A refreshing change
A refreshing change
Seeking normalcy, woman turns to surgery
By JOHN FAUBER
Posted: June 3, 2006
It was a cold spring day, but, as usual, Stephanie Rebone was sweating.
By noon, she was on her second pair of socks. Because of her excessive perspiration, her sock collection, at last count, stood at 75 pairs.
Working from her computer, she placed paper towels at the base of the keyboard. She typed a few words and then dabbed her wet palms.
With some of her sweat glands stuck in the "on" position, Rebone, 24, has devised all kinds of tricks and adaptations to deal with her condition, known medically as hyperhidrosis.
When she opens a door, she may have to use her shirt to help her get a good grip in the doorknob.
As an engineering consultant, she meets a lot of new clients. To avoid having to shake their hands, she keeps her hands occupied with something like a laptop computer.
"I always do the laptop trick," she said. "You have so much stuff in your hands that you can't shake hands."
But about two weeks ago, after years of living a life dominated by sweat, Rebone tried the ultimate trick.
She was put under general anesthesia. Two dime-sized port holes for a surgical device and a video camera were cut on each side of her chest. Her lungs were collapsed. And inch-long segments of nerves in her rib cage that control sweat glands were cut out.
At first glance, this might seem like a drastic and expensive solution to a minor cosmetic problem, the latest trendy medical indulgence in a society preoccupied with appearances.
But hyperhidrosis can be miserable for many of the 7.8 million Americans, or roughly 2.8% of the population, who are estimated to have it. People with the condition produce four to five times the normal amount of sweat.
Doctors tell of patients whose sweating was so bad that it shorted out computer keyboards; of a police officer who had trouble holding his gun; of a young mother who was reluctant to hold her baby for fear the infant would slip; of a 12-year-old boy whose classmates called him "Swamp Thing."
An altered life
For Rebone, it meant constantly altering her life.
She took three or four showers a day. Her purse always held extra pairs of socks, undershirts and athlete's foot spray.
She stayed away from weddings and other events that required a lot of hand-shaking. She avoided holding hands with her boyfriend. She could not wear sandals or high heels because she would slip out of them, and she couldn't walk barefoot because she would leave wet spots on the floor.
She constantly changed her bed sheets. She avoided trying on clothes in stores because "you don't want to do that to clothing."
She washed her hands 20 times a day.
"If I'm with a group of friends, I go to the bathroom a lot to freshen up," she said. "If it gets too bad, I'll just leave.
"I hate summer. I absolutely hate it."
But this summer looks to be much different.
May 19 was the day the sweating stopped.
At 7:56 a.m., she got a kiss from her boyfriend before she was wheeled down a hallway to the bustling pre-operative area of Froedtert Memorial Lutheran Hospital in Wauwatosa. Nurses fitted her with identification bracelets and put in IV lines, including one for a sedative.
"It feels like tequila," Rebone said as the drug began working.
A few minutes later, her doctor, cardiothoracic surgeon Mario Gasparri, stopped by her room and asked how she was doing.
"Let's do it," Rebone said.
The surgery to correct hyperhidrosis is known as a sympathectomy. It involves cutting out a section of the sympathetic nerve chain, which activates specific sweat glands.
For people such as Rebone, whose primary sweating occurred in her palms, about an inch-long piece of nerves that runs between the second and fourth rib is removed.
The surgery has been around for decades, but doctors say the number of procedures has increased substantially in recent years with the advent of minimally invasive, video-assisted endoscopic surgery.
Until about four or five years ago, only a small number of centers offered the procedure, but now there are dozens of hospitals all over the country that have it, said Mark Krasna, a professor of surgery and chief of thoracic surgery at the University of Maryland Medical Center.
Between 400 and 1,000 of the surgeries are done each year in the United States, estimated Krasna, who has done nearly 500 himself and who trains doctors to do the procedure.
"It's starting to grow," he said.
At Krasna's hospital, the surgery costs about $10,000, he said.
Other centers have charged as much as $80,000, doctors said.
At Froedtert, the cost, including a one-night hospital stay, is $28,000.
Daniel O'Hair, a cardiothoracic surgeon at Aurora St. Luke's Medical Center, said he, too, has seen an increase in the procedures in the last couple of years, partly because patients, on their own, are seeking out surgeons who do the operation.
"Very few physicians really understand this (condition)," he said. "A lot of times, the patients are better educated."
Insurance companies, grudgingly, will pay for the procedure, though doctors say insurers sometimes will not authorize surgery until an appeal is written.
It's a young person's surgery, with the vast majority of procedures done on people in their teens and 20s.
A long history
As far back as she can remember, Rebone sweat excessively on her palms, feet and underarms.
She was teased about it as a child.
Later, when she brought it up with doctors, they told her it was just stress from school or work. So she took yoga classes and ate healthier, but it didn't get better.
