients with vascular insufficiency, but the results were poor. Lumbar sympathectomies are rarely done for this purpose in today’s medical world, and is being replaced by different medications. This is not to be confused with the lumbar sympathectomy procedure for excessive foot sweating.

Another condition for which Lumbar Sympathectomies are rarely done, is for complex regional pain syndrome or sympathetic neuralgia. Since this syndrome is not well understood, the results are inconclusive.

The Lumbar Sympathectomy procedure is, however, very effective in treating plantar hyperhidrosis. The same principal applies in cases of palmar hyperhidrosis, where a thoracic sympathectomy is very effective in treating excessive hand sweating. The current success rate is approximately at 97-98%.

Like in any other surgical procedure that tries to correct physiological – genetic problems with mechanical solutions, the issue of recurrence will always be a possibility. Even though the possibility is extremely low, it can happen.

There are two main factors that typically contribute to this: The inexperience of the surgeon, and the fact that some anatomical variations can exist (everyone’s body is different). The surgeon of choice should have extensive experience and knowledge.

Questions

When does conversion from an endoscopic lumbar sympathectomy to open lumbar sympathectomy happen?
Overweight patients, or those patients who had previous operations performed in the vicinity of the lumbar region (such as c-section, hysterectomy, kidney operation), can create scar tissue. This will make the endoscopic lumbar sympathectomy more difficult to perform. The option of an open procedure is always available, but extremely uncommon.

Does lumbar sympathectomy affect pregnancy?
So far there is no known connection between lumbar sympathectomy and the ability to become pregnant. On the contrary, Dr. Reisfeld’s female patients who had this procedure have become pregnant without any issues.

Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
No, but there are some instances in which patients describe a temporary increase in their hand sweating after their lumbar sympathectomy. Those patients already had the thoracic sympathectomy performed for their excessive hand sweating. This is temporary.

Could my feet become too dry after lumbar sympathectomy?
There has been one case where a patient was complaining that her feet after the lumbar sympathectomy were very dry to the level of discomfort. This particular patient had only plantar hyperhidrosis done without any palmar hyperhidrosis associated with it.

The rest of the cases where the lumbar sympathectomy procedure was done after thoracic sympathectomy did not report this effect. The reason for this extreme dryness in a patient who only had plantar hyperhidrosis is unknown at this time. More cases will have to be done in order to understand this problem better.

Wear flip flops again without worrying about sweat!
Contact Us To Learn About The Cure

• Lumbar Sympathectomy Study

A Surgical Solution for Excessive Foot Sweating

A Lumbar sympathectomy is done under general anesthesia. It involves 3 small cuts for the endoscopic approach into the retro-peritoneal area. Once the surgeon is there, a space is developed and the sympathetic chain at the lumbar region is located. At this point, it is either excised or clamped at the levels L3-L4. This particular procedure is done on both sides. The operation takes about an hour to perform and in contrast to the endoscopic thoracic sympathectomy, the patient should stay over at the hospital for one day.

As more experience is gained by the doctor, a lumbar sympathectomy can be performed on an outpatient basis. In a typical case like this, if the operation starts early in the morning and the anatomical relations are displayed easily, the resulting discomfort can be brought down to a minimum. This enables the patient to leave the hospital later that day.

Many more cases must be done in order to establish a definitive pattern, which would allow us to do the majority of these cases on an outpatient basis. There are a few sensory nerves located close to the lumbar sympathetic chain. It is very important to avoid them, but even if the nerve is damaged, the result can be some numbness in the inner thigh region. Fortunately, this is temporary.

The current success rate is approximately 97-98%. Possible side effects include bleeding, pain, discomfort.

Even though retrograde ejaculation has not been proven to be a problem in Lumbar Sympathectomy procedures, it is worth discussing.

Potential patients for Lumbar Sympathectomy should be aware of the fact that sometimes, in very rare cases, due to technical difficulties there might be a need to change the operation. The procedure would change from an endoscopically assisted Lumbar Sympathectomy, to an open Lumbar Sympathectomy.

This will involve incisions on both sides measuring about two inches in size. The added discomfort or pain is very well tolerated by patients in situations where the operation had to be converted. The scarring is minimal as well.

It is important to keep in mind that this is a technical difficulty that can arise. Prior to the surgery, the patient is given the very clear choice to allow conversion from an endoscopically assisted to an open lumbar sympathectomy. The reason this is offered is to allow for more approaches to successfully complete the procedure.

The current method being used to perform ELS gives us better opportunities to examine the sympathetic chain. Obviously different centers use different approaches, but in comparing the methods, we found out that our current method gives an ability to examine the sympathetic chain over a longer segment. This enables us to make sure that all sympathetic fibers below the lumbar vertebra #2 are clamped for the best results.

It is a known fact that all sympathetic fibers below the lumbar vertebra #2 run to the feet. If the lumbar sympathectomy is done in a lower level (ie 3 or 4), one might miss some very fine fibers that run to the feet. This could result in a less successful outcome.

Clinical Results Thus Far (500 + Cases):
The clinical experience accumulated since 2008 shows that the lumbar sympathectomy is a very effective method for treating severe plantar (sweaty feet) hyperhidrosis. Most of our patients previously had ETS performed with zero results. As time goes by more people with primary plantar hyperhidrosis are having lumbar sympathectomy performed as well.

The success rate is about 97-98%, and side effects such as increased compensatory sweating, pain, discomfort, and scars are minimal. Retrograde ejaculation (male patients), sexual dysfunction, or hypotension has not occurred in any of Dr. Reisfeld’s 500+ lumbar sympathectomy cases. Dr. Reisfeld continues to work hard to further develop and improve this procedure. No other surgeon comes close to this level of experience.

In ETS cases, at about 3 to 4 days after the lumbar sympathectomy, another bout of sweating occurs. As we learned from previous ETS cases, this is a short bout of sweating and it stops in a few hours or up to a day later. So far no increase in compensatory sweating has been noted after the lumbar sympathectomy procedure. Some patients will have an initial increase in their compensatory sweating, compared to what they had after the procedure.

The ELS procedure will cause fluctuation in the amount of compensatory sweating, but in the long run, these changes will go back to normal. This is why the time interval between ETS and ELS should be at least 6 months. On the other hand, patients who experience any level of compensatory sweating after an ETS procedure should expect that level to stay. Keep in mind ETS is a separate procedure from the lumbar sympathectomy. Learn more about ETS.

Some patients who previously had ETS done, and later underwent lumbar sympathectomy experience hand sweating. This a temporary occurrence and will resolve itself in a short time.

So far, information about compensatory sweating in patients who had only lumbar sympathectomy done is not yet available. This is due to the small number of cases where only the lumbar sympathectomy was performed. In the small amount of cases where only lumbar sympathectomy procedures were done, compensatory sweating was mild. It is still too premature to draw any definite conclusions.

In regards to the recurrence rate after an endoscopic lumbar sympathectomy, the numbers are not yet in. There are rare reports of some limited-partial recurrence. This can be the result of abnormal branches that are supplying the feet with sympathetic innervation. Again, those observations were made in a very small number of cases, and more time will be needed to define the exact reason for this limited recurrence.

Related Studies:
In 2013 Dr. Reisfeld published another important study in regards to the treatment of severe plantar hyperhidrosis. Dr. Reisfeld is proud to be one of the few surgeons who has invested his time and effort to study and advance this subject. View this study.

In a paper published in December 2009, there is a description with results with in regards to the surgical treatment of plantar-feet hyperhidrosis. Across 90 patients, the procedure had a high success rate and overall satisfaction. For a brief summary of this paper see -> Endoscopic lumbar sympathectomy for plantar hyperhidrosis.

In a separate study about (Endoscopic sympathectomy for palmar and plantar hyperhidrosis: results in 107 patients), published in 2000. French surgeons performed 78 lumbar sympathectomies. Their results are similar to those published in the previous paper, as well as by Dr. Reisfeld in his published/peer reviewed paper on ELS. The French authors performed ELS only on women.

The History of The Lumbar Sympathectomy
Lumbar Sympathectomy is a procedure that used to be performed for patients with vascular insufficiency (blood supply problems – to lower legs). The idea was that by doing a sympathectomy, the vaso constrictive influence of the sympathetic chain on the blood vessels would be abolished. Therefore, the blood vessels would be open and provide a better blood supply to the legs.

This was done for many elderly patients with vascular insufficiency, but the results were poor. Lumbar sympathectomies are rarely done for this purpose in today’s medical world, and is being replaced by different medications. This is not to be confused with the lumbar sympathectomy procedure for excessive foot sweating.

Another condition for which Lumbar Sympathectomies are rarely done, is for complex regional pain syndrome or sympathetic neuralgia. Since this syndrome is not well understood, the results are inconclusive.

The Lumbar Sympathectomy procedure is, however, very effective in treating plantar hyperhidrosis. The same principal applies in cases of palmar hyperhidrosis, where a thoracic sympathectomy is very effective in treating excessive hand sweating. The current success rate is approximately at 97-98%.

Like in any other surgical procedure that tries to correct physiological – genetic problems with mechanical solutions, the issue of recurrence will always be a possibility. Even though the possibility is extremely low, it can happen.

There are two main factors that typically contribute to this: The inexperience of the surgeon, and the fact that some anatomical variations can exist (everyone’s body is different). The surgeon of choice should have extensive experience and knowledge.

Questions

When does conversion from an endoscopic lumbar sympathectomy to open lumbar sympathectomy happen?
Overweight patients, or those patients who had previous operations performed in the vicinity of the lumbar region (such as c-section, hysterectomy, kidney operation), can create scar tissue. This will make the endoscopic lumbar sympathectomy more difficult to perform. The option of an open procedure is always available, but extremely uncommon.

Does lumbar sympathectomy affect pregnancy?
So far there is no known connection between lumbar sympathectomy and the ability to become pregnant. On the contrary, Dr. Reisfeld’s female patients who had this procedure have become pregnant without any issues.

Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
No, but there are some instances in which patients describe a temporary increase in their hand sweating after their lumbar sympathectomy. Those patients already had the thoracic sympathectomy performed for their excessive hand sweating. This is temporary.

Could my feet become too dry after lumbar sympathectomy?
There has been one case where a patient was complaining that her feet after the lumbar sympathectomy were very dry to the level of discomfort. This particular patient had only plantar hyperhidrosis done without any palmar hyperhidrosis associated with it.

The rest of the cases where the lumbar sympathectomy procedure was done after thoracic sympathectomy did not report this effect. The reason for this extreme dryness in a patient who only had plantar hyperhidrosis is unknown at this time. More cases will have to be done in order to understand this problem better.

Wear flip flops again without worrying about sweat!
Contact Us To Learn About The Cure

• Lumbar Sympathectomy Study

Why are My Hands Cold and Clammy?

Patients who are suffering from Palmar hyperhidrosis will often complain of cold and wet or clammy hands. The reason for this clammy feeling is twofold. First, the overacting sympathetic chain causes vaso-constriction (narrowing of the blood vessels), which slows down the blood flow to the fingers. This, combined with the evaporation of sweat can cause clamminess.

Another symptom that is associated with both cold/clammy hands, is a discoloration of the fingers to a somewhat red or blueish color. The reason this sometimes happens is typically due to vaso constriction of the blood vessels. This slows the flow of blood in those areas of the body (hands and feet). With this restricted flow, there is also more oxygen extracted from the blood, resulting in a darker color.

The sympathectomy procedure will create a temporary warming of the fingers right after the surgery which is not permanent. For some it lasts for a few months, or years on very rare occasions. The reason for this is that the sympathectomy is much more effective on the sweat glands when compared to the blood vessels.

The blood vessels are autonomous in their ability to constrict or dilate, and that explains why the cold aspects of the clamminess symptoms may come back. Cold hands can also be caused by certain vascular disorders. These cause a pathological narrowing of the blood vessels. An appropriate discussion between the doctor and patient in regards to medical treatment of this condition would be an appropriate step.

There are some explanations as to why the cold and clammy feeling becomes more intense, but the reasons are vast and complex. There are some medications that can be used (alpha blockers), and the usage of those medications to help with the clamminess should be discussed with the treating physician.

Should I have Surgery if I Only Have Cold Hands?
This is a very common question. Cold hands alone is not an appropriate reason to do the surgery. In the above paragraphs, the physiological mechanisms of cold and clamminess symptoms are explained. It is a difficult subject to understand, but hopefully our explanation helps. Please post any questions you have in the comments below!

Other topics of interest:

• Sweaty Hands
• Frequently asked hyperhidrosis questions

Please view our disclaimer.

While doctors don’t know why excessive sweating starts, the most likely cause is genetics. Medical Scientists have successfully linked hyperhidrosis to an over-activity in the sympathetic nervous system, which is genetically determined.

In cases of palmar hyperhidrosis (hand sweating), the responsible sympathetic ganglia that receive the signal for that abnormal activity are located within the upper part of the chest cavity. In cases of plantar hyperhidrosis (foot sweating), the responsible sympathetic ganglia that receive the wrong signal are located within a section of the lumbar sympathetic chain. This is a simplified way of explaining the complex anatomical and neurological basis for excessive local hyperhidrosis (Excessive sweating of the Hands, Feet & Armpits).

Further explanation of the problem can be divided into two categories:

• Generalized hyperhidrosis – Over the entire body.
• Focal (Localized) hyperhidrosis – Focused in one area. (Hands, Feet, Face, Armpit)

Causes of Excessive Sweating – Generalized Hyperhidrosis
In cases with generalized hyperhidrosis, excessive sweating can appear in most parts of the body. It can happen on the face, body, and extremities. In those cases, most of the patients do have some other systemic problems such as obesity, febrile illnesses, some sort of neoplastic disease (cancers), or some endocrinological disorders (thyroid glands, etc).

A search for a specific reason to explain excessive sweating in general can be long. A cause cannot be found in every case, in which case the diagnosis of idiopathic hyperhidrosis can be applied to those cases. Idiopathic meaning “unknown.” Cases of generalized hyperhidrosis usually appear in the adult population, where cases of focal hyperhidrosis (hands, feet, armpits) usually start at a younger age.

It is not uncommon to hear mothers call about their infants who suffer from excessive sweating. This is more bothersome to the parents than the child at that time. It is usually later in life, when the child has more social and functional needs such as school, that hyperhidrosis can become a serious and bothersome issue.
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Another common situation that is asked about very often, is the manifestation of upper body sweating in elderly patients, especially elderly women. This could present a unique situation where aging, hormonal changes, weight, and lack of activity can contribute to this particular type of sweating. Even though it is a common question, a specific cause cannot be identified.

