Facial Blushing and Flushing
When It Is Severe, and Every Test Has Come Back Normal

Tell someone you have panic attacks and they understand. Tell them your face goes red and they smile and call it endearing. That gap — between how serious the problem is to live with and how seriously it is taken — is one of the defining features of the condition, and it is the reason many people stop mentioning it at all.

It also tends to start young. Many people date the problem to their school years and were told at the time that they would grow out of it. Some do. Many do not, and arrive in their twenties, thirties or later with the same problem and the added weight of having been told for years that it was a phase.

The practical cost is usually work. Meetings where you have to speak. Presentations. Being asked a question with the room turned towards you. Many people describe the dread building for days or even weeks beforehand, and some stop attending altogether. Others describe a sensation of heat rising through the neck and face, sometimes with pins and needles, lasting far longer than the moment that triggered it — half an hour or more of intensity, then hours before the colour fully settles.

Alongside the physical event there is often a second problem: the fear of it happening. In the medical literature this is called erythrophobia, and it can persist independently of the blushing itself. Distinguishing the two matters, because they do not necessarily respond to the same treatment — a point returned to below.

Whether the problem is described as blushing or as flushing makes very little difference at this stage. Most people use both words for the same thing. What matters is establishing why it is happening.

Broadly, severe facial redness has one of two origins.

A systemic cause. Something else in the body is producing the redness — a hormonal condition, a metabolic condition, a skin condition, a medicine, or rarely a tumour producing chemicals that dilate blood vessels. Here the redness is a signal rather than the disease, and treating the underlying condition is what resolves it. An operation would be the wrong answer, and in some cases a dangerous one.

Sympathetic overactivity. No underlying condition is found, and the problem lies in the nerves themselves. The sympathetic nervous system controls the small blood vessels in the skin of the face automatically, without any conscious input. Where that control is overactive, the vessels open too readily, too widely and for too long. This is the group in whom surgery can be considered.

Investigations exist for one purpose: to tell those two apart. That is why the workup comes first and why it is not a formality. Until it is complete, nobody can say honestly which of the two explanations applies, and therefore nobody can say honestly what the right treatment is.

In plain terms, these are the conditions that need to be considered and looked for. Most are common and treatable; a few are rare but important not to miss.

In general terms, the workup falls into four groups. Which of them apply depends on the pattern of symptoms.

Blood tests. Thyroid function, blood sugar and long-term glucose control, hormone levels, and specific markers used to look for the rarer hormone-producing tumours.

Urine tests. Sometimes collected over a full 24 hours, measuring the breakdown products of hormones that would not necessarily show on a single blood sample.

Imaging. A CT or MRI scan, usually of the adrenal glands or abdomen, where the blood or urine results raise a possibility that needs looking at directly.

Skin assessment. Dermatological review where a skin condition such as rosacea is a realistic explanation for the pattern of redness.

Where no systemic cause is found, treatment starts with the non-surgical options. Beta-blockers, most commonly propranolol, are the usual first medical treatment; they often help the racing heart and the physical sense of alarm, though many people find they do less for the redness itself. Other medicines are used where beta-blockers are not tolerated or not effective. Psychological approaches — cognitive behavioural therapy in particular — have a genuine evidence base, especially where the fear of blushing has become as disabling as the blushing.

Two conditions have to be met before surgery is put on the table. First, systemic causes must have been properly looked for, and the results reviewed rather than simply reported. Second, conservative and medical treatment must have been tried and found not to give adequate relief.

This is also the national position. NICE recommends that the operation is considered only in patients with severe and debilitating blushing that has not responded to other treatments, and requires that anyone considering it is given clear written information about what it involves and what can go wrong. This page is part of discharging that requirement. The rest is done in person.

The sympathetic nerve chain runs down each side of the spine, just inside the back of the chest. Specific levels of that chain carry the signals to the blood vessels of the face. Endoscopic thoracic sympathectomy reaches the chain through the chest and interrupts it, so that the signal driving the flushing no longer arrives.

Dr Okiror divides the chain at the second thoracic level — a T2 sympathicotomy. Under the rib-oriented naming system now used internationally, the same procedure is described as an R2 sympathicotomy. The distinction is worth stating plainly because patients comparing surgeons are often given a level without being told which naming system it belongs to. The chain is divided rather than clipped.

That choice is deliberate. When the only randomised trial in this field followed its patients out to a median of sixteen years, division at R2 alone produced a better effect on blushing and higher satisfaction than the more extensive R2–R3 procedure. More extensive surgery did not buy a better result; it cost one.

The operation is performed under general anaesthesia through a single small incision on each side of the chest. Dr Okiror performs it both thoracoscopically and robotically, using the approach best suited to the individual case. It takes around 30 to 45 minutes. No chest drain is left afterwards, which removes the most uncomfortable part of conventional chest surgery, and most patients stay one night, mainly so pain relief can be managed properly before going home. Most people return to desk work within three to five days and to light activity within one to two weeks. Surgery takes place at London Bridge Hospital or The Lister Hospital Chelsea.

