Long-term Outcomes of Partial R3 and Total R4 Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Retrospective Cohort Study

Long-term Outcomes of Partial R3 and Total R4 Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term Outcomes of Partial R3 and Total R4 Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Retrospective Cohort Study Byunghoon Park, Yong-hyuk Choi, Bong-chun Choi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9143288/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To evaluate partial R3/total R4 thoracoscopic sympathectomy for palmar hyperhidrosis, balancing efficacy and side effects. Methods: Retrospective analysis of 37 patients (2018–2024). This study was approved by the Public Institutional Bioethics Committee, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). The primary outcomes were satisfaction, recurrence, and compensatory hyperhidrosis. Secondary outcomes included dryness and improvements in various domains of quality of life. Results: Symptom severity decreased significantly after surgery (mean 4.73 ± 0.51 preoperatively to 1.59 ± 0.76 postoperatively, p < 0.001). Recurrence occurred in 48.65% of patients, but recurrent symptoms were generally mild (mean 1.92 ± 1.09). Patient satisfaction was high (mean 4.19 ± 0.81) and showed a significant negative correlation with both recurrence and recurrence severity; however, it was not significantly associated with the presence or severity of compensatory hyperhidrosis or dryness. Quality of life, including social, occupational, mental, and physical domains, improved markedly postoperatively. Conclusion: Partial R3 and total R4 thoracoscopic sympathectomy for palmar hyperhidrosis achieves high long-term patient satisfaction and quality of life improvement, with recurrence being the most important determinant of satisfaction. Although compensatory hyperhidrosis and dryness are common, they do not significantly detract from overall satisfaction, supporting this hybrid approach as a balanced and effective surgical strategy. Palmar hyperhidrosis sympathectomy compensatory hyperhidrosis patient satisfaction quality of life recurrence Figures Figure 1 Introduction Palmar hyperhidrosis is a disorder of the autonomic nervous system characterized by excessive sweating of the palms, often leading to significant social, occupational, and psychological impairment [ 1 , 2 ]. The condition typically manifests in adolescence or early adulthood and persists throughout life if left untreated. Despite various conservative options including aluminum chloride antiperspirants (20–35% formulations), iontophoresis, botulinum toxin A injections (80–90% efficacy), and oral anticholinergics, these treatments are often temporary or associated with significant side effects, making thoracoscopic sympathectomy the definitive treatment for refractory cases [ 3 , 4 ]. Thoracoscopic sympathectomy has emerged as the gold-standard surgical treatment, providing rapid and often dramatic relief of symptoms [ 5 – 7 ]. However, the optimal level and extent of sympathetic chain interruption remain subjects of ongoing debate, as different approaches are associated with varying risks of recurrence, compensatory hyperhidrosis (CH), and dryness. According to the 2011 Society of Thoracic Surgeons consensus document [ 5 ], R3 or R4 levels are recommended for palmar hyperhidrosis. When patients desire complete resolution of palmar hyperhidrosis while accepting the risk of CH, both R3 and R4 levels should be ablated; conversely, R4-only sympathectomy potentially offers lower CH rates, which represent the most common complication of sympathectomy for hyperhidrosis [ 5 , 8 ], although some residual sweating may persist on the palms. A comprehensive meta-analysis by Felisberto et al. analyzing 857 patients with palmar hyperhidrosis found that higher-level resections (T2-T3) resulted in a 2.26 times greater risk of CH compared to lower levels (RR 2.26, 95% CI 1.57–3.25) [ 9 ]. Similarly, Kim et al. demonstrated that T4 sympathicotomy resulted in significantly lower rates of CH (17.5%) compared to T3 (82.1%), while maintaining comparable satisfaction rates (92.1% vs 85.7%) [ 10 ]. While some studies have demonstrated that R3 ablation results in higher incidence rates of CH compared to R2, the severity is generally significantly less severe [ 5 ]. This wide variation in reported CH rates is attributable to the lack of standardized assessment instruments for CH and the heterogenous populations of study participants [ 5 ]. Traditional approaches targeting the R2 sympathetic ganglia have been associated with high rates and severity of CH; however, the influence of the number of levels interrupted on CH outcomes remains inconclusive [ 5 ]. Lai et al. previously suggested that the extent of ganglion tissue destruction may influence postoperative outcomes, with incomplete ablation potentially leading to nerve regeneration or reorganization, thereby contributing to symptom recurrence [ 8 ]. Despite these concerns, R4-only sympathectomy can yield satisfactory outcomes [ 11 – 13 ]; therefore, our team developed a more tailored approach combining partial ablation of R3 with total ablation of R4, which aims to provide an optimal balance between efficacy and side-effect profile. The present study aims to address this optimal balance by evaluating the long-term outcomes of partial R3 and total R4 thoracoscopic sympathectomy for palmar hyperhidrosis, with a focus on recurrence, CH, dryness, and multidimensional patient-reported outcomes. We hypothesized that this approach would yield high satisfaction and quality of life improvement while minimizing the negative impact of CH and dryness. Methods This retrospective cohort study was conducted in accordance with the STROBE guidelines and was approved by