If prescription antiperspirant, iontophoresis and Botox injections have not given adequate relief from excessive sweating of the hands, underarms or face, keyhole endoscopic thoracic sympathectomy (ETS) may be the next step to consider. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), performs ETS through a single keyhole incision on each side of the chest at London Bridge Hospital and The Lister Hospital Chelsea — for the refractory minority, after conservative options have been tried. It gives reliable, lasting relief from palmar sweating in well-selected patients; the key consideration before proceeding is compensatory sweating, which Dr Okiror discusses honestly and in detail at every consultation, before any decision is made. Referrals accepted from GPs and dermatologists. Self-referrals welcome. Private appointments within 2–3 days.
Last reviewed: July 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Primary hyperhidrosis is caused by overactivity of the part of the nervous system that controls sweating — not by anxiety or lifestyle factors. It produces sweating independent of heat, exercise or emotional state. It has a defined cause and a range of treatments, from antiperspirants through to surgery. It is not a personal failing.
ETS divides the sympathetic nerves responsible for sweating in the treated area, so relief of palmar sweating is usually immediate and the effect is lasting. It works reliably for hand sweating in well-selected patients. It is keyhole surgery, a single small incision on each side of the chest, with most patients staying one night and back to normal activities within a few days. Compensatory sweating is the trade-off to weigh first.
Not everyone with hyperhidrosis is a suitable surgical candidate. Compensatory sweating — increased sweating in untreated areas — is discussed honestly at every consultation. Surgery is recommended only where Dr Okiror is confident the benefit genuinely outweighs the risk for you.
Most patients who reach a consultation about ETS surgery have spent years managing hyperhidrosis with increasing frustration. Understanding where you are in that journey helps clarify whether surgery is the right next step and what to expect from the consultation.
01
High-strength aluminium chloride applied nightly. Effective for mild-to-moderate palmar or axillary hyperhidrosis in some patients. Skin irritation and variable efficacy are common reasons for stopping or moving on. Where this has not provided adequate relief, iontophoresis is the standard next step.
02
Electrical current passed through water or solution applied to the skin. Requires multiple weekly sessions to establish control, then ongoing maintenance. Effective in some patients but demanding in time and commitment. Where iontophoresis has not provided lasting relief or is impractical, Botox injections are next.
03
Botulinum toxin blocks nerve signals to sweat glands in the treated area. Highly effective but temporary — typically lasting 4–6 months, requiring indefinite repeat treatment. Palm injections are painful. For axillary hyperhidrosis, Botox remains an excellent long-term option. Where Botox has not provided adequate or lasting control, ETS surgery is the appropriate discussion.
04
Keyhole division of the sympathetic nerves responsible for excessive sweating. Lasting result for hand sweating. One overnight stay. Most patients notice dry hands on waking from the anaesthetic. The key discussion before proceeding is compensatory sweating — addressed honestly and in full at the consultation before any decision to proceed.
A two-minute self-assessment can help you think through whether surgery is likely to be the right route for your sweating, and prepare for a consultation. It is not a diagnosis, and nothing you enter is saved.
Try the self-assessment →Compensatory sweating is not a complication to be mentioned briefly in a consent form. It is the central consideration in deciding whether ETS is right for you. Understanding it honestly — before surgery — is the purpose of the consultation.
When the sympathetic nerves supplying the hands or face are permanently divided, the body compensates by producing more sweat elsewhere — most commonly the trunk, back, abdomen, or thighs. This is compensatory sweating: the body's way of compensating by redirecting sweat to other areas. It is not the same condition in a new location. It is different in character and usually in volume.
The areas affected and the severity cannot be predicted with certainty before surgery. This is why the consultation is the essential step — not a formality before booking the operation.
Most patients who undergo ETS experience some degree of compensatory sweating. The majority experience mild-to-moderate truncal sweating — manageable with breathable clothing — and consider it an acceptable trade-off for dry hands. A proportion experience more significant sweating, particularly in warm weather or during exercise. A smaller proportion experience compensatory sweating that substantially affects quality of life.
The risk appears higher for patients undergoing ETS at lower sympathetic chain levels (axillary disease) and those with more widespread pre-operative sweating. Dr Okiror uses the clinical picture to inform the discussion.
For patients with severe palmar hyperhidrosis, the comparison is between wet hands affecting every handshake, keyboard, pen, door handle, and social interaction — and dry hands with manageable trunk sweating. Most patients with severe palmar hyperhidrosis, properly counselled, consider that trade-off clearly worth making.
Whether it is the right trade-off for you depends on the severity of your current sweating, your lifestyle, and your tolerance for truncal sweating. That is the question the consultation exists to answer.
Dr Okiror does not recommend ETS to every patient who attends consultation. Patients with mild hyperhidrosis who have not exhausted conservative treatment, those with predominantly axillary sweating where the risk-benefit ratio is less favourable, and those whose work or lifestyle would be significantly disrupted by truncal sweating, may be advised that surgery is not the right option at this stage.
An honest answer — including “not for you” — is the correct answer. The consultation is a clinical judgement, not a sales process.
ETS is performed at London Bridge Hospital or The Lister Hospital Chelsea under general anaesthetic. A single keyhole incision is made on each side of the chest. A thoracoscope is introduced into the chest cavity, the sympathetic nerve chain is identified under direct vision, and permanently divided at the appropriate level for the pattern of sweating being treated.
The procedure takes 30–45 minutes, and most patients stay one night. Relief of palmar sweating is usually immediate and reliable in well-selected patients, and the effect is lasting. Where compensatory sweating develops, it is also permanent — which is why it is discussed in full beforehand.
In selected patients — where the pattern is not cleanly localised, secondary causes have been excluded and conservative measures have been tried — Dr Okiror may treat one side first, to judge the relief and the degree of compensatory sweating before deciding whether to treat the second side. It is a considered option, not a routine one. ETS does not treat sweating of the feet, which is managed without surgery.
Surgery is considered after non-surgical options have been tried. Dr Okiror receives referrals from GPs and dermatologists, and self-referrals are equally welcome.
ETS is most effective for palmar and facial hyperhidrosis. For axillary sweating, the sympathetic level required is lower and the compensatory sweating risk is higher. Botox remains an excellent long-term option for axillary disease. ETS for axillary sweating is considered at consultation where other treatments have failed — assessed more carefully than for palmar disease.
General anaesthetic concerns are common and well understood by the anaesthetic team at London Bridge Hospital. A pre-operative assessment is arranged before every procedure. The anaesthetic for ETS is short-duration and well-tolerated. Your concerns can be discussed with the anaesthetist at the pre-operative appointment.
Self-referrals are welcome. Private appointments within 2–3 days. New consultations from £250. Most major insurers accepted. The consultation covers your sweating pattern, previous treatments, what ETS offers, and what compensatory sweating means for you — before any decision is made.
Questions most commonly asked by patients who are considering ETS surgery for hyperhidrosis.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Private appointments at London Bridge Hospital or The Lister Hospital Chelsea within 2–3 days — the whole pathway can stay in Chelsea for those who prefer. The consultation is thorough and honest — Dr Okiror only recommends ETS where he is confident the benefit genuinely outweighs the risk for your situation. Not every patient who attends leaves with a surgical recommendation. That is the point.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
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