ETS for Excessive Sweating Treatment

In the treatment of excessive sweating, ETS (Endoscopic Thoracic Sympathectomy) is a surgical option especially for patients experiencing intense sweating in the hands and underarm areas. With this method, sweating is stopped by interrupting the sympathetic nerves, and permanent results can be achieved.

The question of who ETS surgery is applied to is important in determining treatment candidates. This method is preferred for individuals who do not respond to other medical treatments, whose quality of life is significantly affected, and who do not have systemic disease. Patients between the ages of 20–40 are generally considered suitable.

The advantages and risks of ETS surgery should be carefully evaluated. While providing a permanent solution is its greatest advantage, side effects such as compensatory sweating may occur in some patients. Performing the procedure by experienced surgeons reduces the risk of complications and increases the success rate.

The recovery process after ETS is fast and patients are usually discharged on the same day. Mild chest pain and fatigue may occur during the first days. Most patients return to their normal lives within a few days and a significant reduction in sweating complaints is observed.

What Is ETS in the Treatment of Excessive Sweating?

Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive method applied in the surgical treatment of excessive sweating (hyperhidrosis), especially in the hands, underarms, and facial area. In this procedure, the relevant part of the sympathetic nerve chain that controls sweating is blocked or cut. Performed under general anesthesia with small incisions, ETS can provide a permanent and effective solution in suitable patients; however, it should be carefully evaluated due to possible side effects such as compensatory sweating.

Why does excessive sweating (hyperhidrosis) occur in our body and how does it develop?

The sweating mechanism is one of the most fundamental and vital functions of the human body. Our body temperature rises when we exercise, stay in a hot environment, or develop a fever. At this point, the thermostat in our brain activates and sends a “work” signal to the sweat glands to cool the body. This is a completely healthy and necessary process. However, in the condition we call “hyperhidrosis,” the settings of this system are disrupted. Even when the body does not need cooling, such as when sitting in a cool room or simply watching television, the nervous system continues to send constant and intense signals to the sweat glands.

We can compare the underlying mechanism of this condition to an electrical system. If the light switch in your house is faulty and turns on and off by itself, the problem is not in the bulb but in the electrical line supplying it. Similarly, in hyperhidrosis, the problem is not in the sweat glands in your hands or underarms (the bulbs), but in the sympathetic nervous system that delivers the command to them (the electrical line). This nerve network is part of the autonomic nervous system, which operates outside of our conscious control. Emotional states such as excitement, stress, fear, or embarrassment can excessively stimulate this system.

As a result of this overstimulation, intense moisture occurs in certain areas of the body. These areas are generally where sweat glands are most concentrated.

The areas where excessive sweating is most commonly seen in the body are as follows:

• Palms
• Underarms
• Soles of the feet
• Facial area
• Scalp

Sweating in these areas occurs beyond the person’s control. The more the patient thinks “I will not sweat,” the more their stress level increases; as stress increases, the sympathetic system becomes more stimulated and consequently more sweating occurs. This becomes a vicious cycle that traps the patient. Scientific data and our clinical observations show that when we surgically interrupt sympathetic nerve transmission, sweating stops immediately. This proves that the source of the problem is definitely neural transmission.

How does excessive sweating affect daily life and social relationships?

Excessive sweating is often described in medical textbooks as a “benign condition that does not pose a life-threatening risk.” However, this definition falls far short of describing the emotional storms experienced by patients. It may not threaten your physical health, but the damage it creates on your mental well-being and quality of life can sometimes be much more severe than that of a chronic disease.

Imagine going to a very important job interview. Your biggest concern is not your abilities or experience but having to shake hands with the interviewer. Or imagine having to constantly come up with excuses to avoid holding hands with someone you like on your first date. For a school-age child, having their exam paper soaked with sweat and the ink spreading may create lifelong exam anxiety. People with underarm sweating often have to completely change their wardrobe. Instead of choosing the color or fabric they want, they choose clothes that show sweat the least. Wearing black, dark navy, and loose clothing and keeping their arms pressed to their body are defense mechanisms commonly developed by these patients.

This constant state of alertness leads the person to serious anxiety. Avoiding social environments, social withdrawal, and even depression are situations we frequently encounter. For us physicians, the most important criterion when deciding on surgery is not the amount of sweat but how much it restricts the patient’s life.

The social difficulties most frequently reported by our patients are as follows:

• Avoiding handshakes
• Wet documents
• Clothing stains
• Concern about bad odor
• Rusting of metal objects
• Inability to use touch screens
• Social isolation
• Loss of self-confidence

Which treatment steps should be followed before deciding on surgery?

Surgical intervention is always the final step in treatment. When a patient walks in and says, “My hands sweat and I want surgery,” we do not immediately take them to the operating room. Medical ethics and scientific approaches require trying less invasive, reversible, and simpler methods first. The treatment algorithm is like a staircase; it begins from the lowest step and moves upward if results are not obtained.

The first step includes topical agents. These are usually special lotions or creams containing aluminum chloride. They are applied to the hands or underarms before going to bed. These substances mechanically block the openings of sweat ducts and prevent sweat from coming out. They are quite effective in mild cases but may cause skin irritation and require continuous use. If this method does not work or the patient is uncomfortable with side effects, the second step is considered.

