The National Collaborative Group for Minimally Invasive Treatment of Hand Sweating was established in Fuzhou in March 2009 under the care, help and support of Prof. Wang Jun, head of the Thoracoscopic Surgery Group of the Chinese Medical Association. In accordance with the development needs of minimally invasive treatment of hand sweating in China in recent years, the group was entrusted with the preparation of the “Clinical Guidelines for Minimally Invasive Treatment of Hand Sweating in China” (2009 edition) by the editorial committee based on the latest research results at home and abroad, and on the basis of repeated consultations with experts from relevant disciplines for several times.
Hand sweating is a clinical condition caused by disorders of the autonomic nervous system, mainly manifested by involuntary secretion of large amounts of sweat from the palms of the hands due to hyper-secretion of local sweat glands, which seriously affects patients’ life, work and social interaction activities. In recent years, with the development of social economy and people’s pursuit of lifestyle, the disease has become more and more concerned. According to a survey, 3 out of every 1000 people suffer from severe hand sweating disorder. However, nationwide, the awareness rate and consultation rate of hand sweating is still at a low level. Therefore, it is useful and necessary to further increase the awareness and treatment of this disorder.
The surgical treatment of hand sweating originated in 1920 when Kotzareff first reported the use of open-heart surgery for thoracic sympathectomy to treat hand sweating, pioneering the use of surgical methods to treat hand sweating. The concept of traditional thoracoscopic thoracic sympathectomy was introduced by Hugh in 1942 and applied in clinical practice. However, it was not widely used because of the complexity and trauma of the surgical approach and method of performing conventional thoracoscopy. It was not until the clinical application of televised thoracoscopic surgery in the 1990s that the ancient procedure of thoracic sympathectomy was rejuvenated and even developed by leaps and bounds. The surgery is no longer massively invasive, but the minimally invasive method of TV thoracoscopy – thoracic sympathetic nerve trunk dissection for hand sweating has obtained good therapeutic results and has been well received and favored by doctors and patients.
China is a region where hand sweating is more prevalent, especially in Fujian, Guangdong, Zhejiang and Taiwan. In recent years, China has achieved good results and accumulated more experience in carrying out minimally invasive techniques for the treatment of hand sweating. On this basis, some units have also carried out a series of meticulous clinical research work. The depth of these studies has positive clinical significance for the clinical standardization of surgical methods, avoidance of surgical risks, further improvement of efficacy, and reduction of surgical complications. At the same time, we should also see that many problems in minimally invasive surgical treatment of hand sweating in China still lack clear understanding, such as the pathogenesis of hand sweating, the indications for surgery, the level of thoracic sympathetic nerve trunk dissection and its surgical style, the judgment of surgical results, and the prevention and treatment of postoperative complications such as compensatory hyperhidrosis are in urgent need of further research, summary and improvement.
Happily, in order to improve the level of hand sweating diagnosis and treatment in China, it was decided by the initiative of all members of the Thoracoscopic Surgery Group of the Thoracic and Cardiovascular Surgery Branch of the Chinese Medical Association, led by Professor Tu Yuanrong of the Department of Thoracic Surgery of the First Hospital of Fujian Medical University, that the National Collaborative Group for Minimally Invasive Treatment of Hand Sweating was established in Fuzhou in March 2009, and the first working meeting of all members was held. This meeting was of high level, scale, seminar level and attainment, and was a successful domestic exchange forum. The experts and professors from more than 20 units across China discussed all aspects of minimally invasive surgical treatment of hand sweating, especially the definition and classification of hand sweating, diagnosis, surgical indications, surgical methods and the prevention and treatment of complications, especially compensatory hyperhidrosis, and made a preliminary consensus.
The experts unanimously agreed that minimally invasive surgical methods are by far the most effective way to treat hand sweating, which can well relieve patients’ pain and is a treatment method worth promoting. For this reason, the collaborative group summarized the results of the conference discussions and formed the Clinical Guidelines for Minimally Invasive Treatment of Hand Sweating in China (2009 edition). The editorial committee of the Guidelines hopes that the Guidelines will help medical and health care professionals at all levels to play a standardizing and guiding role in the diagnosis and treatment of hand sweating, and help patients and the general public who are concerned about health to have a correct understanding of hand sweating. It must be noted that due to the limited level of the editors, there are still many shortcomings in the Guidelines. Therefore, we sincerely hope that all sister organizations in China will give valuable comments on the Guidelines so that they can be improved in the future.
