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Video-assisted thoracoscopy has largely replaced other approaches to the intrathoracic sympathetic chain. Thoracoscopic sympathectomy is most commonly performed for the treatment of severe palmar hyperhidrosis but can be performed for axillary hyperhidrosis, facial sweating, and facial blushing. In addition, thoracoscopic sympathectomy has been used to treat patients with rare vasomotor disorders and chronic pain syndromes of the upper extremities.


Hyperhidrosis is the pathologic condition of sweating in excess of physiologic requirements for thermoregulation. This excess sweating can be quantified in comparison with the general populace, but patients usually present with a typical history. The typical hyperhidrosis patient is young, between 18 and 25 years old and has had palmar and plantar sweating since early childhood. Parents may recall inordinate wetness of the hands and feet during infancy. Patients may recall grade school classmates refusing to hold their hands because of excessive wetness or teachers scolding them for submitting wet, smudged assignments. Puddles of sweat can accumulate on computer and piano keyboards. Entering adulthood, wet hands adversely affect social interaction and influence career choice.

Sweating is sporadic, occurs during periods of stress or calm, and is usually worse during the summer. Although the degree of hyperhidrosis varies, the sweating is much greater than the dampness associated with stress. Within minutes, a dry hand can become soaked, with sweat dripping to the floor. The volar surface of the fingers, thenar and hypothenar eminences, and palmar skin folds fill with perspiration (Fig. 146-1).

Figure 146-1

Typical appearance of palmar hyperhidrosis. Note wetness on thenar and hypothenar eminences as well as on palmar surface of distal phalanges.

Hyperhidrosis sufferers avoid direct or indirect hand contact and have a handkerchief or tissue always available. Characteristic wiping of the hands on their clothing is noticeable. The damp hands are disguised in social situations by a cold drink held in the right hand. This provides an explanation for the dampness and the need to wipe the hand prior to a handshake.

Concomitant plantar hyperhidrosis occurs in nearly all patients with palmar hyperhidrosis. When walking barefoot, wet footprints are created which are similar to those seen after exiting a shower. Though fungal infections are rare, the constant moistness ruins footwear. Axillary hyperhidrosis with associated garment staining and odor (bromhidrosis) is present in as many as 50% of patients with palmar and plantar hyperhidrosis.14


The prevalence of palmar and plantar hyperhidrosis is estimated to be 0.6% to 1% and affects all racial groups.5 Severe axillary hyperhidrosis affects 1.4% of the United States population.6 Patients with classic palmar and plantar hyperhidrosis do not have concomitant illnesses. In contrast, generalized hyperhidrosis, which is treated medically, may be associated with thyrotoxicosis, obesity, neurologic diseases, and rare ...

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