Primary palmar hyperhidrosis (PPH) is a common form of primary focal hyperhidrosis and may persistently affect patients’ learning, occupational performance, social interaction, and psychological well-being. Endoscopic thoracic sympathicotomy is an important minimally invasive treatment for moderate-to-severe PPH. However, postoperative compensatory hyperhidrosis (CH) remains a major factor affecting long-term patient satisfaction and quality of life. Recent studies suggest that the evaluation of surgical outcomes should not be limited to palmar dryness, but should also incorporate patient-centered outcomes, including CH severity, residual palmar moisture, excessive palmar dryness, recurrence, satisfaction, and quality of life. Current evidence supports avoiding high-level or extensive sympathetic interruption and favors lower-level, limited interruption to reduce the risk of moderate-to-severe CH. This review summarizes the definition and assessment of CH, the evolution of surgical concepts, potential mechanisms, risk factors, prediction approaches, individualized level selection, quality control in day surgery, and quality-of-life-oriented follow-up, aiming to provide a reference for risk management of postoperative CH in patients with PPH.