Comparison of cosmetic outcomes between remote‐access and conventional thyroidectomy: A review of the current literature

Abstract

Objective

The pursuit of an esthetically pleasing scar following open thyroid surgery has led to the development of endoscopic thyroidectomy through remote incisions placed in several locations outside the neck. The objective of this study is to review the recent literature and compare the incision site appearance and patient satisfaction with the cosmetic outcome after extracervical and conventional thyroidectomy.

Methods

The English literature published since 2010 was searched through the PubMed/Medline database for studies comparing the cosmetic outcomes between remote‐access endoscopic and conventional thyroidectomy using a form of scar assessment scale.

Results

A total of 9 relevant papers fulfilled the eligibility criteria including 1486 patients. Among them, 595 patients underwent endoscopic thyroidectomy through several remote‐access approaches and 891 patients were assigned to the conventional group. Only one randomized‐controlled trial was identified, whereas among the rest, four were prospective and four were retrospective nonrandomized cohorts. Regarding the extracervical modifications performed in the endoscopic groups, the axillary approach was performed in three studies and the breast approach in four studies, while the retroauricular facelift technique and the transoral vestibular method were applied in one study, respectively.

Conclusions

Evaluation of the wound appearance and patient satisfaction with the cosmetic outcome at various time points during the follow‐up highlighted the superiority of the extracervical approaches over the conventional cervicotomy. Considering these findings, remote‐access techniques could possibly be the ideal surgical method for patients with high esthetic requirements, providing an excellent appearance of the thoroughly exposed neck.

Key points

• Conventional open thyroidectomy is considered the gold standard approach for thyroid diseases.

• Endoscopic thyroidectomy through extracervical incisions provided a scarless appearance of the neck and greater patient satisfaction with the cosmetic outcome.

Increased expectations in terms of cosmetic outcomes have led to the evolution of endoscopic extracervical thyroidectomy. These remote‐access techniques led to greater cosmetic satisfaction among patients, providing a scarless appearance of the neck.

Abbreviations

CT

conventional thyroidectomy

ET

endoscopic thyroidectomy

RCT

randomized‐controlled trial

INTRODUCTION

Since the pioneer Theodor Kocher implemented and evolved a surgical procedure for diseases of the thyroid gland, conventional thyroidectomy (CT) has been performed as the gold standard approach for thyroid diseases. ¹ , ² The standard anterior cervical approach ensures clear surgical view and accessibility, which, in combination with low morbidity and excellent outcomes, led to the widespread adoption of this technique by the majority of thyroid surgeons. ¹ , ² , ³ Τhe high incidence of thyroid diseases in women and the young age of the respective population were followed by escalating cosmetic requirements and resulted consequently in the incorporation of minimally invasive techniques. ² , ⁴

Gagner ⁵ initially introduced endoscopic neck surgery in 1996 and Hüscher et al. ⁶ followed with the first video‐assisted thyroid lobectomy in 1997. These techniques may have minimized the cervical incision; however, the scar remained visible in a cosmetically unfavorable site and was prone to hypertrophy and keloid formation. ¹ The evolving technological advancements enabled the resection of the thyroid through remote extracervical surgical ports, leaving a scarless appearance of the neck. ⁴

Ohgami et al. ⁷ reported their experience with the breast approach in 2000, while Ikeda et al. ⁸ performed an endoscopic axillary neck dissection in 2001, introducing the first remote‐access approach in thyroidectomy and providing safe operative techniques for patients concerned about their cosmetic appearance. After careful evaluation, and cadaveric and animal trials, in 2010, Wilhelm and Metzig ⁹ completed their first clinical application of transoral total endoscopic thyroidectomy (ET) and hence they were able to incorporate natural orifice transluminal endoscopic surgery into endoscopic neck surgery. ¹ Then, Terris et al. ¹⁰ in 2011, described their initial experience with robotic thyroidectomy through a facelift incision in an attempt to avoid the unfamiliar territory of the axillary area and reduce the dissected surface area. ¹

Despite the safe application and the superior cosmetic outcomes of scarless extracervical techniques, the CT through the standard anterior neck incision is still considered the gold standard approach for thyroid resection and is performed by the majority of thyroid surgeons. ¹ , ³ Since the pursuit of a more pleasing result in terms of the appearance of the patients' neck is a strong motivating factor for the refinement of these remote‐access techniques, it is necessary to compare them to the conventional cervical thyroidectomy.

