1.What is Hyperhidrosis?

  Sweating is a normal physiological response to heat. Hyperhidrosis is defined as the sweating amount being more than for normal physiological response to environmental temperature, especially when the sweating areas are restricted to face, hands, armpits or feet, and disturb people’s normal social life or learning.

2.Should Hyperhidrosis be treated? Is there age-limit to receive sympathetic surgery?

Hyperhidrosis is a benign disorder without harm to health. Treatment is considered only when it disturbs people’s normal social life or learning. In my experiences, the smallest patient was three year-old only, the oldest was 79 year-old. There is no age-limit to receive sympathetic surgery. Early surgical treatment is not recommended unless withdrawal behavior due to hyperhidrosis has been found on small child. Surgical treatment is suggested when hyperhidrosis becomes worse after adolescence.

3.Except surgical method, is there conservative method used to treat Hyperhidrosis?

Only surgical method guarantees permanent cure. Conservative managements can be tried, such as disoderant or Ionophoresis but with only temporary effect. Botox injection is not recommended for its limited effect and commercially overemphasized. It is also too expensive and painful comparing to its effect.

4.How many surgical methods are used to treat  
  Hyperhidrosis?

Thers are Endoscopic and conventional open methods to treat Hyperhidrosis. Endoscopic method has completely taken the place of conventional open methods in the world now. Strereotactic cauterization is nearly abandoned for less therapeutic effect and higher recurrent rate.

5.Is there any difference between ETSC/ESB (Endoscopic Sympathetic Block by Clamping) and ETS (Endoscopic Thoracic Sympathectomy or sympathicotomy)?

Interruption of sympathetic tone to hands is the rationale to treat Hyperhidrosis. Cutting or burning sympathetic nerve is conventionally used to treat Hyperhidrosis in ETS. No cutting or burning but clamping nervous trunk only is used in reversible ETSC/ESB. Return of original condition is possible only in ETSC/ESB.

ETSC/ESB is performed through two small incisions made in axilla. Ganglions are clamped by clips , which is made of Titanium, without cutting or burning sympathetic nervous trunk. It takes less than 10 minutes to finish the whole procedures of ETSC/ESB. Paitent usually feels chest or back pain when he is waked from anesthesia. Normal activity is encouraged on the next day after operation. No scar is visible. Reversal procedures can be easily performed by removal of the clips. ETSC/ESB has been clinically used by many surgeons in the world now.

6.Is ETSC/ESB safe？

   ETSC/ESB is a very safe and mature surgical procedure. Dr. Lin has performed Endoscopic sympathetic procedures on more than 6000 cases with different sympathetic disorders since 1989, which included more than 200 foreign patients from more than 30 countries.

7.What kind of Anesthesia is recommended for
   ETSC/ESB? 　

  General anesthesia is the only choice for sympathetic surgery. Local anesthesia is not recommended for its poor anesthetic effect and inhuman.

8.What is the main reason for patient’s regret and  
   then reversal is  requested?　

  Reflex sweating (compensatory sweating) after sympathetic surgery is the main reason for patient’s regret. Without exception, a certain percentage of patients could not tolerate reflex sweating and would like to receive reversal procedure. Reflex sweating happens not only on Hyperhidrotic patients but also on other sympathetic disorders even without sweating disorder. Postoperative sweating phenomenon is a reflex reaction, not compensation. Its mechanism has been first found out by Dr. Lin.

9.How long is the golden time for reversal? Is it  
  difficult to perform reversal procedure?

　The golden period is from three to six months after ETSC/ESB. The previously clamped clips can be removed without difficulty by endoscopy. Effective response of reversal procedure usually appears within three months. The latent duration varies among different patients. Of course, it takes six moths or more to get recovery. No improvement is possible if the reversal procedure is performed too late.

10.Is there any way to treat reflex sweating when it
  happened after a sympathetic procedure?