Traditionally both sides are treated in a single operation. An alternative is to stage it — treat one side, wait, assess the effect and the degree of compensatory sweating, and only then decide whether to treat the second side. Dr Okiror offers this in selected patients, and it is a considered option rather than a routine one.

The argument for it is compensatory sweating, which is the main reason people regret this operation. In a comparison of 126 one-stage bilateral against 135 two-stage unilateral single-port procedures followed for a mean of 7.2 years, compensatory sweating occurred in 21.4 per cent of the one-stage group and 4.4 per cent of the two-stage group. That study was in palmar and axillary hyperhidrosis rather than blushing, so the figures should not simply be transferred — but the direction of the finding is consistent and the difference was substantial. A staged single-port R2 approach has since been reported specifically for severe facial blushing, with low compensatory sweating rates in carefully selected patients. A randomised trial comparing one-stage against staged surgery is currently running.

The costs of staging are real and should be weighed openly. It means two operations, two general anaesthetics and two recoveries rather than one. There is an interval during which the two sides of the face may behave differently, which some people find more difficult than they expect. And if the first side gives a good result with acceptable compensatory sweating, some patients choose not to have the second side at all — which is either an advantage or an incomplete result depending on how you look at it.

Whether staging is the right approach for you is a decision made at consultation, on the severity of your symptoms, how much compensatory sweating would affect your work and life, and how you weigh one operation against two.

There is one randomised trial of this operation for isolated facial blushing, and one very long-term follow-up of the same patients. Those, together with the largest retrospective series, are the honest evidence base. All three are quoted below, including where they disagree.

Compensatory sweating is usual, not occasional. Increased sweating elsewhere on the body, most often the trunk and back, was reported by 93 per cent of patients in the randomised trial at one year and 77 per cent at sixteen years. For most it is mild — a change of what you wear in summer rather than a change of life — and most say they would have the operation again anyway. For a minority it is heavy enough to become the main problem, and it cannot be undone. Gustatory sweating, a little facial sweating with certain foods, occurred in around a third, and dry hands in two-thirds.

Some blushing returns in a substantial minority. Mild recurrence was reported by 30 per cent within the first year and 41 per cent by sixteen years — in most cases milder than before surgery, and without overall satisfaction collapsing. This is the question patients ask each other most often and are answered least honestly. It is discussed before the operation, not after it.

The operation cannot be reversed. The nerve is divided. Everything above is the reason the consultation matters more than the operation.

Beyond compensatory sweating and recurrence, which are covered above because they are the main considerations, the following are set out in full at consultation.

One further point worth separating. Surgery addresses the physical event — the blood vessels opening and the face reddening. Where the fear of blushing has become established over many years, it may persist to some degree even when the blushing itself improves, and it may need its own support alongside. Patients who understand that distinction beforehand tend to be the ones who are satisfied afterwards.

Insurance, Self-Pay
and How to Be Seen

Sympathectomy is recognised by the major insurers, subject to the terms of your individual policy — BUPA, AXA Health, Aviva, WPA, Cigna and BUPA International. Self-funding patients are equally welcome, with a transparent quote provided in advance. New consultations from £250.

Self-referrals are welcome, and Dr Okiror also receives referrals from GPs, dermatologists and physicians. Appointments are usually available within 2 to 3 working days at London Bridge Hospital or The Lister Hospital Chelsea. Video consultation is available where travel is difficult, which is often the practical route for a first appointment while records and scans are being gathered.

To confirm your cover, or to send previous results ahead of a consultation, contact Jo Mitchelson, PA, on 020 7952 2882 or pa@lungsurgeon.co.uk.

Evidence cited on this page

Licht PB, Pilegaard HK, Ladegaard L. Sympathicotomy for isolated facial blushing: a randomized clinical trial. Ann Thorac Surg 2012;94:401–405. doi:10.1016/j.athoracsur.2012.03.076 (ClinicalTrials.gov NCT00225069).
Dittberner FA, Jørgensen OD, Pilegaard HK, Ladegaard L, Licht PB. Sympathicotomy for isolated facial blushing: long-term follow-up of a randomized trial. Eur J Cardiothorac Surg 2024;65(3):ezad414. PMID 38085236.
Smidfelt K, Drott C. Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial blushing. Br J Surg 2011;98:1719–1724. PMID 21928403.
Menna C, Ibrahim M, Andreetti C, et al. Long-term compensatory sweating results after sympathectomy for palmar and axillary hyperhidrosis. Ann Cardiothorac Surg 2016;5(1):26–32.
van der Weijde E, Kuijpers M, Bouma W, Mariani MA, Klinkenberg TJ. Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing. Interdiscip Cardiovasc Thorac Surg 2022;35(5):ivac257.
Cerfolio RJ, de Campos JRM, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011. PMID 21524489.
National Institute for Health and Care Excellence. Endoscopic thoracic sympathectomy for primary facial blushing. Interventional procedures guidance IPG480, published February 2014; now issued as HealthTech guidance HTG331, guidance unchanged.