Any advertising above for ETS or ESB is NOT accepted by us as we are AGAINST ETS and ESB because of the side-effects

Q.1. Why is there no after-care for reversal patients who've had their nerves cauterized? With other surgeons there is post-operative care of atleast three days. Is this because you do not remove scarring if you come across it during the reversal, therefore decreasing any complications needing care?

The way the aftercare is given depends also on how long the patient stays in town after the operation. If the patient stays more than 1 or 2 days then I see them as needed on a daily basis. If they are not hospitalized and prefer to leave town and travel back to their homes they can do so safely. To this date none of my patients have been hospitalized. Some patients due to financial reasons or otherwise decide to leave sooner so further post op care is given over the phone or by e-mail.

With regard to your question about "scar removal" I do remove the scar tissue from both sides of the cut nerve in order to freshen up the nerve and prepare it for grafting. The scar removal has nothing to do with the post op care because this is an internal chest cavity matter. The care for the donor site is very simple and it needs dressing change for the next 2 to 4 days after the operation.

Q.2. Do you think the sural nerve is better than the intercostal nerve to use during a reversal? Dr Lin believes it has the ability to survive better. Do you agree with this?

I heard about Dr. Lin's new technique with regard to the intercostal nerve reversal. I do not have any personal experience with that and in one of my last operations I had neuro surgeon working with me and both of us had a lot of questions about the viability of this approach. It seemed to us to be very complicated so I still do the sural nerve reversal. I'm very much worried about severe post operative chest wall pain so I'm somewhat shy of doing so. Also technically I believe it is much more difficult to do. Currently even the urologists are using the sural nerve in cases where they reconstruct damaged sympathetic fibers when the operation is being done for radical prostatectomy. The sural nerve, as in our cases is used as a guide.

Q.3. I am wondering if there are non-invasive technologies available to determine whether this graft has survived and axons have attached (regenerated) to their intended targets, and to determine the future growth potential this graft may manifest over time? Are MRI, MRN or other imaging technologies available to answer these questions?

No.

Q.4. I understand from a lay position that stem cells from one's own body may provide real answers in the near future for person's with neruological maladies. I saw this on the Christopher Reeves story shown on the ABC network. Would such technology be available to me to either potentiate the viability of my current graft, or to perhaps replace it entirely with an alternative source of nerve tissue that could regenerate the nerve gap between my neuropathy?

A very futuristic possibility still very much in the framework of the lab in the investigative stages. We can all hope that further progress will be made.

Q.5. I am an ETS patient who had my ETS procedure done while lying on my stomach. Dr. Lin thinks I cannot have a reversal because I did not lie on my back. Do you agree with this?

Not necessarily so. If the amount of scar tissue or adhesions is not going to be too much then the approach does not make any difference. The dorsal approach which was done years ago through the back was a big operation but some patients had severe adhesions and scar tissue even though the chest cavity was supposedly not entered. Each case obviously has different obstacles to overcome so a judgment must be made on an individual basis.

Q.6. If someone came to you and showed evidence (i.e a psychiatric report) that they were so psychologically devastated by ETS, what could you do for them?

As a surgeon I am not well equipped with psychological answers and in those kind of cases I would refer them to a psychologist-psychiatrist. Obviously support and understanding should be given to the patient and offer them the one solution that is available to us as surgeons is the reversal procedure.

Q.7. I have read that clamping destroys the nerve after a period of time, and also scarring forms under the clamp. I believe that the pressure of the clamps prevents nerve signals from passing through the tissue, due to the blocking of calcium/potassium/sodium channels which nerves use to transmit electricity. Do you agree with this, and if this is true, how can you reverse the procedure just by removing the clamps. Would the patient have to undergo conventional reversal procedure then to remove scarring and then have a graft?

The sympathetic chain has a canny ability to regenerate. We have seen it on cases that had the excisional method where a patient developed recurrences. What the exact mechanism with recurrences is still unclear. You mentioned a few facts in your question, but I'm not so sure that I can give you the right answer to your questions. What we know from the clinical point of view that the clamps do the same job as the cutting method or the excisional method. By removing the clamps in a reversal procedure there are some elements of the sympathetic chain that are still there and they are possibly promoting regrowth. After switching to the clamping method I found it is much better for the patient as well as myself to have the ability to offer them this type of reversal versus the nerve graft reversal. Some patients regret their ETS within a very short time after the operation (2 to 3 days) and there is nothing more assuring to me as well as the patient that they have a very easy and safe possibility to remove the clips and so far my experience with these short term cases is very good. With regard to the patients who opt to have the clips removed shortly after the operation obviously their reversibility was obtained much quicker than those who chose to have their clamp removal months to a year after the operation. Even in those cases of late removal I have noticed definite improvement which showed in better heat tolerance, upper body sweat and less compensatory sweating. For more information on my work with reversal please refer to http://www.sweaty-palms.com/reversal_ets.html .

