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Sympathotomy (Surgical Treatment for Hyperhidrosis)

Hyperhidrosis (excess sweating) truly affects patients’ quality of life. Too much sweating, from the hands, feet, underarm and face can cause embarrassment and withdrawal from social situations.

Some patients have tried other treatments, including medications and other therapies and have found that they still suffer from excessive sweating. Patients with hyperhidrosis do not have more sweat glands than others. They have an oversensitive reaction, caused by the sympathetic nerve. Surgery may be an option for those patients.

What is a sympathotomy?

A sympathotomy involves cutting the sympathetic nerve, which is the nerve that controls the sweat reaction. Our surgeons have performed sympathectomies and sympathotomies for more than 20 years. Research and experience have proven that cutting the sympathetic nerve in specific places can improve effectiveness and reduce any complications, including compensatory sweating.

In the early days of treating hyperhidrosis, surgeons used to perform sympathectomies, which meant removing the nerve. We no longer recommend that treatment; rather, a sympathotomy is performed, which cuts the nerve in the appropriate place to stop the sweating reaction.

At Johns Hopkins, our surgeons have performed hundreds of these surgeries and have nearly two decades of experience evaluating and treating patients with hyperhidrosis.

Am I a good candidate for the surgery?

This is an excellent question to discuss with your dermatologist and surgeon. It is very important to our doctors to only recommend surgery to those who they feel will have success.

Doctors know that surgery works very well for patients who have excessive sweating on their palms and underarms. Patients with sweating on their face and scalp can also experience success. However, patients with sweating on their feet don’t always experience success after surgery.

What should I expect during surgery?

Sympathotomies are performed using VATS—Video-Assisted Thoracopscopic Surgery. This system allows your doctor to make a very small incision in the underarm area. Using a camera and scope, your doctors can isolate the sympathetic nerve with microscopic precision.

After your surgeon sees and isolates the sympathetic nerve, he or she makes a simple cut in the nerve, in the appropriate place. To do this, your surgeons will count the ribs as where you make the cut influences the outcome. Your surgeon makes the cut on the sympathetic nerve depending on the type of hyperhidrosis you have:

Type of hyperhidrosis: Palmar (hands)
Where cut is made on the sympathetic nerve: Ribs 3 or 4

Type of hyperhidrosis: Axillary
Where cut is made on the sympathetic nerve: Ribs 4 or 5

Type of hyperhidrosis: Facial
Where cut is made on the sympathetic nerve: Near rib 3

Previously, surgeons would cut near rib 2, but we now realize that this can cause compensatory sweating, an unfortunate result of the surgery, where patients may begin excessively sweating from other parts of their bodies. Johns Hopkins no longer performs the procedure in this way.

What should I expect from the surgery?

The surgery is outpatient, which means you leave the hospital on the same day

What are patients’ levels of satisfaction after surgery?

Patients have high satisfaction ratings after surgery, depending on where they first experienced hyperhidrosis. The chart below illustrates the levels of satisfaction:

Type of SurgeryLevel of Satisfaction
Palmar hyperhidrosis (hands)90%
Axillary (underarms)70-80%

What is compensatory sweating?

Compensatory sweating can occur for some patients about six weeks after a sympathotomy. Doctors don’t truly understand why this happens, but it has been linked to cuts made too high on the sympathetic nerve. That is why it is so important to select a surgeon with many years of experience performing this delicate surgery.