ETS Reversal Information

Dr.Reisfeld does perform reversal operations. The type of reversal is dependent on the type of surgery initially performed (the cutting of the nerve, versus the clamping of it).

Over the last decade, more and more ETS surgeries have been performed. Before about 1990, all of the sympathectomies were done in an open fashion that neither physicians or patients preferred. The endoscopic approach made it easier for patients and surgeons alike to accept the operation. It is primarily used for problems like excessive sweaty hands, facial blushing, and facial sweating. The term hypersympathetic activity is used to describe this condition as a physiological manifestation of a hyperactive sympathetic system.

Another reason why more ETS procedures have been done over the last decade, is due to the recent increase and quality of information available on the internet. The dramatic increase in the number of cases being done also brought with it a certain amount of patients (about 3% to 5%) who are unhappy with the results.

For those patients who are unhappy with the results of the surgery, there is a solution. In the past, the only method that was done endoscopically, was the cutting method. For those cases, an attempt was made with some medications, but when that failed then the reversal operations was next. It involved a nerve graft. More recently, the clamping method has also been used, making the reversal operation easier (simply removing the clips). Below, both types of reversals that Dr. Reisfeld has performed in the past are reviewed.

Nerve Graft

With this method, a nerve graft is taken from the ankle region (the sural nerve), and is connected to the divided edges of the sympathetic chain. This is done with a special biological glue. The operation has two components:

  • Mechanical
  • Physiological

Mechanical (Surgery)

The mechanical portion is composed of an endoscopic approach to the prior sympathectomy site (the location where the operation was previously done). The surgeon refreshes the edges of the previously cut nerve. This can be done with an ultrasound scalpel, or with scissors not connected to electricity.

This part is not always possible due to severe scar tissue that builds up during the initial operation. In cases where severe scar tissue is found, the operation may be aborted. Also, any other technical difficulties can terminate the attempt, although this is not common.

Once the area of the previous sympathectomy is prepared, the intercostal nerve graft, or any other nerve graft, is sutured or glued to the missing segment and the procedure is finished. The same procedure is performed on the other side of the chest cavity.


(Time it takes for the nerve itself to resume conduction)

In this second portion, the time needed for the nerve to return to normal sympathetic regulation is a matter that is different from one patient to another. The amount of information that we have about it is very minimal. The process can take a long time, and initial symptoms of recovery will not always show before 6 to 9 months after the reversal.

So far, cases done by Dr. Reisfeld show some improvement. The improvements can be seen in a lessening of compensatory sweating, a better ability to perform exercises, a return of sweat to the facial area and upper body, and better cooling of the upper body regions. These results are similar to those reported by Dr. Telaranta, who also does this reversal.

At a meeting in Germany (2003), the results of nerve graft reversal were presented by Dr. Reisfeld and Dr. Telerantra. Both surgeons reported similar results, however, there is a long way to go in order to get definitive statistical data. In order to get meaningful data, we will need to perform many more cases with a longer followup.

Picture of Reversal for person who previously had the cutting method done

Picture of Reversal for a person who previously had the cutting method done

Similar work for nerve graft reversal is being done by urological physicians (plastic surgeons who use the sural nerve to repair damage done to the sympathetic chain within the pelvic cavity). Here, the sural nerve graft is used as a tube similar to what is done in our reversal procedure. The difference is that they do it immediately at the time of the initial operation.

This other procedure is done in an open fashion with very fine sutures. Their results are not yet etched in stone, and in a recent verbal communication with the leading plastic surgeon who performs these operations, the need for more cases and longer followup was emphasized.

One clear fact, is that the shorter the segment that is cut the better the chances are for reversibility with the nerve graft. There are too few cases to really say anything more than this for now.

Intercostal Nerve Graft

In regards to the intercostals nerve graft method, please refer to the picture below and notice the complex and unique method that can be used to bridge the segment that was taken off in the original ETS surgery.