Definition and classification of hyperhidrosis and hand sweating
Hyperhidrosis (Primary hyperhidrosis PH or Essential hyperhidrosis EH) is a state of hypersecretion of the body’s sweat glands and is a functional disorder in which the exocrine glands are overproductive. As shown in Table 1, hyperhidrosis in a broad sense can be divided into generalized hyperhidrosis and localized hyperhidrosis, with generalized hyperhidrosis often secondary to some neuroendocrine and other systemic disorders.
Localized hyperhidrosis can be divided into primary and secondary hyperhidrosis. Secondary hyperhidrosis is often caused by local inflammation or injury affecting the vegetative nervous system. Primary localized hyperhidrosis is narrowly defined as hyperhidrosis without an obvious organic cause, and sweating is most common on the palms of the hands, soles of the feet and axillae, but rare on the face and perineum, and rare on other parts of the body.
Hand sweating is one of the manifestations of primary localized hyperhidrosis. Patients often have a combination of increased axillary sweating and foot sweating, mainly because of the higher density of exocrine sweat glands in the palms, soles and axillary skin.
Epidemiology and incidence of hand sweating
Data on the incidence and epidemiology of hand sweating are scarce worldwide. Hand sweating is common in Indonesia, Thailand, and Vietnam in Southeast Asia. In Japan, it is also quite common south of Kyushu and in the Ryukyu region, while such cases are rare in the Hokkaido region. Srutton in the U.S. equaled a nationwide survey of 150,000 households in 2004, and the result was a 2.8% prevalence rate, which attracted widespread attention. In addition, large numbers of cases have been reported from Northern Europe, South America, and the Middle East.
The results of a survey conducted by the Department of Thoracic Surgery of the First Hospital of Fujian Medical University in 2004 on 12,803 college and high school students from 20 colleges and universities in Fuzhou City on the prevalence of hand sweating and its associated factors showed that the incidence of hand sweating was 4.59%, with the incidence of severe hand sweating being 0.12%.
The prevalence of hand sweating usually appears in childhood or adolescence and gradually worsens in adolescence, affecting life and learning. 95.6% of patients first present with symptoms at the age of ≤16 years, and 15.3% have a family history of hand sweating.
Clinical manifestations of hand sweating disorder
Patients with hand sweating often complain of excessive sweating on the palms of their hands from childhood or adolescence, which affects their daily life and work, interpersonal communication, and the avoidance and anxiety they feel.
In clinical cases, sweating occurs in several localized areas at the same time, with sweating in the palms, soles, and armpits being the most common, while sweating in the face is rare, and in other parts of the body, the common combinations are: palms + soles, palms + armpits, palms + soles + armpits, etc. Other combinations are rare. The appearance of hand sweating symptoms is mostly related to climate, season, and many factors such as external temperature, emotional changes, and strenuous activities, but may not have any precipitating factors. The symptoms are sudden and intermittent, with most patients having more severe symptoms in the summer and less severe symptoms in the winter. Hand sweating can also be combined with various skin lesions resulting from skin maceration infections of the hands.
Diagnosis of hand sweating
1. History of hand sweating
The diagnosis of hand sweating depends heavily on its historical features, while the physical examination usually has no obvious positive signs other than localized profuse sweat secretion. Laboratory tests also generally do not have specific diagnostic value. Therefore, taking a detailed history is an essential step in confirming the diagnosis of hand sweating.
2. Symptom characteristics
The symptoms of excessive hand sweating can have certain triggers, such as mood swings, anxiety, heat, strenuous exercise, etc. However, in many cases, the symptoms can appear suddenly without warning, and the number of episodes varies daily, each lasting 5 to 30 minutes, but the symptoms of excessive sweating hardly appear in the sleep state.
The symptoms of hand sweating can be clinically graded, for example, into three levels of hand sweating from mild to severe lesions (see Table 2). Of these, moderately severe patients are the ones with clear indications for surgery. This classification is a guide for clinical diagnosis and treatment.
Table 1 Grading of hand sweating symptoms
Mild: moist palms.
Moderate: wetting of one handkerchief when the palm is sweaty.
Severe: dripping beads when palms sweat.
3. Diagnosis and differential diagnosis of hand sweating
(1) Diagnostic points
The diagnosis of hand sweating depends mainly on detailed history taking. The main points of history taking are shown in Table 3.
