ETS surgery for blushing, what the research says

Endoscopic thoracic sympathectomy, usually written ETS, is keyhole surgery on the sympathetic chain, the run of nerve tissue alongside the spine inside the chest. For facial blushing the surgeon interrupts it at an upper level so the signal that opens the blood vessels in the face no longer arrives.

It is done under general anaesthetic, usually as a day case, usually on both sides. The nerve is cut or clipped. Clipping is sometimes described as reversible. In practice the honest position is that you should decide as though it is not.

The number most people are shown

Clinic pages describing this procedure for blushing tend to use the word permanent, report high success, and quote a regret rate in the region of a few per cent. Some are careful and note that psychological approaches should be considered first, since ETS is irreversible and invasive. Others are less careful.

None of that is fabricated. It is selective.

The number from the longest follow up

The largest long term follow up of this operation comes from Sweden, published in the British Journal of Surgery in 2011 by Smidfelt and Drott. It covers 3015 patients who had bilateral ETS between 1989 and 1998. 1700 of them responded to the questionnaire, a response rate of 56.4 per cent, at a mean follow up of 14.6 years.

For facial blushing specifically, the operation was judged successful in 72.8 per cent of patients. That was the lowest of the four indications they measured. Palmar hyperhidrosis, sweaty hands, came out at 95.6 per cent.

Compensatory sweating, which is the body sweating more somewhere else to make up for where it can no longer sweat, was present in 80.0 per cent of the whole group.

6.5 per cent were dissatisfied. 13.5 per cent regretted having the procedure.

And this is the figure that deserves the most attention: the regret rate had risen from 7.8 per cent in an earlier survey of these same patients to 13.5 per cent in this one. Regret after this operation goes up with time, not down. A study with a short follow up will therefore understate it, and most of the numbers you will see quoted come from studies with short follow up.

How to read the difference

Put the two side by side. A clinic page saying two to four per cent regret. A peer reviewed follow up of three thousand of these operations at almost fifteen years saying 13.5 per cent, rising.

Both numbers exist in the literature. Short follow up studies genuinely report lower regret. The reason to weight the long one more heavily is not that the surgeons are dishonest. It is that regret after an irreversible operation is a thing that accumulates, and you are making a decision that will still be true in fifteen years.

Note also that satisfaction was lowest in exactly the group reading this article. Patients operated on for palmar hyperhidrosis were satisfied 86.6 per cent of the time. For facial blushing it was 73.5 per cent.

What compensatory sweating actually means

It is worth being concrete, because the phrase sounds mild and the experience often is not.

It means sweating from the back, chest, abdomen, thighs or feet, in situations where you did not previously sweat, sometimes heavily and unpredictably. In a Danish series of 158 patients, 49 of whom were operated on for facial blushing or facial sweating, compensatory sweating occurred in 89 per cent and was severe enough in 35 per cent that they often had to change their clothes during the day. Both of those figures are for the whole series, all three reasons for the operation together and not the 49 alone, among the 94 per cent who answered the questionnaire; how often it occurred did not differ significantly between the three groups. It does not respond well to treatment and it does not reliably fade.

The trade you are being offered is therefore not blushing removed for nothing. It is, for most people, blushing reduced in exchange for a different visible bodily symptom in a different place. Whether that trade is worth it is a real question with a real answer for some people. It is just not the question the marketing asks.

The other thing the numbers cannot tell you

There is a specific reason for caution with this operation and this indication, and it comes from the psychological literature rather than the surgical one.

In a 2001 trial, people with fear of blushing were treated and their blushing was measured physiologically. The fear went down substantially. The actual measured blushing did not change. The authors concluded that fear of blushing reflects a fearful preoccupation, irrespective of actual facial coloration.

If the fear and the flush can move independently, then removing the flush surgically does not automatically remove the fear. Some people find the fear goes with it. Some people find they have had irreversible surgery and are still bracing in the same rooms, now also sweating through their shirt. There is no way to know in advance which one you are, which is a strong argument for trying the reversible things first.

If you are seriously considering it

Some questions worth asking a surgeon, written down before you go in, because it is hard to ask them in the room.

What is your own regret rate, at what follow up length, and how did you measure it. What proportion of your facial blushing patients report compensatory sweating, and how severe. What exactly do you cut or clip, at which level. If you clip, how many of your patients have had it reversed and what happened. What do you do for patients whose compensatory sweating is severe. Have I been offered anything psychological first, and if not, why not.

If any of those questions produces impatience rather than an answer, that is information.

And read the paper. It is one page of abstract and the numbers are all in it.

Where this site stands

Nowhere. This is not a recommendation for or against surgery and nothing here should be used as one. It is education, not medical advice, and the decision belongs to you and a doctor who has examined you.

What this site does say is that the reversible approaches have decent evidence, cost almost nothing, and cannot leave you sweating through your shirt for the next thirty years. That seems like a reasonable order to try things in.