Upper dorsal endoscopic thoracic sympathectomy: a comparison of one- and two-port ablation techniques

OBJECTIVE

Facial blushing and hyperhidrosis, particularly in the facial, axillary or palmar distribution, are socially, professionally, and psychologically debilitating conditions. Endoscopic thoracic sympathectomy can be carried out through multiple ports or by using a single port and a modified thoracoscope with integrated electrocautery. We reviewed our own experience to compare outcomes between these methods.

METHODS

One hundred and nine consecutive endoscopic thoracic sympathectomies performed on 96 patients (M:F, 30:66) were examined with respect to operative method, symptom control, and patient satisfaction. Complete follow-up was available on 144 treated sides in 77 patients (80.2%), 38 treated with two ports, 39 performed by a one-port procedure. Mean age was 32.6 years (range 18-63) with a median follow-up of 25 months (range 5-85). Pooled data showed that the mean duration hospital stay was 1.6 nights with no deaths, conversions, or neurological injuries.

RESULTS

The one-port group showed superior outcomes in terms of hospital stay, rate of postoperative pneumothorax, and the need for chest drain insertion; however, there was no correlation between number of ports and patient satisfaction. The mean overall satisfaction rating out of 5 was 3.3 with 76.6% of patients rating the outcome as 3 or more. 90.9% had an initial improvement in symptoms, although 21 patients (27.3%) described a late return of symptoms.

CONCLUSION

Endoscopic thoracic sympathectomy can be safely and effectively carried out using a single port with similar results to the traditional two-port procedure. The one-port procedure may allow for a shorter duration of stay and lower complication rate.

Unilateral occipital hyperhidrosis following Chiari I decompression: case report and a review of the literature

INTRODUCTION

Paroxysmal unilateral cephalic hyperhidrosis is a rare disorder of the autonomic nervous system.

CASE REPORT

We report an adult male who developed this disorder almost 20 years after posterior fossa decompression for Chiari I malformation with syringomyelia as a child. Further, the patient presented with spastic diplegia. To date, this patient has refused further operative intervention. The medical literature is reviewed regarding this unusual phenomenon.

CONCLUSION

To our knowledge, hyperhidrosis of the occiput has not been previously reported in a patient with Chiari I malformation with an associated syringomyelia.

Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis: a retrospective clinical and histological review of 15 patients

BACKGROUND

Limited axillary skin excision and selective sweat gland removal from adjacent skin (Shelley's procedure) is currently rarely used for hyperhidrosis.

OBJECTIVES

To determine whether this technique is a good way of permanently reducing axillary sweating.

METHODS

This was a prospective, open, nonrandomized trial of the therapy, conducted in a university dermatology department. A small skin ellipse, parallel to the skin crease lines, was excised from the centre of the area of maximal sweating. The wound edges were undermined to the extent of maximal sweating and the skin reflected. Large visible sweat glands attached to the undersurface of the adjacent skin could be readily identified and were snipped off using scissors. We treated 15 axillae in eight patients with axillary hyperhidrosis. Sweat reduction was assessed by the patients who estimated the percentage reduction in sweating postoperatively. The scar appearance was graded by the surgeon. Haematoxylin and eosin-stained transverse sections of eight axillary skin ellipses from five subjects were examined histologically to establish the size, position and depth of the sweat gland tissue.

RESULTS

All of the patients responded to treatment: mean sweat reduction was 65% (range 40-90%). Mean follow up was 1.3 years (range 0.1-6) and sweat reduction was maintained over this period. Histological material was available from five patients: sweat glands lay slightly deeper than hair follicles; glandular tissue occupied an average thickness of 3.5 mm in the 5-mm thick piece of skin. Apocrine gland lobules were more numerous and larger than eccrine gland lobules. Both gland types were in close apposition and did not occupy distinctly different depths within the skin.

CONCLUSIONS

Local surgery using limited axillary skin excision and selective sweat gland removal remains one of the safest ways of permanently reducing axillary sweating.

Thoracic sympathicolysis for primary hyperhidrosis: a review of 918 procedures

BACKGROUND

Bilateral upper thoracic sympathectomy or sympathicolysis, currently the standard treatment for palmar or axillary hyperhidrosis, is regarded as a safe procedure. This study evaluates the quantitative and qualitative incidence of intraoperative and postoperative complications resulting from bilateral thoracic sympathicolysis.