Table 2 Key points of history taking for hand sweating
1. Identification of the site of onset as localized/generalized sweating
2. Frequency and duration of onset
3. age at onset
4.Family history
5.Whether it is accompanied by fever, night sweats, weight loss, etc.
6.Effect of excessive sweating on personal mood
7.The impact on social, occupational and daily life
8. Determine the exact site of hyperhidrosis
9.Excluding other symptoms of secondary hyperhidrosis
In terms of physical examination, only the manifestations of abnormal sweating and positive signs of secondary skin lesions can be found in general. At the same time, attention must be paid to finding some positive signs for the differential diagnosis with secondary hyperhidrosis. For example, wasting may indicate chronic systemic wasting disease, acromegaly may be related to endocrine system disease, and the possibility of hyperthyroidism should be further ruled out in cases of accelerated heart rate, and the possibility of pheochromocytoma should be noted in cases of elevated blood pressure. If necessary, blood and urine tests, blood glucose, blood T3 and T4 concentrations, and X-ray chest film or chest CT examination can be performed.
(2) Diagnostic criteria
In 2004, John Horrnberger of the American Academy of Dermatology organized a collaborative group of experts from more than 20 institutions to develop a diagnostic reference standard, as shown in Table 4.
Table 4 Diagnostic criteria for hand sweating
Hyperhidrosis of the sweat glands visible to the naked eye for at least 6 months without obvious cause
The diagnosis is confirmed if two of the following conditions are met.
①, Bilateral symmetry of sweating areas
②, at least one episode a week
③, the age of onset is less than 25 years
④. Positive family history of hyperhidrosis
⑤. No excessive sweating during sleep
⑥.Interference with daily work life
If there is fever, night sweats and weight loss, the possibility of secondary hyperhidrosis should be noted.
(3) Differential diagnosis
The differential diagnosis process of hand sweating is shown in Figure 1. from the figure, it can be seen that many diseases have clinical manifestations of hyperhidrosis, either generalized or localized hyperhidrosis may be just some symptoms of a certain disease. Therefore, a correct diagnosis can only be made by an in-depth and detailed history as well as a detailed physical examination. Especially for patients who need further surgery, a series of identification and exclusion are necessary.
Thoracoscopic thoracic sympathectomy
I. Indications for surgery.
1, moderate and severe cases that have been clearly diagnosed, and mild need not consider surgery.
2, severe head and facial sweating, sympathetic muscular dystrophy, ischemic upper limb syndrome such as Raynaud’s disease, advanced pancreatic cancer cancer pain, long QT syndrome, limb red pain, etc. can also be treated by thoracic sympathectomy.
3. It is recommended not to perform two simultaneous surgeries, such as additional alveolar and nodal resection, etc.
4. The age of pediatric surgery is recommended to be above 10 years old, and the family and their children have a strong desire for surgery.
II. Contraindications to surgery.
Patients with secondary hyperhidrosis, severe bradycardia, pleural adhesions, pleural hypertrophy and previous history of thoracic surgery should be contraindicated for surgery, and those with neuroticism should preferably not perform surgery.
Pre-operative preparation
1. Pre-operative diagnosis of hand sweating should be made clearly and the symptoms of hand sweating secondary to other diseases should be excluded through relevant examinations.
2. Preoperative routine examinations include X-ray chest radiographs or chest CT scan, electrocardiogram, and routine laboratory tests such as hematology or immunology and a full set of clinical biochemistry.
3.Recent upper respiratory tract diseases such as cold, cough, fever, gastrointestinal discomfort such as nausea and vomiting, diarrhea and other unexplained discomfort should delay the surgery.
4.Pediatric trachea is thin, X-ray chest radiographs should be made routinely before surgery to select the appropriate type and size of tracheal intubation.
IV. Surgical techniques and methods
1.Anesthesia: choose double-lumen intubation, single-lumen intubation, laryngeal mask or mask ventilation anesthesia according to the actual situation. Ventilation can be stopped during surgery so that the tip of the lung is naturally collapsed. Close monitoring of pulse, heart rate and oxygen saturation, if the oxygen saturation decreases to below 90%, the operator immediately stops the operation, wait for the oxygen saturation of the expanded lung to rise to 95-100%, then stop ventilation again for the surgical operation.
2.Position: Generally, 30°~45° supine, upper arm abducted to 90° with chest wall and fixed on the hand frame to expose bilateral axillae.