The second step is iontophoresis therapy. In this method, the patient places their hands or feet into containers filled with tap water. The device passes a low-voltage electrical current through the water that does not cause discomfort. This current temporarily blocks the sweat gland ducts and stops sweating. It is a very safe method but can be inconvenient. It must be applied several times a week, with each session lasting 20–30 minutes. Sweating returns when treatment is stopped.

The third step is Botulinum Toxin, known as Botox. Botox temporarily paralyzes the nerve endings that go to the sweat glands. When the nerve ending is paralyzed, it cannot send the “work” signal to the sweat gland and sweating stops. It produces remarkable results especially in underarm sweating. However, its effect is not permanent; it lasts about 4 to 6 months on average and the procedure must be repeated. Additionally, when applied to the palms it may be painful and may cause temporary weakness in hand muscles.

The treatment options that should be tried before surgery are as follows:

• Antiperspirant creams
• Medical lotions
• Iontophoresis devices
• Botox injections
• Oral medications

What is Endoscopic Thoracic Sympathectomy (ETS) surgery and how is it technically performed?

ETS surgery is a minimally invasive surgical procedure that comes into play when all other treatments have failed. “Minimally invasive” means performing surgery with the least possible damage to tissues without making large incisions in the body. This procedure is performed using the Video-Assisted Thoracoscopic Surgery (VATS) technique, which represents a revolution in thoracic surgery.

The surgery is performed under general anesthesia, meaning the patient is completely asleep during the procedure and feels nothing. As surgeons, we make a very small incision in the patient’s underarm area to access the chest cavity. This incision is usually about 1 centimeter and sometimes even smaller. Through this tiny opening, we insert a thin rod called a thoracoscope, which has a high-resolution camera and light source at its tip. The camera reflects the image inside the chest cavity onto large screens in the operating room. This allows us to see the internal anatomy much more clearly and magnified than with the naked eye.

Guided by the image on the screen, we locate the sympathetic nerve chain that runs downward along the spine. This chain extends on both sides of the spine like a pearl necklace. The essence of the surgery is blocking this chain at the correct level, which carries the signals responsible for excessive sweating. The procedure is usually performed on both sides (right and left) in the same session. Each side takes about 15–20 minutes. In total, the patient remains under anesthesia for about 45–60 minutes. Since there is no major muscle cutting or rib spreading, postoperative pain is minimal and recovery is extremely fast.

Which methods and levels are used during nerve blockade in surgery?

There are different schools of thought and techniques in the surgical world to stop conduction in the sympathetic chain. The main goal is to prevent the “sweat” command coming from the brain from reaching the hands. To achieve this, the integrity of the chain must be disrupted.

The two most commonly used methods are clipping and cauterization. In the clipping method, we do not cut the nerve chain; instead, we compress the nerve using small clips made of titanium. Although this method is theoretically considered reversible, complete reversal is not always possible because nerve tissue is crushed. In the other and more commonly used method, cauterization, the nerve chain is cut or burned using special surgical instruments and heat energy. This provides a permanent and definitive blockage.

As important as which technique is used is “at which level” the intervention is performed. The sympathetic chain is numbered according to spinal levels as T1, T2, T3, and T4. Each level controls a different region of the body. A procedure performed at the wrong level may either fail to stop sweating or increase unwanted side effects. For example, the T3 level is usually targeted for hand sweating, while the T4 level is recommended for underarm sweating. For facial flushing or facial sweating, higher levels (T2) are targeted. The surgeon’s mastery of this anatomical map is the key to success.

The main techniques and targets used in ETS surgery are as follows:

• Clipping method
• Cauterization method
• T2 level targeting
• T3 level targeting
• T4 level targeting

What is Compensatory Hyperhidrosis (Reflex Sweating), the most important side effect of surgery?

This is the subject on which we spend the most time with our patients and must be the most honest and transparent about when discussing ETS surgery. Compensatory Hyperhidrosis, or Reflex Sweating, is not a complication of the surgery but a physiological consequence. The surgery has a success rate of over 95% in stopping hand sweating and around 85–90% in underarm sweating. However, this success comes with a trade-off:

Our body is a perfect thermoregulation (heat balance) machine. When we surgically close the exit gates in the hands or underarms, the body still needs to release the heat accumulated inside. The sympathetic system essentially says, “If I cannot release this heat through the hands, I must find another route,” and activates areas that previously never sweated or sweated very little. This is similar to how water finds a new path when its original flow is blocked.

Statistics and our clinical experience show that reflex sweating occurs in the vast majority of patients undergoing ETS surgery (80–90%). For most patients, this condition is mild or moderate and tolerated with the mindset of “I am willing to accept a slightly sweaty back in exchange for dry hands.” However, in a small but significant group of patients (3–5%), this sweating may be very severe and even more disturbing than the original problem. The patient may have to change clothes several times a day. Therefore, it is essential that the patient understands and accepts this risk before deciding on surgery.