　It is very difficult to treat reflex sweating whenever it is triggered. Only a few of such patients can be luckily controlled by anticholinergic medicines.

   Reconstruction of sympathetic nervous trunk is the only way to return the continuity of sympathetic tone, but only a few clinical experiences was reported in the world. Dr. Lin has designed a new reconstructive technique of sympathetic nerve that can be performed totally by endoscopic method. This newly designed method is “Intercostal Nervous Grafting” (ICNG).  

Prevention of side effect before operation is much more important than postoperative management. ETSC/ESB possesses preoperatively preventive character in sympathetic surgery.

11.What are the advantages and disadvantages of  ICNG and SNG?

(I) Advantages of intercostal nervous graft (ICNG):

a) From the viewpoint of Human Anatomy:

1)      There are a dozen of intercostal nerves (ICN) communicating with sympathetic nervous trunk and ganglions in each thoracic cavity, which are composed of large amount of sympathetic nervous fibers. In addition, the size of ICN usually accords with the size of sympathetic nervous trunk. Its location and size become the first choice in reconstructive surgery of sympathetic nervous trunk. ICN is a Gift from God for sympathetic nervous reconstruction, isn’t it?

On the contrary, there is only one sural nerve in each ankle; its location is so far from thoracic cavity. The sizes of sural nerves are so various and difficult to accord with the size of sympathetic nervous trunk.

2)      The length of nervous graft:

The length of intercostal nervous graft can be taken as long as clinical necessity. But, the length of sural nervous graft is limited for the sake of its location and less survival rate.

3)      Factors influencing graft survival:

Blood supply is the most important influencing factor to guarantee survival of a graft. Micro-vascular circulation of ICN is completely preserved when ICNG is prepared as a rotation flap for reconstruction. It is impossible to preserve vascular circulation of sural nervous graft when it is removed from ankle. Tissue fluid is the only but very unreliable factor to support sural nervous survival.

b) From the viewpoint of human physiology:

Though two main neuro-transmitters, Acetylcholine and Noradrenaline, are the same among different nervous fibers, different nervous functions are determined by different co-neurotransmitters in different nervous systems. Nervous fibers have similar or the same co-neurotransmitters in the same nervous system. The role of nervous graft should not only bridge the gap between cut nerves but also return transmission of neuro-transmitters and co-transmitters. Tissue histology reveals that intercostal nerves are composed of large amounts of sympathetic nervous fibers. The more similarities between donor and recipient, the better operative results are anticipated. Intercostal nerve is more similar with sympathetic nervous trunk than sural nerve between their compositions. Anatomic bridge between the gaps is not enough to guarantee normal transmission of neuro-transmitters. Only ICNG preserve its physiologic function in whole process of sympathetic reconstructive surgery.

c) Surgical technique:

Sympathetic reconstruction with intercostal nervous graft can be performed totally by one stage of endoscopic method. It takes 3 - 4 hours to complete whole procedures of ICNG.

Two-stage operation is necessary on sural nervous grafting, which includes endoscopic preparation of intra-thoracic surgical field and removal of sural nerve from ankle area by open method. More than 6 hours are necessary for SNG.

 (II) Disadvantages of Intercostal nervous graft:

A few possible disadvantages are found in ICNG. Temporary chest tight or pain, small area of numbness in armpit or anterior chest wall is normally encountered after ICNG. But, they usually disappear in a month.

                    Permanent numbness of both small toe areas cannot be avoided after SNG.

Table 1

(Left): body surface of intercostal innervation, overlaps of innervated areas are found.

(Right): intercostal nerves in intrathoracic cavity.

                                  Procedures of ICNG

12.Is recurrence possible after ETSC/ESB?

     Recurrent rate is less than 1.0%. Incomplete surgical procedure is the main cause of recurrence when it happened within three months after operation. Nervous regeneration is considered the main cause of recurrence when sweating returns more than three months after operation.