The British Institute for Blushing and Sweating
The British Institute for Blushing and Sweating is based in London and is run by Mr David Greenstein MD BSc FRCS. Mr Greenstein is a Leading Consultant Vascular Surgeon who has a special interest in the treatment of hyperhidrosis (excess sweating) and erythrophobia (blushing).
An operation to cure blushing
The constant fear of facial blushing (erythrophobia) or excessive sweating of the hands, face or armpits (hyperhidrosis) can result in a feeling of frustration and unhappiness. Many patients feel this condition often 'holds back' their life, both socially and at work. Some patients develop avoidance behaviour. Erythrophobia and hyperhidrosis can both be successfully treated by a new 'keyhole' surgical technique called endoscopic thoracic sympathectomy (ETS).
Hyperhidrosis treatment (excess sweating)
Excessive hand, facial or armpit sweating is usually caused by an overactive sympathetic nervous system. This nervous system is also known as the autonomic nervous system as we have no control over it. In addition these nerves can cause rapid facial blushing and as a result can lead to social embarrassment, social phobia and impaired quality of life.
These conditions can be significantly improved by dividing the sympathetic nerves using a technique known as endoscopic thoracic sympathectomy (ETS). Generalised body sweating as well as a more prolonged facial flushing do not respond well to ETS.
Non-operative treatment for hyperhidrosis
This should always be considered first as ETS is irreversible. The mainstay of treatment for axillary (armpit) sweating is botulinum toxin injections, which are only effective for up to 12 months. These are less effective for palm sweating. These toxins are also used for the treatment of skin creases. Psychological treatment as well as drugs such as beta blockers may help with facial blushing and social phobias.
Operative treatment for facial blushing and excess sweating
The decision to operate for these distressful conditions must be weighed up against the risk of the potential complications and side effects associated with surgery. This can only be decided on an individual basis. Traditionally, ETS surgery is irreversible as the cut nerve does not regrow. However there are new techniques which involve clipping of the sympathetic nerve. This may have some potential benefits if the side effects are too severe as ETS can then be reversed successfully in 20-30% of cases.
Contraindications to surgery
ETS surgery is contra-indicated in patients who are obese or who have suffered from significant chest disease. The procedure is also not indicated in elderly patients, patients with cardio-respiratory disease or patients who have previously had chest surgery.
After the surgery
Often there can be some sharp pain around the wounds and sometimes the upper back, although this soon wears off. Return to work can be as little as 2 days post surgery, but the time can vary depending on the individual. Return to sporting activities can take up to two weeks.
Conventional ETS surgery
This is 'keyhole' surgery that is performed under a general anaesthetic. Two small cuts are made in each armpit 0.5cm in diameter and the sympathetic nerve is divided. The wound is closed with dissolvable sutures and the scar is minimal. The procedure lasts approximately 40 minutes. A post operative chest X-ray is used to confirm full lung expansion.
New technique for ETS surgery
This technique can be reversed. Clipping of the sympathetic nerve has been shown to be as effective as conventional ETS surgery in stopping blushing and sweating. It has the advantage in that it can be successfully reversed in 20-30% of cases should it be clinically indicated. The only reason to reverse the surgery is if the side effects are too severe.
Results of treatment
The operation has immediate effect. The hands become warm and dry, however the effect on facial blushing will only be noticed in those situations which elicited them. Despite a successful result, patients may occasionally feel a tingling sensation which used to precede sweating or blushing. This can last up to a few months. In the first two weeks after the operation up to 30% of patients can experience 'rebound sweating'. This usually lasts for one day and can be thought of as the last outpouring of the sweat glands.
Current evidence reveals between 93-99% immediate cure for palm sweating, 93-95% for axillary sweating and 97% for facial sweating. At 2 year follow up these results are 87%, 68% and 76% respectively. For facial blushing the immediate technical success is 96%, reducing to 85% at 2 years.
Complications and side effects
In the experience of Mr David Greenstein, Leading Consultant Vascular Surgeon at the Institute, no life threatening complications have occurred from ETS surgery. However, as the 'keyhole' surgery is performed in the chest there is always a possibility that the chest may be opened in the event of bleeding. No operation can ever be guaranteed to be 100% safe. Very rarely there may be an air leak from the lungs which may require a suction drain. A few patients have prolonged pain or numbness in the arm, though permanent paralysis should not occur. Horner's syndrome can occur between 1-3%. This is dropping of the eyelid and a smaller pupil, but no visual impairment. This may be transient or permanent. Wound or chest infection occurs in less than 5%
One side effect is excessive dryness of the hands. This may require use of moisturising creams. As the sweating is reduced from the head and neck approximately 80% of individuals complain of compensatory sweating elsewhere in the body such as the abdomen, legs and feet. This is the body's way of keeping the internal temperature neutral at 37°C. The degree of compensatory sweating varies upon the individual. Gustatory sweating, which is sweating induced by smells and tastes occur in up to 30% of individuals but very few regard this as a major problem.
Although some patients may feel general fatigue, physical performance has been shown not to be reduced on stress testing despite the heart rate being reduced by 10%.
Quality of life after ETS surgery
Evidence reveals that ETS in fully informed individuals improves the quality of life. For facial blushing 85% are fully satisfied, 15% were to some degree dissatisfied and 2-4% of patients regretted the operation.
For further information or for a consultation please contact the Institute:
The Hospital of St John & Elizabeth
Grove End Road
Tel (UK): 0207 078 3822
Visit their sister site: www.varicoseveins.co.uk
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