The aim of this article is to review the available literature and compare the cosmetic outcomes and patient satisfaction with the cosmetic outcome in terms of the current remote‐access endoscopic approaches applied in thyroid surgery and CT.

METHODS

A review of all published studies regarding the postoperative cosmetic result of extracervical ET and CT was performed. A comprehensive research of the literature was conducted through the PubMed/Medline database up to February 2020. The following terms combined with Booleans AND/OR were applied: “thyroidectomy,” “cosmesis,” “cosmetic,” “cosmetic results,” “incision,” “scar,” “esthetic.” Only articles written in the English language and published from 2010 onwards were included, whereas reports on pediatric populations, human cadavers, or animal models, and studies with outcomes irrelevant to the point of interest were omitted. Moreover, multiple studies that involved the same cohort of patients were considered just once. Articles that reported on lymph node dissection or parathyroid surgeries as primary procedures were excluded, while studies with insufficient data on the primary subject of the present review were omitted. Other exclusion criteria were the absence of a scar assessment scale or comparison between extracervical endoscopic and computed tomography (CT). Because of the limited number of relevant randomized‐controlled trials (RCTs), prospective and retrospective uncontrolled trials were subsumed as well. Nevertheless, case reports, expert opinions, and other reviews were not used for data extraction.

Consequently, the present review was restricted to studies containing a scar assessment scale to clearly report patient satisfaction with the cosmetic outcome following an extracervical endoscopic thyroid surgery in comparison to conventional resection.

RESULTS

As the flow diagram (Figure 1) shows, a total of 1354 papers were initially identified from the PubMed/Medline database search process. The elimination of duplicates and the abstract or title‐based screening led to 479 potentially relevant articles for further full‐text evaluation. Considering the aforementioned criteria, in the final selection stage, two papers were excluded because of inefficient data on the surgical method and the scar satisfaction scale used. Another two were omitted because of the nature of the satisfaction scale that they included, which was restricted to either a negative or a positive answer. Therefore, nine studies fulfilled the eligibility criteria and were eventually selected for the review.

Figure 1.

Flowchart of the literature search and study selection process. ET, endoscopic thyroidectomy, CT, conventional thyroidectomy

A total of 1486 participants were estimated in all nine studies, 595 of whom underwent endoscopic thyroidectomy through remote‐access surgical ports and 891 were assigned to the conventional group. Among the included articles, only one was an RCT including a total of 33 patients, whereas in the rest of the studies, the patients either chose the surgical approach of their preference or they were chosen as more suitable for each technique. The satisfaction with cosmetic outcomes is assessed by the patients themselves at different time points from the first postoperative week to the first year using various predefined numerical scales. Considering the overall findings, the superiority of the endoscopic thyroid resection in terms of cosmetic outcomes was conspicuous regardless of the remote‐access surgical port.

As detailed below regarding the extracervical modifications performed in the endoscopic groups, three studies reported use of the axillary approach, four reported use of the breast approach, one study reported use of the transoral vestibular method, and another one reported use of the retroauricular facelift technique. Subsequently, the studies were divided into four subgroups, and their primary outcome measures are presented in four tables.

ET axillary approach versus CT

Three studies, including 309 patients, compared patient satisfaction concerning the cosmetic outcome between transaxillary ET (128 patients) and CT (181 patients) and proved the statistically significant ascendancy of endoscopic operation (Table 1). Even though the most recent paper of Jantharapattana et al. ¹¹ included a small number of patients, it was the only relevant RCT, while the other two were nonrandomized prospective ¹² or retrospective ¹³ and included more than twofold number of participants.

Table 1.

ET axillary approach versus CT

Author (year)	Study design	Number of patients	ET surgical approach	Scar assessment tool	Assessor	Timing of scar assessment (postop)	Satisfaction with the cosmetic outcome	P value
Jantharapattana et al. (2017)	RCT	33 (CT = 17, ET = 16)	TGET	VAS: 0–10	Patient	1 week	CT < ET	>0.05
						6 months	CT < ET	<0.05
Huang et al. (2016)	Prospective cohort	198 (CT = 123, ET = 75)	Single‐port access UAA ET with CO2 gas insufflation	UW‐QOL: 0–100	Patient	1 and 6 months	CT < ET	<0.05
				PSAQ: 9–36	Patient	1 and 6 months	CT < ET	<0.05
Lee et al. (2012)	Retrospective cohort	78 (CT = 41, ET = 37)	UAA ET with CO2 gas insufflation	NS: 1–4	Patient	6 months	CT < ET	<0.05
Tae et al. (2011)	Retrospective study	67 (CT = 36, ET = 31)	GUABA/GUAA ET	NS: 1–5	Patient	1 week, 1, 3, and 6 months	CT < ET	<0.05

Note: The bold values simplify the result of the reference papers.

