Bilateral R2 sympathetic surgery for craniofacial hyperhidrosis: a 10-year retrospective cohort study on long-term outcomes and development of a prognostic predictive model.

Abstract

Objective: To evaluate the long-term efficacy and safety of bilateral R2 sympathetic surgery for CFH, to characterize the 10-year longitudinal trajectory of postoperative CH and recurrence, and to identify clinically accessible predictors of CH and postoperative satisfaction that may assist in preoperative risk communication. Preliminary nomograms were developed and internally validated using the area under the curve (AUC), calibration plots, sensitivity, and specificity.

Materials and methods: A total of 127 patients who underwent bilateral R2 sympathetic surgery for CFH between April 2013 and April 2023 were retrospectively analyzed. Baseline characteristics, operative details, and follow-up outcomes were extracted from medical records and structured telephone interviews. Predictive features were selected using least absolute shrinkage and selection operator (LASSO) regression. Cox proportional hazards and multivariate logistic regression models were subsequently applied to identify independent predictors of CH and satisfaction, respectively. Nomograms were developed and internally validated using the area under the receiver operating characteristic curve (AUC), calibration plots, sensitivity, and specificity.

Results: All patients achieved immediate resolution of craniofacial sweating, accompanied by a significant postoperative heart rate reduction (84.8 ± 11.68 → 72.17 ± 7.54 bpm, P < 0.001). Severe CH (grade IV) developed in 70.1% of patients, predominantly involving the thoracoabdominal (84.3%) and thigh (54.3%) regions. Cox regression identified preoperative heart rate > 79.5 bpm (HR = 2.46, 95% CI 1.61-3.75, P = 0.0002) and sympathetic clamping (HR = 5.69, 95% CI 3.03-10.67, P = 0.001) as independent risk factors for severe CH. Logistic regression showed that lower preoperative thoracoabdominal sweating was associated with higher postoperative satisfaction (OR = 0.05, 95% CI 0.01-0.23, P = 0.001). The nomograms demonstrated adequate discrimination and calibration.

Conclusion: Bilateral R2 sympathetic surgery achieves rapid and durable relief of craniofacial hyperhidrosis with sustained high satisfaction over 10 years. Beyond confirming efficacy, the extended follow-up uniquely demonstrates that CH severity stabilizes within the first postoperative year and does not worsen over time-a critical finding for patient reassurance. Preoperative resting heart rate > 79.5 bpm and the use of sympathetic clamping independently predict severe CH, whereas lower baseline thoracoabdominal sweating predicts superior satisfaction. Although the proposed nomograms require external validation before routine adoption, they offer a practical, individualized reference for preoperative risk communication and, combined with the intraoperative choice of electrocautery, support a dual-phase strategy for optimizing surgical outcomes in CFH patients.