Cosmetic surgery techniques, such as having a patient sit or stand while incision sites are marked so they blend into natural lines of the body, can improve the aesthetic result of thyroid surgery as well, researchers say.
"We have found that while keeping the management of the underlying thyroid problem as the first priority, we can still achieve a maximal cosmetic result," says Dr. David Terris, a pioneer in minimally invasive techniques that have dramatically reduced the size of the hallmark base-of-the-neck incisions.
Dr. Terris, who chairs the Medical College of Georgia Department of Otolaryngology-Head and Neck Surgery, wanted to know if cosmetic surgery principles he learned in the facial plastic surgery part of his training could further improve results.
He did a prospective analysis of 248 patients who required varying approaches to thyroid surgery, from a standard, several-inch-long neck incision to remove huge thyroids to minimally invasive techniques that cut the incision size in half to endoscopic approaches that reduce incision size half again. Patients were operated on at MCG Medical Center between September 2003 and June 2006.
Most thyroid patients requiring surgery are women – 198 women compared to 50 men in this new study published in the July issue of The Laryngoscope – and many are concerned with the cosmetic result, says Dr. Terris. "It matters to them how big the scar is, if it's even, if it's hidden in a skin crease, if the edges are nicely aligned."
All patients sat up to have their incision sites marked. "You want the incision to be in a location that corresponds to a cosmetically favorable area when you are upright at a dinner party, not stretched out on an operating room table," says Dr. Terris.
Other techniques applied included:
- Trimming traumatized edges at the incision sites. "Especially with the minimal-access techniques, the idea is to customize the incision to the size of the disease rather than one size fits all, which is how thyroid surgery was done just five or six years ago, with a big incision for everybody," says Dr. Terris. "Sometimes we still make big incisions, but more often, we make a smaller incision just big enough to get the thyroid out." Skin edges sometimes get frayed as surgeons remove large nodules from relatively small incisions. "Rather than make a bigger incision, we excise that edge so you have nice, fresh dges that come together quite well."
- Using surgical glues instead of sutures. "You can line up edges and get them accurately apposed without any risk of railroad-tracking using the glue," he says, referencing tracks left by traditional sutures or staples. "It's also convenient for patients because they don't have to come back on a certain date to get the stitches removed; they just peel it off."
- Minimizing trauma to surrounding skin. "The conventional way to get to the thyroid gland is to raise up the skin to the hyoid bone above the Adam's apple and down to the clavicles, then start working on the muscles in the throat that surround the thyroid gland, separate those, then get down to the gland." But all that raising of tissue, called flaps, means hoping it will lie back down as it's supposed to. "What we recognized is that you don't need to raise those flaps all the way up and all the way down. We make our incision, we go right down to the muscles, separate them, do the work we need to do, then close them. It saves time during surgery, it saves dissection and we are not creating a big space that we hope sticks back down."
- Minimizing use of drains. Drains to manage post-surgery oozing have been used pretty much since thyroid surgery was invented. "It used to be common, rather than removing the entire thyroid, to leave a little rind, if you will, of the thyroid behind," says Dr. Terris. The hope was the remaining tissue might reduce or even eliminate the need for thyroid medicine afterward. The reality is the patients ended up on medicine and the rind often caused oozing and sometimes recurrent disease. Now doctors take out the whole thyroid or all of one side, depending on the extent of the disease. Also today, minimally invasive techniques and other surgical improvements such as the thin, ultrasonic harmonic scalpel, have reduced overall surgical trauma. In the study, only 111 of the 248 patients got drains, 60 of whom had conventional thyroidectomy.
Researchers reported that only one of the 248 patients required additional treatment for their surgery scar; she received steroid injections for hypertrophic scarring.
"Although there continues to be enthusiasm for the use of these smaller incisions to accomplish thyroid surgery, it is likely that the application of well-known cosmetic principles is equally important to achieving optimal outcomes," Dr. Terris and his co-authors write.
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