3.Incision: Make a 1.0 cm incision in the 5th intercostal space in the mid-axillary line, insert the Trocar and then place a 5 mm 0° or 30° thoracoscope, ask the anesthesiologist to stop ventilation, make another 1.0 cm incision in the 3rd intercostal space in the anterior axillary line under the guidance of the thoracoscope and place the Trocar as the operation hole, enter and exit the electrocoagulation hook and other corresponding instruments through this hole and operate through the monitor. The choice of incision location and size can also be adjusted by the operator according to his own experience and habits.
4.Operation: After entering the thoracic cavity, the thoracoscope first identifies the anatomical structure of the upper thorax. Since the first rib is often covered by soft tissues such as yellow fat pad, the second rib is clearly visible at the apex of the thorax, and the sympathetic nerve stem is located next to the lateral side of the rib cranium, which is white in color, and is only 2-3mm in diameter when magnified under the microscope, and can be perceived by lightly touching and sliding with the electrocoagulation hook. The corresponding nerve trunk was cauterized by electrocoagulation on the surface of the 3rd or 4th rib. In order to eliminate the presence of Kuntz bundles and traffic branches, a further 2-3 cm of cautery can be extended laterally on the surface of the rib. After the operation, the field is carefully checked for active bleeding, and after confirming that the palm temperature rises 1-2°C, the anesthesiologist is instructed to expand the lung under thoracoscopic surveillance, withdraw the thoracoscope and suture the incision, and place a thin 16F tube in the other incision, with one end extending into the roof of the chest and the other end placed in water outside the chest, and then withdraw the tube after the anesthesiologist has fully deflated the lung and suture the second incision. After the operation on one side, the opposite side is operated on, and the procedure is the same. As long as the hemostasis is complete and no damage to the lung tissue occurs, it is not necessary to leave a chest tube in place.
The above is a two-hole procedure, but a single-hole thoracoscope, a TV mediastinoscope or a “Y” pleural biopsy scope can also be used. All three lumpectomy tools are used to perform intrathoracic surgery through a skin incision 2-4 cm long (one-hole approach). The anesthesia and surgical approach are the same as described above. The choice of anesthesia and lumpectomy can be made by the operator according to his conditions, equipment and experience, and there is no need to make rigid rules.
Procedure and cut-off site
Thoracoscopic sympathetic nerve surgery in the upper thorax can be performed in three ways: excision, resection, and branchotomy; excision has long been abolished, and branchotomy is not very effective, and sympathectomy is now recognized as the mainstream procedure. The method of blocking the sympathetic stem can be electrocoagulation cautery, titanium clip closure, or ultrasonic knife cut, we recommend the simple and effective electrocoagulation cautery as the first choice, the latter two methods are more complicated, the effect is also not ideal, should not be promoted. We recommend the following table for reference.
1, palm temperature monitoring: preoperative palm thermometer, and connected to the anesthesia machine display, pay attention to palm temperature changes and repeated bilateral comparison. Thoracic sympathetic nerve cut before the hand temperature is generally between 25 ℃ ~ 28 ℃, some even can not be measured, if the hand temperature is high can be artificially performed palm local physical cooling to 30 ℃ or less. The palm temperature rises quickly after the nerve is cut, and when the palm temperature rises rapidly by 1-2℃ or more, it can be considered effective, which can be used as one of the important reference bases for intraoperative nerve block. If the palmar temperature never rises, it is recommended to cut off T2 decisively to prevent the presence of traffic branches or incomplete cut.
2. The patient’s heart rate (rhythm) and blood pressure should be noted during the operation, and the oxygen saturation should be monitored.
3. Individual patients may experience transient respiratory distress after extubation after surgery, and may continue to receive oxygen in the resuscitation room for observation.
4. After returning to the ward, the patient should be monitored for electrocardiography and oxygen saturation until the next day.
Surgical complications and treatment
1.Intraoperative bleeding
Intraoperative hemorrhage is usually an injury from the intercostal vein or the branch of the odd vein when separating the thoracic sympathetic nerve chain, but there is also bleeding from the trocar into the chest, including tearing of the intercostal vessels. The right thoracic sympathetic T3 or T4 nerve trunk is closer to the branch of the odd vein, and its surface is often crossed by small longitudinal and transverse claw-like veins, so great care should be taken when operating. Another method is to use the electrocoagulation hook on one side of the nerve stem to push the nerve stem to the other side with slight force, rotate while electrocautery, also can pick out the nerve stem, once bleeding, do not panic and blindly cauterize electrocoagulation, should immediately use endoscopic forceps clamp electrocoagulation to stop bleeding, or clip small gauze ball compression to stop bleeding, generally can be successful.
