The interganglionic interruption of the sympathetic chain between the ganglia T1 and T2 is the preferred method for the treatment of craniofacial hyperhidrosis and sympathicogeneous erythema with erythrophobia. In the 90s, the nerve was usually transected or even coagulated at the level of the second rib. Due to the anatomical variability of stellate ganglion (T1), which in a minority of patients extends over the anterior surface of the second rib, sometimes even reaching the lower edge of the rib, a s.c. Horner's syndrome (hanging eyelid, etc.) was not an uncommon outcome. Nowadays, surgical clips of titanium are almost exclusively used for compressing the nerve in order to block the signal transmission. The clips are preferably applied at the lower edge of the second rib (upper limit of the ganglion Th2). Clips have the advantage that they can be removed in case of complications, with partial restoration of nerve function, provided they are removed within a short time. Within a few hours or days, however, the pressure of the clips causes irreversible damage to the nerve, eventually leading to permanent interruption, analogous to a cut.
Fig.1: Tip of electrode at the lower edge of the 2nd rib and lateral to the sympathetic chain.
Fig.2: The pleura is perforated with the tip of the electrode.
Fig.3: Enlargement of the pleura window to approx. 8 mm. The cut edge shows whitening of tissue due to heat, which however is minimal (< 1mm) because of the use of pure cutting current. Coagulating current should be avoided whereever possible to prevent collateral heat damage to the nerve and to underlying structures.
Fig.4: Freeing the interganglionic segment between T1 and T2.
Fig.5: Clip application (1)
Fig.6: Clip application (2)
Fig.7: Removal of the clip applicator.
Fig.8: Final result.