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 Table of Contents  
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 302-307

Thoracic sympathectomy for hyperhidrosis with and without botulinum toxin injection

1 Lecturer of Cardiothoracic Surgery, Al Azhar University, Faculty of Medicne of Girls, Cairo, Egypt
2 Lecturer of Cardiothoracic Surgery, Cairo university, Egypt

Date of Submission17-Feb-2019
Date of Decision26-Jun-2019
Date of Acceptance18-Sep-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Elkahely Mohamed
Lecturer of Cardiothoracic Surgery, Al Azhar University Faculty of Medicne of Girls, Cairo, 11731, Egypt. Hadyek Helwan Building Number 18 Armed City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_30_19

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Background and aims Primary hyperhidrosis is a disorder of excessive sweating of unknown etiology, associated with emotional, psychological, and educational problems. This study described our experience in managing hyperhidrosis via endoscopic thoracic sympathectomy (ETS) with and without intradermal botulinum toxin type A (BTX-A) injections.
Patients and methods This retrospective study included 50 patients treated by ETS with either BTX-A (20 patients) or not (ETS only; 30 patients) in security forces hospital, Saudi Arabia, between January 2014 and February 2017. Information was obtained from computerized medical records and a telephone survey about postoperative complications.
Results A total of 50 patients were operated and included in this study. The mean age was 23.55±6.12 years. The majority (70%) had axillary and palmar hyperhidrosis and 30% had palmar hyperhidrosis. In ETS, surgical technique was done at T2–T3 level in 56% of patients. Mean ETS procedure time was 39.6±14.29 min, with no conversion. Mean hospital stay was 1.5±0.85 days. Success rates of ETS in patients with axillary and palmar were 95 and 96.7%, respectively, whereas success rates of BTX-A+ETS in patients with axillary and palmar were 100 and 100%, respectively. Compensatory sweating was recorded in 20% among every group, with minimal other postoperative and postinjection complications being recorded, with no significant difference between studied groups (P=0.316).
Conclusion BTX-A injection followed by ETS is safer and effective and has minimal postoperative complications.

Keywords: endoscopic, hyperhidrosis, sympathectomy, thoracic

How to cite this article:
Abu-Gamila R, Mohamed E, Nosair A. Thoracic sympathectomy for hyperhidrosis with and without botulinum toxin injection. Al-Azhar Assiut Med J 2019;17:302-7

How to cite this URL:
Abu-Gamila R, Mohamed E, Nosair A. Thoracic sympathectomy for hyperhidrosis with and without botulinum toxin injection. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 8];17:302-7. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/302/271675

  Introduction Top

Hyperhidrosis is a pathological disorder of excessive sweating beyond the physiological needs for thermoregulation, which may severely affect a person’s quality of life [1]. Primary hyperhidrosis (PH) results from the overactive sudomotor system, which controls sweat output, with no apparent cause. Secondary hyperhidrosis can be caused by endocrine disorders, infection, genetic, malignancy, neurologic, and miscellaneous causes [2].

PH can be treated both surgically and nonsurgically. Surgical procedures include endoscopic transthoracic sympathectomy (ETS), arthroscopic shaving of the glands, and excision of sweat glands. These treatments are invasive, may be associated with serious complications and high recurrence rates, and require operative fees, time to reoperate, and anesthesia [3].

Therefore, an ideal treatment should be safe and long lasting and should be more tolerable than topical agents, and it should result in high patient satisfaction rates. With these criteria in mind, botulinum toxin type A (BTX-A) has emerged as an important treatment option for patients with focal PH. The toxin inhibits the release of acetylcholine, preventing the hyperstimulation of eccrine sweat glands that leads to excessive sweating [4]. Several randomized studies have shown that BTX-A is a safe, effective, and durable method of treating patients with PH [5],[6],[7],[8],[9].

  Aims Top

Our study aimed to evaluate the efficacy of BTX-A injection before ETS, which may provide long-term follow-up data, and investigate the occurrence, severity, and significant of postoperative BTX-A+ETS complication.

  Patients and methods Top

Study patients

A total of 50 patients with PH indicated for ETS were retrospectively studied. Thirty-eight (76%) patients were females and 12 (24%) patients were males, ranging in age from 16 to 32 years, with a mean age of 23.55±6.12 years. Of the 50 studied patients, 20 (40%) of them underwent BTX-A injection before surgery. The study was conducted in the period from January 2014 to February 2017, with follow-up in the clinic for 1 year, in security forces hospital, Saudi Arabia, with adequate ethical approval.

All patients were evaluated medically with particular attention given to possible neurological or endocrine diseases, and any suspected case of secondary hyperhidrosis or any contraindication to the use of BTX-A was excluded from the study.


