Reply by the Authors of the Original Article

Letter to the Editor

First of all thank you very much for your valuable contribution to the specific area of thoracic surgery and the management of craniofacial hyperhidrosis (CH) and Raynaud syndrome. The authors mentioned that palmar temperature monitoring is an important way of measuring the effectiveness of sympathetic chain clipping surgery.There is a controversy about the clipping level for CH. Some authors recommend T1-level sympathectomy below the stellate ganglion (SG) for complete cure of CH, while the other authors advise to performT2-level sympathectomy avoiding injury to stellate ganglion and prevent the Horner syndrome.[1] [2] Licht et al reported a significantly higher success rate in the T3 sympathectomy group than in T2.[3] Nicholas et al, as a comment in their systematic review, recommended medical treatment as a first-line therapy due to its efficacy and safety, whereas T2 sympathectomy should be considered for patients refractory to first-line therapy.[4] The basic principle of the surgical treatment of CH should be to prevent SG injury, and to accomplish this, one should be aware of the possibility of injuring SG, and the anatomical variations should also be taken into consideration. Several methods, such as intraoperative monitoring of forehead skin perfusion and observation of the change of pupillary size and monitoring of contralateral or ipsilateral temperature changes of the finger surface, have been described in the literature for effectiveness and safety of video endoscopic sympathectomy.[4] [5] Monitoring of palmar temperature has been the most frequently used method so far. The rationale behind this method is that an increase in skin blood flow causes increase in palmar skin temperature. However, the significance of this increase shows a wide range, meaning that some authors consider 0.4°C as significant, while others consider 10°C to predict the effectiveness of the surgery.[6]

As a result, the authors' series includes a limited number of patients and lacks objective methods (statistical comparison). Further studies with increased numbers of patients are recommended to evaluate this method.

• References

• 1 Lin TS, Fang HY. Transthoracic endoscopic sympathectomy for craniofacial hyperhidrosis: analysis of 46 cases. J Laparoendosc Adv Surg Tech A 2000; 10 (5) 243-247
• 2 Kao MC, Chen YL, Lee YS, Hung CC, Huang SJ. Craniofacial hyperhidrosis treated with video endoscopic sympathectomy. J Clin Laser Med Surg 1994; 12 (2) 93-95
• 3 Licht PB, Ladegaard L, Pilegaard HK. Thoracoscopic sympathectomy for isolated facial blushing. Ann Thorac Surg 2006; 81 (5) 1863-1866
• 4 Nicholas R, Quddus A, Baker DM. Treatment of primary craniofacial hyperhidrosis: a systematic review. Am J Clin Dermatol 2015; 16 (5) 361-370
• 5 Wu JJ, Hsu CC, Liao SY, Liu JC, Shih CJ. Contralateral temperature changes of the finger surface during video endoscopic sympathectomy for palmar hyperhidrosis. J Auton Nerv Syst 1996; 59 (3) 98-102
• 6 Crandall CG, Meyer DM, Davis SL, Dellaria SM. Palmar skin blood flow and temperature responses throughout endoscopic sympathectomy. Anesth Analg 2005; 100 (1) 277-283