the Public Institutional Review Board Designated by Ministry of Health and Welfare, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). Written informed consent was obtained from all participants. A total of 37 patients with severe palmar hyperhidrosis, defined as a Hyperhidrosis Disease Severity Scale (HDSS) score of 4, underwent video-assisted thoracoscopic partial R3 and total R4 sympathectomy at Seiyeon Pain Clinic between February 2013 and January 2024. Inclusion criteria were age between 15 and 65 years, severe palmar hyperhidrosis refractory to conservative management, and a minimum postoperative follow-up of 12 months. Patients with significant psychiatric or physical comorbidities that could interfere with outcome assessment or those who had participated in other clinical trials were excluded. The surgical procedure was performed under general anesthesia with the patient in a semi-Fowler position. A two-port thoracoscopic approach was used. Partial ablation of the R3 sympathetic ganglion was achieved using radiofrequency ablation at 80°C for 60 seconds, targeting approximately 50% of the ganglion to preserve some thermoregulatory function and reduce the risk of excessive dryness (Fig. 1 ). Total ablation of the R4 ganglion was then performed in a standard fashion. All procedures were bilateral unless contraindicated. Postoperative care included routine chest radiography to rule out pneumothorax and standardized pain management. The rationale for combining partial R3 with total R4 ablation is grounded in the need to balance efficacy and side-effect profile. Traditional R2 or R3 ablation, while effective in eliminating palmar sweating, is associated with a high risk of severe CH and dryness [ 9 , 14 ], which can be more distressing to patients than the original condition. Conversely, R4-only ablation may reduce these side effects but at the cost of higher recurrence rates and incomplete symptom control. Our hybrid approach of partial (approximately 50%) R3 ablation combined with total R4 ablation was designed to achieve the efficacy of multiple-level interruption while preserving some neural elements that may maintain thermoregulatory homeostasis, thereby reducing the severity of CH. Primary outcomes were patient-reported satisfaction, measured on a 5-point Likert scale; the occurrence and severity of recurrence, defined as the return of bothersome sweating after an initial period of relief; and the occurrence and severity of CH. Secondary outcomes included the occurrence and severity of dryness and changes in quality of life across social, occupational, mental, and physical domains. Quality of life was evaluated using a structured questionnaire developed for this study, which included items on social activity, occupational performance, mental well-being, and physical comfort. Statistical analyses were performed using R version 4.4.2. Continuous variables were summarized as means and standard deviations, while categorical variables were presented as frequencies and percentages. Preoperative and postoperative symptom severity scores were compared using the Wilcoxon signed-rank test. Correlations between satisfaction and other variables, including recurrence, CH, and dryness, were assessed using Spearman's rank correlation coefficient. Associations between the occurrence and severity of recurrence, CH, dryness, and satisfaction were analyzed using the Mann-Whitney U test. A p-value of less than 0.05 was considered statistically significant. Results The study included 37 patients aged 20 to 55 years (mean age 36.35 ± 8.76 years), consisting of 26 males and 11 females (70.27% male). All patients had severe palmar hyperhidrosis prior to surgery, with a mean preoperative symptom severity score of 4.73 ± 0.51. Following surgery, the mean postoperative symptom severity score decreased significantly to 1.59 ± 0.76 (p < 0.001). Recurrence of palmar hyperhidrosis was observed in 18 patients (48.65%), with a mean recurrence severity score of 1.92 ± 1.09. Among those with recurrence, the mean score for daily life interference was 1.81 ± 1.17, indicating that recurrent symptoms were generally mild and did not substantially disrupt daily activities. Patient satisfaction with the surgical outcome was high, with a mean satisfaction score of 4.19 ± 0.81. Satisfaction was found to have a significant negative correlation with both the presence of recurrence and the severity of recurrent symptoms (Spearman's ρ = −0.48, p = 0.002), indicating that patients without recurrence or with only mild recurrence reported higher satisfaction. In contrast, neither the presence nor the severity of CH was significantly associated with satisfaction (p = 0.828 and p = 0.605, respectively). CH developed in 35 patients (94.59%), with a mean severity score of 3.41 ± 1.24. Among these patients, six (16.22%) developed severe CH with a severity score of 5. Among all 37 patients, including those with severe CH, only 2 patients required topical agents to manage CH, and no other patients pursued additional treatment despite the presence of inconvenience attributable to CH. Dryness was reported by 18 patients (48.65%), with a mean severity score of 2.14 ± 1.29. Similar to CH, neither the occurrence nor the severity of dryness showed a significant relationship with satisfaction (p = 0.793). Quality of life improved markedly after surgery. The mean score for perceived improvement in quality of life was 4.16 ± 1.09, with substantial gains reported in social activity (mean 4.13 ± 0.88), occupational performance (mean 4.00 ± 1.03), mental well-being (mean 4.30 ± 0.81), and physical comfort (mean 4.17 ± 1.07). The majority of patients indicated that they would choose to undergo the procedure again (mean 4.11 ± 1.26) and would recommend it to others (mean 4.00 ± 