Q.8. Can you say 100% that ETS patients with clamps can be successfully reversed?

I would never say so and so far I quote the patients a success rate of 65 to 75% This depends on the interval between the first operation and the clamp removal date and also on patients own ability to recover and heal the damage. We do not have that many cases to make a significant statistical analysis.

Q.9. I've been told that you believe in waiting six months before going for a reversal? Other surgeons like Telaranta and Lin don't agree with this. Dr Telaranta believes you should go straight away. Why do you disagree with that, and ask patients to wait a little while?

I want to clarify the statement that you made. I'm not saying that one should wait six months before clamp removal because certain side effects that a patient may see within the first week or so are not necessarily going to stay. The body needs some time to adjust to the sympathectomy and some initial side effects will get better with time. For those patients I try to reassure them and wait a little while. On the other hand if a patient is adamant about removal of the clamps then I will do it as soon as possible. The reason for this answer is that we do not yet have a definite statistical analysis about the optimal time between the first operation and the clamp removal.

Q.10. One obvious thing i've noticed are patients who are confused by your procedure. They aren't sure exactly how you perform the reversal. They can't understand why they are able to walk out of surgery almost straight away. Do you do the same procedure as Dr Lin and Dr Telaranta by using the nerve graft as a conduit between the T1 and the next viable nerve? Unfortunately I have been unable to clarify anything about your procedure because I couldn't go to the States to see you. Can you just make it a little clearer for the patients?

My nerve graft reversals so far took between 3 hours to 6 hours. All of them went back to the hotel or home the same day. Basically the techniques are the same and I use the nerve graft as a conduit between the uppermost and lowermost cut of the nerve. I use one graft on either side. My anesthesiologist is an excellent one and he is the only one I work with for the last 7 years. The amount of discomfort is not any more then after regular ETS and the cut in the lower leg as long as it might be does not add a lot to the pain or discomfort. I believe that the intercostal nerve graft reversal will require more time in the hospital and will result in more pain. With my reversal procedure I tell patients that there are two aspects of the operation.

The technical aspect: In this part of the procedure I enter the chest cavity to find out if the procedure can be done. In some cases the amount of scar tissue or adhesions is so severe that it prevents me from doing the operation because of the risks involved. In those cases I will abort the procedure in order to not endanger ones life. If the scar tissue or adhesions can be handled then the nerve ends are freshened using a cold knife or harmonic scalpel. Obviously this is done on both sides of the chest cavity after that I go down to the ankle region and harvest the sural nerve to the required length that was measured before.

The Physiological Aspect: How much physiological response will be obtained and how much recovery will the patient get depends on many factors including time, health conditions, and many other factors which are still unknown. So far I have done 11 nerve graft reversals and the results are mixed. Patients get upper body sweat, facial sweating, better heat tolerance, and better exercise tolerance.

Q.11. You are incredible experienced with ETS, and are well-known in the industry. What do you think of doctor's who are cauterizing many levels on the sympathetic track? Do you think there are 'cow-boys' out there?

The sympathectomy has undergone many fine adjustments over the years. Cutting vs. clamping, multiple to single levels along the sympathetic chain. Those contributed to better results and better outcomes. Obviously there will be some new surgeons who are not so experienced and bad results will be seen.

Q.12. I once read a comment where you stated that there are no known physiological implications to upper body anhidrosis following a T2 ETS. But what about cosmetic changes such as dry skin, loss of skin tone, changes to skin texture and a more 'aged' complexion due facial dryness and increased sun sensitivity? Steam is universally used to cleanse the face and promote sweating in beauty salons, so wouldn't trapped dirt become a problem post ETS? Is there a loss of oil or inability of glands to bring oil to the surface of the skin on the face? What happens to sweat glands on the upper body after ETS? Would breast feeding be a problem after ETS due to changes in glands? Have any of your patients experienced post ETS pregnancy problems such as difficulty maintaining body temperature? What about menopause and hot flashes?
Madonna

Q.13. Dr Telaranta recently stated he "will not operate any longer on blushing or hyperhidrosis patients, because [he] feels that these indications are not sufficient alone and lead to unnecessarily heavy side effects". How do you feel about this? Does it concern you that a leader in this field is now turning his back on the industry to focus on the Reversals and research in the area of Parkinson's Disease, mainly because of the indication of heavy side-effects?

Q.14. Dr Telaranta has put a link to my site on his site to inform every patient of the possible side-effects. Would you be willing to do this to give a patient every possible opportunity to be educated about possible 'trade-offs'?

Q.15. Dr Lin works with the intercostal nerve due to it's ability to stay live, therefore allowing nerve signals to pass through and allow neurotransmission quickly, rather than the sural which dies and then of course acts like a "tube" for the axons to migrate along. Do you think the intercostal has the ability to stay live indefinately as opposed to the sural?

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