METHODS

From 1996 to 2004, 458 consecutive patients with primary hyperhidrosis underwent surgery. These patients comprised 143 men (31.2%) and 315 women (68.7%) with a mean age of 26 years (range, 14-52 years). In all but seven cases, the procedure was bilaterally synchronous.

RESULTS

No mortality was recorded. The anhydrosis rate was 97.4%, with a hypohidrosis rate of 2.4% and a failure rate of 0.2%. The latter was resolved with reintervention. The mean hospital stay was 17 h. The rate of major perioperative complications with conversion to thoracotomy was 0.4%. The overall rate of postoperative complications was 3.6%. The complications and rates observed were as follows: pneumothorax (2.06%), subcutaneous emphysema (1.08%), pleural bleeding (0.2%), hemothorax (0.1%), and atelectasis (0.1%). Compensatory hyperhidrosis was observed in 48.4% of the patients, but the sensation of compensatory hyperhidrosis was reported in 85.6% of the cases. Excessive dryness of the hands was reported in 0.38%, Horner's syndrome in 0.32%, and gustatory hyperhidrosis in 1.1% of the cases. The overall satisfaction rate was 88.5%.

CONCLUSIONS

The results suggest that endoscopic bilateral thoracic sympathicolysis is an effective method for managing primary hyperhidrosis, especially severe palmar hyperhidrosis, but it is necessary to inform patients fully concerning the undesirable effects.

Treatment of Osmidrosis Using the Ultrasonic Surgical Aspirator: A Case Report

Numerous surgical methods have been introduced to treat osmidrosis. However, many problems with wound healing have been reported, including haematoma, seroma, skin necrosis and severe scarring. Ultrasound energy liquefies sweat glands via cavitation, but minimally affects blood vessels and nerves at the same energy level. Our patient was treated with ultrasonic surgical aspiration, which allowed the effective removal of the apocrine glands with little scarring. The ultrasonic surgical aspirator offers a safe and effective method to treat osmidrosis with few complications. This is the operation of first choice, especially for the patients who are sensitive about their surgical scars.

Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: a safe outpatient procedure☆

OBJECTIVE

To verify the feasibility and compare the results of thoracoscopic sympathectomy under local anaesthesia (LA) and spontaneous breathing vs. general anaesthesia (GA) with one-lung ventilation.

METHODS

Two groups of consecutive patients underwent one stage bilateral T2-T3 thoracoscopic sympathectomy under LA (n=15) and GA (n=30) by the same surgical team for treatment of primary palmar hyperhidrosis. The groups were homogeneous for relevant demographic, physiological and clinical data, including pulmonary function. In both groups, patient's satisfaction was evaluated 24h after surgery by a simple interview and scored into five grades (1=very poor to 5=excellent), while quality of life (QOL) was evaluated by SF-36 and Nottingham's Health Profile questionnaires before and 6 months after surgery. A cost comparison between groups concerning devices, drugs, global in operating room time, medical personnel and hospital stay was also carried out.

RESULTS

No operative mortality was recorded. The overall in operating room time for the whole bilateral procedure under LA was 63.55+/-10.58 vs. 86.05+/-5.75 under GA (P<0.01) and temperature increased in all patients from a baseline of 25.42+/-0.56 up to 32.15+/-0.84 degrees C. All patients undergone LA were discharged the same day after a chest roentgenogram and a short stay in the outpatient clinic. Among them three patients (20%) experienced a minimal (<30%) pneumothorax that required no treatment, while five (33.3%) had a trunk compensatory sweating that spontaneously resolved on the long run. Patients undergoing GA were discharged after a mean stay of 1.38+/-0.6 days. Among these, eight (26.6%) had prolonged trunk compensatory sweating that did not persist longer than 3 months. At a follow-up of 7.16+/-2.97 months, QOL was significantly improved with no difference between groups. The overall rate of satisfaction was greater in the LA group (P<0.05).

CONCLUSIONS

In our study, awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis could be safely and effectively performed as an outpatient procedure in patients refusing GA. Postoperative quality of life was equal to that in patients undergone the same procedure under GA, while patient satisfaction was better and cost were significantly reduced.