1.18). Notably, the degree of preoperative symptom severity was positively correlated with postoperative satisfaction (Spearman's ρ = 0.38, p = 0.025), suggesting that patients with more severe baseline symptoms experienced greater perceived benefit from surgery. (Table 1 ) Table 1 Factors associated with satisfaction and improvement in quality of life Factor Satisfaction Improvement in quality of life p -value Spearman's ρ p -value Spearman's ρ Presence of recurrence a 0.0038 0.0435 Recurrence severity 0.0025 -0.48 0.0161 -0.39 Daily life interference by recurrence 0.0035 -0.47 0.0057 -0.45 Presence of CH a 0.8283 0.6056 CH severity 0.3440 0.6280 Daily life interference by CH 0.1490 0.0461 -0.33 Occurrence of dryness a 0.7936 1.0000 Dryness severity 0.8981 0.6593 Daily life interference by dryness 0.5393 0.6324 CH compensatory hyperhidrosis a Assessed using the Mann-Whitney test No major perioperative complications were observed except for a single case of unilateral pneumothorax (2.7%), which was successfully managed with closed thoracic drainage. No patients required reoperation or revision surgery during the follow-up period. Discussion This study provides robust evidence that partial R3 and total R4 thoracoscopic sympathectomy is an effective and well-tolerated surgical strategy for patients with severe palmar hyperhidrosis. This hybrid approach was associated with a high rate of symptom improvement, substantial gains in quality of life, and a favorable safety profile. CH incidence is considerably higher than recent reports of lower-level sympathectomy. Specifically, Martinez et al. reported 36.26% CH after R2-R3 sympathectomy [ 15 ], while Xu et al. reported 74.3% after T3 or T4 procedures [ 16 ]. However, our higher incidence may reflect more thorough long-term follow-up and stricter CH definition, as recommended by Sang et al. [ 12 ]. This high CH incidence, also, did not significantly affect patient satisfaction or willingness to recommend the procedure. Previous studies have similarly demonstrated considerable variation in reported CH rates across trials; this variation is attributable to the absence of standardized research instruments for assessing CH. Although some previous studies reported that the severity of CH and dryness significantly impacts satisfaction scores, our findings are consistent with recent evidence suggesting otherwise. In a comprehensive review by Chudry et al. [ 17 ], the studies focusing on endoscopic thoracic sympathectomy achieved > 95% symptom improvement with CH occurring in 67–68% of patients, yet patient satisfaction remained > 90% [ 17 ]. Similarly, Kuijpers et al.'s experience with 326 prospectively analyzed procedures demonstrated that despite CH being absent or moderate in 70.6% of patients and an additional 29.4% experiencing severe CH, the overall recommendation rate of the procedure was 87.7% [ 18 ]. Furthermore, Masarwa et al. reported similar findings in Palestinian patients, where 78% developed CH but 86% stated their expectations were met [ 19 ]. While Martinez-Hernandez et al. [ 15 ] observed a high symptom improvement rate (97.8%), they found that both symptom control and the presence of CH significantly impacted patient satisfaction. In contrast, our findings uniquely demonstrate that recurrence severity (ρ=-0.48, p = 0.002) is the primary determinant of dissatisfaction, and remarkably, neither CH nor dryness significantly impacted satisfaction. The finding that neither CH nor dryness significantly impacted satisfaction is noteworthy and has important implications for clinical practice. It suggests that patients are willing to tolerate moderate side effects if their primary concern, palmar sweating, is effectively addressed. This underscores the importance of thorough preoperative counseling to establish realistic expectations and to emphasize recurrence as the main factor influencing long-term satisfaction. The positive correlation between preoperative symptom severity and satisfaction (ρ = 0.38) suggests that preoperative assessment using validated tools such as the HDSS could enhance surgical decision-making and reduce postoperative regrets. Our study has several limitations. The retrospective design and single-center setting may limit the generalizability of our findings. The sample size, while adequate for exploratory analysis, may not be sufficient to detect rare complications or to fully characterize the spectrum of patient experiences. Additionally, the use of a non-validated quality of life questionnaire, although comprehensive, may introduce some measurement bias. Future prospective, multicenter studies using standardized outcome measures are warranted to confirm and extend our findings. In conclusion, partial R3 and total R4 thoracoscopic sympathectomy offers a favorable balance between efficacy and side-effect profile for patients with severe palmar hyperhidrosis. Recurrence remains the most important determinant of patient satisfaction, while CH and dryness, though common, do not significantly detract from overall quality of life. This hybrid approach should be considered a viable surgical option and may serve as a new standard for the management of this challenging condition. Declarations The authors have no relevant financial or non-financial interests to disclose. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Public Institutional Bioethics Committee, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). All participants gave their informed consent prior to their inclusion in the study. References Ro KM et al (2002) Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg 35(2):382–386 Romero FR et al (2016) Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. Bras Dermatol 91(6):716–725 Solish MJ, Savinova I, Weinberg MJ (2022) A Practical Approach to the Diagnosis and Treatment of Palmar Hyperhidrosis. Plast Reconstr Surg Glob Open 10(3):e4172 Walling HW, Swick BL (2011) Treatment options for hyperhidrosis. Am J Clin Dermatol 12(5):285–295 Cerfolio RJ et al (2011) The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 91(5):1642–1648 Adar R et al (1977) Palmar hyperhidrosis and its surgical treatment: a report of 100 cases. Ann Surg 186(1):34–41 Hashmonai M, Kopelman D, Assalia A (2000) The treatment of primary palmar hyperhidrosis: a review. Surg Today 30(3):211–218 Lai YT et al (1997) Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery, 41(1): pp. 110-3; discussion 113-5 Felisberto Júnior G et al (2016) Comparison between high and low levels thoracic sympathectomy for the treatment of palmar and axillary primary hyperhidrosis: systematic review and meta-analysis. Rev Col Bras Cir 43(6):486–492 Kim WO et al (2010) Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis. Am J Surg 199(2):166–169 Liu Y et al (2009) Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy. Eur J Cardiothorac Surg 35(3):398–402 Sang HW et al (2017) Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review. Surg Endosc 31(11):4357–4369 Zhang W et al (2017) A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis. Sci Rep 7(1):129 Ersin OE et al (2025) The effects of sympathectomy ganglion levels on late complications in the treatment of hyperhidrosis. J Minim Access Surg 21(2):175–182 Martínez-Hernández NJ et al (2024) Endoscopic thoracic sympathectomy for primary hyperhidrosis: an over a decade-long follow-up on efficacy, impact, and patient satisfaction. J Thorac Dis 16(12):8292–8299 Xu J et al (2024) Long term outcomes and risk factors of compensatory hyperhidrosis after thoracoscopic sympathectomy in primary palmar hyperhidrosis patients: a retrospective single-center study. J Cardiothorac Surg 19(1):590 Chudry H (2022) The treatment of palmar hyperhidrosis - a systematic review. Int J Dermatol 61(11):1303–1310 Kuijpers M et al (2022) Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach. J Clin Med, 11(3) Masarwa H et al (2024) Incidence and Severity of Compensatory Hyperhidrosis Following Bilateral Sympathectomy. Ann Vasc Surg 108:317–324 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9143288","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619132287,"identity":"8e670daf-21c0-4c68-a354-f016f0692f33","order_by":0,"name":"Byunghoon Park","email":"","orcid":"","institution":"Seiyeon Pain Clinic","correspondingAuthor":false,"prefix":"","firstName":"Byunghoon","middleName":"","lastName":"Park","suffix":""},{"id":619132288,"identity":"9e4f1a45-d452-4fb0-bf74-f1a7351aff37","order_by":1,"name":"Yong-hyuk Choi","email":"","orcid":"","institution":"Seiyeon Pain Clinic","correspondingAuthor":false,"prefix":"","firstName":"Yong-hyuk","middleName":"","lastName":"Choi","suffix":""},{"id":619132289,"identity":"7d316406-5b4d-43b3-9282-9b405cd54e11","order_by":2,"name":"Bong-chun Choi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYFACxgYQycPG3nwMzGdjJ1KLDB/PsTQGhgSgFmYi7bKRk8gxA2thIKRFvr25TeJDxR0eNomcbw8+/tgmz8fMwPjhYw5uLQZnDrZJzjjzjIeN5+12wxkJtw3bmBmYJWduw6NFIrFNmrftMND7udukeRJuMwK1sDHz4tEiP/9hm/RfkBaGnGcgLfYEtTDcYGyTZgRp4chhA2lJJKjF4Exis2XPGaAWnmNmkjPSbie3MTM24/WLfPvxhzd+VBy2BwbdM4kPNrdt57c3H/zwEZ/DGBhYJNAEIJGLDzB/IKRiFIyCUTAKRjgAAFN9TGEUe4xdAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0006-4715-4148","institution":"Seiyeon Pain Clinic","correspondingAuthor":true,"prefix":"","firstName":"Bong-chun","middleName":"","lastName":"Choi","suffix":""}],"badges":[],"createdAt":"2026-03-17 03:05:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9143288/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9143288/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106901825,"identity":"37e38c92-74ed-4b19-81c8-872ab23aaf6c","added_by":"auto","created_at":"2026-04-14 15:04:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":319808,"visible":true,"origin":"","legend":"\u003cp\u003eLeft-sided thoracoscopic view showing T3 partial ablation and T4 total ablation with an radiofrequency ablator\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9143288/v1/884704c71d2859b3adc63991.png"},{"id":108490916,"identity":"98b53d54-385d-4dae-a6b9-25972af6795a","added_by":"auto","created_at":"2026-05-05 09:49:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505916,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9143288/v1/d738e976-c09f-4f07-a605-e179eb09b241.pdf"}],"financialInterests":"","formattedTitle":"Long-term Outcomes of Partial R3 and Total R4 Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePalmar hyperhidrosis is a disorder of the autonomic nervous system characterized by excessive sweating of the palms, often leading to significant social, occupational, and psychological impairment [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. The condition typically manifests in adolescence or early adulthood and persists throughout life if left untreated. Despite various conservative options including aluminum chloride antiperspirants (20–35% formulations), iontophoresis, botulinum toxin A injections (80–90% efficacy), and oral anticholinergics, these treatments are often temporary or associated with significant side effects, making thoracoscopic sympathectomy the definitive treatment for refractory cases [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thoracoscopic sympathectomy has emerged as the gold-standard surgical treatment, providing rapid and often dramatic relief of symptoms [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the optimal level and extent of sympathetic chain interruption remain subjects of ongoing debate, as different approaches are associated with varying risks of recurrence, compensatory hyperhidrosis (CH), and dryness.