Endoscopic thoracic sympathectomy (ETS) is a minimally invasive procedure that can treat different types of hyperhidrosis, including armpit sweating (axillary hyperhidrosis), sweaty palms (palmar hyperhidrosis) and excessive facial sweating and blushing. ETS is a same-day (outpatient) procedure.

The Hyperhidrosis Center team is highly skilled in performing ETS. Our dedicated nurses are available to support patients and answer any questions, and can even put them in touch with former satisfied patients.

How ETS is Performed

The surgery is performed through two keyhole incisions (each about a quarter of an inch) made under the armpit. Using a telescope called a thoracoscope — a thin instrument with a light source and tiny fiberoptic camera attached — the surgeon views a magnified area to be operated upon.

The surgeon selects sympathetic nerves or nerve ganglia (nerve terminals) in the chest and then cuts them, interrupting nerve impulses in the sweat glands. This doesn't harm the sympathetic nervous system because there is overlap in the functioning of the sympathetic chain of nerves.


Who Can Undergo ETS? 

Most patients from ages 10 to 65 can be treated with ETS. The surgery is not appropriate for those with cardio-respiratory illness, pleural disease, untreated thyroid disease or excessive scarring of the chest. Our team reviews each patient's individual medical condition and unique needs and determine if they are good candidates for ETS.

Benefits of ETS

Because ETS is performed through small keyhole incisions rather than a large chest incision, there's no scarring, less pain and a faster recovery. The entire surgery takes about one hour, and most patients go home later that day. There may be some soreness at the incision site and in the chest area, but the sutures are below the skin and they will dissolve. Patients can shower the next day and return to work and normal activities within several days.

Risks of ETS

ETS is performed under general anesthesia and carries the risks of any surgical procedure, including reactions to medications, bleeding or infections.

During ETS, the surgeon deflates the lung to enable them to see the sympathetic nerve. Deflating a lung during surgery is routine in all types of thoracic surgical procedures and has no associated risks. When ETS is completed, the lung is reinflated. A small amount of air is left in the chest cavity (pneumothorax), but the air is reabsorbed within a few days and there are no long-term effects. In rare instances, bleeding into the chest may occur (hemothorax). If the blood does not resolve on its own, a repeat thoracoscopic procedure to remove blood clots from the chest cavity may be needed.

Possible Side Effects of ETS

Compensatory Sweating
The most common side effect of ETS is compensatory sweating - excessive sweating of the back, abdomen, thighs, and legs. About 70 percent of patients who undergo ETS will experience compensatory sweating to some degree. Patients who only have palmar hyperhidrosis are the least likely to have significant compensatory sweating following ETS. When ETS is performed for axillary hyperhidrosis (armpit sweating), the risk of compensatory sweating increases. Generally, everything from the nipple line up will be dry from the ETS procedure. Compensatory sweating is tolerated well by most patients and is, in most cases, viewed as far more manageable than their initial problem of hyperhidrosis. The medication Robinol has been effective in some cases in decreasing generalized body sweating.

Horner's Syndrome
The incidence of developing Horner's Syndrome - marked by droopy eyelids, constricted pupils, and the absence of face sweating - is very rare (about 0.3 percent). It can occur if the sympathetic nerve near the T1 level is also disrupted. The risk of Horner's syndrome is highest in patients who undergo ETS for facial hyperhidrosis and/or blushing, since the sympathetic nerve chain is cut closer to the T1 level compared with ETS for other types of hyperhidrosis.

Gustatory Sweating
Gustatory sweating - sweating of the face while eating or smelling certain types of foods - happens in a small number of patients following ETS, but it is usually not a major problem.

Neuritis and Neuralgia
Neuritis and neuralgia, which is non-specific pain in the back between the shoulder blades, occurs in a very small number of patients and is secondary to irritation of the nerve endings. This condition usually stops on its own and is rarely severe or permanent. It can be treated with non-steroidal anti-inflammatory drugs, such as Motrin.

Brachial Plexus Injury
This condition, marked by weakness or paralysis of the upper extremities, is extremely rare and is caused by an injury to the spinal nerves.

Decreased Heart Rate
Many patients experience a 10 percent drop in heart rate after surgery, but this condition has not been demonstrated to affect endurance and tolerance of exercise. In fact, ETS seems to benefit patients with certain arrhythmias of the heart. Nevertheless, competitive athletes who depend on the maximization of their heart rate need to consider this possible side effect more closely than others.

Dry Facial Skin
After ETS, some patients notice dry skin in their face, neck, and scalp. It can be treated with moisturizing creams. Drying of the skin often has the effect of improving acne in many patients.

Insurance Coverage for ETS

Hyperhidrosis is considered a medical condition with serious physical and psychological complications when not treated. Therefore, ETS is usually covered by health insurance because it is considered a medical necessity and not a cosmetic procedure.

However, your policy may require you to try more conservative methods first, such as medications or iontophoresis. Check with your individual health insurance coverage to determine your benefits.