Liposuction for axillary hyperhidrosis

Excessive axillary sweating is a common problem for which many patients frequently seek dermatological advice. The removal of axillary sweat glands using liposuction with tumescent anaesthesia in an outpatient setting is a relatively short and simple procedure with few complications, as seen in this case series. We present 10 patients treated with axillary liposuction under tumescent anaesthesia. Of the 10 patients treated, four relapsed with axillary hyperhidrosis and required additional liposuction to the same area. The longest time to relapse was 15 months, with 4 months being the shortest time. Six patients have not required additional liposuction, with 7 years being the longest time of remission. The complications reported were bruising in the axillae of two patients and relapse of hyperhidrosis in four patients.

Surgical treatment of axillary hyperhidrosis with liposuction equipment: risks and benefits

Axillary hyperhidrosis poses a serious problem to the affected patients. So far, the conservative measures employed seem to be disappointing, operations with axillary skin excision, undermining and/or skin reconstruction may cause secondary functional and cosmetic problems, whereas botulinum A toxin injections need to be repeated frequently. The aim of this study was to establish the safety, efficacy, and durability of subdermal (subcorial) suction sweat gland curettage in the treatment of axillary hyperhidrosis. So far, the method seems to be devoid of possible risks and drawbacks. In the last 4.5 years, 15 patients with axillary hyperhidrosis were operated on with the use of liposuction tools. First operations were performed in general anesthesia, then in tumescent anesthesia. The procedure of suction curettage was performed with the use of 3- to 4-mm wide liposuction cannulas. The patients were closely monitored during early stages of the healing process; then they were evaluated at 1 and 3 months, and finally at 1-4 years of the operation, when they were asked to assess the effects of the operation. Four patients had recurrence of the disease within 3 months; three of them were reoperated on, with good result. At 1-4 years of the operation, all our responders (ten of 15 patients) stated that the disease had completely subsided. The following complications were observed during the process of healing: hematomas, transient skin unevenness, and partial skin flap necrosis. In conclusion, subdermal suction curettage seems to be superior to botulinum A toxin injections by the effect durability, and to the surgical methods with skin excision and undermining by the probably lower complication rates.

Plantar hyperhidrosis and pitted keratolysis treated with botulinum toxin injection

BACKGROUND

Sulcate plantare keratolysis or pitted keratolysis (plantar keratolysis sulcatum) is a disease that is commonly found in tropical countries. Patients have also reported plantar hyperhidrosis.

OBJECTIVE

Two patients with pitted keratolysis resistant to topical and systemic treatments are described.

METHODS

Both patients were injected with botulinum toxin distributed evenly through the plantar extension.

RESULTS

The response to the treatment was excellent despite using a low dose of botulinum toxin with the plantar keratolysis healing completely.

CONCLUSION

Hyperhidrosis may be considered the major etiologic factor for pitted keratolysis that does not respond to treatment.

Iontophoresis with glycopyrrolate for the treatment of palmoplantar hyperhidrosis

To determine the comparative efficacy of tap water iontophoresis to iontophoresis with the anticholinergic glycopyrrolate, we undertook a single-blinded right-left comparison study in 20 patients with palmoplantar hyperhidrosis. Most patients had their palms treated and one patient had the soles treated. We compared the duration of symptom relief following iontophoresis with glycopyrrolate unilaterally to iontophoresis with glycopyrrolate bilaterally. Patients filled in daily efficacy assessment cards. Each palm was rated as 'dry', 'slightly wet', 'moderately wet' or 'very wet'. Following treatment with unilateral tap water iontophoresis, unilateral glycopyrrolate and bilateral glycopyrrolate, patients reported hand dryness for a median of 3, 5 and 11 days, respectively. As the data was paired, treatment differences were analysed using a sign-rank test. Bilateral glycopyrrolate was superior to both unilateral glycopyrrolate and tap water in most patients. Unilateral glycopyrrolate was superior to tap water in most patients. All differences between groups were found to be statistically significant. We postulate that the increased efficacy of bilateral glycopyrrolate when compared with unilateral glycopyrrolate relates to its systemic absorption. We conclude that glycopyrrolate iontophoresis is more effective than tap water iontophoresis in the treatment of palmoplantar hyperhidrosis and that glycopyrrolate iontophoresis has both local and systemic effects on perspiration.

