Abstract

Background

Thyroid carcinoma (TC), especially differentiated thyroid carcinoma (DTC), is one of the most common malignancies in the head and neck region [1, 2]. The prognosis of DTC is excellent, with a 10-year survival rate greater than 91% [3]. This disease is more likely to occur in young women, who may be concerned about the aesthetic appearance of the scar resulting from the thyroidectomy. Therefore, the pursuit of more favorable aesthetic effects is a priority for thyroid surgeons.

Since the introduction of endoscopic parathyroidectomy by Gagner in 1996 and endoscopic thyroidectomy by Hüscher CS et al. in 1997, new techniques, such as a robotic-assisted transaxillary approach, a video-assisted anterior chest approach and a transoral endoscopic approach, have been reported to improve the cosmetic results [4–7]. Compared with open procedures, these techniques undoubtedly have some advantages, such as faster recovery and scarless incision. However, these innovative procedures present the disadvantages of increased operative time, additional endoscopic instrumentation, and new complications, including brachial plexus injury and external and internal jugular vein, carotid artery or tracheal lesions. Moreover, these procedures cannot ensure the radical resection of thyroid carcinoma as with open access, which is the standard approach for thyroid carcinoma [8].

Even without the assistance of endoscopic instruments, thyroidectomy with an incision between 3 and 3.5 cm long can be performed by a professional endocrine surgeon. A recent cohort study found that incision length may not be critical in decision making for thyroid cancer surgery [9]. Moreover, other head and neck procedures such as oral cavity surgery have shown no improvement in patient satisfaction with lip-splitting mandibulotomy approach versus trans-oral approach [10]. Therefore, the aim of this study was to evaluate and compare the surgical outcomes, aesthetic effects and incision length of different access procedures in patients with DTC.

Methods

Aesthetic evaluation tool

The Patient and Observer Scar Assessment Scale (POSAS) was used as an assessment tool in our study. The POSAS scale is a reliable and feasible tool for linear scar evaluation [12, 13]. The POSAS included the observer scale and the patient scale. The Observer Scar Assessment Scale (OSAS) score was obtained by the same observer; this scale includes 5 items graded on a 10-point scale with 1 indicating normal skin and 10 indicating the worst scar imaginable. A summary score of 5 indicates normal skin, and a summary score of 50 is the worst possible scar result. The Patient Scar Assessment Scale (PSAS) consists of 6 items. All items are graded by the patient on a 10-point scale; a summary score of 6 to 60 represents the range from normal skin to the worst imaginable scar. After scoring the items, the observer and the patients rated the overall scar appearance on a visual analogue scale corresponding to a 10-point scale (Fig. 1).

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Fig. 1

The Patient and Observer Scar Assessment Scale

Results

Patient characteristics

One hundred twenty patients were divided into the conventional access (CA) group, the aesthetic principles access (APA) group and the minimally invasive access (MIA) group, with 40 patients per group. The age distribution of the whole population ranged from 25 to 57 years, and the average age was 37.0 years in the CA group, 35.4 years in the APA group and 37.6 years in the MIA group. There were no significant differences among the three groups. Papillary carcinoma accounted for more than 95% of all cases.

Digital images obtained from the patients of the three groups are shown in Fig. 2. The best cosmetic effect was seen in patients with the APA approach, and the worst cosmetic effect was seen in patients with the MIA approach. The cosmetic effect of patients receiving the CA approach was between those of the APA approach and MIA approach (Fig. ​(Fig.22).

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Fig. 2

Digital images obtained from the patients after surgery. a: Conventional access thyroidectomy (CA); b: Aesthetic principles access thyroidectomy (APA); c: Minimally invasive access thyroidectomy(MIA)

Comparison of the patient and observer assessment scale scores among the three groups

Our results showed that cosmetic satisfaction was highest in the APA group, followed by the CA group and then the MIA group. The best aesthetic score was obtained in the APA group using the Observer Scar Assessment Scale (OSAS) (APA vs. CA, P < 0.001; APA vs. MIA, P < 0.001; CA vs. MIA, P = 0.0326). Patient Scar Assessment Scale (PSAS) scores were significantly lower in the APA group and the CA group than that in the MIA group (APA vs. CA, P = 0.874; APA vs. MIA, P < 0.001; CA vs. MIA, P < 0.001). Significantly lower objective scar ratings were found in APA group patients (APA vs. CA, P = 0.06; APA vs. MIA P < 0.001; CA vs. MIA, P = 0.003) than in CA groups. Very small differences were found in overall patient satisfaction and scar length between patients in the APA group and the CA group, and the patients in these two groups showed lower scores than those in the MIA group (satisfaction: APA vs. CA, P = 0.323; APA vs. MIA, P < 0.001; CA vs. MIA, P < 0.001; scar length: APA vs. CA, P = 0.999; APA vs. MIA, P < 0.001; CA vs. MIA, P < 0.001) (Table 2, Fig. 3).

