Hyperhidrosis & Excessive Sweating Frequently Asked Questions

1. Why should I travel to Los Angeles to see Dr. Reisfeld?
2. What is the success rate of ETS?
3. What is the recovery period for the surgery?
4. Can thoracic sympathectomy and lumbar sympathectomy be done at the same time?
5. What is the best procedure for my excessive foot sweating?
6. Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
7. What is the age range for patients to have the ETS procedure done?
8. Is the ETS procedure right for me?
9. Where is the procedure performed?
10. Who performs the procedure?
11. What about insurance? How much does the surgery cost?
12. What if I do not have health insurance, what should I do?
13. What if my insurance says they do not cover this particular procedure
14. How does Dr.Reisfeld determine if the surgery is right for me?
15. Do the titanium clips interfere with anything?
16. Is it difficult to schedule a date for the surgery?
17. Does there need to be a separate ETS procedure for separate areas of excessive sweating?
18. What is the possibility of recurrence?
19. Who is not eligible for this surgery?
20. Are there cases that can not be done and why?
21. What is the difference between cutting the nerve versus clipping the nerve?
22. What about hand sweating and armpit sweating?
23. Is the ETS procedure an option for facial sweating and facial blushing?
24. Is Hyperhidrosis Hereditary?
25. What are the psychological impacts of hyperhidrosis?
26. What is the reversal operation?
27. If I only have excessive armpit sweating, what type of procedure is right for me?
28. How secure are the titanium clips?
29. How do I schedule an appointment?
30. What is the difference between rosacea and blushing?
31. What about the Kuntz nerve?
32. What is the recurrence rate / failure rate?
33. Heart Rate Changes?
34. Can excessive sweating be treated non-surgically?
35. What happens to the rest of the sympathetic chain?
36. How do I know if my sweating is excessive and considered hyperhidrosis?
37. What is compensatory sweating?
38. Does the clamping method guarantee reversibility of the procedure?
39. Do you collapse the lungs during surgery?
40. Do the clamps set off alarms in airport metal detectors?
41. Discussion on the correlation between social phobias and ETS.
42. Why does Dr. Reisfeld not recommend ETS for facial blushing, facial sweating and axillary sweating?

Why should I travel to Los Angeles to see Dr. Reisfeld?
Dr. Rafael Reisfeld, M.D., F.A.C.S., A.B.M.S., is a Board-Certified surgeon, diplomat of the American Board of Surgery, and known worldwide as one of the very best doctors in the field of hyperhidrosis helping thousands stop sweating and start living. He has performed more ETS procedures than any other U.S. doctor. He has has dedicated his entire practice to hyperhidrosis, pioneering new techniques and advancing critical research. Dr. Reisfeld has authored numerous peer reviewed medical papers and has been featured in newspapers, magazines, and television reports such as CBS, Fox News, Newsweek and others nationwide. Dr. Reisfeld takes the time to speak with each and every patient before the surgery instead of staff or personel who are not exerpts in this field.

How do I know if my sweating is excessive and considered hyperhidrosis?
Simple questions that patients should ask themselves.

• Does my condition bother me socially or functionally?
• Do your hands drip from time to time from the sweating?

What is the success rate of ETS?
Sweaty palms are cured in over 98% of cases. As a matter of fact after years of doing the Thoracic Sympathectomy it is becoming more evident that the success rate for plantar hyperhidrosis (foot sweating) is no more than 30%. For this reason the lumbar sympathectomy is emerging option as a new approach for those patients who did not get any relief with their plantar sweating after the thoracic sympathectomy or for those whom their plantar sweating is their major problem. The success rate of lumbar sympathectomy for excessive foot sweating is about 95%.

Can thoracic sympathectomy and lumbar sympathectomy be done at the same time?
So far these two procedures have not been done at the same time. There are a few reasons for this.

1. We do not have the ability to judge what will be the response of the sympathetic system when two locations (thoracic and lumbar) are affected at the same time. We do not have any way to ascertain what reaction the body would have.
2. Lumbar sympathectomy is usually a longer and more demanding procedure. As far as it is known so far these two procedures have never been done together. Dr. Reisfeld believes the procedures should be done separately.
3. So far very limited clinical experience has been obtained in regards to doing both lumbar sympathectomy and thoracic sympathectomy at the same time. Those cases were done with one side thoracic sympathectomy and the same side lumbar sympathectomy on one day, and the other sides were done at a later date. The results were good but the final clinical recommendation at this point is not to perform both procedures at the same time because we still have some unanswered physiological questions such as blood pressure and adjustments of sympathetic system to this new approach.

