Reversing of ETS is very controversial. Done correctly, the need for ETS reversal is exceedingly rare. In the early years, when our understanding of sympathetic nerve physiology and the results of ETS was yet unknown, many patients underwent aggressive ablative procedures, whereby the sympathetic nerves from T2 to T5 were destroyed, and unfortunately a significant number of patients developed severe compensatory sweating. Looking to provide relief for this devastating complication, different surgical strategies developed, because there isn’t any effective medical therapy for severe compensatory sweating. One idea was to place a piece of nerve harvested from beneath the skin behind the ankle between the two ends of the divided sympathetic nerve. This operation has been proven to be ineffective for reversing compensatory sweating. Several centers around the world continue to perform this procedure, at great cost to patients, yet there is no conclusive authoritative data to support this practice.

The concept of nerve clamping evolved as a possible strategy to allow ETS reversal should a patient develop severe post-operative compensatory sweating. Theoretically because the sympathetic was left intact, and dysfunctioned by placing a micro-clamp across it, removal of the clamp would allow the nerve to regenerate, and reverse the symptoms of compensatory sweating. Initial scattered reports of reversal after clamp removal were favorable, and guidelines regarding timing of clamp removal after ETS were developed. As more reports of reversal were published, its become apparent that ETS reversal after clamp removal is unpredictable.

At our center, the need for clamp reversal is very rare. Patients with palmar hyperhidrosis are only offered ETS if they have severe symptoms that fail to respond to medical therapy. We do not perform ETS for armpit, facial or plantar sweating, and therefore we are less likely to have patients with poor outcomes, who are dissatisfied with their results. We also perform only T3 sympathectomy, which has been shown to result in much less frequent and severe compensatory sweating. Despite a general consensus that ETS-T3 is the best procedure for palmar hyperhidrosis, there are still institutions where surgeons perform more extensive radical sympathectomies, resulting in a far greater incidence of compensatory sweating.

Before considering ETS for palmar hyperhidrosis, it is important to try non surgical remedies first. ETS is a permanent life changing procedure. When performed for the correct indications, by well experienced surgeons the results are outstanding, and the need for reversal is very rare.

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