90
R. P. JEPSON AND J . D . HARRIS
'•'^ Greenacre, Phyllis (1965) : On the Development 26 Kuypers, B. R. M., and Cotton D. W. K. (1972) r " Conditioning of Sweating", a Preliminaryand Function of Tears, in Emotional Growth, Report, Brit. J. Derm., 87, 154. International Universities Press Inc., New York, 1, 249. "Jepson, R. P., and Harris, J. D. (1976) : "Surgical i* Allen, Judith A., Armstrong, Janet E., and Roddie Aspects of Hyperhidrosis", Aust. J. Derm.,. I. C. (1973) : " The Regional Distributes of Emotional Sweating in Man ", / . Physiol. 235, 17, 90. 749. '* Greenacre, Phyllis (1952) : Urination and Weeping, 28 List, Carl F., and Peet, Max M. (1939) : "Sweat Secretion in Man; Disturbances of Sweat in Trauma Growth and Personality, International Secretion with Lesions on the Pons Medulla and Universities Press Inc., New York, p. 106. Cervical Portion of Cord", Arch. NeuroL '5 Seidenberg, Robert (1961) : " Palmar Hyperhidrosis Psychiat., 42, 1089. and Linking ", Arch. gen. Psychiat, 89, 283.
SURGICAL ASPECTS OF HYPERHIDROSIS* R. P. jEPSONf AND J. D. H A R R I S J Adelaide SUMMARY
Experience has demonstrated that severe hyperhidrosis, resistant to medical therapy, can he cured permanently by sympathetic denervation of the hands or feet, or by skin excision for axillary problems. The technique and results of these procedures is discussed. The clinical profile is so characteristic that differential diagnosis is not a problem. Whether a condition which is socially embarrassing rather than life threatening warrants surgery, is discussed.
Our accumulative experience, over the past twenty-five years, involves several hundreds of patients referred by physicians and dermatologists for excessive sweating, often after extensive and expensive attempts have been made to control this condition by pharmacological and local therapies. Frequently, these patients have sweated excessively since birth, or from the date of body-image awareness; occasionally a strong family history was present, either through a parent or a sister. It is even more common to find a parent of a severe hyperhidrotic sweats freely in excess of normal, but is not a true hyperhidrotic. Predominantly the sufferer is female, in ratio of at least 10 : 1 , and although the youngest was eight-years-old and the eldest 38, the majority clustered in the 17-23 year age group. It is interesting to note that Cloward,^ reporting from Hawaii with a different ethnic population, found a female/male
ratio of 45 : 37, with a heavy loading towards those of Japanese ancestry. Occupationally, as might be expected with the Australian sample, they were mostly students or clerks, though we number several doctors among our patients. The clinical profile is a fairly standard one. Patients get excessive sweating in bursts,, occasionally spontaneously, but usually provoked by fine movements, touch or emotionally charged situations. The change from a dry skin to a glistening, beaded, dripping one, is dramatic. The hands, the most commonly affected part, may literally run in rivulets with sweat and need constant blotting and wiping to control. The school child, student and typist smudge and snail-track their scripts, the salesgirl is shame-faced with her client. From the axilla the sweat cascades down the chest wall, soiling blouses and shirts and creating an odour problem that even " M u m " can't solve. The feet may perspire to a degree that requires regular removal of shoes * Presented at the Annual Meeting of the Australasian to pour out the water. With such a degree of College of Dermatologists, Adelaide, May 1976. t Senior Visiting Vascular Surgeon, Royal Adelaide contact moisture, the skin becomes blistered Hospital, Adelaide. and sodden, with subsequent secondary J Honorary Vascular Surgeon, Queen Elizabeth infections. Without having recourse to any Hospital, Adelaide.