Botulinum toxin type A injection

Regarding pre-injection counseling and consent, detailed counseling was done with the patient with respect to the following:
  1. The treatment plan and the overall esthetic goals, with realistic expectations for the treatment outcome.
  2. The desired and potential adverse effects of the botulinum toxin injection procedure and the longevity of the results, paying close attention to the patient’s long history of safe use, the low probability of any of these effects occurring, and the fact that most of adverse effects are mild and transient.
  3. Avoiding the medications that inhibit clotting such as vitamin E, aspirin, and NSAIDs, for a period of 10–14 days before treatment, to reduce the risk of bruising.
  4. The patients were instructed not to message the treatment area after injection.

On the day of the procedure, a detailed consent form was completed and signed by every patient.

Reconstitution of the BTX-A and handling was as follows: BTX-A (Botox) (Allergan Inc., Dublin, Ireland) was provided for the study in vials 100 U of vacuum-dried neurotoxin complex. The toxin was reconstituted with normal saline, directly before the procedure, to a concentration of 40 U/1 ml (dilution of 2.5 ml normal saline : 100 U/vial).

Injection technique was done as follows: all the injection procedures in our study were conducted in the outpatient clinic. The free nerve endings responsible for the pain sensation occur in the papillary dermis and epidermis, whereas the sweat glands are imbedded deep in the dermis and in the upper layer of the subcutaneous tissue.

The cutaneous areas of the skin were treated with a mixture of local anesthetic (EMLA cream) before injection, or chilled with ice packs to minimize pain and stinging. All the usual precautions of sterility and skin preparation before injection were followed. Marking of the injection sites of both palms and axillae was done, with an average of 35–50 sites, and 1.5–2 cm apart. The toxin was freshly reconstituted and a 30-G needle on 1-ml insulin syringe was used for the injection procedure. With the bevel facing upward, the needle penetrates the skin tangentially, and is then advanced for approximately 2 mm before injection. The thumb is taken off the syringe plunger for a second or two before withdrawal, to prevent the back flow of the botulinum toxin and its wastage.

Intradermal/subdermal injections were done with an optimal effort to deliver the toxin as close as to the sweat glands and presumably less painful than more superficial injections. A small zone of visible blanching attests to the deep dermal injection. However, the deeper the injection, the greater the risk of causing weakness of the small muscles of the hand and weakening of the grip. Injections of the tips of the fingers were performed superficially owing to the presence of an extensive capillary network.

Postinjection instructions were as follows: postinjection ice compresses were applied on the skin to reduce the bruising and minimize the injection pain, and the patients were advised not to message the treatment area. An immediate postinjection information chart was added to the file of the patient.

Postinjection follow-up visits were at 2 weeks, 4 weeks, and then monthly up to12 months after injection and were inspected for detailed observation of the anhydrotic response as well as any adverse effects or complications.

Endoscopic thoracic sympathectomy

ETS was performed in all cases under general anesthesia with double-lumen intubation. The patient was placed in the supine position in bilateral and dead lateral in unilateral sympathectomy. The material was inserted through two openings, one located in the fourth intercostal space in the mid-axillary line and the other in the third space before the axillary line. The sympathetic chain was interrupted, with an endoscopic diathermy hook, at different levels depending on the location of the hyperhidrosis ([Table 3]). In each case, we cauterized the ganglion over the neck of the rib with coagulation diathermy from the superior edge of the rib to just above the inferior edge. The patient was kept under observation in the ambulatory major surgery unit and was discharged on the same day if no postoperative complications occurred.

Statistical analysis

Statistical analysis was done using the IBM SPSS, version 24.0 (Mission Hills, California, USA). Continuous data were analyzed and depicted as means and SD, whereas categorical data were reported as frequencies and percentages. χ2 test was used for association between categorical variables. Differences were considered significant if P value was less than 0.05.

  Results Top

Patients’ characteristics

This study was done on both sexes, with a higher proportion of females (76%) having ETS compared with males (24%). The mean age of having ETS was 23.55±6.12 years, with the youngest being 16 years old, whereas the eldest being 32 years. Most patients who had ETS were aged 21–30 years, representing 46% of the sample, whereas patients aged 31 years and above represented the lowest proportion (12%) of the study sample. The preoperative BMI distribution is as follows: the majority (48%) of patients were in the normal category, followed by overweight (32%), underweight (10%), and obese category (10%) ([Table 1]).
Table 1 Characteristics of the study population

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Distribution of primary hyperhidrosis by area affected