Sweat gland morphology and periglandular innervation in essential palmar hyperhidrosis before and after treatment with intradermal botulinum toxin

BACKGROUND

Intradermal botulinum toxin (Btx) produces long-lasting relief of focal hyperhidrosis, but its mechanism of action is poorly understood.

OBJECTIVE

To study the effect of Btx A on the size and innervation of sweat glands in patients with palmar hyperhidrosis.

METHODS

Palmar skin biopsy was performed in 26 hyperhidrotic patients before scheduled Btx treatment and in 11 controls. Twelve of the patients also underwent biopsy 1 to 6 months after the Btx injections. Sweat gland morphology was investigated by light microscopy; the cross-sectional area of the secretory tubule and its lumen was measured by image analysis. Immunofluorescence (IF) with antibodies to the neural markers protein gene product 9.5 (PGP 9.5) and growth-associated protein 43 (GAP 43), and to vasoactive intestinal peptide (VIP) and calcitonin gene-related peptide (CGRP), was used to analyze the periglandular innervation.

RESULTS

The gross morphology of the sweat glands was similar in patients and controls, with no significant differences in tubular and luminal areas between the groups. After Btx treatment, the tubular dimensions remained unchanged, but the lumen tended to be smaller ( P = .07). Around the glands, increased GAP 43 staining indicating sprouting was seen within 3 months after Btx treatment ( P = .016); whereas the PGP 9.5 staining was decreased in most specimens ( P = .09) indicating lack of functional nerve growth. No change in VIP or CGRP immunoreactivity was observed.

CONCLUSIONS

The sweat glands appear structurally normal in hyperhidrotic patients before Btx therapy, whereas after therapy the luminal area of the gland is frequently diminished. The IF data GAP 43/PGP 9.5 suggest that Btx therapy induces long-standing functional denervation of the sweat glands, which might explain its anti-transpiratory efficacy.

Treatment of axillary hyperhidrosis by chemodenervation of sweat glands using botulinum toxin type A

Primary axillary hyperhidrosis is a medical condition characterized by excessive underarm sweating that is thought to result from localized hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers. It can be associated with significant professional, physical, and emotional impairment as well as considerable difficulties in social situations and in personal relationships. Available therapies have been limited by short-lived effectiveness and in some cases significant adverse effects that can put patients at risk for potentially serious complications. Chemodenervation of sweat glands using botulinum toxin type A (BTX-A), which has long-lasting therapeutic efficacy with minimal adverse effects, has emerged as a unique therapy for treating primary axillary hyperhidrosis. This article reviews the chemodenervation procedure, including patient preparation, BTX-A administration, and patient assessment and follow-up.

Inguinal, or Hexsel's hyperhidrosis

Inguinal Hyperhidrosis (IH) is a focal and primary form of hyperhidrosis in which the individual has intense sweating in the inguinal region. It usually appears in adolescence, not later than the age of 25, in the most cases, and continues into adulthood. With a sample of 26 patients we described Inguinal Hyperhidrosis (IH). Fifty percent of the patients have a positive family history of this condition or other forms of focal or generalized hyperhidrosis, which suggests a familial pattern. Biopsies performed on the inguinal area in a patient with IH and control patient showed normal histology. Excessive perspiration in the inguinal area significantly affects the quality of life of the patients. It is an embarrassing condition that produces large wet stains on the clothes, therefore making daily activities difficult and compromising the emotional, professional and social life of the affected patients. The therapies commonly used for other forms of focal hyperhidrosis are not yet referred in the literature specifically for IH. Intradermal injections from botulinum toxin provide positive results for the patients and controls the sweating for 6 months or more. It is a simple, safe and effective treatment for this condition and the results significantly improve the quality of life of the affected individuals.

A family with a variant form of primary hypertrophic osteoarthropathy restricted to the lower extremities

We report a case of a family with a variant form of primary hypertrophic osteoarthropathy (HOA) restricted to the lower extremities without digital clubbing or cutaneous changes. Three family members suffered from pain, swelling and hyperhidrosis of both feet. X-rays showed destruction and osteoproliferative changes of the metatarsal bones with periostal hyperostosis close to the talus. There was an increased 99m-Tc-MDP uptake in the early phase of bone scintigraphy. Fibrosis of the marrow with stimulated osteoclastic resorption and the presence of detritus synovialitis were visible in a bone and joint biopsy. All known infectious, neurologic, metabolic and malignant diseases, which affect the bone and joints, were excluded.

