Does compensatory sweating occur in every patient?

Compensatory sweating (increased sweating in the back, abdomen, or legs) occurs in 50-70% of patients with classic ETS using clipping or cutting methods. However, with our Ramisectomy technique, this rate drops to 5%. While usually mild-to-moderate and tolerable, knowing this risk in advance is critically important.

If the clipping method is used, it is theoretically reversible, but the reversal rate is in only 30% of the patients in 6-9 months. For this reason, the decision to operate should be made carefully.

Treatments›Chest Wall & Hyperhidrosis›VATS-ETS

VATS-ETS (Endoscopic Thoracic Sympathectomy / Ramisectomy)

Minimally invasive sympathetic nerve division for palmar, axillary, and facial hyperhidrosis

Procedure Time

30-60 min

Hospital Stay

1 night

Recovery

5-7 days

Success Rate

Palmar 95-98% / Axillary 90-95% / Facial-Cranial 90% / Plantar 50-70%

In Short

In the VATS-ETS Sympathectomy/Ramisectomy technique, only the side branches (rami albi and rami grisei) before and after the ganglion node are divided with a hook cautery at levels corresponding to the sweating area (T3-4 for hand/underarm, T2 for face/scalp, T5 for feet) — while the sympathetic chain itself is completely preserved (no cutting, burning, or clipping of the main chain). This approach results in compensatory sweating in fewer than 5% of patients.

Who Is a Candidate?

Suitable Candidates

✓ Severe palmar hyperhidrosis
✓ Axillary hyperhidrosis
✓ Facial hyperhidrosis / blushing
✓ Unresponsiveness to conservative treatments
✓ Bromhidrosis (foul smell)

Not Eligible

✗ Severe pulmonary disease
✗ Prior thoracotomy
✗ Patients who cannot accept compensatory sweating (informed consent is critical)

How the Procedure Works

1. General Anesthesia

Double-lumen intubation; one lung is deflated.

2. VATS Access

A thoracoscope (5mm) is inserted through two small incisions.

3. Ramisectomy

T2-4 side branches (rami) are divided. If foot sweating is also present, T5 side branches are also divided.

4. Bilateral Procedure

Both sides can be done in the same session or in separate sessions 4 weeks apart. Separate sessions reduce compensatory sweating risk to below 2%.

Benefits & Expected Outcomes

90-95% success rates for palmar hyperhidrosis.
Immediate effect (on the operating table)
Minimal scarring

Risks & Complications

⚠️ As with any medical procedure, there are risks. The following is evidence-based information.

• Compensatory sweating: 50-70% with burning, clipping, or cutting methods. With Ramisectomy: 5% if both sides done in same session, 2% if done in 2 separate sessions 4 weeks apart.
• Horner syndrome (rare, <1%)
• Pneumothorax
• Gustatory sweating (sweating while eating, rare)

Recovery Process

Day 0

Bilateral procedure

Postop Day 1

Discharge

Day 5-7

Daily activity

Month 1

Follow-up

Tests Required for Evaluation

Upload the following documents in your Free Evaluation form for remote candidacy assessment:

✓ Spirometry
✓ Chest PA X-ray
✓ Preoperative laboratory
✓ Hyperhidrosis Disease Severity Scale (HDSS) — see below

What Is the Hyperhidrosis Disease Severity Scale (HDSS)?

HDSS is a 4-point clinical scale measuring the severity of sweating and its impact on quality of life. It focuses on how much sweating restricts daily activities, not just the amount of sweating.

Score	Patient Description	Severity
1	My sweating is never noticeable and never interferes with my daily activities.	Mild
2	My sweating is tolerable but sometimes interferes with daily activities.	Mild / Moderate
3	My sweating is barely tolerable and frequently interferes with daily activities.	Severe
4	My sweating is intolerable and always interferes with daily activities.	Severe

Score 3 or 4 → Severe hyperhidrosis; considered an indication for surgical intervention (VATS Ramisectomy).

Measuring treatment success: A 1-point decrease ≈ 50% reduction; a 2-point decrease ≈ 80% reduction and meaningful treatment success.

Can be supplemented with objective methods such as the iodine-starch test (Minor's test) or DLQI when needed.

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Compare Your Options

Feature	RAMISECTOMY T2-4	ETS (Clip, Burn)	Medications	Botox
Efficacy (palmar)	Permanent	90-95%	30-50%	80% (temporary)
Permanence	Permanent	Permanent	Temporary	3-6 months
Compensatory sweating	5%	50-70%	None	None

Patient Experience

For years I avoided shaking hands with people. After surgery, that same day I shook someone's hand for the first time.

🇸🇪

Anonymous patient

Sweden · 28 years old

Frequently Asked Questions

Scientific References

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