As a result, an effective treatment is not always easy to find. Another common location of excessive sweating that patients mention is hairline sweating and scalp sweating. It is described by patients as if they just got out of the shower. This is another form of sweating which is not responsive to current surgical treatment. This would be more closely associated with facial hyperhidrosis.

Causes of Excessive Sweating – Focal Hyperhidrosis
In focal hyperhidrosis, there are specific sites where excessive sweating occurs. The most common areas of the body are the hands, armpits, and feet. In these cases of focal hyperhidrosis, the most likely explanation is a genetic trait.

We know that in most studies, a genetic connection was shown in about 50% to 60% of the cases. Even though the genetic connection is very well established genetic manipulation for the purpose of treatment is still a very long ways off. Dr. Reisfeld believes one day this will be a key element in the treatment of focal hyperhidrosis.

This sympathetic chain innervates the glands (supplies with nerve endings), known as the apocrine and eccrine glands, responsible for perspiration throughout the entire body. The eccrine sweat glands are mainly concentrated in the palms of the hands and soles of the feet. In most cases, the hands and feet are affected. To a lesser degree, the face and armpits (axilla) regions are affected. Another possible manifestation of the hyperactive sympathetic activity is facial blushing.

It used to be a common thought that excessive hand sweating was caused by an overactivity of the thyroid gland, but over the years this was disproved. Another theory was that patients who suffered from anxiety problems would have excessive hand sweating. This was also proven to be wrong, as patients can have severe palmar hyperhidrosis (hand sweating) even in the most relaxed settings.

Having said that, it is still true that anxiety and or socially unpleasant situations can add to this, just as they would affect a person without hyperhidrosis. This is because of the secretion of sympathetic-like materials/hormones (mediators) from different organs in the body.

Sometimes people sweat heavily because of other illnesses, such as hyperthyroidism, psychiatric disorders, menopause, obesity, and some medications. These causes must first be ruled out before Primary Hyperhidrosis can be diagnosed. Dr. Reisfeld speaks with potential candidates for the procedure over the phone or in person to review their condition and advise them of their best options.

Sweating Symptoms:
Sweat can occur in many different areas on the body. Most commonly, focal hyperhidrosis occurs on the palms of the hands. In such cases, this condition is known as Palmar Hyperhidrosis. But hyperhidrosis is not just limited to the hands. It can also occur on the face, the soles of the feet (plantar), and in the armpits (axillae).

Regardless of where it occurs, excessive sweating presents an incredible difficulty to those living with the condition. When the act of shaking hands presents a problem, business and day-to-day life can become very uncomfortable. Many patients report that they are embarrassed to hold the hands of those they love and those they are closest to.

Some patients report that the sweat prevents them from being as sociable and intimate as they would like to be, as they are forced to hide in the shadow of hyperhidrosis. Other problems occur, such as smeared ink when writing, or an inability to use electronic devices such as keyboards and computers. Driving with excessive hand sweating can become hazardous as well.

There are several cases of broken ankles due to excessive foot sweating causing slips from shoes or sandals. Recently a patient was seen with a very nasty broken left ankle after a slip and fall due to an extreme case of plantar hyperhidrosis. This and other cases show that it is not only the functional or embarrassing feet sweating but it is also a safety issue which cannot be ignored by the patient or the insurance companies when it comes to the justification for the treatment.

Hyperhidrosis can deeply affect people socially and functionally in their everyday lives. Thankfully, there is a proven surgical solution for the condition.

Hyperhidrosis is a constant challenge:
By saying this we do not mean that it happens 24 hours a day, but we’re referring to the fact that it happens on a daily basis. For example, the vast majority of patients who suffer from hyperhidrosis have dry hands and feet at night. Very few patients will describe excessive sweating during night time.

The explanation for this is that during night time the sympathetic activity in the body declines to a minimal level. Subsequently, blood pressure and pulse rate are also down. Constant sweating also means that it happens in winter as well as in summer. If the patient is afflicted with hyperhidrosis, then it becomes a constant issue.

In rare occasions, a small number of patients will describe reduction in the amount of excessive sweating as they grow older. This can happen due to some unknown genetic changes.

Questions

Is the anatomy of the sympathetic chain the same for everyone?
No, although the sympathetic chain is similar in most people, in some cases it may be different. Only very experienced surgeons will be able to identify the abnormality and solve any issues presented.

Does diabetes have anything to do with hyperhidrosis?
There is no correlation between diabetes and hyperhidrosis, but patients who have diabetes might also have hyperhidrosis. Uncontrolled diabetes can produce generalized body hyperhidrosis, which is different from focal hyperhidrosis (armpits, hands, feet). View our complete page on hyperhidrosis and diabetes.

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Hyperhidrosis Questions:
For questions please fill out the form on our contact us page so we can better understand your condition in order to better answer your questions.

Other topics of interest:

• Sweaty Hands
• Sweaty Feet
• Armpit Sweating
• What is ETS – Endoscopic Thoracic Sympathectomy
• Details of the surgery
• Patient Success Stories
• Frequently asked hyperhidrosis questions

Please view our disclaimer.

Dr. Reisfeld is one of the world’s top hyperhidrosis surgeons. This page describes the most effective types of surgery, depending on the location and severity of a patient’s hyperhidrosis. Dr. Reisfeld is the only surgeon in the world who is an expert at all three major procedures listed below. This gives him unparalleled expertise in performing these surgeries:

1. For those who suffer primarily from severe and excessive hand sweating (palmar hyperhidrosis), endoscopic thoracic sympathectomy is most appropriate. Learn more about Endoscopic Thoracic Sympathectomy (ETS)
2. For those who suffer from severe excessive foot sweating (plantar hyperhidrosis) as their primary or only area of excessive sweating, or for those patients who did not see any results from endoscopic thoracic sympathectomy, endoscopic lumbar sympathectomy is appropriate. Learn more about Endoscopic Lumbar Sympathectomy (ELS)
3. For patients suffering from excessive armpit sweating (axillary hyperhidrosis), the current method is axillary suction currettage.

• Patients who suffer from excessive hand sweating as well as armpit sweating can benefit from a slightly modified ETS approach.

Learn more about Surgical Treatment of Axillary Hyperhidrosis

4. Even though ETS and ELS are very effective in treating hyperhidrosis in specific areas, these surgeries cannot be performed at the same time. At least 6 months should be allowed between each surgery. This time allows the body to adjust to physiological changes. It is up to the doctor and patient to determine which surgery is most appropriate for the patient.

Advantages of ETS Surgery For Hand Sweating

• ETS is the only procedure available that provides a proven surgical solution to excessive hand sweating (palmar hyperhidrosis).
• The procedure is proven to be safe and effective.
• This procedure has a 98-99% success rate.
• Dr. Reisfeld is highly experienced, performing the procedure on an almost a daily basis.
• Patients are able to go home the same day.
• Patients are able to return to their normal daily routine within a short time.
• For more information on ETS click here

Details of The Surgery (ETS – Endoscopic Thoracic Sympathectomy):

• The procedure itself is done on an outpatient basis. The patient returns home or to their hotel the same morning.
• The operation is done under general anesthesia. Two very small incisions are made.
• Air is inserted through the incision into the chest cavity. The reason for the air is to push the lungs away from the operation site. At no time does the lung collapse because we use single lumen intubation to prevent this from happening. This means that air is exchanged through both lungs throughout the entire procedure. Different ETS surgeons use different techniques. Some surgeons use double lumen endotracheal tubes, which in turn, can lead to a collapsed lung. Even with a collapsed lung, however, the lung will go back to its normal position once it is inflated again.
  • Endoscopic equipment (a fiber optic camera and a working instrument) is then inserted. Two high-resolution monitors are placed on either side of the patient, so the doctor has a perfect view of the custom-made instruments he is using.
  • The sympathetic chain is located along the rib’s head.
  • The endoscopic instruments are used to clamp the T3 to T4 segment of the sympathetic nerve node responsible for the cause of excessive sweating. Four titanium clips are placed on each side of the nerve chain. In cases of severe armpit sweating, clips are applied on the T5 level. The total amount of clips can range from 4 to 6. The theoretical basis for this idea is the fact that most of the sympathetic innervation to the head area originates at a T2 level. Leaving this segment intact renders more body surface (upper body) with sympathetic innervation, which results in less compensatory sweating. In 2006 Dr. Reisfeld completed an important clinical study on patients showed that the number of patients with severe compensatory sweating was reduced when the procedure was done at the T3-T4 level compared to the T2-T3 level. At the present time, for patients with the typical symptoms of sweaty hands, sweaty feet, and armpit sweating, Dr. Reisfeld performed the sympathectomy on the segment between the 3rd and the 5th rib. More clinical studies and research will need to be done to prove this further, but Dr. Reisfeld is very pleased with the findings so far.
  • Once the surgery is completed, the air is taken out and the lung returns to its normal position. The instruments are carefully removed.
  • The incision is then sutured internally with absorbent sutures. This eliminates the necessity for suture removal.
  • The process is then repeated on the other side of the chest.
  • At the present time, clamping is the procedure of choice, and the one recommended by Dr. Reisfeld. The primary reason for using this clamping procedure, is that it leaves the possibility for easy reversal if needed. If a patient is unhappy with the results of the procedure, a reversal may be done by performing a nerve graft operation. This procedure is much more involved, and time consuming when compared to clamp removal. In the clamping method, reversal is much easier because it simply requires removal of the clips, and by doing so gives the nerve segment the ability to regenerate. It has been shown that some patients who had the clamps removed showed less compensatory sweating (compensatory hydrosis or reflex sweating), or a total recovery from their previous symptoms.
  • Patients who have an similar problem with sweating in the hands and armpit area will benefit from the endoscopic thoracic sympathectomy on levels T3, T4, and T5. In other words, for those patients who describe their excessive hand sweating as equal to their excessive armpit sweating, adding sympathectomy at the T5 level will give them a higher chance of minimizing or eliminating their armpit problem as well. On the other hand, if patients only have excessive armpit sweating, Dr. Reisfeld’s current opinion is that a sympathectomy should not be done for isolated armpit sweating.
  • What happens to the rest of the sympathetic chain?
    There is tremendous overlap in function within the sympathetic chain, so there are no known long-term side effects. As the name implies, this is a chain of ganglia and not just one nerve.
  • Do you collapse the lungs during surgery?
    No, Dr. Reisfeld uses the single lumen intubation method. This allows air to go in and out of the lungs at all times. Surgeons that are using the double lumen technique collapse the lung on the side they where they are operating.
  • Dr. Reisfeld has performed dozens of clamp removal procedures. The results vary but about 50% of those cases showed improvements in their clinical condition. This translated into a reduction of compensatory sweating, better exercise tolerance, re-appearance of sweat in the hands and upper body, etc. Obviously more time is needed to come to any definite conclusions, but even in these scenarios, the results are promising
  • Most patients are able to walk out of the medical center within 2 hours after surgery. Regular physical activity and returning to work are both possible in one week or less. Scarring is minimal (About 10mm or 1cm), as the incisions are small and well hidden in the folds of skin.
  • Dr. Reisfeld personally checks up with each of his patients post surgery to ensure they are perfectly taken care of, and to answer any and all of their questions. Dr. Reisfeld takes pride in his excellent patient care. This is very evident in any of the patient testimonials he has received. To read what patients, from all walks of life, have to say about Dr. Reisfeld click here.
  • To learn more about how this life changing procedure could possibly help you, please contact us. Do you have a question that is not answered here? Just ask and we will answer. To ask your question click here.

Lumbar Sympathectomy – For Excessive Foot Sweating:

This particular procedure was added to the variety of surgical treatments for focal hyperhidrosis in 2006. Pioneering work was done in Brazil, Austria, and France. This work showed that a lumbar sympathectomy could be done efficiently, safely, and successfully for those patients with excessive plantar hyperhidrosis (foot sweating).
Lumbar Diagram

In this procedure, the doctor creates an incision to access the sympathetic chain that runs along the lumbar vertebrae. The operation is done under general anesthesia and takes about 1 to 2 hours. Patients typically go home the same day. However, in rare instances, some patients stay at the hospital for one night and then go home the next day.

If the operation starts early in the morning, the resulting pain and discomfort can be brought down to a minimum, enabling the patient to leave the medical facility 2-3 hours later. Typically patients can return to normal activities, such as work, within a few days.

In rare cases, the patient’s anatomy may be more difficult, so the operation may take a little longer. It should be re-emphasized again that because this is a more involved operation, that some patients may need a slightly longer stay at the medical facility. Dr. Reisfeld is always cautious to ensure the patients safety and well-being, so travel plans may be adjusted accordingly.

With the experience accumulated since about 2007, it became obvious that athletes with very developed lumbar area muscles were a special case. The sympathetic chain might be located between or underneath the muscle in these instances. This discovery was crucial, but it also meant that the procedure would need to be altered for athletes.

The operation is done endoscopically. In this approach there are three small cuts made on the side of the abdomen (flank region). The largest cut is about 15mm or 1.5cm, and the other two on each side are about 5-7mm. Through these cuts, endoscopic equipment is inserted. A space behind the abdomen is developed, and then the sympathetic chain running along the lumbar vertebrae is located.

The sympathetic chain is then clamped below the second lumbar vertebra. It is important to be at that level, to reduce the possibility of side effects. The exact location is confirmed with the help of X-Rays during the operation. In extremely rare cases, there may be a necessity to convert the operation from an endoscopic approach, to an open approach. The only difference here, is that one of the incisions is slightly longer. The amount of pain and the time spent at the hospital are the same.

The reasons that sometimes necessitate conversion to an open approach are: obesity, anatomical variations, and safety. The operation has about a 97-98% success rate, and it can help those patients where plantar hyperhidrosis is a major problem.

Make sure before any decisions are made to discuss the particulars of this operations with an experienced hyperhidrosis surgeon. To ask questions and learn more about how this life changing procedure could possibly help you, please contact us.