What is the best procedure for my excessive foot sweating?
Excessive foot sweating or plantar hyperhidrosis usually appears together with palmar hyperhidrosis. Solitary foot sweating without excessive hand sweating can also appear but in a very low percentage of cases. We realized that the thoracic sympathectomy (ETS) does not help very much with excessive foot sweating. Since approximately 2004 Lumbar Sympathectomy has proven to be the best current option to treat patients with severe plantar hyperhidrosis (excessive foot sweating).

It still behooves patients with foot sweating to first try conservative measures before opting for a surgical solution. For more in depth information please see our foot sweating section.

Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
Basically the answer is no, there are some instances in which patients describe a temporary increase in their hand sweating after their lumbar sympathectomy. Those patients already had the thoracic sympathectomy for their excessive hand sweating. This temporary and short increase is unexplained so far.

What is the recovery period for the surgery?
For ETS the recovery period is usually very short. After the hour-long operation, the patient spends about two hours in the recovery room and then goes home. Returning to normal life can be accomplished in a few days.

As for the lumbar sympathectomy operation the recovery is somewhat longer. This does not mean the procedure presents any additional risks. Patients stay at the hospital at least one night and rarely 2 nights. The lumbar procedure is much more demanding procedure for the doctor and the patient but recovery has proven to be relatively easy. Overweight patients pose another degree of difficulty to the surgeon. Make sure you talk with the surgeon extensively about this procedure.

Axillary suction currettage patients (Armpit Sweating) do generally have a milder post operative course with regard to pain. There might be some swelling and fluid accumulation which are of a temporary nature. Patients typically leave the surgical center the same day.

What is compensatory sweating?
This is the common name used to the appearance of sweat in other parts of the body after the sympathectomy was done. The compensatory sweating also known as (reflex sweating or compensatory hydrosis) can appear on the lower legs, thighs, abdomen, or the back. Generally speaking everything from the nipple line up will be dry after ETS. All patients will get some sort of compensatory sweating (compensatory hydrosis or reflex sweating) which does not have necessarily any correlation to the amount of hand sweating existing before the operation. The majority of the patients will get it on a level that is acceptable by the patients, which we call mild to moderate. Between 3 to 5% of the patients will get it on a severe level which will make those patients unhappy ones. The compensatory sweating (compensatory hydrosis or reflex sweating) is a byproduct of the operation no matter what method was used. It really depends on how close the follow-up is being conducted by the different surgeons to give a definite statistical analysis of those cases.

What is the age range for patients to have the ETS procedure done?
The age range of patients for which Dr. Reisfeld performs the ETS procedure is between 10 years old and 66 years old. Dr. Reisfeld assesses each patient on a case by case basis. Generally speaking at present the recommendation for younger patients is to wait until they have gained more physiological, physical and mental maturation. This means that the potential patients should wait until the approximate age of 15 or 16. It is however recommended that Dr. Reisfeld be contacted for a much more precise assessment. Please see our section on younger age hyperhidrosis.

What happens to the rest of the sympathetic chain?
There is tremendous overlap in function within the sympathetic chain, so there are no known long-term side effects.

What about insurance? How much does the surgery cost?
Most insurance companies cover the procedure because it is considered a medical necessity. Our office, as a courtesy, will call your insurance carrier to verify benefits in the event that you chose to have the procedure. For those who do not have health insurance see our related question.

What if I do not have health insurance, what should I do?
Some patients who do not have health insurance want to purchase insurance coverage for the operation. As a rule of thumb health insurance coverage should not be obtained just for this procedure. If one gets health insurance coverage it should first be followed with conservative attempts to treat hyperhidrosis. Those attempts should be documented by health care professionals so the insurance companies will see a sincere attempt to treat it with alternative methods. To learn more visit our alternative methods to treat hyperhidrosis section.

What if my insurance says they do not cover this particular procedure?
Lately there is a trend by some large insurance companies to exclude hyperhidrosis treatment from their policies. A similar example of this is the trial to exclude patients from getting surgical treatment for excessive obesity. In our opinion if a patient makes the effort to first try conservative measures to help their problem with no success then the surgical option should not be excluded from their policies. If a patient finds out that the surgical hyperhidrosis treatment is excluded from their policy the patient should challenge their health insurance provider. Many of our patients have successfully challenged their insurance carriers and received authorization to cover the procedure. Please feel free to contact us for more information.

Do you collapse the lungs during surgery?
No, the method that is being used by Dr. Reisfeld is a single lumen intubation which allows air to go in and out of the lungs at all times. Those surgeons that are using the double lumen technique the lung on the operated side is being collapsed.