2. Cardiac arrest
There have been isolated reports in the literature of intraoperative cardiac arrest or postoperative severe bradycardia requiring pacemaker maintenance. Therefore, it is important to be vigilant when performing this procedure, especially when performing sympathetic chain dissection on the left side, because this side is the dominant side of cardiac innervation, and the dissection may have a certain effect on the heart rate, so the procedure should be performed on the right side first. The patient’s heart rate (rhythm) and blood pressure should be highly monitored during the operation. However, most studies have concluded that the effects of this procedure on the cardiovascular system, although present, are generally minimal.
3. Pneumothorax
Only 0.4-2.3% of patients require chest drainage, and tension pneumothorax is rare. The common causes of pneumothorax are: direct injury to lung tissue when trocar enters the chest, tearing of the pleural apex when the lung is atrophied, and rupture of the original pulmonary blister at the lung apex when the lung is expanded. Since thoracic sympathectomy is generally not routinely done for thoracic flushing, it is more difficult to detect the rupture of the lung, and if the gas is found to be incomplete when exhausting after surgery, chest drainage should be placed.
4.Subcutaneous emphysema
It can occur alone or along with pneumothorax, and its incidence is 2.7%. It usually appears around the incision and is confined to the chest, and it is quite rare to involve the mediastinum, retroperitoneum, or even the scrotum. Mild subcutaneous emphysema usually does not require treatment, but attention is drawn to the presence of a combined pneumothorax, while severe subcutaneous emphysema mostly requires placement of subcutaneous drainage.
5. Pulmonary atelectasis or pneumonia
The main points of prevention and treatment are to thoroughly ventilate the lungs after surgery, to get out of bed early after surgery, to do more deep breathing, to pat the back and to cough up sputum.
6, postoperative transient palm sweating: transient sweating occurs within a week after surgery, and is characterized by more severe or similar symptoms of palm sweating after surgery than before surgery, appearing at any time of the day or night, lasting from a few minutes to several hours, and recurring several times a day, without any causative factors, and resolving itself after a week. The mechanism is not known, but it may be due to a possible “sensitization” or “rebound” of the effectors within 1 week after the sweat glands are de-sympathetically innervated, resulting in overproduction of sweat glands. Patients should be informed before surgery, otherwise they may be concerned if the procedure is a failure.
Long-term complications
1, compensatory hyperhidrosis: also known as postoperative side effects, is the most common complication after sympathetic nerve surgery in the upper thoracic segment, the mechanism of occurrence is unknown, mainly manifested by the absence of postoperative sympathetic innervation in one or more areas, such as the chest, abdomen, back, buttocks, thighs and calves sweating significantly increased than before surgery. The causative factors are mainly high temperature or after activity, and about 3-5% of patients may be related to emotional excitement or mental tension. The incidence is about 70-80%, and severe cases are not rare. The grading criteria of postoperative compensatory hyperhidrosis can be referred to Table 6. Most patients can tolerate and improve more easily after a period of adaptation and psychological adjustment, and it does not affect the quality of life after surgery, but there are still about individual patients who may cause discomfort and life disturbance as a result, which is the main reason for patient dissatisfaction after treatment. Therefore, how to prevent and alleviate postoperative compensatory hyperhidrosis has become one of the main topics in the treatment of hand sweating in recent years. The incidence of compensatory hyperhidrosis after traditional T2-4 sympathectomy is as high as 28.9-98%, and thus the procedure has been abandoned. In recent years, it has been reported that preservation of T2 and single severance of T3 or T4 sympathetic nerve can greatly reduce its incidence.
2, gustatory sweating: manifested as sweating when smelling special fragrance or eating spicy food, the incidence of which varies from 1% to 56%. The mechanism is unknown.
3. Postoperative relapse: It occurs mostly 6 months to 2 years after surgery, and the symptoms of postoperative relapse are generally milder than those before surgery. Its incidence is about 1% or less, and it is presumed to occur because: (1) the sympathetic nerve was not completely resected during surgery, and there are still side branches or mutated branches left, especially the kuntz nerve was not resected; (2) nerve regeneration; (3) nerve mutation, which may be related to the innervation of T1 thoracic sympathetic nerve. Intraoperative monitoring of palm skin temperature can determine the completeness of sympathectomy and should be used routinely. For postoperative recurrence in cases of first surgery with preserved T2, reoperation to sever T2 is recommended for treatment.