SURGICAL ASPECTS OF HYPERHIDROSIS
special probing, we have never been impressed that these people axe, in their psychological makeup, other than an ordinary cross-section of the population. As a definitive treatment we have employed a sympathetic denervation for hand and foot sweating. In no case where an adequate sympathectomy has been performed have we failed to eliminate the sweating, nor have we yet seen, in 25 years, a relapse or recurrence. The technique we favour for the upper limbs is a Telford approach, through a supraclavicular incision with the exposure of the inferior wedge of the stellate ganglion, below the subclavian artery. This enables the second thoracic ganglion with a couple of centimetres of chain above and below to be resected. The stellate ganglion is alwa^ys demonstrated and spared ; otherwise a Horner's syndrome with its associated morbidity will result. The fibres from the stellate to the hand do not contain any significant sudomotor, nor probably vasomotor, fibres, and there is no pragmatic or theoretical reason for its removal. A side bonus of this operation is that the hands which sometimes have a high peripheral vascular tone are left considerably warmer. The control of foot sweating requires the traditional lumbar extraperitoneal approach to the chain, with the resection of 5 cm orientated on the third lumbar vertebra. The axillae had been, until the appearance of the Hurley and SheUey paper in 1963, more of a problem. The somatic innervation to the skin of the axiUa is through the inter-costo-brachials from T2 or sometimes T3, but the sympathetic sudomotor fibres accompanying these somatic nerves may arise from ganglia lower down the chain, certainly to include T4 and possibly T5. This implies that to denervate the axillary skin, a more extensive caudal sjnnpathectomy is required than for the hands. Through the standard supra-clavicular approach this is still feasible in most patients, but requires a painstaking dissection of the chain through a restricted access. It may be that in such
91
patients where an extensive upper thoracic sympathectomy is required, the Cloward approach using a costo-transversectomy is superior. Alternatively the sweat-bearing skin from the axilla can be excised as recommended by Hurley and SheUey. Originally the area was mapped out by a starch-iodine technique, but experience has shown, and we have done over fifty of these operations, that the sweat-bearing area corresponds pretty accurately to the hair area. It is our practice, therefore, to excise under general anaesthetic, the hair-bearing elHpses and close the incisions with a Z-plasty. Again, if all the hair bearing area is excised, none of these patients have had a recurrence of sweating. The skin of the axillae is very soft and stretches easily, so much so that many of the scars tend to be broad. Infection has not been a serious problem. In brief, therefore, we do an extensive upper thoracic sympathectomy for the patient with hand and axilla sweating, a limited T2 resection for hands alone, an axillary skin excision for arm-pit sweating, and a lumbar sympathectomy for the feet. Whether such operations are really necessary we discuss frankly with the patients. Although this is an occupationally frustrating and socially embarassing lesion, it is not a fatal one. Its natural history is not recorded, but we do not see patients out of their thirties, and the implication is that it is eventually self-limiting. Although these procedures are not dangerous, the cervical sympathectomy has some morbidity, especially in the hands of the occasional operator. Nevertheless we would, regard the predictable results as excellent and we believe these patients to be universally grateful for the release from the bondage of sweat. 118 Barnard Street, North Adelaide, S.A. 5006. REFERENCE " Hyperhydrosis ", 1 Cloward, R. B. (196 Neurosurg., 30, 545.
/.
R. P. JEPSON AND J . D . HARRIS
'•'^ Greenacre, Phyllis (1965) : On the Development 26 Kuypers, B. R. M., and Cotton D. W. K. (1972) r " Conditioning of Sweating", a Preliminaryand Function of Tears, in Emotional Growth, Report, Brit. J. Derm., 87, 154. International Universities Press Inc., New York, 1, 249. "Jepson, R. P., and Harris, J. D. (1976) : "Surgical i* Allen, Judith A., Armstrong, Janet E., and Roddie Aspects of Hyperhidrosis", Aust. J. Derm.,. I. C. (1973) : " The Regional Distributes of Emotional Sweating in Man ", / . Physiol. 235, 17, 90. 749. '* Greenacre, Phyllis (1952) : Urination and Weeping, 28 List, Carl F., and Peet, Max M. (1939) : "Sweat Secretion in Man; Disturbances of Sweat in Trauma Growth and Personality, International Secretion with Lesions on the Pons Medulla and Universities Press Inc., New York, p. 106. Cervical Portion of Cord", Arch. NeuroL '5 Seidenberg, Robert (1961) : " Palmar Hyperhidrosis Psychiat., 42, 1089. and Linking ", Arch. gen. Psychiat, 89, 283.
SURGICAL ASPECTS OF HYPERHIDROSIS* R. P. jEPSONf AND J. D. H A R R I S J Adelaide SUMMARY
Experience has demonstrated that severe hyperhidrosis, resistant to medical therapy, can he cured permanently by sympathetic denervation of the hands or feet, or by skin excision for axillary problems. The technique and results of these procedures is discussed. The clinical profile is so characteristic that differential diagnosis is not a problem. Whether a condition which is socially embarrassing rather than life threatening warrants surgery, is discussed.