Treatments for Excessive Armpit Sweating:

• • In isolated cases, excessive armpit sweating can cause substantial discomfort, embarrassment, and social anxiety. There are a lot of treatment options, such as aluminum chloride lotions or antiperspirants. There are many varieties on the market as well (over the counter or prescribed).
  • BOTOX® Cosmetic also exists as a potential treatment to control armpit sweating, but it is costly and temporary.
  • Multiple surgical approaches have been used, from excision of the skin in the armpit area, to less invasive procedures where the inner layer of the armpit area skin is curated. Varying degrees of success have been noted.
  • Laser ablation or energy applied to the armpit through ultra sound ablation were used with somewhat inconsistent results. The opinion held by Dr. Reisfeld, is that the axillary suction curretage option has better long term results, but even in the doctor’s capable hands, results can vary. The procedure is short and results in a minimal amount of pain. Some swelling and discomfort are to be anticipated but those are temporary.
  • To learn more about how this life changing procedure could possibly help you, please contact us. It is important to note that patients should always try conservative methods and consult with their doctors before embarking on a surgical approach.

Groin Sweating:

For those patients who suffer primarily from groin sweating, visit our groin sweating page to learn about the options available.

Questions

Can I do the operation if I have scoliosis?
Yes, but we would need to know the degree of scoliosis. In experienced hands, this anatomical variation can be handled. Experience on the doctor’s part is needed to locate the nerve, which could slightly be off the regular course as a result of the condition.

Hyperhidrosis Questions:

For questions please fill out the form on our contact us page so we can better understand your condition in order to better answer your questions.

The information on this site is not to be used for diagnosis and or treatment, or to be used in place of professional medical advice from your doctor or physician. This web site is intended as an introduction to suction curettage. When considering this or any surgical procedure, consult with your surgeon for any additional information regarding the surgery, risks, complications, recovery, and results.

Can The Clamps Move After a Sympathectomy?

The sympathectomy procedure for excessive hand sweating, also known as palmar hyperhidrosis, has undergone many improvements over the last few years. The old method, in which the surgeon had to make large incisions in the neck, chest, or the back in order to reach the sympathetic chain, was replaced with the endoscopic method. This enables the surgeon to reach that location with minimal trauma and minimal downtime.

The next change came with the application of small titanium clamps to the sympathetic chain in order to stop the flow of nerve impulses to the sweat glands. The advantage of this method is that it offers a possibility for reversal. If a patient develops side effects which are worse than the original problem, the procedure can be undone. To date, Dr. Reisfeld has performed 30 reversals with a success rate of 68%.

Patients often ask if the clamps can move. For example, if a patient is engaged in a heavy physical activity. After performing thousands of surgeries using the clamping method, Dr. Reisfeld is not aware of any cases which showed a migration of the clips.
Click here for more info.

Other topics of interest:

• Sweaty Hands
• Details of the surgery
• Frequently asked hyperhidrosis questions

Please view our disclaimer.

The Differences Between Palmar and Plantar Hyperhidrosis

Most patients who suffer from palmar hyperhidrosis (excessive hand sweating) will also have excessive sweating in the feet (plantar hyperhidrosis). In the past when topical measures such as drysol, drionic or other conservative treatments did not help, patients then looked to surgical alternatives.

The Endoscopic thoracic sympathectomy (ETS) procedure is very effective for the treatment of palmar hyperhidrosis, but it is not as effective for plantar hyperhidrosis. The reason for the difference in success rates is not known. That being said, the current theory is the fact that most of the sympathetic innervation to the plantar sweat glands originates in the lower thoracic sympathetic ganglia and the first lumbar ganglia.

By performing the thoracic sympathectomy those ganglia are not affected. The sympathetic nervous system is made up of multiple sites that have different functions. The sympathetic chain in the lumbar region controls plantar sweating.

Up until a few years ago, there was some hesitation in performing the lumbar sympathectomy as well as the upper thoracic sympathectomy because of potential sympathetic dysfunction. For male patients, the side effects could also include retrograde ejaculation. Over the last few years, additional clinical work has been carried out in South America and Europe.

This research revealed that performing a lumbar sympathectomy after an upper thoracic sympathectomy does not cause sympathetic dysfunction. Instead, it offers a high rate of success for excessive plantar hyperhidrosis. By obtaining anatomic knowledge about the distribution of the sympathetic nerves in the lumbar region we now know that as long as you stay within the blockade level at or below lumbar vertebra #2, there is no influence on the male ejaculation process.

A Bilateral lumbar sympathectomy can be carried out on an outpatient basis or a very short hospital stay. It involves three small cuts on the left and right flank. The sympathetic chain at the L2-L4 level is clamped.

Other topics of interest:

• Sweaty Hands
• Sweaty Feet

Please view our disclaimer.

Heart Rate changes after endoscopic thoracic sympathectomy

When sympathectomy is performed for excessive hand sweating or palmar hyperhidrosis it is known to have a beta blocking effect on the heart. When the sympathectomy was performed at the second rib level there was about 6-8% reduction in the heart rate .For the regular patient who is not engaged in a very heavy physical activity it did not make a significant change. On the other hand those patients who are very physically engaged in demanding physical activities should know that their heart rate could potentially not go above 135 bpm.

Over the last few years some changes were applied to the method in which the operation is carried out. The first one is the clamping method which contains the possibility of reversal. The other change is that the level of the sympatectomy is lowered down to third rib level or T-3 level .What Dr. Reisfeld has found is that undergoing the surgery with the new methods those patients can raise their heart rate to about 155-160 bpm. The exact explanation is not yet known, but this could be due to the way the sympathetic fibers connected to the heart are organized. The cardiac sympathetic fibers come from the necks sympathetic ganglia and they converge to the heart and the aortic root at or about the T2 level. By doing the clamping method at the T3 level it allows most if not all of the sympathetic fibers to reach the heart without interruption and so rate change is much less pronounced.

Other topics of interest:

• Sweaty Hands
• What is ETS – Endoscopic Thoracic Sympathectomy
• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Please view our disclaimer.

The Top Reasons to Perform ETS

Dr. Reisfeld has been stating for several years that ETS should be conducted only for sweaty hands and feet. All other issues, including facial blushing, facial sweating, and axillary sweating have not been alleviated properly with an Endoscopic Thoracic Sympathectomy.

Dr. Reisfeld’s claims were recently reinforced by a paper published at the Mayo Clinic Proceedings. He believes that the results of the paper reflect his own vast experience with sympathectomies. As previously stated on this website and others, any patient with severe hand sweating or palmar Hyperhidrosis should first try conservative treatment options. Please see the Alternative Treatment page of the site for further details.

Understanding ETS Controversies
It is interesting to see that a higher number of unhappy patients came from countries where ETS was done for reasons other than severe palmar hyperhidrosis. In those places, facial blushing, facial sweating, and axillary hyperhidrosis were quoted as the main reason for doing the ETS procedure.

Those patients did not see the results they were looking for. They were also are left with bad side effects. This is the reason why Dr. Reisfeld, through his vast experience and research on this topic, maintains his position that ETS should only be done for patients who suffer from severe palmar hyperhidrosis.

It is Dr. Reisfeld’s belief that facial hyperhidrosis and or facial blushing should be treated with medications or other methods, instead of surgery. Axillary hyperhidrosis or armpit sweating should be treated with local measures, such as suction curettage, in order to prevent generalized side effects such as compensatory sweating.

Other topics of interest:

• Sweaty Hands
• What is ETS – Endoscopic Thoracic Sympathectomy
• Details of the surgery
• Patient Testimonials
• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Do you have a question that is not answered here? Just ask and we will answer you right away. To ask your question click here.

Please view our disclaimer.

My physician is not knowledgeable with hyperhidrosis, what shall I do?

To this day unfortunately there are many doctors who simply do not have an understanding of hyperhidrosis. Overall lack of knowledge about this subject is still very common within the general medical society. It is slowly becoming more acknowledged by physicians but if a response from a physician to the patient is lacking you can refer them (the doctor) to this site and links to all the in depth information provided including the various papers written by Dr. Reisfeld in respected peer reviewed medical journals. Dr. Reisfeld is also happy to speak with any physician about it.

Proven Cure for Sweaty Feet

• Success Rate
• Sweaty Feet Symptoms
• Sweaty Feet Causes
• Diagnosis
• Papers
• World Expert
• Questions

Sweaty feet (excessive foot sweating) is known medically as plantar hyperhidrosis. Most patients who have sweaty hands will also have sweaty feet. Excessive foot sweating can be as severe as hand sweating, sometimes even worse.

Problems in everyday life, both socially and functionally, can be difficult as a result. Shoes can be ruined, sandals cannot be worn, heels can be too difficult to wear, and foot odor or fungal infection can become problematic. It can lead to relationship and marital problems as well as difficulties at the work place. Fortunately, there is finally an outpatient surgical solution to this problem with a 97-98% success rate.

Sweaty Feet Treatment – Success Rate
The proven surgical solution, specifically for excessive foot sweating, is now offered by Doctor Reisfeld. This procedure offers an amazing 97-98% success rate. Why not 100%? There are some rare cases in which anatomical abnormalities can be found, preventing the surgeon’s ability to complete the operation safely.

Also, in some rare cases severe scarring from previous unrecognized infections, previous chemical lumbar sympathectomies, or other surgeries can prevent the surgeon from completing the operation safely. Safety always comes first in these elective procedures.

You may ask why is this important? Many hyperhidrosis surgeons will offer a completely different and much less effective surgical solution for excessive foot sweating called Endoscopic Thoracic Sympathectomy (ETS). The long term reduction rate of ETS for foot sweating is only 15-20%.

Dr. Reisfeld performs the Lumbar Sympathectomy (ELS), which has a much higher success rate of 97-98%. A recent survey conducted by Dr. Reisfeld (3500 patients who had previous ETS) shows that some of the patients did see improvements after ETS for their foot sweating, but a great number of them still suffer from excessive foot sweating.

For these patients, the Lumbar Sympathectomy is offered as the most effective option with high success rates. Doctor Reisfeld is the only surgeon in the U.S. and one of only a handful of skilled doctors in the world that performs this highly specialized procedure. Technically this procedure is basically different from the thoracic sympathectomy in that the space to get to the lumbar sympathetic chain has to be created by the surgeon which makes the operation a bit longer. Compared to the Thoracic Sympathectomy which can take anywhere from 30-40 minutes, the lumbar sympathectomy is somewhat longer between 75 minutes to 90 minutes (just over an hour). Once the space is created a delicate process takes place in order to isolate the sympathetic chain from the surrounding structures. For more details on the procedure visit our details of hyperhidrosis surgery page.

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Symptoms of Plantar Hyperhidrosis
As mentioned before, palmar hyperhidrosis (sweat hands) is one type of hyperhidrosis. There is a unique manifestation of sweat that is limited from the ankles to the toes. This particular anatomical distribution is missed by regular physicians who are looking for different causes to explain plantar hyperhidrosis.

Usually plantar hyperhidrosis is associated with palmar hyperhidrosis in more than 99% of the cases. Palmar hyperhidrosis is uniquely limited to the wrist and the fingers. When the patient has both excessive foot and hand sweating, this should direct the treating physicians to the diagnosis of focal hyperhidrosis.

As said before throughout this website, it is highly likely a genetically determined pathology (meaning someone in the family has or had it). A conservative treatment should be tried first, but keep in mind that the success rate is limited. Nevertheless, attempts should be carried out.

Causes of Excessive Foot Sweating
As far as we know, the same gene that causes palmar hyperhidrosis (excessive hand sweating) is responsible for excessive foot sweating as well. The gene causes heightened activity in the sympathetic chain, which is part of the involuntary nervous system. The difference, is that clinical manifestation of palmar hyperhidrosis will show itself earlier in life than plantar hyperhidrosis.

This is to say that excessive hand sweating is usually a problem earlier in life than excessive foot sweating. In our estimates, the reason for that is the maturation process of plantar sweat glands takes longer than palmar sweat glands. Of interest is the fact that plantar hyperhidrosis (feet) as well as palmar hyperhidrosis (hands) are limited to a specific part of that organ.

In plantar hyperhidrosis, the excessive sweating appears from the ankles down. In the case of palmar hyperhidrosis, the excessive sweating appears from the wrist down to the hands.

Diagnosis of excessive foot sweating:
How do I know if this surgical procedure is right for me? Plantar hyperhidrosis usually is associated with palmar hyperhidrosis. In about 5-10% of patients, plantar hyperhidrosis is the major symptom that requires attention. If a patient has to change their socks a few times a day, routinely has ruined shoes due to sweat, has macerated skin, and or recurrent infections that produce smell, these are all signs.

Any of the above or a combination of the above can be a reason to consult with a physician, and to try some conservative measures. This is a subjective issue that must be brought to the attention of a physician.

For Former ETS Patients
Performing upper Thoracic Sympathectomy (ETS) for excessive hand sweating often times does not fully solve the problem of excessive foot sweating. Only a small percentage of patients had the desired improvement. Until recently, no specific operation was offered for patients suffering from excessive foot sweating.

Surgeons in other countries developed the Lumbar Sympathectomy, which is specifically targeted for excessive foot sweating. In this special approach, a specific segment of the sympathetic chain within the lumbar region is cut or clamped to relieve excessive foot sweating. The important difference between a Thoracic Sympathectomy and a Lumbar Sympathectomy, is that the Thoracic Sympathectomy helps specifically with excessive hand sweating, while Lumbar Sympathectomy helps specifically with excessive foot sweating.

It should be understood that even though patients who suffer from hand sweating also suffer from excessive foot sweating, the Thoracic Sympathectomy (ETS) helps mainly with excessive hand sweating. For those patients who underwent a Thoracic Sympathectomy and did not see improvements with their foot sweating they now have the new and proven option of Lumbar Sympathectomy to help with their symptoms. This is great news for anyone suffering from excessive foot sweating.

Unique Hyperhidrosis Expertise
Doctor Reisfeld is currently the only known surgeon who has the expertise to perform both the Endoscopic Thoracic Sympathectomy and the Endoscopic Lumbar Sympathectomy procedures. He has authored or co-authored multiple peer reviewed papers and studies on the topic. This speaks greatly to his years of dedication and practice as a pioneer in the field of hyperhidrosis. When it comes to selecting the very best hyperhidrosis surgeon in the world, Dr. Reisfeld tops most people’s lists.

Currently, Dr. Reisfeld performs unique procedures for each type of focal hyperhidrosis. To learn more about each procedure, please see our hyperhidrosis treatments page.

