Endoscopic Thoracic Sympathectomy Surgery for Hyperhidrosis: Patient and Physician Perspectives

Hyperhidrosis

Image courtesy of DermNet

Sixteen-year-old Cole Villaflor was diagnosed with hyperhidrosis in elementary school after dealing with excessive sweating from an early age. Cole’s daily life was affected when interacting with friends, completing school assignments, and playing basketball. Cole went through numerous treatments over 4 years, including topicals and Botox, however, none were successful. After doing his own research, Cole came across the work of Timothy Fairbanks, MD, a pediatric surgeon, the division chief and co-director of the pediatric surgery program at Rady Children’s and a professor of surgery at UC San Diego, and Michael Levy, MD, PhD, a pediatric neurosurgeon and the chief of pediatric neurosurgery at Rady Children’s and a board-certified neurosurgeon at UC San Diego. Cole and his family met with Fairbanks and Levy to discuss a hopeful new treatment to improve Cole’s hyperhidrosis.

In October 2022, Fairbanks and Levy performed an endoscopic thoracic sympathectomy (ETS) surgery on Cole. ETS is a minimally invasive procedure utilizing 3 small incisions to cut or clamp the sympathetic chain in hopes of eliminating excessive sympathetic nerve activity.¹ After Cole’s ETS surgery, he was able to quickly return to his daily routines without worrying about excessive sweating.

Dermatology Times spoke to Cole, his mother, Lynn Villaflor, and Dr Levy for additional insights into Cole’s hyperhidrosis diagnosis and ETS treatment.

Cole Villaflor

Dermatology Times: What activities in your life were most affected by your hyperhidrosis? How did you feel during that time?

Cole: The activities most affected by my hyperhidrosis were social gatherings, schoolwork, and basketball. My hands would be very sweaty, making it uncomfortable to shake hands and high-five friends. Also, this made it hard to grip a basketball, whether for a game or practice. During games, my hands would become very swollen from fluid accumulation. This made my hands quite uncomfortably tight. In writing essays at school, the moisture would dampen and tear the page, and gripping a traditional or Apple Pencil was difficult. This made me anxious to participate in the activities I loved and made me want to avoid them.

Dermatology Times: If you were to give advice to another teenager about a hyperhidrosis diagnosis and how your life has changed since the ETS procedure, what would you say?

Cole: Some advice I would give to anyone dealing with hyperhidrosis is to do your own research and try multiple, different solutions such as antiperspirants and medications first. If you didn’t find the results you were looking for, then I would move on to exploring other options like Botox injections and surgery. Since my surgery, I have been able to enjoy a newfound sense of confidence, as I no longer have to fear social interactions and previously uncomfortable situations. I am grateful to everyone who played a part in my surgery at Rady Children’s Hospital and, in hindsight, would definitely do it again.

Lynn Villaflor

Dermatology Times: What was the hardest part about watching hyperhidrosis affect Cole’s daily life?

Lynn: It is so stressful to see your child constantly having difficulties with basic activities of daily living that they cannot control despite trying so many doctor-recommended suggestions and in turn seriously affect their confidence. Cole’s love and commitment to basketball was being challenged by his constant need to wipe his hands on his nonabsorbent jersey and toweling them off on the sidelines. He is a hardworking kid who takes his grades seriously. So, it’s hurtful when what you produce is a mess because you can’t control your sweat. He had teachers complain about the work he turned in, as it didn’t appear he took pride in its appearance and yet he had put a lot of effort into creating quality work.

Dermatology Times: What advice would you give to other parents or caregivers about supporting a child through hyperhidrosis?

Lynn: I would highly recommend parents support their child by being a strong advocate for them which involves moving along to the next treatment option if after a few months or treatments their child is not seeing significant improvement. I waited a year between some, unsure of how to help Cole. Doctors seemed to downplay the severity and highly discouraged surgery. Get second opinions from other medical professionals and know that there are options. The severity and success or failure of treatments will lead you to the one appropriate for your child. With the frequency I would watch Cole apply and reapply topical lotions I became very concerned about the frequent exposure to the chemicals on his skin. Botox was worth trying but with 30 shots to each hand and no significant decrease in sweating, there was no solution. Yet one dermatologist called surgery “archaic with poor results.” Unfortunately, I think the dermatologists, as we saw multiple, perhaps as a profession, just lack the education on the success of this surgery when done with talented, highly respected surgeons like we have right here in San Diego at Rady Children’s. Finding them is not unlike any research you should do for any type of surgery you may choose to undergo.