Our accumulative experience, over the past twenty-five years, involves several hundreds of patients referred by physicians and dermatologists for excessive sweating, often after extensive and expensive attempts have been made to control this condition by pharmacological and local therapies. Frequently, these patients have sweated excessively since birth, or from the date of body-image awareness; occasionally a strong family history was present, either through a parent or a sister. It is even more common to find a parent of a severe hyperhidrotic sweats freely in excess of normal, but is not a true hyperhidrotic. Predominantly the sufferer is female, in ratio of at least 10 : 1 , and although the youngest was eight-years-old and the eldest 38, the majority clustered in the 17-23 year age group. It is interesting to note that Cloward,^ reporting from Hawaii with a different ethnic population, found a female/male
ratio of 45 : 37, with a heavy loading towards those of Japanese ancestry. Occupationally, as might be expected with the Australian sample, they were mostly students or clerks, though we number several doctors among our patients. The clinical profile is a fairly standard one. Patients get excessive sweating in bursts,, occasionally spontaneously, but usually provoked by fine movements, touch or emotionally charged situations. The change from a dry skin to a glistening, beaded, dripping one, is dramatic. The hands, the most commonly affected part, may literally run in rivulets with sweat and need constant blotting and wiping to control. The school child, student and typist smudge and snail-track their scripts, the salesgirl is shame-faced with her client. From the axilla the sweat cascades down the chest wall, soiling blouses and shirts and creating an odour problem that even " M u m " can't solve. The feet may perspire to a degree that requires regular removal of shoes * Presented at the Annual Meeting of the Australasian to pour out the water. With such a degree of College of Dermatologists, Adelaide, May 1976. t Senior Visiting Vascular Surgeon, Royal Adelaide contact moisture, the skin becomes blistered Hospital, Adelaide. and sodden, with subsequent secondary J Honorary Vascular Surgeon, Queen Elizabeth infections. Without having recourse to any Hospital, Adelaide.
SURGICAL ASPECTS OF HYPERHIDROSIS
special probing, we have never been impressed that these people axe, in their psychological makeup, other than an ordinary cross-section of the population. As a definitive treatment we have employed a sympathetic denervation for hand and foot sweating. In no case where an adequate sympathectomy has been performed have we failed to eliminate the sweating, nor have we yet seen, in 25 years, a relapse or recurrence. The technique we favour for the upper limbs is a Telford approach, through a supraclavicular incision with the exposure of the inferior wedge of the stellate ganglion, below the subclavian artery. This enables the second thoracic ganglion with a couple of centimetres of chain above and below to be resected. The stellate ganglion is alwa^ys demonstrated and spared ; otherwise a Horner's syndrome with its associated morbidity will result. The fibres from the stellate to the hand do not contain any significant sudomotor, nor probably vasomotor, fibres, and there is no pragmatic or theoretical reason for its removal. A side bonus of this operation is that the hands which sometimes have a high peripheral vascular tone are left considerably warmer. The control of foot sweating requires the traditional lumbar extraperitoneal approach to the chain, with the resection of 5 cm orientated on the third lumbar vertebra. The axillae had been, until the appearance of the Hurley and SheUey paper in 1963, more of a problem. The somatic innervation to the skin of the axiUa is through the inter-costo-brachials from T2 or sometimes T3, but the sympathetic sudomotor fibres accompanying these somatic nerves may arise from ganglia lower down the chain, certainly to include T4 and possibly T5. This implies that to denervate the axillary skin, a more extensive caudal sjnnpathectomy is required than for the hands. Through the standard supra-clavicular approach this is still feasible in most patients, but requires a painstaking dissection of the chain through a restricted access. It may be that in such
91
patients where an extensive upper thoracic sympathectomy is required, the Cloward approach using a costo-transversectomy is superior. Alternatively the sweat-bearing skin from the axilla can be excised as recommended by Hurley and SheUey. Originally the area was mapped out by a starch-iodine technique, but experience has shown, and we have done over fifty of these operations, that the sweat-bearing area corresponds pretty accurately to the hair area. It is our practice, therefore, to excise under general anaesthetic, the hair-bearing elHpses and close the incisions with a Z-plasty. Again, if all the hair bearing area is excised, none of these patients have had a recurrence of sweating. The skin of the axillae is very soft and stretches easily, so much so that many of the scars tend to be broad. Infection has not been a serious problem. In brief, therefore, we do an extensive upper thoracic sympathectomy for the patient with hand and axilla sweating, a limited T2 resection for hands alone, an axillary skin excision for arm-pit sweating, and a lumbar sympathectomy for the feet. Whether such operations are really necessary we discuss frankly with the patients. Although this is an occupationally frustrating and socially embarassing lesion, it is not a fatal one. Its natural history is not recorded, but we do not see patients out of their thirties, and the implication is that it is eventually self-limiting. Although these procedures are not dangerous, the cervical sympathectomy has some morbidity, especially in the hands of the occasional operator. Nevertheless we would, regard the predictable results as excellent and we believe these patients to be universally grateful for the release from the bondage of sweat. 118 Barnard Street, North Adelaide, S.A. 5006. REFERENCE " Hyperhydrosis ", 1 Cloward, R. B. (196 Neurosurg., 30, 545.
/.