\u003c/p\u003e \u003cp\u003eAccording to the 2011 Society of Thoracic Surgeons consensus document [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], R3 or R4 levels are recommended for palmar hyperhidrosis. When patients desire complete resolution of palmar hyperhidrosis while accepting the risk of CH, both R3 and R4 levels should be ablated; conversely, R4-only sympathectomy potentially offers lower CH rates, which represent the most common complication of sympathectomy for hyperhidrosis [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e], although some residual sweating may persist on the palms.\u003c/p\u003e \u003cp\u003eA comprehensive meta-analysis by Felisberto et al. analyzing 857 patients with palmar hyperhidrosis found that higher-level resections (T2-T3) resulted in a 2.26 times greater risk of CH compared to lower levels (RR 2.26, 95% CI 1.57–3.25) [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similarly, Kim et al. demonstrated that T4 sympathicotomy resulted in significantly lower rates of CH (17.5%) compared to T3 (82.1%), while maintaining comparable satisfaction rates (92.1% vs 85.7%) [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. While some studies have demonstrated that R3 ablation results in higher incidence rates of CH compared to R2, the severity is generally significantly less severe [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. This wide variation in reported CH rates is attributable to the lack of standardized assessment instruments for CH and the heterogenous populations of study participants [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional approaches targeting the R2 sympathetic ganglia have been associated with high rates and severity of CH; however, the influence of the number of levels interrupted on CH outcomes remains inconclusive [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Lai et al. previously suggested that the extent of ganglion tissue destruction may influence postoperative outcomes, with incomplete ablation potentially leading to nerve regeneration or reorganization, thereby contributing to symptom recurrence [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite these concerns, R4-only sympathectomy can yield satisfactory outcomes [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]; therefore, our team developed a more tailored approach combining partial ablation of R3 with total ablation of R4, which aims to provide an optimal balance between efficacy and side-effect profile.\u003c/p\u003e \u003cp\u003eThe present study aims to address this optimal balance by evaluating the long-term outcomes of partial R3 and total R4 thoracoscopic sympathectomy for palmar hyperhidrosis, with a focus on recurrence, CH, dryness, and multidimensional patient-reported outcomes. We hypothesized that this approach would yield high satisfaction and quality of life improvement while minimizing the negative impact of CH and dryness.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e This retrospective cohort study was conducted in accordance with the STROBE guidelines and was approved by the Public Institutional Review Board Designated by Ministry of Health and Welfare, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). Written informed consent was obtained from all participants. A total of 37 patients with severe palmar hyperhidrosis, defined as a Hyperhidrosis Disease Severity Scale (HDSS) score of 4, underwent video-assisted thoracoscopic partial R3 and total R4 sympathectomy at Seiyeon Pain Clinic between February 2013 and January 2024. Inclusion criteria were age between 15 and 65 years, severe palmar hyperhidrosis refractory to conservative management, and a minimum postoperative follow-up of 12 months. Patients with significant psychiatric or physical comorbidities that could interfere with outcome assessment or those who had participated in other clinical trials were excluded.\u003c/p\u003e\u003cp\u003eThe surgical procedure was performed under general anesthesia with the patient in a semi-Fowler position. A two-port thoracoscopic approach was used. Partial ablation of the R3 sympathetic ganglion was achieved using radiofrequency ablation at 80°C for 60 seconds, targeting approximately 50% of the ganglion to preserve some thermoregulatory function and reduce the risk of excessive dryness (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Total ablation of the R4 ganglion was then performed in a standard fashion. All procedures were bilateral unless contraindicated. Postoperative care included routine chest radiography to rule out pneumothorax and standardized pain management.\u003c/p\u003e\u003cp\u003eThe rationale for combining partial R3 with total R4 ablation is grounded in the need to balance efficacy and side-effect profile. Traditional R2 or R3 ablation, while effective in eliminating palmar sweating, is associated with a high risk of severe CH and dryness [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e], which can be more distressing to patients than the original condition. Conversely, R4-only ablation may reduce these side effects but at the cost of higher recurrence rates and incomplete symptom control. Our hybrid approach of partial (approximately 50%) R3 ablation combined with total R4 ablation was designed to achieve the efficacy of multiple-level interruption while preserving some neural elements that may maintain thermoregulatory homeostasis, thereby reducing the severity of CH.\u003c/p\u003e\u003cp\u003ePrimary outcomes were patient-reported satisfaction, measured on a 5-point Likert scale; the occurrence and severity of recurrence, defined as the return of bothersome sweating after an initial period of relief; and the occurrence and severity of CH.