If you’re considering ETS, this is the one thing I want you to understand fully before anything else. Compensatory sweating is the major concern for most of my patients — and rightly so. Let me explain what it is, how likely it is, and how I try to keep it from becoming a problem.
What compensatory sweating is
ETS works by interrupting the sympathetic nerves that signal your hands, underarms or feet to sweat. When those areas stop sweating, the body can “compensate” by sweating more in other areas — most commonly the stomach and back. As a rule of thumb, any area below the nipple line is at risk.
What I typically tell my patients is this: expect that roughly 30% of the sweat you currently have in your hands, underarms or feet can be redirected elsewhere, usually to the trunk. For most people that is a trade well worth making — dry hands in exchange for some sweating on the back — but it has to be a trade you would genuinely accept.
How common is it?
Being honest about the numbers matters. Some degree of compensatory sweating affects roughly half of patients. A smaller group — somewhere between about 1 in 4 and 1 in 10 — find it severe enough to bother them.1,2 It is the single biggest reason a patient might regret the surgery, which is exactly why we talk about it so carefully beforehand.
The most important rule: the higher the nerve interruption, the higher the risk
Here is the principle that guides how I operate: the higher up the sympathetic chain you interrupt the nerve, the more likely — and more severe — the compensatory sweating tends to be.3,4 That is why I use a restrictive, carefully targeted approach, interrupting the nerve at the lowest effective level for your particular problem rather than a more extensive interruption. It is a deliberate trade: a more limited procedure gives up a little in exchange for a meaningful reduction in compensatory sweating.
What makes it worse
Compensatory sweating isn’t constant — it tends to flare in certain situations. It is usually worse when it is hot and humid outside, and when you are very anxious or stressed. Knowing that helps patients anticipate it and put it in context.
Why I’m so selective about who I operate on
Because compensatory sweating is the main risk, careful patient selection is the single most important thing I do to keep results good. Not everyone with hyperhidrosis is a good candidate for ETS — there is a specific group of patients for whom I don’t recommend it, and I set that list out in detail in Dr. Irshad’s Take.
In practice, I operate on only about 30% of the patients I see for hyperhidrosis. For the other two-thirds, I recommend alternative treatments instead. That selectivity is deliberate — it is how I make sure the people who do have surgery are happy with their results.
Common questions
What is compensatory sweating?
How common is compensatory sweating after ETS?
Where does compensatory sweating usually show up?
What makes compensatory sweating worse?
Can compensatory sweating be avoided?
References
- Lin ZY, Lin M. Which patients are more likely to experience compensatory hyperhidrosis after endoscopic thoracic sympathectomy: a meta-analysis and systematic review. PeerJ. 2025;13:e19097.
- Menna C, Ibrahim M, Andreetti C, et al. Long-term results of sympathectomy for palmar and axillary hyperhidrosis. Ann Cardiothorac Surg. 2016;5(1):26–32.
- Schmidt J, Bechara FG, Altmeyer P, Zirngibl H. Endoscopic thoracic sympathectomy for severe hyperhidrosis: impact of restrictive denervation on compensatory sweating. Ann Thorac Surg. 2006;81(3):1048–1055.
- Lee SS, Lee YU, Lee JH, Lee JC. Comparison of the long-term results of R3 and R4 sympathicotomy for palmar hyperhidrosis. Korean J Thorac Cardiovasc Surg. 2017;50(3):197–201.