Chinese Medicine, 2009, 1, 19-22
Published Online September 2009 in SciRes (www.SciRP.org/journal/cm)
T3/T4 Thoracic Sympathictomy and Compensatory
Sweating in Treatment of Palmar Hyperhidrosis
ABSTRACT
Compensatory sweating (CS) is one of the most common postoperative complications after thoracic sympathectomy,
sympathicotomy or endoscopic sympathetic block (ESB) for palmar hyperhidrosis. This study was conducted to examine
the relevance between CS and the sympathetic segment being transected in the surgical treatment of palmar hyper-
hidrosis, and thus to detect the potential mechanism of the occurrence of CS. The rates of occurrence and severity of CS
are lowered with the lower sympathetic chain being transected
Keywords: thoracic sympathicotomy, palmar hyperhidrosis, compensatory sweating
1. Introduction
Compensatory sweating (CS) is one of the most common
postoperative complications after thoracic sympathec-
tomy, sympathicotomy or endoscopic sympathetic block
(ESB) for palmar hyperhidrosis. Severe CS in some
cases has an adverse effect on patients’ quality of life,
but the exact mechanism of this complication is not clear.
This randomized prospective study was designed to in-
vestigate the correlation between the sympathetic tran-
section level and postoperative CS in patients with pal-
mar hyperhidrosis. One hundred and sixty-three patients
with palmar hyperhidrosis treated from October 2004 to
June 2006 were randomly divided into two groups: in-
tercostal video-mediastinoscopic thoracic sympathi-
cotomy at T3 level in 78 patients and at T4 level in 85
patients..
2. Methods
Of the 163 patients, 96 were male and 67 were female,
the age of the patients was from 14 to 52 years with a
median of 28.3 years. All patients had excessive sweat-
ing in hands as the chief complaint. The severity of
sweating was graded into mild, moderate and severe lev-
els. Systemic or secondary hyperhidrosis was excluded
before randomization. ECG and chest X-ray examination
were performed routinely. The basic data of T3 (78 pa-
tients ) and T4 (85) groups are shown in Table 1.
2.1. Anesthesia
The procedure was performed under single-lumen in-
tubated general anesthesia, by which a low volume ven-
tilation or block of ventilation for 2−3 minutes was taken
to collapse the lung lobe, then the thoracic sympathetic
trunk could be clearly identified in parallel to the verte-
bral column. Saturation of blood oxygen (SO2) was care-
fully monitored during the operation. After re-ventilation
when SO2 was less then 0.80, the operation was paused
until SO2 reached the normal level.
2.2. Intercostal Video-mediastinoscopic
Sympathicotomy
A 2.0−2.5 cm incision was made between the second and
third rib at armpit, then a video-mediastinoscope was
inserted into the thoracic cavity to identify the T3 sym-
pathetic ganglion by inspection and palpation. Normally,
the rib that can be seen at the top of the cavity is the
second, and the first rib is often covered by surrounding
fat tissue. Then an electrocautery hook was inserted to
isolate and cut the sympathetic chain at the level of T3 or
T4 according to preoperative randomization. An ablation
area around the cutting site of the sympathetic chain was
extended with a range of 2 cm along the rib to destroy
the nerve fibers of Kuntz completely. Video-mediastino-
scope was removed at the end of the procedure, and the

J. YANG ET AL.
20
suction tube was aspirated while the lung was reinflated
and continuous positive pressure was exerted for a few
seconds. Then the suction tube was removed quickly and
the incisions were closed with absorbable suture. No
closed chest drainage was performed. Chest X-ray and
ECG were performed on day 1 after the operation1,2.
2.3. Statistical Analysis
The chi-square test and radit analysis were used in ana-
lyzing the result through statistical software SPSS 11.0
for Windows. A P value less than 0.05 was considered
statistically significant.
3. Results
3.1. Operative Results
There was no conversion to open techniques. Neither
perioperative mortality nor serious complications such as
cardiac arrythmia or arrest were observed during the op-
eration. The median duration of the operation was 30
minutes (range, 20 to 40 minutes). Palmar hyperhidrosis
was cured in all patients shortly after sympathicotomy
with warm and dry hands, and the temperature at the
palm increased by 1.5−3°C compared with that before
sympathectomy. No bradycardia or Horner’s syndrome
was encountered. Hospital stay for all patients ranged
from 1 to 2 days. All patients resumed their normal life
and work within 2 weeks after discharge from the hospi-
tal.
3.2. Follow-up
Phone-call or letter follow-up were available for 163
patients after sympathicotomy, 8 of them lost contact.
The period of follow-up lasted for 3−24 months. The
mean duration was 13.8 ± 6.2 months. No recurrence of
palmar hyperhidrosis was observed. Information of
postoperative sweating over the body was collected for
analysis. The severity of CS was classified into three
levels according to the definition described in the litera-
ture3: mild: a little more sweating than before, no influ-
ence on normal daily activities; moderate: more sweating
than before, a mild influence on normal daily activities,
which embarrasses the patient; severe: obvious sweating
with severe influence on normal daily activities, which
makes the patient regret for receiving sympathicotomy.