The sweating caused her to be thirsty constantly. Athlete's foot also was a regular problem.
The actual cause of so-called primary hyperhidrosis is unknown, but it is believed to involve a dysfunction of the sympathetic nervous system and its connections to the brain. That, in turn, leads to an over-activation of some of the 2 million to 5 million sweat glands in the body.
It's not a mental disorder, and it's not caused by stress or anxiety, though stress can aggravate it, doctors said.
A family history of the condition is found in 25% to 50% of cases, so there's a one-in-four chance that Rebone will pass the condition on if she has children.
Rebone said she did not even know she had a "condition" until about two years ago when she was reading an article in Cosmopolitan magazine.
"I said, 'Oh my God, that's what I have.' "
She then did a Google search of hyperhidrosis and found several chat groups devoted to the condition.
She since has tried a variety of treatments, including a super-strong antiperspirant and a prescription drug, but neither worked well, she said.
She also considered the latest treatment, Botox injections, but decided for the more permanent fix of surgery instead.
The risks of surgery
The surgery itself is not without its downsides.
In 1% of patients, there can be serious complications such as infection, bleeding or a later collapse of the lung.
In up to 5% of patients, a complication known as Horner's syndrome can develop as the result of nerve damage that causes eyelid drooping and an enlarged pupil.
Between 5% and 10% of patients may develop gustatory sweating, which is sweating brought on by eating. Essentially, the brain and nervous system are overstimulated by the taste and smell of food.
"Instead of just salivating, they break out in a sweat," said Krasna, of the University of Maryland.
The most common surgical complication, however, is a phenomenon known as compensatory sweating.
In about 60% of patients, excessive sweating will appear somewhere else on the body, such as the torso or thighs.
"The vast majority of people are happy with the tradeoff," said Keith Naunheim, chief of thoracic surgery at St. Louis University Health Sciences Center.
That's because the surgery works so well, at least for the most troubling hand sweating.
It is 95% effective for hand sweating, about 75% for underarm and facial sweating and 25% for foot sweating, according to the Society of Thoracic Surgeons.
And if it works, the benefit occurs almost instantaneously, as soon as the nerves are removed. For many patients, the surgery can be a life-changing experience, doctors said.
"I do lung cancer surgeries and esophageal cancer surgeries that save people's lives," Naunheim said. "The most grateful patients I have are the hyperhidrosis patients."
On the operating table
At 9:15 a.m., Rebone, draped in sterile blue sheets, lies on her side on the operating table under general anesthesia. One arm is extended up over her head so that doctors can get to the area under her armpit.
Thoracic surgeon Gasparri, who has done more than 30 of the procedures, injects the area with a local anesthetic and makes two incisions, one for the video camera and one for his instruments.
Moments later, Rebone's right lung and inner rib cage are on display on three color monitors in the operating room.
Using the breathing tube, doctors deflate her right lung.
"The lung won't always get out of the way, so you have to play with it," said Gasparri, who is also an assistant professor of thoracic surgery at the Medical College of Wisconsin.
Using a cauterizing instrument, he cuts through the transparent membrane lining the inside of the ribs, exposing part of the sympathetic nerve chain. He tells another surgeon who is learning the procedure and assisting him that the key is identifying the second through fourth ribs and avoiding veins.
At 9:30 a.m., the anesthesiologist says the oxygen saturation in Rebone's blood is running a little low. So her right lung is momentarily inflated to get the oxygen count up.
After just a few minutes of cauterizing, the nerve is completely exposed.
At 9:38, Gasparri snips it off with tiny shears and pulls out an inch-long section. It looks like a small brown worm.
"That's it," Gasparri says. "Let's do the other side."
With Gasparri assisting, Joe Wizorek, the cardiothoracic surgeon who is learning the technique, takes out the second nerve segment on the other side.
After Rebone's lung is re-inflated, a physician's assistant checks her for perspiration.
"Dry left hand," says Mary Jo Matzke. "Dry right hand."
Gasparri steps to the foot of the operating table.
"Actually, her feet are dry, too," he says.
Five days after the surgery, Rebone's hands were completely dry, but she still had flashes of her former life.
She called it phantom sweating. It was the tingling in her hands that used to immediately precede a sweating episode. Only now, the sweat never arrives.
She said she is very pleased with the results.
In addition to dry hands, her underarms and feet are much drier, she said. But she has noticed a significant amount of compensatory sweating on her lower back.
On May 25, she did something she had not done in years: She went shopping for sandals and high-heeled shoes.
At Goldi's in Shorewood, she eyed a pair of pink canvas wedge sandals that she never would have been able to wear in the past.
Then she tried on a pair of black heels and admired the look in the mirror.
"Oh, these are fun," she said.
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