The areas of the body where reflex sweating is most commonly seen are as follows:

• Back region
• Front chest wall
• Abdominal area
• Back of the legs
• Buttocks
• Groin region

Can the problem of reflex sweating be treated?

When reflex sweating develops, unfortunately its treatment is not as easy or definitive as the original hand sweating. This situation is the most significant factor reducing patient satisfaction after surgery and the issue surgeons have the most difficulty managing. Once the nerve is cut or damaged, reversing the new balance established by the body becomes quite difficult.

Treatment approaches generally focus on alleviating symptoms. Unfortunately, there is no “magic wand” that can completely eliminate reflex sweating. We primarily recommend lifestyle changes and medical treatments. Using special functional clothing made of fabrics designed to absorb sweat and prevent it from showing can improve patient comfort. Anticholinergic medications may reduce sweating overall, but their long-term use is difficult due to side effects such as dry mouth or blurred vision. In some cases, Botox may also be applied to areas affected by reflex sweating, but when large areas (such as the entire back) are involved, this method becomes both costly and impractical. Therefore, the best treatment is actually the best patient selection. When the patient undergoes surgery with full awareness and acceptance of this risk, it helps prevent disappointment afterward.

The methods used in managing reflex sweating are as follows:

• Topical creams
• Oral medications
• Functional clothing
• Weight control
• Diet adjustments

What is the right age and patient group for surgery?

ETS surgery is not performed on every person who sweats. Correct patient selection is half of surgical success. The ideal patient is someone diagnosed with “Primary Local Hyperhidrosis.” This means there should be no underlying systemic disease such as thyroid disease, infection, diabetes, or cancer causing the sweating. If a patient experiences generalized sweating across the whole body, they are not suitable for surgery. Because stopping whole-body sweating is impossible and may disrupt the body’s heat balance, creating a life-threatening situation.

Age is perhaps the most sensitive point for us. We generally prefer not to perform this surgery on individuals under the age of 18. There are two valid reasons for this. The first is physiological; hormones are highly active during adolescence and the sweating mechanism has not yet stabilized. Sometimes sweating decreases on its own after puberty ends. The second and more important reason is the ability to give informed consent. It is difficult for a 15–16-year-old to fully understand and weigh the lifelong risk of reflex sweating. Under social pressure they may say, “As long as my hands are dry, I accept anything.” However, when they reach the age of 30, back sweating may bother them much more. Individuals aged 18 and above tend to evaluate the risk-benefit balance more realistically.

Patient groups that are not suitable for surgery include:

• Patients with secondary hyperhidrosis
• Individuals who are severely overweight
• Those with generalized body sweating
• Patients with pleural adhesions
• Individuals with unstable psychological conditions
• Those with unrealistic expectations

Why is the consent and information process so critical?

As a surgeon, my preliminary consultations with patients sometimes take longer than the surgery itself. In ETS surgery, the “Informed Consent Form” is not just a legal obligation or a document to be signed and set aside. This form and the process behind it form a bridge of trust between the patient and the physician.

During this process, it is not ethical to talk only about success. The high probability of reflex sweating, the unpredictability of its severity, the irreversible nature of the surgery (because reconnecting the nerves is very difficult and often unsuccessful), and risks such as eyelid drooping (Horner syndrome), although rare, must be explained clearly. If a physician tells you, “This surgery has no side effects and guarantees a solution,” it is wise to pause and think. There are no guarantees in medicine. The correct approach is the honest statement: “This surgery will dry your hands, but your back may sweat instead—do you accept this trade-off?” The patient must undergo surgery knowing this exchange. Only in this way can patients be prepared for postoperative outcomes and avoid disappointment.

The issues that must be discussed during the consent process include:

• Risk of reflex sweating
• Irreversibility
• Possibility of Horner syndrome
• Risk of pneumothorax
• Anesthesia risks
• Success rates

What is the recovery process like after surgery?

One of the greatest advantages of ETS surgery is the high level of patient comfort. When the surgery is completed, patients are taken to the recovery room. Most patients look at their hands the moment they wake up, and seeing the mixture of surprise and happiness on their faces is priceless. Their hands are warm and completely dry. For someone who has been used to cold and wet hands for years, this feels strange but wonderful.

Once patients are transferred to the ward, they may feel mild pain related to the small incisions under the arms. This pain is usually similar to muscle pain and can easily be controlled with simple painkillers. The majority of patients are discharged on the evening of the surgery after eating and walking around. At the latest, they return home the following morning. In other words, the hospital stay rarely exceeds 24 hours.

After returning home, no special care is required. Since the stitches are aesthetic, dressings are usually unnecessary; keeping the area clean and dry is sufficient. A short follow-up visit is typically scheduled about one week later. If patients have a desk job, they can return to work within 3–4 days; if they have a physically demanding job, within about one week. During recovery, breathing exercises are recommended to ensure the lungs function at full capacity.

Points to consider after surgery include:

• Keeping the wound area clean
• Avoiding heavy lifting
• Breathing exercises
• Drinking plenty of fluids
• Regular walking
• Avoiding sudden movements

Frequently Asked Questions