Table 2

Comparison of Patient and Observer Assessment Scale scores

Variables	CA (N = 40)		APA (N = 40)		MIA (N = 40)		P value
	Mean ± SD	Median (range)	Mean ± SD	Median (range)	Mean ± SD	Median (range)
Scar length (mm)	48.35 ± 4.29	46(43–56)	48.25 ± 2.65	48(44–55)	30.00 ± 3.00	30(24–35)	<0.001
POSAS score
OSAS	9.80 ± 2.54	10(6–13)	7.48 ± 2.46	7(5–12)	11.48 ± 3.60	11(6–17)	<0.001
PSAS	9.52 ± 3.18	9(6–16)	8.98 ± 2.75	8(6–14)	13.27 ± 4.56	12(8–21)	<0.001
Objective scar rating	3.05 ± 1.47	3(1–5)	2.35 ± 1.35	2(1–5)	4.10 ± 1.19	4(2–6)	<0.001
Overall patient satisfaction	1.98 ± 1.25	2(1–4)	1.60 ± 0.63	2(1–3)	3.37 ± 1.43	3(1–6)	<0.001

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CA conventional thyroidectomy, APA aesthetic principles access thyroidectomy, MIA minimally invasive thyroidectomy, POSAS Patient and Observer Scar Assessment Scale, OSAS Observer Scar Assessment Scale, PSAS Patient Scar Assessment Scale

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Fig. 3

Comparison of the Patient and Observer Assessment Scale scores

Discussion

Recent advances in surgery have focused on minimally invasive techniques. The concept of minimally invasive surgery (MIS) was first proposed by Wickham, an English urologist [14]. The goal of MIS is not only to make smaller incisions but also to minimize wound complications, decrease postoperative pain and hospital stays, and attain better aesthetic outcomes. The MIS principle has also been adopted by surgeons focusing on thyroid cancer.

Regardless of which minimally invasive thyroidectomy approach is used, video-assisted techniques and the development of extracervical surgical approaches aim to reduce scarring. Miccoli et al. compared scar satisfaction from video-assisted thyroidectomy, parathyroidectomy and conventional techniques using a non-validated verbal response scale to assess overall patient satisfaction 1 month after surgery. Bellantone also asked patients to rate their overall satisfaction with their scar at 3 and 6 months after surgery and compared the results for video-assisted and conventional thyroidectomies. The results of these two studies showed that smaller neck incisions improved patient satisfaction with scar cosmesis [15, 16]. However, long-term assessment methods were used in other studies, and no significant differences in patient satisfaction were noted between incisions from minimally invasive techniques and those from conventional surgery [17]. The study by Toll EC et al. demonstrated no association between absolute scar length or relative scar length ratio and patient satisfaction at 2–24 months after the conventional approach thyroidectomy. There was also no association found between absolute or relative scar length and satisfaction in female patients [18]. In our study, the follow-up time was more than one year. Although MIA was performed to improve postoperative scars, it led to the worst aesthetic effects as a result. The relationship between scar length and patient satisfaction does not appear to be as certain as previously thought.

Wound healing studies have demonstrated that scars usually develop after 6–8 weeks following re-epithelization, and a period of 6–18 months is required for scar maturation. Healing and remodeling are largely completed by 8–12 months; and scars might be delayed until 1 year for evaluation [19, 20]. Therefore, the observation time is critical to drawing an appropriate conclusion. There are many factors potentially influencing patient satisfaction with scar cosmesis instead of the length of the incision, such as the degree of hypertrophy, keloid formation, pigmentation, and discomfort experienced by patients [18]. Mow et al. showed that the cosmesis of mini-incision total hip replacement scars was inferior to that of standard-incision scars because skin and soft tissue damage were produced by the high retractor pressures, which were needed for exposure using a limited skin incision [21]. When a minimally invasive approach was used, the use of retractors for a longer time to increase exposure was inevitable. Thus, the edges of the wound might be traumatized from the stretching of the surgical wound to remove a gland or perform central lymph node dissection (CLND). These injuries could inevitably affect the aesthetic level of wound healing.

In addition to improvement of incision appearance, decreasing postoperative complications was another principle of the MIS approach. The first credible records of thyroid surgery appeared in the School of Salerno in the thirteenth century, although the techniques consisted simply of the use of cottons and hot irons for hemostasis. The technique of capsular dissection made the conventional access thyroidectomy practical and relatively safe [22–24]. In our study, CA was deemed a reliable method and showed very low postoperative complications, with only one case with bleeding, who required a second hemostasis and one case of temporary asymptomatic hypocalcemia, who was self-healed 5 days after the operation. There was one case of permanent RLN palsy in the MIA group. However, RLN did not occur in the CA group or the APA group. This adverse event might have been caused by the excessively short incision, which led to a poor surgical field and increased risk of damage to important structures, such as the parathyroid glands and RLN, at the cost of a longer operation time. Nevertheless, our current study had some limitations, such as small sample size, all patients from a single-center study. Thus, a large-scale, prospective, multicenter clinical study should be conducted to validate these findings.

Conclusion

In summary, these results suggest that aesthetic principles access produces the best surgical outcomes in TC patients. Minimally invasive access thyroidectomy demonstrated the highest rate of postoperative complications and the worst aesthetic results, although it has the advantages of less intraoperative blood loss and a reduced scar length. However, conventional thyroidectomy may obtain an ideal aesthetic result using the principles of aesthetic surgery. Head and neck surgeons should pay closer attention to aesthetic principles in thyroidectomy. Indeed, unnecessarily small incisions may cause unsatisfactory results; therefore, thyroid surgery need not be performed through excessively short incisions for the sake of patient satisfaction with the scar’s appearance.

Acknowledgments

Abbreviations

Authors’ contributions

QX, TW and XM conceived and performed most of the surgeries; QX, TW and XM provided the study materials or patients; QX, TW and XM collected and assembly of data; QX, TW, QL and XM made the data analysis and interpretation, and GL and QL provided comments and critical revisions. All authors have read and approved the final version of this manuscript.

Notes

Contributor Information

Xiao Ma, Phone: 86-1088196672, Email: moc.qq@oaixadam.

Qi-jun Xia, Email: moc.361@aixohceremmus.

Guojun Li, Email: gro.nosrednadm@ilg.

Qin Li, Email: moc.361@300821ilniq.

References