  • The difficulties that a surgeon might encounter when performing the intercostals nerve graft procedure are few. Among them, are the length of the segment that was taken, and the amount of scar tissue that might be found during the initial exploration.
  • In the picture (open diagram), one can see a harvested intercostal nerve at the third rib level. This was harvested and freed from the surrounding tissues and flipped over to the site of the previously divided sympathetic nerve. The theoretical benefit of this intercostal nerve graft, is that the blood supply is maintained to the harvested nerve. The intercostal nerve also contains some sympathetic and sensory fibers, which might add to the physiological response. Again, with this method more cases have to be done, and more follow-up is needed.
  • As equipment and technical dexterity improves, it is now possible to perform the intercostal grafting procedure with very fine sutures to connect the end of the graft. With this technique, a there is a better chance of recovery. Both methods that are now used are done with robotic equipment or modern refined endoscopic equipment.
  • As said in the previous paragraph, the incorporation of suturing in order to bring the nerve ends together is much more effective and promising. More cases are needed to provide a definite statement. Situations where numbness in the chest wall where the nerve was used is now better understood, but further follow-ups are required to understand this rare occurrence.
  • This is a very complex procedure, so let’s review:

    1. The harvested intercostal nerve has a limited length that can be used to connect the lower part of the sympathetic chain to the upper part that was cut. If a patient had more than 2-3 levels that were cut, the amount of nerve available might not be enough for a successful connection. Obviously This decision not to move forward can be done only after a long time is spent in the operating room to determine if you they have the appropriate measurements. No pre-operative decisions can be made before an actual operation, thus complicating the matter even further.
    2. If the previous ETS procedure was done at a high level (T2-T3), it makes the preparation of the upper end of the sympathetic chain too close to the stellate ganglion to enable a safe connection. This could also potentially cause Horner’s syndrome if the procedure is performed. Because of the limited number of cases done, and the fact that the success rate is yet to be established, it is better not to risk this permanent complication. You should discuss this type of procedure with your surgeon before moving forward.

Reversal Using The Clamping Method

Since about 1999, the clamping method has became the method of choice for Dr. Reisfeld. Dr. Reisfeld only does the clamping method for his patients. If a patient is unhappy with the results, the clamps can be taken out, giving the patient more potential for reversal and recovery.

So far, Dr. Reisfeld has performed several clamp removal reversals. those cases have shown improvement in compensatory sweating (compensatory hydrosis or reflex sweating), and performance ability. The healing process and improvement of the symptoms can take up to a year.

Dr. Reisfeld wishes to emphasize that the clamping method does not guarantee complete reversal. He simply believes that the clamping method offers the best chances of recovery.

As time goes by, more cases will be done and more information will be gathered. Those results and experiences will be posted as soon as they are available. For the time being, about 37 reversal cases have been done on patients who previously had the clamping method. About half of them show improvement.

The improvement presents itself with a reduction of compensatory sweating, return of sweat to the facial region, and minimal to mild hand sweating. As more time has passed, we are getting more and more patients who indeed testify that the clamp removal reduced or eliminated their side effects. In some of those cases it took 2 to 3 years to see the benefits from clamp removal. This fact is in line with the knowledge that nerve growth and recovery of the autonomous nervous system is a very slow process.

Recently, an unpublished medical paper described the experience of European surgeons that described the results of clamp removal over 10 years. It reflects the opinion of Dr. Reisfeld, that the clamp removal does have positive results over time. One should bear in mind that it is a very complicated matter, and not all the facts are yet known to us. The sympathetic chain is still a very unknown entity in neurological science.

A lot has yet to be explored. We know that it has some sort of regeneration ability, but to what degree is still a mystery. We can draw clinical experience through statements, but again those are not always consistent. The fact is that some cases showed recovery after clip removal, which was primarily a factor of time but not always.

Also one should bear in mind that compensatory sweating is something that changes with time, even without clip removal. If a patient wishes to have their clamps removed, they should speak to their surgeon.

Do you have any questions that were not answered here? Would you like to speak with Dr. Reisfeld to answer those questions? To learn more about what we can do for you, contact The Center for Hyperhidrosis by contacting our office.


  1. Joe  September 4, 2018


    I had ETS performed in 2013. They cut me between T2 and T3. Is there any way that nerve reconstruction can be done? Is there any chance that the nerves may connect correctly and grow all the way back to where they were?