All 50 patients had more than two areas affected by PH; hence, they are grouped into areas that affected them the most. A total of 30 patients (60%) underwent ETS only, whereas 20 (40%) patients underwent BTX-A injection before ETS ([Table 2]). Of the ETS patients, 20 had PH affecting their axilla and hands and 10 had PH in their hands only, whereas among 20 patients who underwent ETS+BTX-A, 15 had PH affecting their axilla and hands and 5 had PH in their hands only. No patient recorded was affected by PH to their axilla only. There was insignificant difference between studied groups regarding the affected areas (P=0.295) ([Table 2]).
Table 2 Distribution of primary hyperhidrosis by area affected

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Level of sympathectomy performed

There were very little variations to the surgery that had been performed, as we were examining a single center performing state-of-the-art surgery. The level of sympathectomy that was predominantly used in this sample was T2–T3 accounting for 56% of the total surgeries. This is followed by the T2, T3, and T4 level, accounting for 40% of the surgeries. Two patients had sympathectomy at levels T3–T4, which only contributed 4% to the total surgeries. Mean ETS procedure time was 39.6±14.29 min with no conversion. Mean hospital stay was 1.5±0.85 days ([Table 3]).
Table 3 Level of sympathectomy performed

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Postoperative results

We noticed that 85% of ETS patients with hyperhidrosis involving the axillary region had complete (90–100%) resolution of symptoms, 10% had partial (60–90%) resolution, and only 5% of patients had recurrence of their PH (success rate of ETS in these patients was 95%). Moreover, 86.7% of ETS patients with hyperhidrosis involving the palmar region had complete resolution of symptoms, 10% had partial resolution, and only 3.3% of patients had recurrence of their PH (success rate of ETS in these patients was 96.7%).

We also noticed that 93.3% of ETS+BTX-A patients with hyperhidrosis involving the axillary region had complete resolution of symptoms, 6.7% had partial resolution, and no patient had recurrence of PH (success rate of ETS+BTX-A in these patients was 100%). Moreover, 90% of ETS+BTX-A patients with hyperhidrosis involving the palmar region had complete resolution of symptoms, 10% had partial resolution, and no patient had recurrence of PH (success rate of ETS+BTX-A in these patients was 100%) ([Table 4]).
Table 4 Degree of resolution of primary hyperhidrosis in patients after endoscopic thoracic sympathectomy by area

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Postoperative complications

Mild compensatory sweating (CS) (postoperative increase of sweating in regions of the body where it had not been previously observed) was seen in six (20%) patients of ETS and four (20%) patients of ETS+BTX-A, which was determined between 3 and 5 months after the operation. In security forces hospital, the number of patients experiencing any complications operatively and postoperatively was very low. Among ETS patients, two patients developed pneumothorax as a result of the surgery, one patient have severe pain at the operation site, and one patient developed postsympathetic neuralgia, whereas among ETS+BTX-A patients, one patient developed pneumothorax, three patients developed postinjection pain, and two patients developed postinjection bruising, with insignificant difference between the two groups (P=0.251) ([Table 5]).
Table 5 Complications of endoscopic thoracic sympathectomy with and without botulinum toxin type A

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  Discussion Top

PH is a social problem and disruptive condition of unknown pathogenesis, with approximately 40% of patients seeking medical treatment. The prevalence of hyperhidrosis is 0.6–1%, of which 50% have axillary hyperhidrosis [10].

Several treatment varieties have been recommended for the treatment of PH. In most cases, BTX-A and ETS are contemplated only when the less-invasive medical treatments, such as topical or systemic medications (including glycopyrrolate and clonidine) and iontophoresis, have failed to provide adequate control of PH [11].

The strength of our study is that it focuses on the usage of a mixture of medical and surgical techniques used in management of PH. It is also important to highlight that this is the first study of its kind in Saudi Arabia that provides an excellent background of the success rate with minimal complications that could spearhead many future studies around PH and its treatment.

Our study revealed that more females were seeking ETS as a cure for PH compared with males (76% females vs. 24% males). This differs from what many authors have reported, as the majority of the papers [7],[12],[13],[14] found that the incidence of PH in men and women is the same. Our analysis also showed that age, sex, and BMI did not affect the rate of postoperative complication in these patients. A well-known study investigating factors affecting the outcome following ETS by Jaffer et al. [15] supports this notion, as their findings also revealed that age, sex, and BMI did not affect the outcome of the surgery.

In current study, the most common affected area was axillary-palmar hyperhidrosis (70%), followed by palmar only (30%), with no patient recorded affected by PH to their axilla only. In line with our findings, the most common clinical condition in the study by Reis et al. [8] was axillary-palmar hyperhidrosis (35.9%), followed by palmar-plantar (28.2%), isolated axillary (15.3%), and isolated palmar hyperhidrosis (10.3%). On the contrary, Grunfeld et al. [6] reported a greater incidence of axillary hyperhidrosis (51%), followed by plantar (30%), palmar (24%), and frontal hyperhidrosis (10%).