Plantar Hyperhidrosis and mild Palmar Hyperhidrosis
For patients who have plantar hyperhidrosis as well as mild palmar hyperhidrosis, there’s something to note. If you decide to do the ELS surgery first, you might experience an increase in palmar hyperhidrosis to a level that was not significant before. How long this increased level of palmar hyperhidrosis will occur is not yet known, but the patient should be aware of this possibility. Whether ETS will be necessary or not is still unknown.

History of The Lumbar Sympathectomy
Since about 2005, a lot of information was obtained in regards to the performance of a lumbar sympathectomy for those patients who suffer from plantar hyperhidrosis. This new information also helped people who underwent an endoscopic thoracic sympathectomy and didn’t see improvements.

This information about lumbar sympathectomy was gathered initially in countries such as Brazil, France and Austria. The Lumbar sympathectomy became the operation of choice for those patients. It is done equally on female and male patients. The question of whether or not the operation will affect retrograde ejaculation in male patients was proven not to be a problem.

The solution was to adjust the level of the lumbar sympathectomy below lumbar vertebrae #2. This particular question should be discussed at length with the surgeon before any male patients proceed with lumbar sympathectomy regardless.

Percutaneous chemical denervation ( chemical lumbar sympathectomy) of the lumbar sympathetic chain is practiced in some places, but depending on the material used, the effect can be temporary or run the risk of associated injuries to nearby organs such as the ureters or blood vessels.

The reason for that risk is that when the chemical component is injected, it can progress to nearby structures without any ability to limit its spread. The benefit of surgical lumbar sympathectomy is that those organs nearby are recognized and protected throughout the procedure.

Pain after the operation is typically minimal and temporary. So far the pain after a lumbar sympathectomy is described as less than the pain experienced after ETS. A decision to go forward with this operation should be considered only after a detailed discussion with the surgeon to perform the procedure occurs. To learn more about the details of lumbar sympathectomy click the link. Most of the patients had a one night stay and occasionally some patients go home the same day.

In summary, as excessive hand and foot sweating becomes better understood in the medical field, we can now say that those problems are best helped with surgical approaches once the conservative measures have been used with no success. Excessive hand sweating (palmar hyperhidrosis) can be fixed in about 97-98% of the cases with an upper Thoracic Sympathectomy.

With this procedure, excessive foot sweating can only be partially healed. Now, thanks to extensive clinical work done in other countries such as Brazil and Europe, as well as with the United States, excessive foot sweating can be cured with a lumbar sympathectomy. For patients on whom Thoracic Sympathectomy did not help with their feet, the Lumbar Sympathectomy is a valuable and viable procedure.

New Observations
For patients that have compensatory sweating in the groin/buttocks areas after having first done the ETS procedure, there is some observed improvement after performing the lumbar sympathectomy at a level of L2 or close to L2 as possible. This observation came about after Dr. Reisfeld performed a lumbar sympathectomy at this level for patients with foot sweating and they claimed that their groin/buttock sweating improved.

Learn more about the Lumbar Sympathectomy for foot sweating treatment.

Lumbar Sympathectomy Doctor/Peer Reviewed Paper:
Dr. Reisfeld finished working on an important published paper regarding his experience with the initial 65 patients who underwent the lumbar sympathectomy. The paper is very significant because it adds further proof to the validity of performing endoscopic lumbar sympathectomies for patients who suffer from resistant plantar hyperhidrosis. The paper is available for review here:

Endoscopic Lumbar Sympathectomy for Focal Plantar Hyperhidrosis Using the Clamping Method – August 2010.

Second Paper
A second paper, completely dedicated to the topic of lumbar sympathectomy, will appear soon in peer reviewed surgical journals. This paper deals with the issue of lumbar sympathectomies. The accumulative experience of about 154 patients is reviewed. The experience gained between the first paper (2010) and now is reflected and, as time goes by, the increased number of cases performed is going to shed more light into the problem. This will improve the technique, outcome, and satisfaction of patients involved.

Questions:

What if I have only plantar hyperhidrosis (foot sweating) without any palmar hyperhidrosis (hand sweating)?
We are seeing more cases where the patient’s only problem is plantar hyperhidrosis. It is a somewhat smaller group of patients, but their foot sweating is severe enough to pose as many problems as people with hand sweating. Dr. Reisfeld is happy to discuss your specific condition on a one-on-one basis to help you determine if surgery is the right option for you.

As more experience is gained over time a solitary presentation of plantar hyperhidrosis only is not a good indication to do ELS. For some unexplained reasons those patients with only plantar hyperhidrosis do not respond as well to lumbar sympathectomy. They might get some temporary relief of plantar hyperhidrosis but it is not a long lasting relief. The reason for that is not known however if more information becomes available in the future then the approach might be changed. It is imperative for the patient, who suffers only from excessive foot sweating, to talk with the doctor who understands the problem and is aware of the unique situation of plantar hyperhidrosis.

What is The Truth about Subdermal Curettage as a Treatment Method for Plantar Hyperhidrosis?
You may have read that subdermal laser curettage is being used by some doctors as a treatment for plantar hyperhidrosis. This is a way to entice patients to go this route with no proven success rate or any value to it. Patients who chose this route describe total failure with this approach and a tremendous amount of pain and discomfort.

They also describe an inability to use their feet, which confines them to wheelchairs (temporarily). Laser suction curettage, or simply suction curettage, in the axillary area has some value in isolated cases of axillary hyperhidrosis.

These days, doctors could offer another approach for the treatment for axillary sweating (armpit sweating). The reason there is no value in this approach in cases of plantar hyperhidrosis, is because of the fact that there is almost no subcutaneous tissues in the plantar region.

Foot Sweating (Plantar Hyperhidrosis) Summary
Excessive foot sweating can be a serious problem, both in social settings and everyday functional activities. This can also affect intimacy between couples due to the smell, discomfort, and embarrassment it causes. This is especially true for women having difficulties wearing the appropriate footwear.

You may ask what should I do? Those affected should first discuss the matter with their doctor and then first try the conservative hyperhidrosis treatment measures available. If those measures do not give satisfactory relief, then consideration should be given to the hyperhidrosis surgical treatment options.

At present, the endoscopic lumbar sympathectomy procedure has been refined to the level that it can now be done on an outpatient basis. This allows patients to return home or to their hotel on the same day as the procedure. The success rate for the surgical procedure is excellent at 98%

Hyperhidrosis Testimonials
“I am able to wear whatever shoes I want. I can buy a beautiful dress, a beautiful pair of shoes, and not the shoes that are “ok” just because my feet will sweat.”
Florijana Read More From Florijana

“I not only love my dry hands, but I love my dry feet and armpits as well. In the summer I was able to wear sandals and even flip flops! I just can’t believe how well my body has responded to the procedure.”
Susana Read More From Susana

“I believe the surgery took place sometime in 2001. I am happy to say that everything is going well. I attribute the ETS procedures as a major part of my success.” (7 Years Later)
Paul Read More From Paul

“I admire your impeccable professionalism and your utmost skill in the performance of this highly technical and precise surgical procedure. I have waited many years since I was a young girl to properly get rid of this problem. My knowledge as a dermatologist led me to the best procedure, and to the best doctor.”
Ligaya.B, M.D. Read More From Doctor Ligaya

“I had the ETS surgery for palmar hyperhidrosis done in 2003, and wanted to thank you and your staff for all of the help. Taking a standardized test in the past was nearly impossible without handing in a sopping wet ScanTron sheet. Since my surgery date, I was able to take the paper and pencil medical school entrance exams. I applied to medical school, and now I am a second year medical student in Ohio! This surgery changed my life.”

Sarah Read More From Sarah

“I would also like to thank all of your staff for such a pleasant experience. They were very friendly and helpful. From the first time that I made a phone call to your office, up to the time in the recovery room. Everyone made me feel very comfortable and well taken care of.”

Peggy.P Read More From Peggy

Read from several touching thank you letters Dr. Reisfeld has received over the years since 1996.

Frequently Asked Sweaty Feet Questions:

• Is it normal to have sweaty feet?
• What is the best procedure for my excessive foot sweating?
• What is Lumbar Sympathectomy?
• What if my insurance says they do not cover this particular procedure?
• Why should I travel to Los Angeles to see Dr. Reisfeld?
• Does lumbar sympathectomy affect pregnancy?
• What to expect after the lumbar procedure
• Please see our hyperhidrosis frequently asked questions section for additional questions.
• Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?

Do you have any questions about foot sweating that were not answered here? Would you like to speak with Dr. Reisfeld to answer those questions? To learn more about what we can do for you, contact The Center for Hyperhidrosis by contacting our office or post your comments or questions below and we will do our best to reply.

Please view our disclaimer.

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What about the websites against the surgery?

First and foremost people considering the surgery should understand the facts.

The vast majority of patients experience a higher quality of life after the operation as compared to before the operation. Many studies have been conducted that showed better quality of life (QOL) after ETS.
ETS has been around and improved since the early 1990’s. It’s important to choose a doctor who does the surgery on a routine basis and has expert understanding of the physiology involved with this operation.
Every surgeon is different with their methods and techniques.
Fact – The success rate of the ETS (hands) surgery is 98-99% Dr. Reisfeld has conducted peer review studies documenting the success of this surgery.
Fact – The success rate of the ELS (feet) is also in the range of 98%. Dr. Reisfeld has conducted peer review studies documenting the success of this surgery.
Dr. Reisfeld speaks with each and every patient carefully evaluating their case.

Among the thousands who have had the operation there will be a certain number of patients who are going to be unhappy with the outcome. It’s important to first understand the many factors that can contribute to this.

Having the surgery done for the wrong reasons:
Among those are patients who had the operation done for clinical situations that ETS is not the best solution for. Dr. Reisfeld believes that ETS should not be done for facial sweating, facial blushing, or isolated axillary hyperhidrosis because of the unsatisfactory end results. Unfortunately there are many doctors, throughout the world, including in the U.S. who will do surgery for the above conditions even though it’s wrong in Dr. Reisfeld’s opinion.

Unfortunately some of those unhappy patients, who had the surgery done for the wrong reasons, are now advocates against the surgery. You have to look at each case carefully to really understand reasons for failure.

Dr. Reisfeld speaks with every single patient carefully evaluating their case. Often he will refuse to do the surgery when he feels that the operation is not best suited for the patient.

The doctor who performs the surgery:
Any doctor who wants to perform ETS should be aware of the right indications to perform that surgery. Besides the basic technical aspects that can be mastered there is a need to understand the basic problem of excessive focal hyperhidrosis and the ultimate results when the operation is performed for the wrong reason. Dr. Reisfeld comes across patients who are experiencing negative side effects from an operation that was not right for them.

Who the patient speaks with before the surgery:
All patients should make sure they speak with the doctor who performs the actual surgery vs. anyone else. Unfortunately in many places this is not being done.

Do not rush into the surgery:
There are various conservative measures that should be considered before doing the surgery. It is a sound recommendation to try those first. See our alternative hyperhidrosis treatments page for more information.

Other topics of interest:

• Frequently asked hyperhidrosis questions
• Ask Dr. Reisfeld a question

Do you have a question that is not answered here? Just ask and we will answer you right away. To ask your question click here.

Please view our disclaimer.

Can poisons or certain foods influence hyperhidrosis?

Basically the answer is no. Hyperhidrosis is a genetically induced illness. As it’s show in many papers more than 50% of the patients do have some family history of that particular illness in their family tree. It can skip generations so you may not see it in your immediate family but previous generations may have had it. Please see our page on genetic history.

What is the difference between “truncal sympathectomy” vs. “ramicotomy” for hyperhidrosis?

Over the last so many years there questions about the right operation for Palmar hyperhidrosis came time and time again. Obviously the older and the very aggressive surgical methods (trans cervical approach, dorsal approach from the back, transthoracic approach) to perform sympathectomy were replaced by the endoscopic approach (ETS).

The second improvement that was implemented over the years was the move from performing ETS at the second level (T2) to lower levels (T3, T4, T5). Basically lowering the level of the sympathectomy lowered down the number of cases with severe compensatory sweating. It did not eliminate it completely but statistically the numbers are better. The third improvement that happened that came about was doing the sympathectomy with titanium clamps vs. destruction of the sympathetic chain trunk.

Another surgical possibility that was tried was to divide the rami (nerve branches) that go towards the hands and the armpits. The reason for doing so was the idea that it would produce less severe compensatory sweating cases. In a small amount of studies with a limited amount of patients and limited follow-up it showed that there was reduction in the amount of cases with severe compensatory sweating. On the other hand more long term studies showed higher recurrence rates. So it’s a matter of choosing between possibly less severe compensatory sweating and higher possibility of recurrence.

Dr. Reisfeld feels optimistic about what Ramicotomy may have to offer as a less aggressive surgical approach. The decision about doing Ramicotomy is something that would need to be determined on a case by case basis after careful discussion between the surgeon and patient.

What about excessive sweating in the buttocks area?

Excessive buttocks sweating can be a side effect of ETS where part of the compensatory sweating from the ETS procedure presents itself in the buttocks region.

Cases of primary buttocks sweating, where the patient did not previously have the ETS procedure, are rare but are known to occur. The treatment for the primary cases should be conservative ones with lotion, etc. There have been cases where excessive buttocks sweating was improved after the lumbar sympathectomy procedure that was done for plantar sweating (foot sweating). It is still premature to conclude that lumbar sympathectomy will help primary or secondary cases of excessive buttocks sweating.

Obesity and Buttocks Sweating
Overweight people have a higher tendency to have isolated buttocks sweating but the same solution should also be applied to them in a way that conservative treatment with lotions, possible oral medications, and special clothing with high absorption power should be attempted. The possibility that sub-dermal laser ablation coupled with suction curettage will be of any help is still too early to tell.

Possible Treatment for previous ETS patients
In summary the only surgically addressable problem of buttocks sweating will be those patients who previously had the ETS surgery done and as part of their compensatory experienced excessive buttocks sweating. As mentioned in previous pages of this website there is an improvement with compensatory sweating of the buttocks area when lumbar sympathectomy is done specifically for foot sweating. This could be accomplished when the level of the lumbar sympathectomy is kept as close to the L2 level as possible. By staying close to the L2 level surgically, the sympathetic fibers to the buttocks area are also clamped thus helping with buttocks sweating. As more information is gained more accurate answers can be given. As more experience has been gained when one performs ELS in certain patients where the anatomical layout is showing that certain branches of the sympathetic chain are splitting towards the groin and the buttocks area and those are clamped it will give improvement to those patients in regards to their buttocks and in groin sweating. This does not apply to all patients because the anatomy is different from one person to another.