More and more procedures have been performed as the information available on the procedure has become more accessible through the Internet and other information mediums. There has been some reluctance from the insurance companies to cover the cost. As for general information, hyperhidrosis is most likely a genetic disorder and not a cosmetic one. It is recognized by international health organizations as well as by the government as a medical entity. Obviously, the insurance industry is trying to limit the number of these operations from a purely financial perspective. We are working very hard to educate the insurance industry about this disease entity and teach them that this is a physiological ailment and not just a cosmetic or mental problem. Progress is being made in this regard especially with the amount of medical articles and clinical studies written recently by Dr. Reisfeld and other surgeons.

It is very important for patients to show any evidence that they first tried some sort of conservative treatment such as Drysol, Drionic, Robinul, etc. If insurance companies require documentation, then the patient will be provided with the appropriate documentation. In every case, our office will call the insurance company for pre-authorization. Some insurance companies will demand certain steps to be taken beforehand. In these cases, we will tell the patients exactly what is needed and guide them through the process. Some insurance companies will not respect the pre-authorizations they originally gave out earlier; however, we will do our best to follow up on that issue. Generally speaking, most of the insurance companies will cover this procedure. HMO's, in almost all cases, do not cover the procedure.

Since the insurance issue has become so important, we would like to re-emphasize that patients first try some conservative approaches to deal with their excessive sweating. Also, it is very helpful and important to keep documentation that shows such measures were taken.

For those patients who are not covered by any kind of medical insurance there is an inclusive charge that covers the facility fees, anesthesia fees, as well as the surgical fees. For more information feel free to contact our office or call our friendly staff with no obligation and we will be happy to help you.
Phone: (310) 557-3037

How does Dr.Reisfeld determine if the surgery is right for me?
This is a very difficult question to answer since we do not have any objective measurements to find out what the "level" of hyperhidrosis is. Unfortunately, there are no x-rays, blood tests, or any other objective means by which to determine if a patient is the ideal candidate. Through discussions that Dr. Reisfeld conducts with the patient, a clinical decision is made based on many key factors. Every case is unique, and Dr. Reisfeld takes time to thoroughly assess each and every case before making his clinical decisions.

Does the clamping method guarantee reversibility of the procedure?
The clamping method, which originated in Taiwan, gives a much better option for those patients who are unhappy with the outcome of the surgery and are seeking to do the reversal. Before the clamping method was introduced, the only option that was viable for the patients was the nerve graft reversal. Having the clamps applied gives the patient as well as the surgeon a much easier approach to provide a possibility for reversal. Dr. Reisfeld has performed so far several clamp reversals and the statistical numbers are indicating some degree of reversibility which manifests itself with return of sweat to the upper parts of the body, some recurrence of hand sweating, better heat tolerance etc. Obviously the degree of reversibility varies among patients and we need to do more cases in order to establish more precise statistical data on this. Do the titanium clips interfere with anything?
Titanium clips are entirely safe for the long and short-term and do not "interfere" with medical examinations such as x-rays, MRI scans, etc.

Is it difficult to schedule a date for the surgery?
Scheduling a visit is very easy and simple. Because the operation will not require excessive time away from work (usually less than one week), you can schedule the surgery at your convenience. A consultation and examination with the doctor are required beforehand. The procedure itself will take only about an hour.

Is there a need for separate procedures to treat different areas of excessive sweating?
Sympathetic surgery has developed and improved over the last several years. As stated in other parts of this website, excessive hand sweating is best treated with ETS, which might also help with excessive armpit sweating. Unfortunately sweaty feet (plantar hyperhidrosis) is not improved as much with ETS. For sweaty feet the appropriate procedure today is lumbar sympathectomy. For isolated excessive armpit sweating axillary suction currettage is recommended. Ultimately every patients situation is different and discussion with a surgeon is required.

Who is not eligible for this surgery?
You are not a candidate for the procedure if you suffer from severe cardio-respiratory illness, pleural disease, or untreated thyroid diseases. Dr. Reisfeld takes the time to personally communicate with people and determine if the surgery is right for them after reviewing several factors of their unique situation. The benefit to this is that you speak directly with Dr. Reisfeld who is an expert in the field, as opposed to staff or personnel who are not.

Are there cases that can not be done and why?
In certain cases some old scarring can prevent performing the operation in a safe manner. This type of scarring can be the result of previous pneumonia that was not necessarily clinically obvious. Chest Trauma can result in internal scarring (adhesions) that can prevent safe performance. Some very unusual anatomical abnormalities can also prevent doing the operation in a safe manner. This happens in extremely rare cases.