3.3. CS
CS with different severity occurred immediately or at
day 1 after sympathicotomy (Table 2). The most com-
mon sites of CS included the back and chest. The un-
common sites included the waist buttock, and thigh. CS
occurred not more common in patients with T4 sympa-
thicotomy than in those with T3 sympathicotomy
(P<0.05). No severe CS was seen in all patients. Mild CS
was not significantly different between T4 and T3 sym-
pathicotomy group (P>0.05), but less moderate CS oc-
curred in patients with T4 sympathicotomy than in T3
patients (P<0.05).
4. Discussion
CS is a phenomenon of a greater amount of sweating
elsewhere in the body after treatment for hyperhidrosis4,5.
It has an effect on patients’ satisfaction to the surgery.
4.1. Mechanism of CS
Up to the present, the mechanism of CS after sympathi-
cotomy remains poorly understood, and there is no ac-
ceptable explanation for it. The concept of “compensa-
tion” described in the 1970s indicates that a greater
amount of sweating elsewhere in the body compensates
for the lack of sweating in the treated body area in order
to maintain sweating balance of the whole body6,7.
However, recent data are conflicting with this theory.
One is that there is no CS after the treatment with
botulinum toxin for palmar hyperhidrosis8.
Although the exact mechanism is still unknown, the
occurrence of CS is believed to be a result of disturbance
of the sympathetic system after surgery. After comparing
different surgical approaches for hyperdirosis, Lin et al9
concluded that destruction of the nerve reflex arch be-
tween the sympathetic trunk and hypothalamus is re-
sponsible for excessive sweating elsewhere in the body
after sympathicotomy. It’s a disorder of imbalanced
regulation of sweating of the body. They suggested that
preservation of the negative afferent tone to the hypo-
thalamus be the key technique for the prevention of
postoperative CS. This hypothesis is so far the most sat-
isfactory explanation for CS after sympathicotomy and is
already verified by other clinical studies.
4.2. Influence of CS on Human Body
Patients’ lifestyle with CS will not be affected3. Only
after repeat enquiries many patients may complain of
more sweating elsewhere in their body after surgery,
without effect on their normal life. This condition is
called mild CS (minor), normally consisting of the ma-
jority of cases with CS. In the present study, the mild CS
accounted for 47.4% in T3 group and 37.6% in T4 group
respectively. In some patients excessive sweating occurs
at some new sites of the body after surgery and the new
hyperhidrosis has an adverse effect on patients’ lifestyle.
This condition is so called compensatory hyperhidrosis,
with which the patient has a decreased but acceptable
satisfaction to the procedure. This kind of CS is classi

J. YANG ET AL.
21
Table 2. CS after T3/ T4 sympathicotomy
fied as moderately severe. In the present study the mod-
erate CS accounted for 23.1% in T3 group and 7.1 % in
T4 group respectively. In a few cases, unfortunately, se-
vere excessive sweating occurs elsewhere in the body,
making the patient feel anguished and embarrassed, even
regret for having the sympathicotomy done. This condi-
tion is called severe CS. No a single case of severe CS
was found in the present study.
4.3. Correlation Between CS and the Level of
Thoracic Sympathicotomy
The correlation between CS and surgical approaches,
particularly the level of thoracic sympathetic chain
transaction is a hot topic for investigation in this field in
recent years. According to the anatomy and physiology
of the upper thoracic sympathetic chain, limiting de-
struction area or lowering the transection level of the
sympathetic chain will result in a localized desympathe-
tization, which would be a theoretical basis for the pre-
vention of CS10,11. This hypothesis is supported by clini-
cal findings12,13. For example, a comparative analysis by
Yoon et al14,15 showed that CS after T3 sympathicotomy
(16.73%) was significantly less than that after T2− T
3
sympathicotomy (45.8%), but with almost the equal
therapeutic rate of 100% for palmar hyperhidrosis under
the two procedures. Comparison of T2− T
4 sympathi-
cotomy with T4 sympathetic clipping for the treatment of
palmar hyperhidrosis16 showed that T4 sympathetic clip-
ping resulted in a significantly less CS but an equal
therapeutic effect on hyperhidrosis. At present more and
more surgeons agree that the preservation of T2 ganglion
and sympathetic segment above can lead to a major re-
duction of CS, particularly embarrassing and disabling
CS, which is also supported by the results of the present
study17,18.
Whether lowering sympathetic transection level from
T3 down to T3 can reduce further CS or not is worth in-
vestigating since there is no randomized clinical trial
about it. The results of the present randomized clinical
trial showed that the incidence of moderate CS was sig-
nificantly lower in T4 sympathicotomy group than in T3
group (P<0.05), although there was a similar incidence
of mild CS in the two groups (P>0.05). This finding in-
dicates that lowering the thoracic sympathetic transection
level further can significantly reduce both incidence and
severity of CS. Single T4 sympathetic transection or
clipping as a popular surgical procedure for palmar hy-
perhidrosis has been accepted by more and more sur-
geons19,20.
In conclusion, these clinical findings are helpful to
better understand dominant characteristics of the upper
thoracic sympathetic chain and the exact mechanism of
CS after sympathicotomy although this side effect can
not be avoided completely at the moment.
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