A chain of nerves called the sympathetic chain runs down the inside of your chest wall, one on each side, just alongside the spine. Signals for sweating and blood flow to the hands, armpits and face travel through specific levels of that chain. Which level controls what is reasonably predictable: the level around the second rib mainly drives the face, the third rib the palms, the fourth and fifth the underarms.
The surgeon collapses one lung slightly, inserts a camera and instrument through small cuts between the ribs, finds the chain over the rib, and interrupts it — by burning it, cutting it out, or placing a titanium clip on it. The other side is then done the same way. Sweat signals below that point never reach the hands, and the palms go dry within minutes. It is one of the fastest and most complete results in dermatology.
The problem is that you have not removed the body's need to sweat. You have removed a large chunk of its capacity to do it in the usual places. The nervous system compensates by turning up sweating in areas that still have their nerve supply — typically the back, chest, abdomen, groin and thighs. This is called compensatory sweating, and it is not a rare complication. It is the expected consequence of the operation. Most people get some. In most of those it is tolerable. In a minority it is severe enough that they change clothes several times a day and say plainly they regret the surgery.
Clipping the nerve rather than cutting it was introduced with the idea that the clip could be removed if compensatory sweating was intolerable. In practice reversal is unreliable — some people improve, many do not, and the longer the clip has been on, the less likely it is to help. Treat clipping as permanent too, not as an undo button.
Insist on a specific conversation about compensatory sweating with the surgeon who will operate — not a brochure, not a coordinator. Ask what proportion of their own patients report it, how many describe it as severe, and how many have told them they regret the operation. A surgeon who does this well will answer directly.
Get the non-surgical treatments properly documented. Insurance almost always requires evidence that antiperspirants, iontophoresis, Botox and oral medication were tried and failed. That documentation also protects you from having surgery before you have really tried the alternatives.
Consider trying palm Botox first if you never have. It is temporary, it is a reasonable preview of what dry hands feel like, and some people discover that is enough.
Talk to people who have had it — both the happy ones and the unhappy ones. Online hyperhidrosis communities contain both, and reading the regret accounts before rather than after is the single most useful thing you can do.
Stop smoking well ahead if you can. This is lung surgery, and the recovery is different in smokers.
Follow the fasting instructions exactly — this is a general anesthetic.
Arrange someone to take you home and stay with you overnight, and plan for a possible overnight admission.
Arrange a week off work for a desk job, longer for physical work.
You are under general anesthetic and asleep for the whole thing. You will not feel or remember any of it.
The anesthetist places a breathing tube that lets one lung be deflated at a time, so the surgeon has room to see inside the chest.
Two or three small cuts, usually about a centimeter each, are made in the armpit or between the ribs on one side. A camera and instruments go in through them.
The surgeon identifies the ribs and finds the sympathetic chain running over them, confirms the correct level, and interrupts it — burning, cutting or clipping.
The lung is reinflated, the instruments come out, and the small cuts are closed. Some surgeons leave a small drain in for a few hours.
The same is done on the other side.
The whole operation usually takes about an hour to 90 minutes. Palms are often noticeably warm and dry as soon as you wake up, and people frequently notice this in the recovery room.
You will have a chest X-ray afterward to confirm the lungs are fully reinflated.
Most people go home the same day or after one night. Chest tube requirements and how quickly the lungs reinflate decide which.
Shoulder and upper back pain in the first few days is very common and often surprises people. It comes from air and irritation around the diaphragm and it settles. Prescribed pain relief for a few days is normal.
The small incisions are sore for about a week. Keep them dry for the first couple of days and follow your surgeon's dressing instructions.
Deep breathing exercises matter. You will be asked to take slow deep breaths regularly for the first week to keep the lungs fully expanded.
Desk work is usually reasonable at about a week. Lifting, gym and physical work generally wait two to four weeks.
Compensatory sweating typically begins within days to a few weeks. It often gets somewhat better over the first six months to a year, and then stays where it is. What you have at a year is broadly what you keep.
For sweaty palms, ETS works and it works immediately. Hands are usually dry in the recovery room and stay dry. Very few operations in dermatology deliver a result that reliably. That is why it continues to be done despite everything below.
Facial sweating and blushing also respond well when the correct level is targeted, though results here are somewhat less predictable than for palms.
Underarm sweating responds least reliably, and treating for underarms means a bigger interruption of the chain and worse compensatory sweating. It is not a good reason to have this operation.
Feet are not reliably treated. Some people find their feet improve, many do not, and it should not be part of your reason for going ahead.
Compensatory sweating is the result nobody advertises. Most people who have ETS develop it. For most of them it is manageable — a sweatier back in summer, a change of shirt on a hot day. For a minority it is severe: soaking through clothes several times a day, in an area that is harder to hide than hands were. Reported rates vary widely between surgeons and studies, which tells you something about how it is counted rather than that it is uncommon. It usually appears within weeks, may soften over the first year, and then is permanent.
Satisfaction overall is high in most reported series, and the small group who regret it tend to regret it strongly and permanently. Both of those things are true at once, and you should hold both when deciding.
Reversal, if you need to hear it once more, is unreliable. Removing a clip helps some people and not others, and the chance of benefit falls the longer it has been in place.
There is no home version of chest surgery, and there is no supplement, device or technique that mimics it.
What matters more is what should come before it. The full non-surgical ladder for sweaty palms is: clinical-strength aluminum chloride antiperspirant applied to completely dry hands at night, iontophoresis done properly at home for at least a month, Botox injections to the palms, and oral glycopyrrolate or oxybutynin. Each of these is reversible. Working through all of them, properly and for long enough, is not a delaying tactic — a large share of people never need to consider surgery at all.
If your sweating is mainly in the underarms, the whole surgical question is off the table. miraDry, Botox, Qbrexza and Sofdra handle that area without touching any nerves.