Do you suffer from this? For those patients who suffer from hydro hidradenitis suppurativa please refer to our groin sweating page.

• Lumbar Sympathectomy
• Groin Sweating

Hyperhidrosis in Males

Statistical analysis from many clinical studies shows that the percentage of males with hyperhidrosis is somewhat less the female population, but not to a significant degree.

This difference could also be the result of social and cultural perspectives between males and females. Men are sometimes less concerned about sweating as it pertains to their masculinity.

In modern society, there are many jobs, social interactions, and settings (relationships) that will have the same degree of embarrassment on males with this condition. Over the years, statistically speaking, more men have been asking about a surgical solution for hyperhidrosis.

We have found that patients with a family history of hyperhidrosis have more history of the condition on their mother’s side of the family.

Male Foot Sweating
Compared to the female population affected by excessive foot sweating (plantar hyperhidrosis), men are less particular about it. Never the less, having wet socks throughout the day, producing bad odor, and recurrent skin problems such as infection and maceration can pose serious problems.

Men also report the necessity to change and or buy footwear on a very frequent basis. The ELS procedure can go a long way towards relieving the symptoms of this condition. For more information please visit our foot sweating page.

Male Armpit Sweating
Excessive armpit sweating can pose serious problems for men in professional and social settings. Armpit sweating that repeatedly appears through one’s clothing can be embarrassing. Men with this issue are often forced to wear certain types of clothing or to go to great lengths to hide their condition.

Generally speaking, male armpit odor is stronger than females, and therefore can be more bothersome to those around you. To learn more about this please visit our armpit sweating section.

Male Hand Sweating (Sweaty Palms)
Sweaty Palms, or sweaty hands, present problems for men in both the workplace and in social settings. Shaking hands in a business meeting, for example, can be embarrassing for men who refuse to shake hands because of their sweaty palms.

Sometimes it can create degrading comments from those you’re shaking hands with. Learn more by visiting our hand sweating page.

For both male and female patients, ts the same principles apply. Each patient should take time to understand what hyperhidrosis is first. Then, they should discuss the situation with their doctor. Conservative treatments should come first. If satisfactory improvements do not occur, then it’s time to discuss possible surgical options with a surgeon who is knowledgeable in the procedures available.

The surgery itself is often a liberating type of experience for many who have suffered with this condition for years.

The procedure is done on an outpatient basis (same day). Patients can resume physical activity in a relatively short time period (days not weeks). There is also a very small amount of scarring.

• Symptoms and Causes
• Hyperhidrosis Surgical Treatments
• Do you think you suffer from hyperhidrosis? Find out for sure, Contact Us

Female Hyperhidrosis – Symptoms, Causes, & Treatments

Hyperhidrosis affects between 1.5% and 2% of the population. There is a significant number of cases in women as well as men. Hyperhidrosis has many social and functional implications that can affect women. This can be especially difficult for women in certain situations; ranging from being able to wear certain types of shoes or clothing to social and relationship settings, as well as workplace settings. Some patients express issues affecting self-confidence, frustration, and overall social inhibition due to this condition.

Female Feet Sweating
Severe feet sweating (plantar hyperhidrosis) usually affects women more than men. This may be due to women’s focus and style of footwear and fashion of today’s society. Patients who suffer from severe sweating, usually cannot wear certain types of shoes, such as high-heels or even sandals, due to the sliding from the excess sweat. Excess sweat can cause slipping, which some patients have reported causing accidents, falls, and ankle fractures. For patients not having the freedom to choose their preferred footwear can be a frustrating experience. Many of Dr. Reisfeld’s previous patients have expressed the liberating experience of wearing shoes again without the fear of embarrassment or for fear of their safety.

Of interest is the fact that young female patients, in their teens, who suffer from hyperhidrosis and already had the ETS procedure for their hands, are pushing more and more to get their ELS as well. This is because of the above mentioned problems they face where their plantar hyperhidrosis (excessive feet sweating) is becoming a major problem as much as it affects females in the somewhat higher age group.

Patients who experience excessive foot sweating that was not helped by the ETS procedure should consider the ELS procedure as a possible alternative solution. Learn more about foot sweating.

Female Hand Sweating
For women, their hands like their feet represent a very feminine characteristic. This is especially true when it comes to relationships and intimacy. Other important daily routine activities such as using a computer, smart phone, driving, or applying makeup, can pose certain challenges to those who are affected by palmar hyperhidrosis (excessive sweating of the hands). If more conservative measures that are recommended for every patient are not successful than a surgical approach is often times considered. To learn more about the surgical procedure please visit our hand sweating page.

Female Armpit Sweating
Learn more about excessive armpit sweating treatment.

The surgery itself can offer a liberating experience for patients who have suffered from this condition for many years.

With regards to the cosmetic results, the ETS operation is done with minimal scarring. Many patients do not consider this a negative due to the relief that they experience after the procedure. Surgical solutions should only be considered after other more conservative and alternative methods are tried first.

• Symptoms and Causes
• Hyperhidrosis Surgical Treatments
• Contact Us

Is obesity a factor in performing ETS (hands) or ELS (feet) surgery?

Obviously obesity plays a role not only with the amount of sweating the patient has but also with the technical challenge of doing any operation on an obese person. Patients who are obese have more sweat glands per square inch than a non-obese person. An obese person has more overall body surface.

Any operation on an obese person creates a challenge both from the anesthesia point of view as well as on the technical aspect of the procedure itself. For example the sympathetic chains in the chest or in the lumbar region are covered with more fatty tissue in an obese person making the isolation of the nerve difficult or sometimes even imprecise to proceed with a safe operation.

Obesity does not exclude you from doing the procedure but it may have an impact. Each case should be discussed with the surgeon doing the procedure.

Night Sweating:

A certain amount of people describe or ask about their night sweating. They wake up in the morning and their hair is soaked and their pillow is wet. This is not a type of focal hyperhidrosis that can be treated with any surgery. Mostly these questions come from the more mature age group but from time to time those questions are posed by younger patients. In the younger age group obesity is a factor as well as some underlying diseases such as diabetes or thyroid problems which should be investigated by the primary care physician.

The exact cause of night sweating is unknown at it can be a normal variant in a certain population group. Underlying anxiety could also contribute to this problem or certain dietary habits.

A small percentage of patients (1-2%) will report excessive night sweating after ETS. In most of the cases this is a temporary situation where the patient is experiencing excessive night sweating for which the reason is still unknown. Luckily this night sweating is on a temporary basis and most likely has to do with thermal regulation. This situation is self-limiting and of those who complained about it none reported long term effects.

Do you experience night sweating? What have you tried to deal with this?

Nervousness, Anxiety, Apprehension and Hyperhidrosis

Even though hyperhidrosis is mediated by familial genes and it is an involuntary reaction there is always some level of nervousness, anxiety and apprehension that will increase the amount of sweating. A person afflicted with hyperhidrosis can go from normal dry hands to totally wet ones – dripping in a matter of seconds when that patient is having any level of nervousness, anxiety or apprehension. At the same time those afflicted with hyperhidrosis can have sweaty hands even in the most relaxing states of their lives. To what degree changes in mental status can affect the sweating is nothing that can be easily measured. It is easy to say to a patient “calm down” but it is not something easily done.

This particular connection between nervousness etc to hyperhidrosis has lead physicians and patients alike to the usage of “relaxing medications” or anti-anxiety medications. Also alcohol is known to have a relaxing effect and hence reduces the sweating but all of the above mentioned modalities are not the most appropriate approaches to the problem. Recreational drug use is also known to reduce the sweating because of the relaxing effects. Again here it is not recommended as a treatment modality.

Does diabetes have anything to do with hyperhidrosis?

Is there any connection between Hyperhidrosis and diabetes? Diabetes mellitus has two forms: type 2 diabetes and type 1. Type 2 diabetes is a situation where the pancreas does not produce enough insulin to control blood sugar levels. It most commonly appears in the later parts of life, but not always.

We treat this type of diabetes with oral medications, weight reduction, increased physical activity, and a healthy lifestyle. Type 1 diabetes is a clinical condition in which the patient must supply insulin to the body by means of injection. It is beyond the scope of this forum to discuss it in more detail.

Hyperhidrosis and diabetes have no direct connection. Hyperhidrosis is commonly a result of genetics. Diabetes, if left uncontrolled for years, can cause peripheral neuronal damage.

Damage is commonly found in the (sensory fibers) nerves. Diabetes does not affect the sympathetic chain, which belongs to the involuntary nervous system. The somatic and sympathetic fibers are different in their origin, purpose, and function.

Diabetes and hyperhidrosis can appear independently. A sympathectomy should not have any direct effect on one’s state of diabetes. Uncontrolled diabetes can produce generalized body hyperhidrosis, which is different from focal hyperhidrosis (armpits, hands, feet).

A Surgical Solution for Excessive Foot Sweating

A Lumbar sympathectomy is done under general anesthesia. It involves 3 small cuts for the endoscopic approach into the retro-peritoneal area. Once the surgeon is there, a space is developed and the sympathetic chain at the lumbar region is located. At this point, it is either excised or clamped at the levels L3-L4. This particular procedure is done on both sides. The operation takes about an hour to perform and in contrast to the endoscopic thoracic sympathectomy, the patient should stay over at the hospital for one day.

As more experience is gained by the doctor, a lumbar sympathectomy can be performed on an outpatient basis. In a typical case like this, if the operation starts early in the morning and the anatomical relations are displayed easily, the resulting discomfort can be brought down to a minimum. This enables the patient to leave the hospital later that day.

Many more cases must be done in order to establish a definitive pattern, which would allow us to do the majority of these cases on an outpatient basis. There are a few sensory nerves located close to the lumbar sympathetic chain. It is very important to avoid them, but even if the nerve is damaged, the result can be some numbness in the inner thigh region. Fortunately, this is temporary.

The current success rate is approximately 97-98%. Possible side effects include bleeding, pain, discomfort.

Even though retrograde ejaculation has not been proven to be a problem in Lumbar Sympathectomy procedures, it is worth discussing.

Potential patients for Lumbar Sympathectomy should be aware of the fact that sometimes, in very rare cases, due to technical difficulties there might be a need to change the operation. The procedure would change from an endoscopically assisted Lumbar Sympathectomy, to an open Lumbar Sympathectomy.

This will involve incisions on both sides measuring about two inches in size. The added discomfort or pain is very well tolerated by patients in situations where the operation had to be converted. The scarring is minimal as well.

It is important to keep in mind that this is a technical difficulty that can arise. Prior to the surgery, the patient is given the very clear choice to allow conversion from an endoscopically assisted to an open lumbar sympathectomy. The reason this is offered is to allow for more approaches to successfully complete the procedure.

The current method being used to perform ELS gives us better opportunities to examine the sympathetic chain. Obviously different centers use different approaches, but in comparing the methods, we found out that our current method gives an ability to examine the sympathetic chain over a longer segment. This enables us to make sure that all sympathetic fibers below the lumbar vertebra #2 are clamped for the best results.

It is a known fact that all sympathetic fibers below the lumbar vertebra #2 run to the feet. If the lumbar sympathectomy is done in a lower level (ie 3 or 4), one might miss some very fine fibers that run to the feet. This could result in a less successful outcome.

Clinical Results Thus Far (500 + Cases):
The clinical experience accumulated since 2008 shows that the lumbar sympathectomy is a very effective method for treating severe plantar (sweaty feet) hyperhidrosis. Most of our patients previously had ETS performed with zero results. As time goes by more people with primary plantar hyperhidrosis are having lumbar sympathectomy performed as well.

The success rate is about 97-98%, and side effects such as increased compensatory sweating, pain, discomfort, and scars are minimal. Retrograde ejaculation (male patients), sexual dysfunction, or hypotension has not occurred in any of Dr. Reisfeld’s 500+ lumbar sympathectomy cases. Dr. Reisfeld continues to work hard to further develop and improve this procedure. No other surgeon comes close to this level of experience.

In ETS cases, at about 3 to 4 days after the lumbar sympathectomy, another bout of sweating occurs. As we learned from previous ETS cases, this is a short bout of sweating and it stops in a few hours or up to a day later. So far no increase in compensatory sweating has been noted after the lumbar sympathectomy procedure. Some patients will have an initial increase in their compensatory sweating, compared to what they had after the procedure.

The ELS procedure will cause fluctuation in the amount of compensatory sweating, but in the long run, these changes will go back to normal. This is why the time interval between ETS and ELS should be at least 6 months. On the other hand, patients who experience any level of compensatory sweating after an ETS procedure should expect that level to stay. Keep in mind ETS is a separate procedure from the lumbar sympathectomy. Learn more about ETS.

Some patients who previously had ETS done, and later underwent lumbar sympathectomy experience hand sweating. This a temporary occurrence and will resolve itself in a short time.

So far, information about compensatory sweating in patients who had only lumbar sympathectomy done is not yet available. This is due to the small number of cases where only the lumbar sympathectomy was performed. In the small amount of cases where only lumbar sympathectomy procedures were done, compensatory sweating was mild. It is still too premature to draw any definite conclusions.

In regards to the recurrence rate after an endoscopic lumbar sympathectomy, the numbers are not yet in. There are rare reports of some limited-partial recurrence. This can be the result of abnormal branches that are supplying the feet with sympathetic innervation. Again, those observations were made in a very small number of cases, and more time will be needed to define the exact reason for this limited recurrence.

Related Studies:
In 2013 Dr. Reisfeld published another important study in regards to the treatment of severe plantar hyperhidrosis. Dr. Reisfeld is proud to be one of the few surgeons who has invested his time and effort to study and advance this subject. View this study.

In a paper published in December 2009, there is a description with results with in regards to the surgical treatment of plantar-feet hyperhidrosis. Across 90 patients, the procedure had a high success rate and overall satisfaction. For a brief summary of this paper see -> Endoscopic lumbar sympathectomy for plantar hyperhidrosis.

In a separate study about (Endoscopic sympathectomy for palmar and plantar hyperhidrosis: results in 107 patients), published in 2000. French surgeons performed 78 lumbar sympathectomies. Their results are similar to those published in the previous paper, as well as by Dr. Reisfeld in his published/peer reviewed paper on ELS. The French authors performed ELS only on women.