\u003c/p\u003e\u003cp\u003eSecondary outcomes included the occurrence and severity of dryness and changes in quality of life across social, occupational, mental, and physical domains. Quality of life was evaluated using a structured questionnaire developed for this study, which included items on social activity, occupational performance, mental well-being, and physical comfort.\u003c/p\u003e\u003cp\u003eStatistical analyses were performed using R version 4.4.2. Continuous variables were summarized as means and standard deviations, while categorical variables were presented as frequencies and percentages. Preoperative and postoperative symptom severity scores were compared using the Wilcoxon signed-rank test. Correlations between satisfaction and other variables, including recurrence, CH, and dryness, were assessed using Spearman's rank correlation coefficient. Associations between the occurrence and severity of recurrence, CH, dryness, and satisfaction were analyzed using the Mann-Whitney U test. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 37 patients aged 20 to 55 years (mean age 36.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.76 years), consisting of 26 males and 11 females (70.27% male).\u003c/p\u003e \u003cp\u003eAll patients had severe palmar hyperhidrosis prior to surgery, with a mean preoperative symptom severity score of 4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51. Following surgery, the mean postoperative symptom severity score decreased significantly to 1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Recurrence of palmar hyperhidrosis was observed in 18 patients (48.65%), with a mean recurrence severity score of 1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09. Among those with recurrence, the mean score for daily life interference was 1.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17, indicating that recurrent symptoms were generally mild and did not substantially disrupt daily activities.\u003c/p\u003e \u003cp\u003ePatient satisfaction with the surgical outcome was high, with a mean satisfaction score of 4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81. Satisfaction was found to have a significant negative correlation with both the presence of recurrence and the severity of recurrent symptoms (Spearman's ρ = \u0026minus;0.48, p\u0026thinsp;=\u0026thinsp;0.002), indicating that patients without recurrence or with only mild recurrence reported higher satisfaction. In contrast, neither the presence nor the severity of CH was significantly associated with satisfaction (p\u0026thinsp;=\u0026thinsp;0.828 and p\u0026thinsp;=\u0026thinsp;0.605, respectively). CH developed in 35 patients (94.59%), with a mean severity score of 3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24. Among these patients, six (16.22%) developed severe CH with a severity score of 5. Among all 37 patients, including those with severe CH, only 2 patients required topical agents to manage CH, and no other patients pursued additional treatment despite the presence of inconvenience attributable to CH.\u003c/p\u003e \u003cp\u003eDryness was reported by 18 patients (48.65%), with a mean severity score of 2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29. Similar to CH, neither the occurrence nor the severity of dryness showed a significant relationship with satisfaction (p\u0026thinsp;=\u0026thinsp;0.793).\u003c/p\u003e \u003cp\u003eQuality of life improved markedly after surgery. The mean score for perceived improvement in quality of life was 4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09, with substantial gains reported in social activity (mean 4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88), occupational performance (mean 4.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03), mental well-being (mean 4.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81), and physical comfort (mean 4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07). The majority of patients indicated that they would choose to undergo the procedure again (mean 4.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26) and would recommend it to others (mean 4.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18). Notably, the degree of preoperative symptom severity was positively correlated with postoperative satisfaction (Spearman's ρ\u0026thinsp;=\u0026thinsp;0.38, p\u0026thinsp;=\u0026thinsp;0.025), suggesting that patients with more severe baseline symptoms experienced greater perceived benefit from surgery. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with satisfaction and improvement in quality of life\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSatisfaction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eImprovement in quality of life\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpearman's \u003cem\u003eρ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpearman's \u003cem\u003eρ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of recurrence\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily life interference by recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of CH\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCH severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily life interference by CH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1490\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccurrence of dryness\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDryness severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily life interference by dryness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCH\u003c/em\u003e compensatory hyperhidrosis\u003c/p\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAssessed using the Mann-Whitney test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo major perioperative complications were observed except for a single case of unilateral pneumothorax (2.7%), which was successfully managed with closed thoracic drainage. No patients required reoperation or revision surgery during the follow-up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides robust evidence that partial R3 and total R4 thoracoscopic sympathectomy is an effective and well-tolerated surgical strategy for patients with severe palmar hyperhidrosis. This hybrid approach was associated with a high rate of symptom improvement, substantial gains in quality of life, and a favorable safety profile.