[Histopathological changes in sympathetic ganglia of patients treated surgically for palmar-axillary hyperhidrosis. A study of 55 biopsies]

INTRODUCTION

Primary palmar hyperhidrosis (PPH) mainly affects the sympathetic ganglia. This study aims to analyze the histopathological changes in the sympathetic ganglia of patients with PPH.

MATERIAL AND METHOD

We studied 55 tissue samples from 35 patients with PPH who underwent T2-T3 gangliectomy for definitive treatment of their disease, analyzing the presence of inflammation, chromatolysis and lipofuscin accumulation. Findings were analyzed in relation to age, compensatory sweating and type of surgery: unilateral, synchronic bilateral or sequential bilateral.

RESULTS

We found inflammation in 5.5%, chromatolysis in 61.8% and lipofuscin accumulation in 41.8% of the samples. Chromatolysis and lipofuscin were found without inflammation in 32.1%. Chromatolysis and lipofuscin accumulation were each found in 60% of the samples from synchronic bilateral sympathectomies. However, those percentages decreased between the first and second sympathectomies in sequential procedures, such that chromatolysis was found in 71.4% of first-procedure samples and 42.8% of second-procedure samples; the rates for lipofuscin accumulation changed from 64.2% to 14.2%. Although findings were unrelated to age, they did correlate with compensatory sweating, which was found in 79.7% of patients undergoing synchronic bilateral sympathectomy, 78.5% of sequential bilateral sympathectomy patients and only 56.25% of unilateral sympathectomy patients.

CONCLUSIONS

Neuronal death and lipofuscin accumulation unrelated to inflammation are evident in sympathetic ganglia from patients with PPH. Such changes are atypical for a group of patients whose mean age is 29 years, unless such lesions are the result of functional hyperstimulation. Surgery performed sequentially does not lead to overloading of contralateral T2-T3 ganglia; on the contrary, decreased injury is evident.

Treatment of compensatory hyperhidrosis with botulinum toxin type A

Compensatory hyperhidrosis is a common and potentially severe side effect of bilateral endoscopic thoracic sympathectomy. We describe a patient with severe compensatory hyperhidrosis as a result of this procedure. We treated the patient with 2 separate series of subcutaneous botulinum toxin type A injections to the right upper abdomen and achieved anhidrosis in 5 weeks. Although botulinum toxin is already an established treatment modality for primary hyperhidrosis, there is little experience using it for the treatment of compensatory hyperhidrosis. Because of its efficacy and low side-effect profile, we believe botulinum toxin may play a significant role in treating compensatory hyperhidrosis as a first-line agent.

Needlescopic thoracic sympathetic block by clipping for craniofacial hyperhidrosis: an analysis of 28 cases

BACKGROUND

Endoscopic thoracic sympathectomy or sympathicotomy of the lower part of the stellate ganglion is an efficient method for the treatment of craniofacial hyperhidrosis, but postoperative compensatory sweating may be troublesome in some patients. Needlescopic thoracic sympathetic block by clipping may achieve a similar effect as well as providing a possible reverse operation for patients who suffer from intolerable postoperative compensatory sweating.

METHODS

Between January 1998 and June 2000, we collected a total of 28 patients with craniofacial hyperhidrosis. There were 15 men and 13 women with a mean age of 39.2 years (ranges, 19-50). All patients were placed under single-lumen intubated anesthesia in a semisitting position. Two ports were needed. We used a 2-mm 0 degrees thoracoscope and endo clips to perform a sympathetic block by clipping the lower third of the stellate ganglion at the second intercostal space.

RESULTS

The operation was usually accomplished within 20 min (ranges, 15-30). All patients were discharged within 4 h after the operation. There were no surgical complications or surgical mortality cases. All patients achieved improvement of craniofacial hyperhidrosis without recurrent symptoms after a mean of 25.3 months (range, 12-41) of follow-up. Twenty-five patients (85.7%) developed compensatory sweating of the trunk and lower limbs. One of these patients could not tolerate this postoperative sweating; he therefore underwent a reverse operation and obtained improvement of the compensatory sweating 18 days after removal of the endo clips.