Dermatology Times: What advice or tips would you give to families considering the ETS procedure?

Lynn: If you find your child increasingly frustrated as treatments fail, they are getting older and are being more impacted by their hyperhidrosis, you will be relieved to find the ETS procedure. This surgery, when done by such talented and well-respected surgeons as we found in Dr. Levy and Dr. Fairbanks, is remarkable. We really appreciated our visits with the surgeons. Ask questions so you understand what and how the surgery is performed and what recovery entails. Yes, it's surgery, but after meeting and asking away, we felt so reassured that surgery was the right option for us. Dr. Levy and Dr. Fairbanks operate together. The results are immediate, and we are thrilled with them and what it has meant for our child.

Michael Levy, MD, PhD

Dermatology Times: Can you please describe the severity of Cole’s hyperhidrosis and how it was impacting his daily life? 

Levy: The hyperhidrosis impacted him significantly. With this condition in general, one of the primary concerns is socialization. It makes it difficult to do things like shake hands, touch people’s arms, or anything else that may involve touching someone because their hands are so wet. Cole's biggest worry was that his wet hands made it more difficult for him to play basketball. It can also make it hard to use an iPhone, type on a keyboard, or write things down as the sweat can soak the paper.

Dermatology Times: In your opinion, how did Cole’s hyperhidrosis severity compare to other patients you have performed ETS on?

Levy: It’s really variable, but it’s significant for all of the patients we’ve seen and truly a life-altering condition. It’s not just a minor increase in sweat. If you don’t have it, it’s hard to understand. When shaking hands with someone, their hand is wet as they pull it back. Cole’s hands made the basketballs he used at practice wet. There are many different ways it can impact people, but it is overall an embarrassing and, at times, disabling phenomenon.

Dermatology Times: How long have you been performing ETS? In your opinion, what are its advantages and disadvantages?

Levy: I first learned how to perform ETSs many years ago while at CHLA and Cedars Sinai from 2 adult neurosurgeons who had been performing the procedure. Current surgery has been facilitated by significant improvement not only in the surgical approach would in the endoscopes utilize. Today, the technologies available are more advanced. In my opinion, there are no disadvantages, we have had no patients who have not been satisfied with the outcome or anyone that didn’t have a successful procedure. Sometimes, the procedure can cause sweat to appear elsewhere, but that hasn’t happened with any of our patients. In fact, in addition to their hands, we’ve even had kids who have had their feet sweat less!

The advantages are that the surgery is not difficult to perform in the hands of the appropriate team, usually a day surgery, and incredibly effective. Patients feel their hands, even when they're still coming out of anesthesia, and they have dry hands. It’s curative at the time that the procedure is done.

Dermatology Times: Can you please elaborate more on the importance of a multidisciplinary approach with dermatologists to support patients with hyperhidrosis? 

Levy: During the procedure, my part as the neurosurgeon is the easy part, I'm just cutting the nerve that has been visualized and freed up by the General Surgical team. Dr. Tim Fairbanks does the most significant work of displacing the lungs and providing a better view of the anatomy. The best outcomes are based upon the person who is doing the thoracic endoscopy. If we could set up a multidisciplinary approach so dermatologists could be part of the team, that would be great. They could still treat the patients and help achieve success, but with most cases of hyperhidrosis, surgery is the only way to actually cure the disease. If dermatology could educate patients and work with them to provide primary referrals to us, the system would be even more efficient.

Reference

1. Endoscopic thoracic sympathectomy. University of California San Franciso Department of Surgery. Accessed November 20, 2023. https://surgery.ucsf.edu/conditions--procedures/endoscopic-thoracic-sympathectomy.aspx