The History of The Lumbar Sympathectomy
Lumbar Sympathectomy is a procedure that used to be performed for patients with vascular insufficiency (blood supply problems – to lower legs). The idea was that by doing a sympathectomy, the vaso constrictive influence of the sympathetic chain on the blood vessels would be abolished. Therefore, the blood vessels would be open and provide a better blood supply to the legs.

This was done for many elderly patients with vascular insufficiency, but the results were poor. Lumbar sympathectomies are rarely done for this purpose in today’s medical world, and is being replaced by different medications. This is not to be confused with the lumbar sympathectomy procedure for excessive foot sweating.

Another condition for which Lumbar Sympathectomies are rarely done, is for complex regional pain syndrome or sympathetic neuralgia. Since this syndrome is not well understood, the results are inconclusive.

The Lumbar Sympathectomy procedure is, however, very effective in treating plantar hyperhidrosis. The same principal applies in cases of palmar hyperhidrosis, where a thoracic sympathectomy is very effective in treating excessive hand sweating. The current success rate is approximately at 97-98%.

Like in any other surgical procedure that tries to correct physiological – genetic problems with mechanical solutions, the issue of recurrence will always be a possibility. Even though the possibility is extremely low, it can happen.

There are two main factors that typically contribute to this: The inexperience of the surgeon, and the fact that some anatomical variations can exist (everyone’s body is different). The surgeon of choice should have extensive experience and knowledge.

Questions

When does conversion from an endoscopic lumbar sympathectomy to open lumbar sympathectomy happen?
Overweight patients, or those patients who had previous operations performed in the vicinity of the lumbar region (such as c-section, hysterectomy, kidney operation), can create scar tissue. This will make the endoscopic lumbar sympathectomy more difficult to perform. The option of an open procedure is always available, but extremely uncommon.

Does lumbar sympathectomy affect pregnancy?
So far there is no known connection between lumbar sympathectomy and the ability to become pregnant. On the contrary, Dr. Reisfeld’s female patients who had this procedure have become pregnant without any issues.

Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
No, but there are some instances in which patients describe a temporary increase in their hand sweating after their lumbar sympathectomy. Those patients already had the thoracic sympathectomy performed for their excessive hand sweating. This is temporary.

Could my feet become too dry after lumbar sympathectomy?
There has been one case where a patient was complaining that her feet after the lumbar sympathectomy were very dry to the level of discomfort. This particular patient had only plantar hyperhidrosis done without any palmar hyperhidrosis associated with it.

The rest of the cases where the lumbar sympathectomy procedure was done after thoracic sympathectomy did not report this effect. The reason for this extreme dryness in a patient who only had plantar hyperhidrosis is unknown at this time. More cases will have to be done in order to understand this problem better.

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• Lumbar Sympathectomy Study

Proven Cure for Sweaty Feet

• Success Rate
• Sweaty Feet Symptoms
• Sweaty Feet Causes
• Diagnosis
• Papers
• World Expert
• Questions

Sweaty feet (excessive foot sweating) is known medically as plantar hyperhidrosis. Most patients who have sweaty hands will also have sweaty feet. Excessive foot sweating can be as severe as hand sweating, sometimes even worse.

Problems in everyday life, both socially and functionally, can be difficult as a result. Shoes can be ruined, sandals cannot be worn, heels can be too difficult to wear, and foot odor or fungal infection can become problematic. It can lead to relationship and marital problems as well as difficulties at the work place. Fortunately, there is finally an outpatient surgical solution to this problem with a 97-98% success rate.

Sweaty Feet Treatment – Success Rate
The proven surgical solution, specifically for excessive foot sweating, is now offered by Doctor Reisfeld. This procedure offers an amazing 97-98% success rate. Why not 100%? There are some rare cases in which anatomical abnormalities can be found, preventing the surgeon’s ability to complete the operation safely.

Also, in some rare cases severe scarring from previous unrecognized infections, previous chemical lumbar sympathectomies, or other surgeries can prevent the surgeon from completing the operation safely. Safety always comes first in these elective procedures.

You may ask why is this important? Many hyperhidrosis surgeons will offer a completely different and much less effective surgical solution for excessive foot sweating called Endoscopic Thoracic Sympathectomy (ETS). The long term reduction rate of ETS for foot sweating is only 15-20%.

Dr. Reisfeld performs the Lumbar Sympathectomy (ELS), which has a much higher success rate of 97-98%. A recent survey conducted by Dr. Reisfeld (3500 patients who had previous ETS) shows that some of the patients did see improvements after ETS for their foot sweating, but a great number of them still suffer from excessive foot sweating.

For these patients, the Lumbar Sympathectomy is offered as the most effective option with high success rates. Doctor Reisfeld is the only surgeon in the U.S. and one of only a handful of skilled doctors in the world that performs this highly specialized procedure. Technically this procedure is basically different from the thoracic sympathectomy in that the space to get to the lumbar sympathetic chain has to be created by the surgeon which makes the operation a bit longer. Compared to the Thoracic Sympathectomy which can take anywhere from 30-40 minutes, the lumbar sympathectomy is somewhat longer between 75 minutes to 90 minutes (just over an hour). Once the space is created a delicate process takes place in order to isolate the sympathetic chain from the surrounding structures. For more details on the procedure visit our details of hyperhidrosis surgery page.

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Symptoms of Plantar Hyperhidrosis
As mentioned before, palmar hyperhidrosis (sweat hands) is one type of hyperhidrosis. There is a unique manifestation of sweat that is limited from the ankles to the toes. This particular anatomical distribution is missed by regular physicians who are looking for different causes to explain plantar hyperhidrosis.

Usually plantar hyperhidrosis is associated with palmar hyperhidrosis in more than 99% of the cases. Palmar hyperhidrosis is uniquely limited to the wrist and the fingers. When the patient has both excessive foot and hand sweating, this should direct the treating physicians to the diagnosis of focal hyperhidrosis.

As said before throughout this website, it is highly likely a genetically determined pathology (meaning someone in the family has or had it). A conservative treatment should be tried first, but keep in mind that the success rate is limited. Nevertheless, attempts should be carried out.

Causes of Excessive Foot Sweating
As far as we know, the same gene that causes palmar hyperhidrosis (excessive hand sweating) is responsible for excessive foot sweating as well. The gene causes heightened activity in the sympathetic chain, which is part of the involuntary nervous system. The difference, is that clinical manifestation of palmar hyperhidrosis will show itself earlier in life than plantar hyperhidrosis.

This is to say that excessive hand sweating is usually a problem earlier in life than excessive foot sweating. In our estimates, the reason for that is the maturation process of plantar sweat glands takes longer than palmar sweat glands. Of interest is the fact that plantar hyperhidrosis (feet) as well as palmar hyperhidrosis (hands) are limited to a specific part of that organ.

In plantar hyperhidrosis, the excessive sweating appears from the ankles down. In the case of palmar hyperhidrosis, the excessive sweating appears from the wrist down to the hands.

Diagnosis of excessive foot sweating:
How do I know if this surgical procedure is right for me? Plantar hyperhidrosis usually is associated with palmar hyperhidrosis. In about 5-10% of patients, plantar hyperhidrosis is the major symptom that requires attention. If a patient has to change their socks a few times a day, routinely has ruined shoes due to sweat, has macerated skin, and or recurrent infections that produce smell, these are all signs.

Any of the above or a combination of the above can be a reason to consult with a physician, and to try some conservative measures. This is a subjective issue that must be brought to the attention of a physician.

For Former ETS Patients
Performing upper Thoracic Sympathectomy (ETS) for excessive hand sweating often times does not fully solve the problem of excessive foot sweating. Only a small percentage of patients had the desired improvement. Until recently, no specific operation was offered for patients suffering from excessive foot sweating.

Surgeons in other countries developed the Lumbar Sympathectomy, which is specifically targeted for excessive foot sweating. In this special approach, a specific segment of the sympathetic chain within the lumbar region is cut or clamped to relieve excessive foot sweating. The important difference between a Thoracic Sympathectomy and a Lumbar Sympathectomy, is that the Thoracic Sympathectomy helps specifically with excessive hand sweating, while Lumbar Sympathectomy helps specifically with excessive foot sweating.

It should be understood that even though patients who suffer from hand sweating also suffer from excessive foot sweating, the Thoracic Sympathectomy (ETS) helps mainly with excessive hand sweating. For those patients who underwent a Thoracic Sympathectomy and did not see improvements with their foot sweating they now have the new and proven option of Lumbar Sympathectomy to help with their symptoms. This is great news for anyone suffering from excessive foot sweating.

Unique Hyperhidrosis Expertise
Doctor Reisfeld is currently the only known surgeon who has the expertise to perform both the Endoscopic Thoracic Sympathectomy and the Endoscopic Lumbar Sympathectomy procedures. He has authored or co-authored multiple peer reviewed papers and studies on the topic. This speaks greatly to his years of dedication and practice as a pioneer in the field of hyperhidrosis. When it comes to selecting the very best hyperhidrosis surgeon in the world, Dr. Reisfeld tops most people’s lists.

Currently, Dr. Reisfeld performs unique procedures for each type of focal hyperhidrosis. To learn more about each procedure, please see our hyperhidrosis treatments page.

Plantar Hyperhidrosis and mild Palmar Hyperhidrosis
For patients who have plantar hyperhidrosis as well as mild palmar hyperhidrosis, there’s something to note. If you decide to do the ELS surgery first, you might experience an increase in palmar hyperhidrosis to a level that was not significant before. How long this increased level of palmar hyperhidrosis will occur is not yet known, but the patient should be aware of this possibility. Whether ETS will be necessary or not is still unknown.

History of The Lumbar Sympathectomy
Since about 2005, a lot of information was obtained in regards to the performance of a lumbar sympathectomy for those patients who suffer from plantar hyperhidrosis. This new information also helped people who underwent an endoscopic thoracic sympathectomy and didn’t see improvements.

This information about lumbar sympathectomy was gathered initially in countries such as Brazil, France and Austria. The Lumbar sympathectomy became the operation of choice for those patients. It is done equally on female and male patients. The question of whether or not the operation will affect retrograde ejaculation in male patients was proven not to be a problem.

The solution was to adjust the level of the lumbar sympathectomy below lumbar vertebrae #2. This particular question should be discussed at length with the surgeon before any male patients proceed with lumbar sympathectomy regardless.

Percutaneous chemical denervation ( chemical lumbar sympathectomy) of the lumbar sympathetic chain is practiced in some places, but depending on the material used, the effect can be temporary or run the risk of associated injuries to nearby organs such as the ureters or blood vessels.

The reason for that risk is that when the chemical component is injected, it can progress to nearby structures without any ability to limit its spread. The benefit of surgical lumbar sympathectomy is that those organs nearby are recognized and protected throughout the procedure.

Pain after the operation is typically minimal and temporary. So far the pain after a lumbar sympathectomy is described as less than the pain experienced after ETS. A decision to go forward with this operation should be considered only after a detailed discussion with the surgeon to perform the procedure occurs. To learn more about the details of lumbar sympathectomy click the link. Most of the patients had a one night stay and occasionally some patients go home the same day.

In summary, as excessive hand and foot sweating becomes better understood in the medical field, we can now say that those problems are best helped with surgical approaches once the conservative measures have been used with no success. Excessive hand sweating (palmar hyperhidrosis) can be fixed in about 97-98% of the cases with an upper Thoracic Sympathectomy.

With this procedure, excessive foot sweating can only be partially healed. Now, thanks to extensive clinical work done in other countries such as Brazil and Europe, as well as with the United States, excessive foot sweating can be cured with a lumbar sympathectomy. For patients on whom Thoracic Sympathectomy did not help with their feet, the Lumbar Sympathectomy is a valuable and viable procedure.

New Observations
For patients that have compensatory sweating in the groin/buttocks areas after having first done the ETS procedure, there is some observed improvement after performing the lumbar sympathectomy at a level of L2 or close to L2 as possible. This observation came about after Dr. Reisfeld performed a lumbar sympathectomy at this level for patients with foot sweating and they claimed that their groin/buttock sweating improved.

Learn more about the Lumbar Sympathectomy for foot sweating treatment.

Lumbar Sympathectomy Doctor/Peer Reviewed Paper:
Dr. Reisfeld finished working on an important published paper regarding his experience with the initial 65 patients who underwent the lumbar sympathectomy. The paper is very significant because it adds further proof to the validity of performing endoscopic lumbar sympathectomies for patients who suffer from resistant plantar hyperhidrosis. The paper is available for review here:

Endoscopic Lumbar Sympathectomy for Focal Plantar Hyperhidrosis Using the Clamping Method – August 2010.

Second Paper
A second paper, completely dedicated to the topic of lumbar sympathectomy, will appear soon in peer reviewed surgical journals. This paper deals with the issue of lumbar sympathectomies. The accumulative experience of about 154 patients is reviewed. The experience gained between the first paper (2010) and now is reflected and, as time goes by, the increased number of cases performed is going to shed more light into the problem. This will improve the technique, outcome, and satisfaction of patients involved.

Questions:

What if I have only plantar hyperhidrosis (foot sweating) without any palmar hyperhidrosis (hand sweating)?
We are seeing more cases where the patient’s only problem is plantar hyperhidrosis. It is a somewhat smaller group of patients, but their foot sweating is severe enough to pose as many problems as people with hand sweating. Dr. Reisfeld is happy to discuss your specific condition on a one-on-one basis to help you determine if surgery is the right option for you.

As more experience is gained over time a solitary presentation of plantar hyperhidrosis only is not a good indication to do ELS. For some unexplained reasons those patients with only plantar hyperhidrosis do not respond as well to lumbar sympathectomy. They might get some temporary relief of plantar hyperhidrosis but it is not a long lasting relief. The reason for that is not known however if more information becomes available in the future then the approach might be changed. It is imperative for the patient, who suffers only from excessive foot sweating, to talk with the doctor who understands the problem and is aware of the unique situation of plantar hyperhidrosis.

What is The Truth about Subdermal Curettage as a Treatment Method for Plantar Hyperhidrosis?
You may have read that subdermal laser curettage is being used by some doctors as a treatment for plantar hyperhidrosis. This is a way to entice patients to go this route with no proven success rate or any value to it. Patients who chose this route describe total failure with this approach and a tremendous amount of pain and discomfort.

They also describe an inability to use their feet, which confines them to wheelchairs (temporarily). Laser suction curettage, or simply suction curettage, in the axillary area has some value in isolated cases of axillary hyperhidrosis.