    • Center For Hyperhidrosis  September 4, 2018

      Hi Joe. So far the different reconstruction methods of the sympathetic chain after the cutting method that was done for hyperhidrosis did not fulfill the hopes of patients and doctors alike. If you talk to a surgeon who claims high success rate be very cautious when you discuss the issue. Thanks

  2. Daniel  August 19, 2018

    I had ETS performed in Sweden in 1997 for facial blushing.
    I have considerable and depressing compensatory sweating in trunk, back and legs.
    Is there any chance of successful reversal surgery?
    Thank you

    • Center For Hyperhidrosis  August 20, 2018

      Hi Daniel. For many years performing ETS for facial blushing fell out of favor due to the increased rate of side effects. Around 1997 it was done in some places especially in Europe. The way it was done high in the sympathetic most likely produced the un wanted side effects. Due to the high location makes it impossible to perform any kind of reversal. There are some surgeons who offer reversal but be careful to discuss it with the surgeon who offers that procedure.
      I do not recommend ETS for facial blushing. Thanks

  3. Alec  March 18, 2018

    Dr. Nielson in Texas. It’s made my face feel is full of fluid or something, it’s constantly puffy it has a sag and bags under my eyes. I just look exhausted all the time and feel that way too. I can barely smile. I went from a young healthy good looking guy to looking horrible.

    • Center For Hyperhidrosis  March 19, 2018

      from your post I understand that you had the ETS for facial blushing? Am I right? As for my self I do not recommend the ETS for facial blushing. The results are not good and the facial blushing is not resolved.
      I recommend the ETS for those patients with severe and excessive hand and feet sweating.

  4. Hugo  February 7, 2018

    I did t3 level ETS for my hands one semester ago, but I’m not satisfied with the results, my compensatory is horrible and I have been suffer from another side effects as well. The method I took was the cutting one. Is there any studies indicating that the compensatory reduce along time? And in last case, is the reversal surgery possible?

    • Center For Hyperhidrosis  February 7, 2018

      The compensatory sweating can fluctuate with the time. You might get reduction but it is not predictable. With regard to the reversal you should discuss the issue with your surgeon.

  5. Kelly  January 6, 2018

    Hi i had Ets surgery where the doctor cut the sympathetic nerve at the 2nd rib level. Is there any way to reverse this? My compensatory sweating is causing me anxiety and depressive symptoms. Please help.

    • Center For Hyperhidrosis  January 7, 2018

      Hi Kelly. Unfortunately a cutting method which was done in the past for ETS does not leave a good surgical option to do it. You might find other surgeons that might offer a solution but be sure to ask the right questions about success rate and experience.

  6. Daniel  December 12, 2017

    Hello I had this surgery like 2 year ago for facial blushing , with clips but I dont really like it the result , my face is so dry and continually red , my question is possible to reverse the surgery I went to see my doctor like a year ago to remove the clips and he told me that wasn’t a good idea , please what do you think , thanks in advance.

    • Center For Hyperhidrosis  December 12, 2017

      Hi Daniel. My self I do not recommend the thoracic sympathectomy for facial blushing. Sorry you had the operation for this problem. Removal of the clips will be your best option. The success rate is not more than 50% but if the clamping method was done that it is possible.
      If you are in the US you can call us at 310-557-3037. Thanks

  7. Katelyn Trevino  May 9, 2017

    If I had Micro ETS where the nerve was cut and not clamped, does this mean this surgery wouldn’t work for me??

    • Center For Hyperhidrosis  May 9, 2017

      Hi Katelyn. It is some what complicated to answer your question in this format. You can call our office and I`ll try to shed some light on your question regarding the ETS you had.

      Our office number is 310-557-3037. Thanks

  8. Alec robertson  November 1, 2016

    I had ets surgery for blushing about 4 years ago, I got the t2 cut, and I’ve had some side effects I don’t like. The first few months everything seemed perfect but now I’ve got bad fatigue, feeling disconnected, etc.. I’ve also got an extremely puffed up and bloated face that makes it hard for me to make facial expressions. Before the surgery I was always smiling and not all the inflammation ‘in my face feels horrible, and it started right after the surgery and continually got worse so I’m sure it’s a side effect. It’s destroying my quality of life, I’m 21 and loook and feel like I’m 40. Is reversal an option for me?

    • Center For Hyperhidrosis  November 1, 2016

      For a long time I objected to the idea that ETS is good for facial blushing. I talk and lectured against it. From the technique used it is extremely difficult or possible to do a reversal. Where was your operation done??