4, Horner’s syndrome: manifested as eyelid ptosis, eye entropion, pupil narrowing, and no sweating on the injured side, is one of the most serious complications of sympathetic nerve surgery in the upper thoracic segment, mainly caused by heat conduction waves to the stellate ganglion during cautery cutting of the sympathetic nerve trunk. The incidence of this complication in conventional T2 sympathetic surgery is also less than 1%. With the use and development of television thoracoscopy, improved surgical methods and the experience of physicians, this complication is very rare, especially since T3 or T4 sympathetic surgery for hand sweating has been performed in recent years. Most cases of Horner syndrome can heal spontaneously with time. The stellate ganglion is covered by a yellow fat pad that can be used as an intraoperative identification marker and care should be taken not to damage it.
Postoperative follow-up of thoracic sympathectomy
Sympathectomy of the upper thoracic segment has become an effective and long-lasting treatment for hand sweating, but the answer to the questions of how, to what extent, and where the procedure was performed is not uniform; whether the removal of sympathetic nerves causes some potential risks to cardiac and pulmonary function; and the effect of the surgical approach on compensatory hyperhidrosis will require long-term follow-up. Therefore, it is necessary to establish a complete set of follow-up data.
All surgical patients should have a complete medical history and contact method before follow-up, as well as a complete surgical record, especially the sympathetic stem procedure, scope and location should not be missed, and should be followed up every 1 month, 6 months and 1 year after surgery, and then once a year in outpatient clinic or by telephone, or a tabulated questionnaire can be conducted.
The follow-up includes: ① the improvement of hand sweat, foot sweat, axillary sweat and skin disease regression after surgery; ② recurrence: time, degree, trigger, site, aggravating or relieving factors; ③ the quality of life after surgery compared with the preoperative situation, satisfaction with the surgery; ④ compensatory sweating situation: time, degree, trigger, site, aggravating or relieving factors; ⑤ any other complications, etc. (Attach the follow-up questionnaire for hand sweating)
Preoperative talk or inform
Thoracoscopic thoracic sympathetic nerve stem dissection is the only effective minimally invasive treatment for hand sweating. More and more patients are requesting surgical treatment because of the mature surgical technique, mini cosmetic incision, significant surgical effect, few complications, quick postoperative recovery, short hospital stay and relatively economical cost. However, we must be aware that any kind of surgery has both advantages and disadvantages. Although this kind of surgery is satisfied by more than 98% of patients after surgery, there are still very few patients who are not satisfied and even regret the surgery. One of the main reasons for this is the common postoperative side effect of compensatory hyperhidrosis, where the “de-sympathetic” areas (such as the trunk or lower extremities) are more sweaty than before surgery.
Although the mechanism of this phenomenon is unknown, recent practice has shown that preserving T2 can greatly reduce the incidence of compensatory hyperhidrosis. Therefore, the preoperative conversation should focus on the following.
1, about compensatory hyperhidrosis: some patients may develop metastatic hyperhidrosis after surgery, which is a common phenomenon, most of which are mild in degree and uncommon in severity. There is no ideal method to eliminate it, only psychotherapy, but the symptoms may gradually decrease with time. For this, patients must be fully prepared psychologically.
2, about recurrence: post-operative recurrence is very rare, the most important reason may be due to nerve walking variation, for this case can be re-operated to cut off T2 to obtain a cure.
3, about axillary sweating and foot sweating: axillary sweating and foot sweating is also a local manifestation of hyperhidrosis. After the thoracic sympathectomy, some patients do have axillary sweating and foot sweating disappeared or reduced, but there are patients who do not relieve or even aggravate, which should also be explained.
4, about fox odor: this is the axillary sweat gland overdevelopment of an abnormal odor of body fluids, the thoracic sympathetic nerve cut may reduce sweat, but can not be cured, this point should also be explained.
5, about head sweating: surgery must be cut T2, after surgery may occur severe head and facial sweating and serious transfer compensatory hyperhidrosis, the operator and the patient must be cautious.
6, about the red face (social phobia): it is not necessarily a disease, the main clinical manifestations of a certain situation, the natural occurrence of shyness, timidity, restlessness, head and facial skin reddening and sweating and other phenomena. Some foreign people use thoracic sympathectomy treatment, received a certain effect, but the recurrence rate is quite high, this case should be the main psychological treatment, should not blindly implement surgery.