In our study, the level of sympathectomy that was mainly used in our center was T2–T3 that accounted for 56% of the surgeries followed by the T2, T3, and T4 level, which accounted for 40% of the surgeries. There were very little variations to the technique of sympathectomy between these two groups, as both groups had their surgeries in a single center. In agree with our result, Scognamillo et al. [16] reported that there were no differences between T2–T4 and T3–T4 sympathectomy in terms of efficacy and outcome of surgeries.

The mean duration of surgery in our center was 39.6±14.29 min. The duration of surgery varies in many studies, but Musa et al. [1] have reported that their mean duration of surgery was 46.6±12.35 min. The duration of surgery has dramatically reduced from the time ETS was introduced in 1930s. Impressively, the mean duration of stay in the hospital in our sample was only 1.5±0.85 days. Compared with our result, Musa et al. [1] found that mean hospital stay was 3.5±1.05 days. Their stay was slightly longer, as nine patients had long duration of hospital stay owing to postoperative complications.

In our analysis, the degree of symptom resolution varied significantly according to the regions affected by hyperhidrosism and the success rates of ETS in patients with axillary and palmar were 95 and 96.7%, respectively, whereas the success rates of BTX-A+ETS in patients with axillary and palmar were 100 and 100%, respectively. The reported success rates for these techniques in curing PH around the world ranges between 94 and 100% with minimal recurrence rates [17],[18],[19],[20]. Although techniques and methods used to interrupt these chains vary between studies, if the correct level is interrupted, the results can be mimicked and this is indicated from the excellent success rate in our center.

The most common adverse effect of ETS is excessive CS, with incidence ranging from 30 to 90% [21],[22],[23]. However, our study showed the incidence of CS was seen in six (20%) patients in ETS patients, and this compared with ETS+BTX-A in which four (20%) patients developed CS, which may be owing to localized effects of BTX-A. In agreement with our study, Eraki and Saad [10], in their study, showed the incidence of CS was seen in 15% of ETS patients compared with 5% of radiofrequency thympatholysis patients.

Most of our patients had single follow-up; hence, we were unable to comment on the follow-up progression of CS. It is a common assumption that CS decreased over time, but based on recent literature, this assertion is probably wrong. A 16-year follow-up in 2013 by Askari et al. [24] revealed that 97.6% of the patients from the study still had CS.Regarding other postoperative complications, three patients or 6.0% of the patients developed pneumothorax postoperatively (two patients in ETS and one patient in ETS+BTX-A). Its incidences have been reported to be around 1–6% in most reports from the literature [7],[9]. Four (8.0%) patients had severe pain requiring additional analgesia (one patient postoperatively and three patients post-BTX-A injection). One patient developed postsympathetic neuralgia in ETS group and two patients developed post-BTX-A injection bruising, which is said to be a rare complication of these techniques.

One of the main disadvantages with treatment of PH was the pain during BTX-A injection. The injection was un-tolerable and painful to three patients in the study; this was reduced by using EMLA cream and/or chilling the palms with ice packs before injection combined with an optimal delivery of the BTX-A in subdermal injections as close to the sweat glands as possible, which would be less painful than more superficial injections. In contrast, intradermal/subcutaneous injections have been given without anesthetics [25],[26], or cold packs were placed on the palms to minimize pain [27]. One study used regional anesthesia of the median and ulnar nerves before intracutaneous injections [28]. Another disadvantage in treating the PH with BTX-A injections was the transient muscle weakness and quicker fatigue of the hands; however, no cases in our study complained of muscle weakness, and it was attributable to the small dose and deeper injection. Numerous studies [25],[26],[27],[29] have reported the weakness of the small muscles of the hand and suggested that it can be potentially reduced by injecting smaller quantities per site at more frequent intervals like done in the current study.

  Conclusion Top

The treatment of PH by intradermal injections of BTX-A is an effective, safe, and minimally invasive treatment option, and when combined with ETS, it provides a high degree of satisfaction and allows patients to return to their professional activities on the same day. It is a precise and easy-to-implement method, after suitable training. Adverse effects and complications are temporary, infrequent, and regress without sequelae. However, the cost of this treatment is still very high.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Smith FC. Hyperhidrosis. Surgery (Oxford) 2013; 31:251–255.  Back to cited text no. 2
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Swartling C, Naver H, Pihl-Lundin I, Hagforsen E, Vahlquist A. Sweat gland morphology and periglandular innervation in essential palmar hyperhidrosis before and after treatment with intradermal botulinum toxin. J Am Acad Dermatol 2004; 54:739–745.  Back to cited text no. 4
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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