These days, doctors could offer another approach for the treatment for axillary sweating (armpit sweating). The reason there is no value in this approach in cases of plantar hyperhidrosis, is because of the fact that there is almost no subcutaneous tissues in the plantar region.

Foot Sweating (Plantar Hyperhidrosis) Summary
Excessive foot sweating can be a serious problem, both in social settings and everyday functional activities. This can also affect intimacy between couples due to the smell, discomfort, and embarrassment it causes. This is especially true for women having difficulties wearing the appropriate footwear.

You may ask what should I do? Those affected should first discuss the matter with their doctor and then first try the conservative hyperhidrosis treatment measures available. If those measures do not give satisfactory relief, then consideration should be given to the hyperhidrosis surgical treatment options.

At present, the endoscopic lumbar sympathectomy procedure has been refined to the level that it can now be done on an outpatient basis. This allows patients to return home or to their hotel on the same day as the procedure. The success rate for the surgical procedure is excellent at 98%

Hyperhidrosis Testimonials
“I am able to wear whatever shoes I want. I can buy a beautiful dress, a beautiful pair of shoes, and not the shoes that are “ok” just because my feet will sweat.”
Florijana Read More From Florijana

“I not only love my dry hands, but I love my dry feet and armpits as well. In the summer I was able to wear sandals and even flip flops! I just can’t believe how well my body has responded to the procedure.”
Susana Read More From Susana

“I believe the surgery took place sometime in 2001. I am happy to say that everything is going well. I attribute the ETS procedures as a major part of my success.” (7 Years Later)
Paul Read More From Paul

“I admire your impeccable professionalism and your utmost skill in the performance of this highly technical and precise surgical procedure. I have waited many years since I was a young girl to properly get rid of this problem. My knowledge as a dermatologist led me to the best procedure, and to the best doctor.”
Ligaya.B, M.D. Read More From Doctor Ligaya

“I had the ETS surgery for palmar hyperhidrosis done in 2003, and wanted to thank you and your staff for all of the help. Taking a standardized test in the past was nearly impossible without handing in a sopping wet ScanTron sheet. Since my surgery date, I was able to take the paper and pencil medical school entrance exams. I applied to medical school, and now I am a second year medical student in Ohio! This surgery changed my life.”

Sarah Read More From Sarah

“I would also like to thank all of your staff for such a pleasant experience. They were very friendly and helpful. From the first time that I made a phone call to your office, up to the time in the recovery room. Everyone made me feel very comfortable and well taken care of.”

Peggy.P Read More From Peggy

Read from several touching thank you letters Dr. Reisfeld has received over the years since 1996.

Frequently Asked Sweaty Feet Questions:

• Is it normal to have sweaty feet?
• What is the best procedure for my excessive foot sweating?
• What is Lumbar Sympathectomy?
• What if my insurance says they do not cover this particular procedure?
• Why should I travel to Los Angeles to see Dr. Reisfeld?
• Does lumbar sympathectomy affect pregnancy?
• What to expect after the lumbar procedure
• Please see our hyperhidrosis frequently asked questions section for additional questions.
• Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?

Do you have any questions about foot sweating that were not answered here? Would you like to speak with Dr. Reisfeld to answer those questions? To learn more about what we can do for you, contact The Center for Hyperhidrosis by contacting our office or post your comments or questions below and we will do our best to reply.

Please view our disclaimer.

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Are there any identifying characteristics for a hyperhidrosis patient?

Family history is a strong indication that one or more family members will be affected by hyperhidrosis. As it has been shown in many peer reviewed clinical papers, more than 51% of the patients have traces of family history. The fact that one family member or another, even not from the same family, is affected does not mean that the inheritance is guaranteed. Hyperhidrosis can skip generations. The intensity of hyperhidrosis varies from one patient to another. No other physiological or physical data are showing any tendency towards hyperhidrosis.

Related pages

• Is Hyperhidrosis Genetic?
• Symptoms and Causes

Is the possibility for hyperhidrosis to be only on one side? What is the solution?

As it is known in medicine there are exceptions to the rule. There are some rare cases in which the patient was complaining of single side hyperhidrosis. The number of operations done for single side hyperhidrosis is even more rare. From the few cases known to Dr. Reisfeld, those who were operated on for the one side developed hyperhidrosis on the other side after the operation.

If the hyperhidrosis is on the non-dominant side of the body a patient may consider not doing the operation as they are less effected.

How many surgeons around the world have competent knowledge and ability to perform hyperhidrosis surgery?

Hyperhidrosis surgery is taught very minimally, if at all, in surgical training programs. It is done infrequently around the world but over the years a group of surgeons develops an affinity to this subject and at present they are the leaders in performing such surgeries. Dr. Reisfeld is one of these leaders who has been involved with the procedure since its pioneering days. Thoracic sympathectomy is known and performed by more able surgeons but again one should look for somebody who has extensive experience and knowledge with this procedure. Lumbar sympathectomy on the other hand is only performed proficiently by a handful of surgeons. It is a very challenging operation technically and requires proctoring for any surgeon who tries to do it for the first time. Again in this case the procedure is seldom done on a routine basis by any doctor. Here deep knowledge about the surgeon performing the operation should be obtained.

I have noticed increased in my urine output after sympathectomy. Why?

One of the effects of sympathectomy is dilatation of the blood vessels (Vaso Dilatation). Because of that there is increased blood flow to the kidneys and as a result more urine output ensues. This particular effect is self limiting due to the fact that the vessels, that have autonomic (self regulating) will get back to their normal size after a short time. Essentially this issue is only temporary (days not weeks). The same can happen to patients who suffer from severe headaches (migraine headaches).

One of the theories connects migraine headaches with narrowing (vaso spasm) of the vessels in the head area. The sympathectomy, especially ETS will cause dilatation of those vessels. Patients describe reduction in the quantity, frequency and intensity of the headaches and allow them to reduce the amount of specific pain killers they took for headaches.

How long does it take for the hands or feet to get dry after the surgery?

The effect of surgery for the hands or feet takes effect immediately. The patients who go into surgery with wet hands or wet feet will feel the drying and the warming effect once they wake up. These immediate results often bring tears and very strong emotional responses from those patients who have suffered with the issue for most of their life and realize they no longer have to suffer. It should also be mentioned that in about 15 to 25% of the cases (3-4 days) they may feel wetness coming to their hands or their feet which lasts only a short time (minutes to a few hours – very rarely). This is a self-limiting process which is explained by the evacuation of sweat that is stored in the sweat glands.

Is there scarring after the hyperhidrosis surgery?

Scarring after endoscopic procedures is usually small and heal well. This goes for every kind of endoscopic surgeries compared with the old fashion techniques that created long scars over the chest and abdominal cavity in order to get into the target organ. In ETS there are two scars measuring about 10 mm. These are small and for a patient who is not producing keloids (imperfections of the outer skin that may develop after surgical incision) will not see the scars weeks or months after the operation. Also the cuts are made in very good cosmetic locations. While doing ELS (endoscopic lumbar sympathectomy) there are three incisions on either side of the flank region and they are also relatively small. The incisions are made in skin lines which helps obscure their visibility.

Does compensatory sweating only happen to hyperhidrosis patients who underwent ETS?

The exact reason for compensatory sweating is yet to be determined. There are some physiological explanations for that but none are yet completely proven. The reason for this statement is that compensatory sweating happens in a mild, moderate or a higher level of sweating. The fact that not everyone responds in the same way to the hyperhidrosis operation points to the unknown nature of this problem. More than that patients who underwent thoracic sympathectomy for reasons OTHER than hyperhidrosis also develop compensatory sweating in different intensities. This last statement shows that compensatory sweating happens to both hyperhidrosis patients and non-hyperhidrosis patients who have undergone the surgery.

Related:

• Compensatory Sweating Page

Are there any alternative interventional methods for lumbar sympathectomy?

Ablation (destruction) of the lumbar sympathetic chain was tried with radiofrequency ablation as well as with injection of phenol (highly concentrated alcohol), known as Chemical Lumbar Sympathectomy, to destroy the sympathetic chain. Even though those were tried the success rate was not proven to be high because in both methods the precise location of the sympathetic chain and the effectiveness of those materials applied did not prove itself. More so with the injection of phenol some serious complications occurred because once the toxic phenol was injected it reached some other important structures in the vicinity causing serious complications.

Learn more about Chemical Lumbar Sympathectomy

For radiofrequency the same problems can occur when radiofrequency ablation (destruction) is applied. The reason here is that there is no exact knowledge of how much energy should be applied to the area and also the pinpoint nature of the procedure makes it very difficult to eliminate the appropriate segment of the lumbar sympathetic chain.

What are the main risks and contra indications for lumbar sympathectomy?

First and foremost any surgeon who attempts to perform lumbar sympathectomy should be very well versed with the anatomy and the technique of how to do the procedure. Any surgeon should be proctored by an experienced surgeon who has done enough procedures (ELS). The reason for this extra caution is the fact that the lumbar sympathetic chain runs very close to major blood vessels, ureter and other nerves that run very close to it. This part particular area of the body is not very familiar to many surgeons. For this reasons many surgeons are not comfortable performing surgeries there.

The side effects such as pain and discomfort are described to be less than thoracic sympathectomy. It is also known that performing lumbar sympathectomy (ELS) below lumbar vertebra L-2 will not cause retrograde ejaculation. Inner thighs compensatory sweating or buttock compensatory sweating which are the results of the thoracic sympathectomy can be lessened with lumbar sympathectomy. Any patient who had the previous retro peritoneal surgery is almost excluded from having this surgery. Statistically more females will choose this operation because of the inability to wear certain types of shoes (high heels, sandals etc.)

Is there any possibility of eyelid sweating after ETS?

A very rare possibility exists with swelling in the eyelids after ETS. This is an unusual side effect and the most likely explanation for this is the fact that the sympathectomy procedure causes vessel dilatation. As a routine we give the patient a lot of intravenous fluids in order to maintain stable cardiovascular condition. As a result of the vessel dilatation as well as the increased amount of intravenous fluids a patient can develop temporary swelling in different areas of the body. This excessive amount of fluids is eliminated over about a 24 hour period through normal body functions.

What is Acetyl Choline?

Acetyl Choline is a neurotransmitter (a messenger in laymen terms) that is a very active ingredient in the autonomic nervous system (sympathetic and parasympathetic). As a neurotransmitter (messenger) it is the chemical structure that triggers sweat production. There are many other actions being caused by this neurotransmitter but this is not the place to talk about those. Most of the conservative measures to treat hyperhidrosis start with oral intake of anti-acetyl choline medications and hence the name anticholinergic agents ie Robinul, Propantheline, Ditropan. The success rate associated with these medications with moderate to severe cases of hyperhidrosis is extremely low. Having said that it is the first line of defense when someone tries to treat hyperhidrosis. Side effects such as blurry vision or dry mouth can happen but in the lower dosage range it’s very unusual. It should also be known that with time efficiency can go down because of the bodies built up resistance (anti bodies). As with any other oral medication if there is a need for higher dosages then one should be aware of the side effects. Consult your physician / pharmacist with regard to that.

Elderly patients with overall body sweat

The situation of a gradual onset of unexplained total body sweat and not limited to the hands feet and armpit is common among elderly patients above their 50s. Most of the patients complaining about this are women that because of unknown reasons develop overall body sweating. They typically describe a situation where their head, scalp and the rest of their body parts are soaked wet minutes after they get out of the shower. Many of them describe other illnesses such as

• Diabetes
• Obesity and poor diet
• Multiple medication usage
• Back pain and or spinal surgeries
• Arthritic problems
• Smoking and or excessive alcohol usage

Also those patients describe multiple other ailments for which attempts were made to help them with medications, surgeries, which did not change their overall complaints with the sweating. Basically the situation is likely due to some imbalance between multiple body functions. It is a sign of the overall aging process where the machine of the body does not fire in the right sequence. A definite solution is not yet available and attempts should be made to restore a healthier way of life including.

• Overall much healthier diet
• Eliminate multiple medications usage
• Overall exercise & activity
• Non-smoking or excessive alcohol usage

Summary
To make the above mentioned clinical situations that were described one should understand that aging brings with it many symptoms that were unknown before. Those symptoms are not typical of focal hyperhidrosis for which a surgical treatment is available and the hallmark of this statement is the fact that all of those manifestations described above appeared around the 50s – 80s. For those patients the only possible approaches will be medications, diet changes and consultations with those physicians who are specialized in geriatric medicine.

Facial and Hair Sweating in the elderly
This is a fairly common complaint among elderly women and men alike. The majority of patients that complain about this issue are women. The prevailing notion is that it is related to hormonal imbalances. The exact definition for hormonal imbalance is still an unclear entity. Women may need hormonal replacement therapy but the best approach is to consult with a good internist or anyone who is an expert in geriatric medicine.

Hopefully this page helps those elderly patients to understand this yet to be solved issue.

What are the long term results after the surgery (ETS)? What should I expect?

Accumulating experience since 1995 shows that the overall satisfaction and the good results of dry hands is applicable to about 95% of the patients. In this group the patients often talk about how the surgery was a very positive life changing experience. Self-confidence and social skills are often improved which can help those patients a lot. Again remember results are different for each patient.

There are two main issues that lowers the overall satisfaction rate.
A) Recurrence which happens to about 2% of the patients
B) Compensatory sweating

A) Recurrence
For some unexplained reasons recurrence of the sweating can happen no matter which method was used. Excision, cauterization and clamping all bear the same rate. The most plausible explanation is the creation of extra anatomical bypass (connections) that leads to resumption of nerve impulses to the hands or feet. The sweat glands are acting after they get nerve signals from the sympathetic chain. Resumption of those signals can happen in a few ways among them is the possibility that signals are going up and down the spinal cord and exit the sympathectomy site at a higher or lower level. We believe that more understanding of neural pathways in the brain as well as in the spinal cord might shed more light into this problem. So far no definite solution exists. In cases of thoracic sympathectomy it is easier to do a redo operation with good results but it is so much more difficult to perform a redo operation in endoscopic lumbar sympathectomy. In any case the recurrence rate is still low and acceptable as long as the recurrence is not as high as before the operation.