CONCLUSION

Needlescopic thoracic sympathetic block by clipping is a safe and effective method for the treatment of craniofacial hyperhidrosis; compensatory sweating may be improved after a reverse operation and removal of the endo clips.

Treatment of axillary hyperhidrosis with botulinum-A toxin

BACKGROUND

Severe axillary hyperhidrosis is a source of great embarrassment and considerable emotional stress to individuals afflicted with this condition. Existing topical and surgical therapies are either ineffective or associated with unacceptable morbidity. We attempt to determine the effect of botulinum-A toxin (Dysport) in the treatment of axillary hyperhidrosis.

PATIENTS AND METHODS

After visualization of hyperhidrosis using the iodine-starch test, 10 patients with axillary hyperhidrosis underwent intradermal injection with 125 units of Dysport on each axilla. Patients were observed for 7 months after treatment.

RESULTS

The treatment was well tolerated without side-effects. All patients experienced relatively complete anhidrosis of the axillary skin after about 1 week for periods ranging from 4 to 7 months.

CONCLUSIONS

Botulinum-A toxin may offer a fast, safe, and highly effective therapeutic option for severe hyperhidrosis.

Anatomical location of T2-3 sympathetic trunk and Kuntz nerve determined by transthoracic endoscopy

OBJECT

Bilateral subaxillary transthoracic endoscopic sympathectomy (TES) is a popular procedure of upper thoracic sympathectomy. The anatomical locations of the T-2 and T-3 sympathetic trunks, as viewed under the endoscope, are varied in the rib head areas. In this study, the authors investigated the more visible anatomical locations of the T-2 and T-3 sympathetic trunks, the so-called nerves of Kuntz, and intercostal rami by performing transthoracic endoscopy.

METHODS

Seventy patients with palmar hyperhidrosis undergoing bilateral TES (140 sides) via the anterior subaxillary approach were included in this study. The operative findings and video images of the T-2 and T-3 sympathetic trunks and ganglia were recorded and analyzed. The anatomical locations of the T-2 and T-3 sympathetic trunks along the horizontal axes of the rib heads were determined using a three-region system constructed by the authors. The area between the rib neck and the medial border of the rib head was equally divided into Region E (external half) and Region M (medial half). The area between the medial border of the rib head and the paravertebral ligament was defined as Region I. The incidence of the T-2 and T-3 sympathetic trunks found in Regions E, M, and I were 31.4 to 42.9%, 50 to 57.1%, and 7.1 to 11.4%, respectively, on the left side, and 24.3 to 34.3%, 57.1 to 65.7%, and 8.6 to 10%, respectively, on the right side. One right (1.4%) and six left (8.6%) Kuntz nerves originating from the T-3 sympathetic trunk were found in seven patients (10%). The intercostal ramus was found around the T-2 rib neck in 24 patients (34.3%), with 18 cases (25.7%) for each side. The intercostal ramus around the T-3 rib neck was found in 17 patients (24.3%): 12 (17.1%) on the right and nine (12.9%) on the left.

CONCLUSIONS

These results indicate that approximately 90% of the T-2 or T-3 sympathetic trunks are located on the rib head. These findings may also be used to assist the surgeon in fluoroscopic guidance for locating the T-2 and T-3 sympathetic trunks during posterior percutaneous sympathectomy.

Pitfalls in thoracoscopic sympathectomy: mechanisms for failure

The technical ease of thoracoscopic sympathectomy has established this as the procedure of choice for upper-limb sympathectomy. Notwithstanding the invariable success of this procedure, those rare instances of unsuccessful sympathectomy are disconcerting to the surgeon. Unsuccessful sympathectomy manifests as persistent or recurrent sympathetic activity after a seemingly successful procedure. The causes of this phenomenon include misinterpretation of the sympathetic chain at thoracoscopy, regeneration of the sympathetic chain, and alternate neural pathways via the nerve of Kuntz. With the large numbers of sympathectomies being undertaken, the few instances of unsuccessful sympathectomy have prompted a review of this subject. Although alternate neural pathways may have little significance when a T2 ganglionectomy is undertaken, anatomic misinterpretation of the sympathetic chain is an important yet under-recognized cause of an unsuccessful sympathectomy. Sympathetic nerve regeneration remains extremely uncommon. Persistent and recurrent sympathetic activity may be successfully managed by resympathectomy performed thoracoscopically.