Outcomes of Single-Level and Multi-Level Thoracoscopic Sympathectomy in Primary Axillary Hyperhidrosis: A Multicenter Retrospective Analysis
Objective: Primary axillary hyperhidrosis is associated with substantial impairment in quality of life, and endoscopic thoracic sympathectomy (ETS) provides definitive treatment in refractory cases. However, the optimal level of sympathetic interruption remains controversial, and evidence directly comparing different surgical levels in axillary disease is limited. This study aimed to compare surgical outcomes among three sympathectomy levels in patients with primary axillary hyperhidrosis.
Methods: This retrospective multicenter study included 83 patients who underwent bilateral clip-based thoracoscopic sympathectomy for primary axillary hyperhidrosis between 2009 and 2023. Patients were stratified into three groups: single-level R3 (n=24), single-level R4 (n=35), and multi-level R2–R4 (n=24). The primary outcome was compensatory hyperhidrosis. Secondary outcomes included complete remission, recurrence, postoperative complications, and patient satisfaction. Factors associated with outcomes were evaluated using univariate and multivariate logistic regression analyses.
Results: Compensatory hyperhidrosis occurred in 83.3% of patients in the R2–R4 group, compared with 75.0% in the R3 group and 54.3% in the R4 group (P=0.045). Complete remission rates were comparable among groups (54.2%, 41.7%, and 34.3%, respectively; P=0.452). In multivariate analysis, R4 sympathectomy was associated with significantly lower odds ratio (OR) of compensatory hyperhidrosis compared with R2–R4 (OR: 0.25, 95% CI: 0.06–0.97; P=0.044). Recurrence rates did not differ significantly among groups (20.8%, 25.7%, and 12.5%, respectively; P=0.466). Recurrence was the only independent predictor of patient dissatisfaction (OR: 0.12, 95% CI: 0.03–0.44; P=0.001).
Conclusion: Single-level R4 sympathectomy appears to provide a favorable balance between treatment efficacy and side-effect profile in primary axillary hyperhidrosis. Multi-level approaches were not associated with improved clinical outcomes but were linked to higher rates of compensatory hyperhidrosis. These findings should be interpreted with caution.
1. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004;51(2):241-248. doi: 10.1016/j.jaad.2003.12.040.
2. Doolittle J, Walker P, Mills T, Thurston J. Hyperhidrosis: an update on prevalence and severity in the United States. Arch Dermatol Res. 2016;308(10):743-749. doi: 10.1007/s00403-016-1697-9.
3. Gross KM, Schote AB, Schneider KK, Schulz A, Meyer J. Elevated social stress levels and depressive symptoms in primary hyperhidrosis. PLoS One. 2014;9(3):e92412. doi: 10.1371/journal.pone.0092412.
4. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up. J Am Acad Dermatol. 2019;81(3):657-666. doi: 10.1016/j.jaad.2018.12.071.
5. Weber A, Heger S, Sinkgraven R, Heckmann M, Elsner P, Rzany B. Psychosocial aspects of patients with focal hyperhidrosis. Marked reduction of social phobia, anxiety and depression and increased quality of life after treatment with botulinum toxin A. Br J Dermatol. 2005;152(2):342-345. doi: 10.1111/j.1365-2133.2004.06334.x.
6. Hamm H, Naumann MK, Kowalski JW, Kütt S, Kozma C, Teale C. Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology. 2006;212(4):343-353. doi: 10.1159/000092285.
7. Glaser DA, Hebert AA, Nast A, et al. Topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis: Results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. J Am Acad Dermatol. 2019;80(1):128-138.e2. doi: 10.1016/j.jaad.2018.07.002.
8. Lakraj AA, Moghimi N, Jabbari B. Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel). 2013;5(4):821-840. doi: 10.3390/toxins5040821.
9. Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg. 2011;91(5):1642-1648. doi: 10.1016/j.athoracsur.2011.01.105.
10. Munia MA, Wolosker N, Kaufmann P, de Campos JR, Puech-Leão P. Sustained benefit lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis. Clinics (Sao Paulo). 2008;63(6):771-774. doi: 10.1590/s1807-59322008000600011.
11. Licht PB, Jørgensen OD, Ladegaard L, Pilegaard HK. Thoracoscopic sympathectomy for axillary hyperhidrosis: the influence of T4. Ann Thorac Surg. 2005;80(2):455-9; discussion 459-60. doi: 10.1016/j.athoracsur.2005.02.054.
12. Toolabi K, Parsaei R, Farid R, Zamanian A. Endoscopic thoracic sympathotomy for primary hyperhidrosis: predictors of outcome over a 10-year period. Surg Endosc. 2022;36(5):3585-3591. doi: 10.1007/s00464-021-08684-8.
13. Jeganathan R, Jordan S, Jones M, et al. Bilateral thoracoscopic sympathectomy: results and long-term follow-up. Interact Cardiovasc Thorac Surg. 2008;7(1):67-70. doi: 10.1510/icvts.2007.162479.
14. de Campos JR, Kauffman P, Werebe Ede C, et al. Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003;76(3):886-891. doi: 10.1016/s0003-4975(03)00895-6.
15. Hong Z, Wu X, Sheng Y, et al. Comparison of the efficacy of ETS with different segments for palmar, axillary and plantar hyperhidrosis. BMC Surg. 2023;23(1):82. doi: 10.1186/s12893-023-01976-x.
16. Boscardim PC, Oliveira RA, Oliveira AA, Souza JM, Carvalho RG. Thoracic sympathectomy at the level of the fourth and fifth ribs for the treatment of axillary hyperhidrosis. J Bras Pneumol. 2011;37(1):6-12. doi: 10.1590/s1806-37132011000100003.
17. Felisberto G Jr, Maria Cataneo AJ, Cristina Cataneo D. Thoracic sympathectomy for the treatment of primary axillary hyperhidrosis: systematic review and proportional meta-analysis. Ann Med. 2021;53(1):1216-1226. doi: 10.1080/07853890.2021.1953126.
18. Naumann M, Hamm H. Treatment of axillary hyperhidrosis. Br J Surg. 2002;89(3):259-261. doi: 10.1046/j.0007-1323.2001.02017.x.
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Article Information
- Article Type Research Article
- Submitted March 5, 2026
- Accepted April 14, 2026
- Published April 20, 2026
- Issue 2026: Online First
- Section Research Article