B) Compensatory Sweating
This is the most commonly mentioned side effect. Everyone who is having sympathectomy , thoracic or lumbar will develop a certain level of compensatory sweating. Statistically speaking the majority of the patients up to 94-95% will have an acceptable level of compensatory sweating which allows them to continue with a normal way of life. Like in any other elective operation there will always be a certain number of patients who will not be satisfied with the level of their compensatory sweating. It is unavoidable and we wish that we could who will have a high or acceptable level of compensatory sweating but we simply cannot at this point.

Patients who had previous ETS are their compensatory level stabilized and now they come for endoscopic lumbar sympathectomy might experience fluctuation of their compensatory sweating that stabilized over the years. The body after ELS and previous ETS is going through a new set of nerve signals and time is needed for stabilization. Time is of the essence because our body is capable of finding a lot of solutions on its own.

What does the future hold for excessive hand and foot sweating in the next 10 to 20 years?

A lot of understanding and knowledge became available over the last 30 to 40 years of treating excessive palmar and plantar hyperhidrosis. The main point that should be known to everybody is the fact that focal (local) hyperhidrosis for the hands and feet is a genetically based condition. Compared to generalized excessive sweating which affects the body as a whole which in most cases is associated with certain conditions such as aging, obesity, diabetes, thyroid problems, blood pressure problems and many others where the treatment is based on treating first the underlying disease or changing of certain life habits that includes weight reduction, increased daily activity, good control on blood sugar levels, etc.

In the focal/local hyperhidrosis cases where the problem starts with genetics it is a more complex issue to solve. Over the years numerous attempts were carried out with medications, lotions, dietary changes, hypnosis psychological treatment, etc were attempted with a minimal or no success rate (See alternative treatments). Due to the fact that genetic manipulation is not yet at hand surgical treatment including the minimally invasive methods such as ETS and ELS became the preferred methods. Obviously because of the invasive nature of the treatment as well as the possible side effects a thorough and a deep discussion should be carried out between the patient and a well-qualified surgeon who is familiar in the theoretical basis of the problem and the technical fine points of performing these procedures.

Is There a Connection Between Autoimmune Diseases and Hyperhidrosis?

This question comes up from time-to-time with patients who develop isolated excessive sweating later in their lives. These same patients have an autoimmune disease. The question that we often get is whether there is a connection between the two.

To our knowledge, there is no connection. One should remember that hyperhidrosis usually starts at an early age. There is also a genetic history in more than 50% of the cases. Autoimmune diseases typically start in the later years of someone’s life (40+).

The hallmark of typical hyperhidrosis is that the patient sweats from the waist down and from the ankles down. This very specific piece of information is missed by a lot of doctors who try to label those patients with an autoimmune disease.

These usually affect the whole body and not specific parts. This distinction is important, and not all doctors understand this. Autoimmune diseases are characterized by the discovery of certain markers in the blood. Hyperhidrosis patients have NO markers in their blood.

Does lumbar sympathectomy affect bladder function?

Experience has shown us that bladder function is not affected by lumbar sympathectomy. This particular fact is based on the amount of cases done so far and nobody male or female reported any issues with bladder function after lumbar sympathectomy. Almost the same question was raised with regard to pregnancy after lumbar sympathectomy which showed that females with plantar hyperhidrosis had no issue with becoming pregnant after lumbar sympathectomy.

Does Hyperhidrosis have any connection to Eczema?

Eczema is a skin condition that includes itchy, dry and red skin which is caused by inflammation. The exact reason for the development of Eczema is not fully understood. Among the various factors that cause it one can look into genetics, abnormal function of the immune system, the environment, activities that cause the skin to be more sensitive, and defects in the skin barrier. As one can see these multiple possibilities are indicating that basically the real reason is unknown. A lot of patients pose the question to us about the connection between eczema and hyperhidrosis. Basically from our perspective the answer is no. The cycles of extreme wetness and then dryness may cause some eczema like skin conditions. Without the excessive sweat the symptoms would likely not be there but this does not mean the person has eczema. Eczema can be seen with hyperhidrosis as a coincidental finding but one should not confuse that as a connection between the two.

What is the truth about subdermal curettage as a treatment modality for plantar hyperhidrosis?

You may have read that subdermal laser curettage is being used by some doctors as treatment for plantar hyperhidrosis which is a way to attract patients to go this route but with no proven success rate or any value to it. Patients who chose this route describe total failure with this approach and tremendous amount of pain and discomfort and an inability to use their feet which confines them to wheelchairs (temporarily). Laser suction curettage or just simply suction curettage in the axillary area has some value in isolated cases of axillary hyperhidrosis. Now a days miradry might offer another approach for the treatment for axillary sweating (armpit sweating). The reason there is no value in this approach in cases of plantar hyperhidrosis is because of the fact that there is almost no subcutaneous tissues in the plantar region to offer subdermal laser ablation or curettage in the foot region.

With regard to the treatment of palmar hyperhidrosis with Miradry so far there is no knowledge about the availability of an appropriate model to treat palmar hyperhidrosis. For the treatment of axillary hyperhidrosis the Miradry application is easier because of the way that the technical aspects are easier to do.

The fact that it sounds like a very non invasive procedure distracts the reader from the real solution that can be given only by disrupting the sympathetic chain innervation to the feet. This disruption can only be done effectively with endoscopic lumbar sympathectomy which has the highest proven success rate.

ELS and former ETS patients

After performing ELS since about 2006 some patients who had ELS after having ETS years ago reported a temporary and a short increase in the status of their dry hands. For some unknown reason this particular phenomenon was reported by very few patients but this was as I said before on a temporary and short basis.

As mentioned elsewhere on this website the level of compensatory sweating basically stays the same as it was after the initial ETS procedure with some reported of cases (not all) of buttocks sweating that was improved with ELS. The reason for inconsistency is based on a different anatomical configuration of the lumbar sympathectic chain which can be different from one patient to another.

• Back to Frequently Asked Questions Page

Can you only have hyperhidrosis on one side?

Since medicine is not an exact science obviously from time to time you hear about things that are rare. Sweating excessively on one side only can happen but it is a very rare occasion. We do not have any answers as to why this happens and even more interesting that a patient presented with one sided palmar hyperhidrosis but the plantar (feet) was presented on both sides.

Relationship between Exercise Induced Asthma and Thoracic Sympathectomy

Even though the exact percentage of patients who suffer from exercise induced asthma that come for ETS is not really known a lot of questions have been raised if sympathectomy can worsen or improve that situation. Clinically, a mild case of exercise induced asthma is not worsened or improved by ETS. Clinical studies that were carried out to evaluate this situation have conflicting results. In some cases a there was a minimal decrease in the forced expiratory flow but in other studies this finding was not substantiated. This might not be true for cases with severe asthma but so far there were no studies done on patients with severe cases of asthma that underwent ETS.

It is recommended that patients with a history of severe asthma should consult with the surgeon as well with a pulmonary specialist in order to take all precautionary measures before proceeding with the procedure. As said at the beginning of this article mild cases of exercised induced asthma can be done without any long-term effects.

Learn more about the details of ETS surgery.

Disabilities and Hyperhidrosis
This question came from patients who are afflicted with other illnesses such as diabetes, deafness, blindness, cerebral palsy and many others as to whether or not their condition is related to hyperhidrosis. Basically the answer is no because hyperhidrosis we know is a genetic illness. Unfortunately it adds to the medical problems that those patients already have and it makes their condition even more difficult to tolerate due to the aforementioned disabilities.

Diabetes and Hyperhidrosis
Diabetes has some correlation with nerve ending damages. We all know about some numbness in the extremities for patients with long standing diabetes when it is not well controlled. It’s somewhat different with regard to the sympathetic chain and in those cases the sympathetic chain belongs to the involuntary nervous system and there is no known evidence that diabetes can affect this part of the nervous system.

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Any correlation between Reflex Sympathetic Dystrophy and previous Endoscopic Thoracic Sympathectomy?

The two entities sympathectomy and RSD are totally unrelated. Reflex Sympathetic Dystrophy or RSD has also other names such as chronic regional pain syndrome. In those situations an injury to an extremity which results in chronic pain can cause some typical situations where patients have pain on a very chronic basis on those extremities and associated with it is redness, swelling, burning sensations and a great deal of discomfort. Unfortunately the treatment of those chronic cases is very difficult and as a result the name Reflex Sympathetic Dystrophy was attached to this clinical presentation with the idea behind it that it is caused by reaction of sympathetic fibers to the previously mentioned injury. It has nothing to do with sympathectomy, as a matter of fact this chronic pain situation is treated at times with sympathectomy not for the issue of sweating but instead to treat the pain. Those attempts are usually unsuccessful, especially if those patients were treated for a long time (months and years), by pain management teams with different treatment modalities such as oral medications, injections, regional blocks etc. By the time those patients come for sympathectomy as a possible cure their illness become not a local illness at the extremity but rather a brain mediated problem which is very difficult to eradicate.

This question and answer was inspired by a patient of ours who had sympathectomy many years ago with very good results which included complete dryness of the hands as well as minimal compensatory sweating. The patient was slightly overweight fell and injured her hands and knees and needed chronic pain treatment. A nuclear study done after a while showed radiological findings of Reflex Sympathetic Dystrophy. So in this case those findings were due to the fall and the prolonged treatment and not because of the ETS.

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How Does Hyperhidrosis Affect a Person’s Fingerprints?

A frequent complaint that we hear from patients who work in the public sector surrounds fingerprinting. Careers such as policing, education or any other governmental agencies require this step.

The accumulation of sweat in the finger-tip area makes it difficult for the person to perform this simple task. It is frustrating when everyone else can do it without hesitation.

Law enforcement candidates complain about its effect on their ability to hold their weapons, as well as writing citations/reports. Many people may view this as something that is insignificant, but for those who live with it daily, it is a serious issue.

There is also the social and psychological components that we need to consider. Learn more about the psychological aspects that affect hyperhidrosis.

What if I only have armpit and foot sweating?

The typical cases that influence the surgeon with the decision who is really fitting into the surgical treatment of focal hyperhidrosis (hands, armpit and feet) which did not respond to conservative measures are those cases that have severe hand sweating, feet sweating and armpit sweating if they suffer from that site as well.

Often the question is asked to us, “What if I only have armpit sweating and severe foot sweating?” For those surgeons who are familiar with these presentations it poses a relative dilemma when the hands are not a part of these three mentioned above. The technical aspect of doing lumbar sympathectomy for those patients with excessive feet sweating is available providing that the patient first tried conservative treatments and he/she is not extremely overweight and does not have any other associated medical problems. That particular operation will not affect axillary sweating at all. Also the fact that before the operation they did not complain about hand sweating does not mean that in the future after performing lumbar sympathectomy they will not develop also palmar hyperhidrosis (hand sweating). It is somewhat a difficult topic to enlighten all inquiries about this particular combinations of excessive sweating so it is highly recommended that the patient discusses this with an experienced surgeons.

Anecdotally in the past a trial to perform ELS for patients with only plantar hyperhidrosis (feet only sweating) was not as successful as thought to be. Not that there were any technical issue but the physiological outcome was not as we hoped it to be. These particular cases of plantar (foot) sweating only was originally limited to these patients from the East horn of Africa. Those patients did not have any other site of sweating but the feet. Those patients who have severe axillary hyperhidrosis as well as feet sweating it is our belief that they can fit into the grand picture / whole picture of hyperhidrosis and those can be benefitting from ELS to solve their problem but not the armpit problem. Again it should be emphasized that because of the complexity of those questions it is a must for a potential patient to discuss this subject deeply with an experienced surgeon.

With more information that comes as the time goes by. We believe that cases with only plantar sweating and especially if they come later in life (mid 20s onward) are not a good candidate for the ELS procedure. No good explanation is available and because it does not have all the traits of primary focal hyperhidrosis this operation should not be done in those circumstances.

What are the main contraindications for ETS?

Any surgeon who attempts to perform endoscopic thoracic sympathectomy should be very well versed and experienced with the anatomy and technique in doing the procedure. This experience should include being proctored by an experienced ETS surgeon. Very few contraindications can exist. Amongst them are obesity which makes the exposure of the sympathetic chain within the chest cavity somewhat difficult and hazardous. Other relative contraindications are previous thoracic surgery cases that can produce a lot of scar tissue and adhesions that would prevent easy access to the site where the sympathetic chain is located. It still can be tried but a good surgeon should know the limitations.

As always perspective patients are encouraged to discuss hyperhidrosis with an experienced surgeon.

Is there any connection between sexual performance and lumbar sympathectomy?

As far as we know from the current information we have both from the anatomy as well as the physiological function of the sexual organs those organs and their performance is mainly regulated by the parasympathetic system. The parasympathetic nervous system is part of the autonomic nervous system (involuntary nervous system) which consists of the sympathetic and the parasympathetic system. The parasympathetic innervation to the male and female sexual organs originates in the sacral region which is far below where the lumbar sympathectomy is done. Currently very precise information about interconnection between the sympathetic and the parasympathetic system is not yet available so based upon clinical information the lumbar sympathectomy does not affect sexual performance.

Negative Impact of severe hyperhidrosis

There are a few aspects that are being negatively influenced by severe cases of hyperhidrosis. Patients can become, in a negative way, very aware of this physical issue by avoiding full social interaction with people in their lives (family, friends, co-workers, relationship partners). Especially for the younger age group this can cause rejection by others.

Relationships
Hyperhidrosis can have a very negative impact on people’s close relationships. Both men and women are fearful of intimacy because of what they consider a very embarrassing sweating problem. This often times interferes with people’s willingness to enter into relationships. Those who have the procedure report to us how liberated they feel socially after moving beyond the embarrassing situation.

Professionally
Professionally certain tasks which are now the hallmark of life such as computers, phones and essentially numerous electronic devices are severely affected. Anything involving your fingerprint can also be affected (electronic fingerprint access for example). Any profession with common social interactions such as shaking hands can be a big problem.

Affects and dangers of using hands or feet
Patients often report their inability to hold pens, pencils and or papers due to the severe wetness. In terms of danger there is a danger of slipping and falling due to sweaty feet.

Does coffee affect hyperhidrosis?

As far as we know normal amounts of coffee cups per day (1-3) should not have any effect on hyperhidrosis. Obviously excessive amounts of coffee, which is a stimulant (heart rate may increase), might have some negative effect with increased sweating in the hands and feet. For some it may also contribute to anxiety for others not so it really depends on the individual.

The best approach with coffee is trial and error. Try it, make observations on how it affects you then decide it you can manage with it.