What is the difference between cutting the nerve versus clamping the nerve?
In the cutting method, the nerve is cut with an electric cautery or with a harmonic scalpel (an ultrasonic device). In the clamping method, titanium clips are applied on the nerve. This ceases the function of that particular nerve segment. Both methods will result in compensatory sweating (compensatory hydrosis or reflex sweating) but the clipping method allows for the possibility of reversal if the compensatory sweating (compensatory hydrosis or reflex sweating) becomes too severe. To learn more about reversal see the reversal section below.

What about hand sweating and armpit sweating?
Many patients will have the combination of hand sweating and armpit sweating (axillary). When the ETS procedure is being done for the hand sweating, about 85% of the patients will see excellent results with regard to their armpit sweating. This is especially true since Dr. Reisfeld will apply clips on the lower levels of the sympathetic chain (Level 3 to 4).

Is the ETS procedure an option for facial sweating and facial blushing?
For more information on this please click here.

Is Hyperhidrosis hereditary?
Yes, Dr. Reisfeld believes there is a genetic correlation in hyperhidrosis. To see Dr. Reisfeld's thoughts on this topic. Click Here.

What are the psychological impacts of hyperhidrosis?
Please read our article that goes into the psychological impacts of hyperhidrosis.

What is the reversal operation?
In the event that a patient is not satisfied with the procedure due to some side effects (compensatory sweating), reversal of the operation can be offered. For more specific information, see our reversal section. For those patients who had the cutting method performed and suffer from severe compensatory sweating, reversal is a possibility that involves a complicated procedure. In this instance, a nerve graft from the ankle is used to bridge the gap in the nerve segment. Over the last two years, Dr. Reisfeld has performed several of the nerve graft reversal operations. The data that was accumulated from those cases shows that at least 60% of the patients will benefit from this procedure in a few aspects. Their compensatory sweating decreases and they start sweating over the upper shoulders, neck, and facial areas. The theory is that once the upper body areas start to sweat the evaporation process causes cooling of the head area. From that location, signals are transmitted to the brain indicating a cooler temperature. The return of upper body sweating could explain the lessening of compensatory sweating and the better ability to tolerate heat. For this rare and unique procedure, please talk to your surgeon.

Recently questions were asked with regard to the use of nerve guides made out of collagen. These nerve guides are used mainly in peripheral nerve repair where there is no gap between the cut ends of the nerve. The nerve tube serves as a protective conduit and supposedly enhances axonal regrowth across a nerve gap. Again, this is only done in peripheral nerve repair. This tube dissolves with time. Other patients ask about the use of schwann cell cultures which, at present, are in the experimental stage and have not yet been used in any clinical cases.

Dr. Reisfeld only performs the clipping/clamping procedure due to the fact that it is much easier to remove the titanium clips than it is to perform a nerve graft reversal in the rare event that it is requested. A nerve graft procedure would be performed for those cases where the cutting method was applied. Dr. Reisfeld does not perform the cutting method because he believes that the clipping/clamping method is a better choice. Statistical data is not yet established for either the clip removal or the nerve graft method. As far as experience shows, after a reversal procedure patients will start getting sweat back on their upper body areas (head and shoulders) and, as a result, compensatory sweating (compensatory hydrosis or reflex sweating) will be reduced. This process might take up to a year.

With the clipping/clamping method, the amount of nerve destroyed is much less than with the cutting method. With less nerve destroyed one can assume that recovery after clip removal would be easier and more effective. In either event, it is very important to discuss these issues, should they arise, with your surgeon.

If I only have excessive armpit sweating, what type of procedure is right for me?
With regard to the presentation of only excessive armpit sweating, sympathectomy does not offer the same high success rate as it does for hand sweating. For that reason, Dr. Reisfeld does not perform ETS if the only complaint of the patient is excessive armpit sweating. The armpit contains two types of sweat glands, eccrine and apocrine. The eccrine glands are affected by the sympathectomy while the apocrine glands are not. Those patients who suffer only from armpit sweating should try conservative methods such as drysol, drionic, certain dry, etc. BOTOX® injections are also a viable option but the duration can be limited to anywhere from 4 to 9 months. If those methods are not helpful, the best option is to go for the superficial lipo curretage of the axillary glands as described.

How secure are the titanium clips?
The clips are very secure and do not require follow up in regards to determining if they are secure or not. However, Dr. Reisfeld does follow up with each and every one of his patients individually in the post surgery phase.

