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Thoracoscopic sympathectomy is a safe, effective, minimally invasive treatment for primary hyperhidrosis.1
A 29 year old man with severe facial hyperhidrosis underwent an uncomplicated right thoracoscopic sympathectomy. Before operating on his left side, a starch-iodine preparation was applied to his face in order to demarcate residual sudomotor function. The preparation becomes blue on exposure to moisture, thereby representing residual sweat gland activity.
Figure 1 demonstrates that sympathetic innervation to the face is strictly unilateral, and nerve fibres do not appear to cross the midline. This is essentially an iatrogenic variation of the harlequin syndrome,2 which usually results from interruption of post-ganglionic sympathetic fibres secondary to malignant invasion.
His facial hyperhidrosis was completely treated once the contralateral sympathectomy was performed.