\u003c/p\u003e \u003cp\u003eCH incidence is considerably higher than recent reports of lower-level sympathectomy. Specifically, Martinez et al. reported 36.26% CH after R2-R3 sympathectomy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], while Xu et al. reported 74.3% after T3 or T4 procedures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, our higher incidence may reflect more thorough long-term follow-up and stricter CH definition, as recommended by Sang et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This high CH incidence, also, did not significantly affect patient satisfaction or willingness to recommend the procedure. Previous studies have similarly demonstrated considerable variation in reported CH rates across trials; this variation is attributable to the absence of standardized research instruments for assessing CH.\u003c/p\u003e \u003cp\u003eAlthough some previous studies reported that the severity of CH and dryness significantly impacts satisfaction scores, our findings are consistent with recent evidence suggesting otherwise. In a comprehensive review by Chudry et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], the studies focusing on endoscopic thoracic sympathectomy achieved\u0026thinsp;\u0026gt;\u0026thinsp;95% symptom improvement with CH occurring in 67\u0026ndash;68% of patients, yet patient satisfaction remained\u0026thinsp;\u0026gt;\u0026thinsp;90% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, Kuijpers et al.'s experience with 326 prospectively analyzed procedures demonstrated that despite CH being absent or moderate in 70.6% of patients and an additional 29.4% experiencing severe CH, the overall recommendation rate of the procedure was 87.7% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, Masarwa et al. reported similar findings in Palestinian patients, where 78% developed CH but 86% stated their expectations were met [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile Martinez-Hernandez et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] observed a high symptom improvement rate (97.8%), they found that both symptom control and the presence of CH significantly impacted patient satisfaction. In contrast, our findings uniquely demonstrate that recurrence severity (ρ=-0.48, p\u0026thinsp;=\u0026thinsp;0.002) is the primary determinant of dissatisfaction, and remarkably, neither CH nor dryness significantly impacted satisfaction. The finding that neither CH nor dryness significantly impacted satisfaction is noteworthy and has important implications for clinical practice. It suggests that patients are willing to tolerate moderate side effects if their primary concern, palmar sweating, is effectively addressed. This underscores the importance of thorough preoperative counseling to establish realistic expectations and to emphasize recurrence as the main factor influencing long-term satisfaction. The positive correlation between preoperative symptom severity and satisfaction (ρ\u0026thinsp;=\u0026thinsp;0.38) suggests that preoperative assessment using validated tools such as the HDSS could enhance surgical decision-making and reduce postoperative regrets.\u003c/p\u003e \u003cp\u003eOur study has several limitations. The retrospective design and single-center setting may limit the generalizability of our findings. The sample size, while adequate for exploratory analysis, may not be sufficient to detect rare complications or to fully characterize the spectrum of patient experiences. Additionally, the use of a non-validated quality of life questionnaire, although comprehensive, may introduce some measurement bias. Future prospective, multicenter studies using standardized outcome measures are warranted to confirm and extend our findings.\u003c/p\u003e \u003cp\u003eIn conclusion, partial R3 and total R4 thoracoscopic sympathectomy offers a favorable balance between efficacy and side-effect profile for patients with severe palmar hyperhidrosis. Recurrence remains the most important determinant of patient satisfaction, while CH and dryness, though common, do not significantly detract from overall quality of life. This hybrid approach should be considered a viable surgical option and may serve as a new standard for the management of this challenging condition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Ethics approval \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Public Institutional Bioethics Committee, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). All participants gave their informed consent prior to their inclusion in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRo KM et al (2002) Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg 35(2):382\u0026ndash;386\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomero FR et al (2016) Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. Bras Dermatol 91(6):716\u0026ndash;725\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolish MJ, Savinova I, Weinberg MJ (2022) A Practical Approach to the Diagnosis and Treatment of Palmar Hyperhidrosis. Plast Reconstr Surg Glob Open 10(3):e4172\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalling HW, Swick BL (2011) Treatment options for hyperhidrosis. Am J Clin Dermatol 12(5):285\u0026ndash;295\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerfolio RJ et al (2011) The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 91(5):1642\u0026ndash;1648\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdar R et al (1977) Palmar hyperhidrosis and its surgical treatment: a report of 100 cases. Ann Surg 186(1):34\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashmonai M, Kopelman D, Assalia A (2000) The treatment of primary palmar hyperhidrosis: a review. Surg Today 30(3):211\u0026ndash;218\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai YT et al (1997) \u003cem\u003eComplications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy.\u003c/em\u003e Neurosurgery, 41(1): pp. 110-3; discussion 113-5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelisberto J\u0026uacute;nior G et al (2016) Comparison between high and low levels thoracic sympathectomy for the treatment of palmar and axillary primary hyperhidrosis: systematic review and meta-analysis. Rev Col Bras Cir 43(6):486\u0026ndash;492\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim WO et al (2010) Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis. Am J Surg 199(2):166\u0026ndash;169\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y et al (2009) Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy. Eur J Cardiothorac Surg 35(3):398\u0026ndash;402\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSang HW et al (2017) Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review. Surg Endosc 31(11):4357\u0026ndash;4369\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W et al (2017) A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis. Sci Rep 7(1):129\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErsin OE et al (2025) The effects of sympathectomy ganglion levels on late complications in the treatment of hyperhidrosis. J Minim Access Surg 21(2):175\u0026ndash;182\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;nez-Hern\u0026aacute;ndez NJ et al (2024) Endoscopic thoracic sympathectomy for primary hyperhidrosis: an over a decade-long follow-up on efficacy, impact, and patient satisfaction. J Thorac Dis 16(12):8292\u0026ndash;8299\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu J et al (2024) Long term outcomes and risk factors of compensatory hyperhidrosis after thoracoscopic sympathectomy in primary palmar hyperhidrosis patients: a retrospective single-center study. J Cardiothorac Surg 19(1):590\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChudry H (2022) The treatment of palmar hyperhidrosis - a systematic review. Int J Dermatol 61(11):1303\u0026ndash;1310\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuijpers M et al (2022) Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach. J Clin Med, 11(3)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasarwa H et al (2024) Incidence and Severity of Compensatory Hyperhidrosis Following Bilateral Sympathectomy. Ann Vasc Surg 108:317\u0026ndash;324\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palmar hyperhidrosis, sympathectomy, compensatory hyperhidrosis, patient satisfaction, quality of life, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-9143288/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9143288/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eTo evaluate partial R3/total R4 thoracoscopic sympathectomy for palmar hyperhidrosis, balancing efficacy and side effects.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eRetrospective analysis of 37 patients (2018\u0026ndash;2024). This study was approved by the Public Institutional Bioethics Committee, a nationally accredited institutional review board (IRB) in South Korea (IRB No. P01-202411-01-008). The primary outcomes were satisfaction, recurrence, and compensatory hyperhidrosis. Secondary outcomes included dryness and improvements in various domains of quality of life.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSymptom severity decreased significantly after surgery (mean 4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51 preoperatively to 1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76 postoperatively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Recurrence occurred in 48.65% of patients, but recurrent symptoms were generally mild (mean 1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09). Patient satisfaction was high (mean 4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81) and showed a significant negative correlation with both recurrence and recurrence severity; however, it was not significantly associated with the presence or severity of compensatory hyperhidrosis or dryness. Quality of life, including social, occupational, mental, and physical domains, improved markedly postoperatively.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003ePartial R3 and total R4 thoracoscopic sympathectomy for palmar hyperhidrosis achieves high long-term patient satisfaction and quality of life improvement, with recurrence being the most important determinant of satisfaction. Although compensatory hyperhidrosis and dryness are common, they do not significantly detract from overall satisfaction, supporting this hybrid approach as a balanced and effective surgical strategy.\u003c/p\u003e","manuscriptTitle":"Long-term Outcomes of Partial R3 and Total R4 Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 15:04:54","doi":"10.21203/rs.3.rs-9143288/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b8abf82-7865-434c-96e6-7753279704ab","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T06:29:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 15:04:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9143288","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9143288","identity":"rs-9143288","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}