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The sympathetic chain reinnervation, either with sural nerve grafts or intercostal nerve remnants, was performed in 51 patients due to postsympathectomy side effects.

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Most patients with CH had been submitted to surgery for redness of the face. The proposed term "sympathetic chain clamping" might suggest the act of blocking and releasing something within a short period of time.

It should be emphasized that earlier clip removal increases the chance of CH reversion. Although this statement makes a certain amount of sense, considering that shorter duration of nerve "compression" improves the result, it is recommended in the world medical literature that the clip removal be performed three months after the surgery in order to obtain a better result.

In a recent study, 13 patients with intense CH were submitted to a second operation to remove the clips, and ten patients recovered, returning to their initial patterns. The clip removal is performed with endoscopic forceps, taking appropriate care with adherences close to larger veins.

Therefore, although the sympathetic blockage with clips is the only nonresectional technique that has been used in the treatment of localized hyperhidrosis, its reversibility is still not totally guaranteed, and patients should be fully informed of this.

This situation is still not often reported in the literature and merits better reflection before it is considered in this consensus. It is speculated that the persistence of plantar hyperhidrosis after thoracic sympathectomy changes patient focus to the plantar sweating. This could cause patients to overestimate the amount of plantar sweating.

Objective data on sweating measurement are necessary to differentiate between patient impression and reality. Lumbar sympathectomy surgery cannot currently be considered a form of CH treatment.

It should be used exclusively in the treatment of primary plantar hyperhidrosis of feet or after thoracic sympathectomy in patients with persistent plantar hyperhidrosis. Lumbar sympathectomy has been performed exclusively in women. In men, there is a risk, albeit low, of developing ejaculatory alterations. This surgery has a real potential to increase CH. Therefore, this possibility, occurring in approximately two thirds of the operated cases, should be discussed with the patient.

Even the worsening of CH after lumbar sympathectomy has no negative impact on quality of life. Generally, women feel very satisfied with the control of plantar hyperhidrosis, even though there is an increase in CH. It has been observed that these alterations occur at several levels and that, different from thoracic sympathectomy, they are independent from the sympathetic chain resection level, since the surgeon always attempts to remove the L2 and L3 lumbar ganglia.

In one study, the appearance of CH was reported in five of eight cases of endoscopic lumbar sympathectomy to control plantar hyperhidrosis. However, the author did not specify which case had been previously submitted to thoracic sympathectomy. Total CH remission, albeit the final objective of the multidisciplinary treatment, is rarely achieved.

Over the years, thanks to advancements in the knowledge of thoracic sympathectomy pathophysiology and better selection of patients who can be submitted to thoracic sympathectomy, the occurrence of CH has decreased significantly. In patients who need sympathectomy in T2 and T3 ganglia, the sympathetic blockage with clipping has been employed in the sympathetic chain.

These techniques are still being studied and might become the surgical treatment of choice due to the possible reversion with the clip removal.

It should be emphasized that, despite all efforts and strategies to reduce the occurrence of intense CH, the best we can currently offer to our patients is prevention. Therefore, it is in the indication of the level of sympathetic chain resection that we have a real possibility to avoid its incidence. Consequently, our main objective should be surgery with zero incidence of intense CH, since it seems clear that "prevention is still the best treatment".

Acknowledgments The authors are grateful for the opportunity to carry out this study on behalf of the Brazilian Society of Thoracic Surgery. References 1.

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