How do I schedule an appointment?
It's easy! Click here to schedule an appointment as well as be sent further information about hyperhidrosis and The Center For Hyperhidrosis. You can also read first hand what Dr.Reisfeld has done for countless others by viewing our patient testimonials.

What is the difference between rosacea and blushing?
Rosacea is a skin condition characterized by blemished skin. It is also characterized with constant redness around the cheeks. See Dr. Nase's web site on Rosacea click here. Sympathetically induced blushing is characterized by facial redness initiated during certain social or functional situations. This is indicated by short bursts of facial redness that happen in conditions that otherwise will not cause facial redness. Usually it starts after puberty (20 - 30 years of age).

What about the Kuntz nerve?
Dr. Reisfeld believes that the Kuntz nerve is a misused term. In the 1920's, Doctor A. Kuntz wrote a paper regarding a nerve he found in cats. That paper was written about the high failure rates when sympathectomies were done for vascular problems with the hands. We know now that the failure rate in those types of operations are related to post-denervation hypersensitivity. In the last symposium on sympathetic surgery in Finland, the overall consensus was that the Kuntz nerve has no bearing on the failure rate of sympathectomy (the actual ETS operation).

Although the Kuntz nerve is mentioned in various publications as being somehow relevant to ETS, proof of the existence of this nerve was never proved or demonstrated. So far, there is no anatomical or physiological proof for the Kuntz nerve. When Dr. Kuntz wrote his paper he stated, "This has not been demonstrated anatomically in man, but has been demonstrated in cats by the use of experimental anatomic methods..."

For a much more in-depth explanation click here

Kuntz A: Distribution of the Sympathetic Rami to the Brachial Plexus: Its Relation to Sympathectomy Affecting the Upper Extremity. Arch. Surg., 15, 871-877, 1927.

What is the recurrence rate / failure rate?
Between 1% and 2% of the patients will develop a recurrence. The recurrence might manifest itself with mild hand sweating under certain situations such as heavy activity, hot weather, or stressful situations. In those mild cases a re-operation may not be needed. But, in those cases that the recurrence is very severe, a redo operation can be performed. So far, the recurrence rates are equal in whatever method the sympathectomy is done.

With regard to the failure rate, one must differentiate between early failure (that happens immediately after the operation) and delayed failure (recurrence that can happen within the first 2 years after the operation). Early failure can happen because of technical or anatomical problems. See our recurrence section as well.

Heart Rate Changes?
Heart rate changes can happen in a small number of cases. There can be slight reduction in heart rate which physiologically has no significance. On the other hand, if a patient is engaged in a heavy physical activity some of them will advise that their maximal heart rate did not reach the same level as before the operation. Since the conversion from the T2 to the clamping of the T3-T4 levels, there are patients who have not noticed any reduction in their heart rate and in fact their heart rate went up to 150 – 160 per minute. There is no long-term adverse effect on cardio-vascular function. To learn more about heart rate changes and sympathectomy please click here. For more information about possible side effects section. Click here

Can excessive sweating be treated non-surgically?
Many medical and commercial preparations are available. To date, they have not been found to be extremely effective or permanent such as ETS.

Is the ETS procedure right for me?
Yes, it may very well be. Dr. Reisfeld consults and meets with every interested patient to determine if the procedure is right for him or her. The cure for hyperhidrosis is both highly effective and extremely safe. Dr.Reisfeld is the most experienced ETS doctor in the U.S. He takes great pride in what he does and it shows time and time again. He performs this proven surgery practically on a daily basis helping those who suffer from hyperhidrosis take their lives back.

Where is the procedure performed?
The procedure is performed at the Beverly Hills Center for Special Surgery, a state-of-the-art facility open since 1984. The center is California state-licensed and Medicare approved.

Who performs the procedure?
Rafael Reisfeld, M.D., is a Board Certified General Surgeon, with over 16 years of experience in the field of surgery. He is an experienced endoscopic surgeon who has performed ETS on thousands of patients.

Dr.Reisfeld is featured in the "Ask The Experts" section of the EFSB Channel.
There is a great list of questions and answers to view. To view the questions and answers click the following links
Ask The Experts part 1
Ask The Experts part 2

To see other media Dr. Reisfeld was featured in, click here.

Do the clamps set off alarms in airport metal detectors?
The titanium clips are very small and will not set off any metal detectors.

To learn more about what we can do for you, please contact The Center For Hyperhidrosis. To contact us now, just click here.

Do you have a question that is not answered here? Just ask and we will answer. To ask your question click here.

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