Abbreviations: CT, conventional thyroidectomy; ET, endoscopic thyroidectomy; GUAA, gasless unilateral axillary approach; GUABA, gasless unilateral axillo‐breast approach; NS, Numeric Scale; PSAQ, Patient Scar Assessment Questionnaire; TGET, transaxillary gasless endoscopic thyroidectomy; UW‐QOL, University of Washington–Quality of Life questionnaire; VAS, Visual Analog Scale.

Specifically, Jantharapattana et al. ¹¹ performed the transaxillary gasless ET in 16 patients with thyroid nodules less than 4 cm in size through a 3 cm length skin incision behind the anterior axillary fold and two additional 0.5 cm incisions posterior to both ends of the first one. At 6 months, wound satisfaction was markedly higher in the ET group, despite the fact that during the early postoperative period, scar appearance was marginally better without significant differences between the two techniques.

In the study performed by Huang et al., ¹² 75 patients with papillary thyroid carcinoma smaller than 3 cm in diameter were subjected to ET using a single 2.5 cm skin incision in the anterior axillary fold with CO₂ insufflation. ¹⁴ By the end of the first month, wound satisfaction was significantly greater in the ET patients and became even higher until the sixth month.

Lee et al. ¹³ reported that 37 patients with papillary thyroid microcarcinoma (PTMC) less than 1 cm in size chose the ET, which was performed with CO₂ gas insufflation through a 3–4 cm incision in the axilla and another minor one around 0.5 cm anteriorly. Except for some cases of transient paresthesia that developed in the ET group, patients were notably satisfied with the scar appearance compared to the CT group at the 6‐month follow‐up.

ET breast approach versus CT

Four studies, which included 847 patients, compared scar cosmesis between breast approach ET (391 patients) and CT (456 patients) (Table 2). Two of them were prospective non RCTs ¹⁵ , ¹⁶ and another two ¹⁷ , ¹⁸ were retrospectively designed studies.

Table 2.

ET breast approach versus CT

Author (year)	Study design	Number of patients	ET surgical approach	Scar assessment tool	Assessor	Timing of scar assessment (postop)	Satisfaction with the Cosmetic outcome	P value
Jian et al. (2020)	Prospective nRCT	100 (CT = 50, ET = 50)	Chest–breast approach	SS: 0–10	Patient	Not specified	CT < ET	<0.05
Cao et al. (2011)	Retrospective study	637 (CT = 352, ET = 285)	Breast approach with CO2 insufflation	Satisfaction levels: 4 grades	Patient	1 month	CT < ET	<0.05
Jiang et al. (2011)	Prospective nRCT	43 (CT = 18, ET = 25)	Breast approach with CO2 insufflation	NSS: 0–10	Patient	3 months	CT < ET	<0.05

Note: The bold values simplify the result of the reference papers.

Abbreviations: CT, conventional thyroidectomy; ET, endoscopic thyroidectomy; nRCT, nonrandomized‐controlled trial; NSS, numerical score system; SS, Satisfaction Scale; UET, unilateral endoscopic thyroidectomy.

Jian et al. ¹⁵  assessed the degree of trauma and esthetic result among patients who underwent CT, endoscopic‐assisted thyroidectomy, and ET, with 50 patients in each group. Due to the objective of the present review, only the outcomes concerning ET and CT techniques were analyzed. The underlying pathology of the patients was a unilateral goiter tumor smaller than 4 cm in size. The chest–breast approach as well as the timing of the scar assessment were not clearly described, but a noteworthy finding in this study was the greater physiological trauma detected following this technique. However, this drawback did not affect the patients' satisfaction with the cosmetic outcome, which was noted to be considerably higher among the three surgical approaches.

Cao et al. ¹⁷ reported that 285 patients with benign thyroid tumors with a maximum diameter of almost 5 cm had undergone ET via the chest–breast approach with low‐pressure CO₂ insufflation. The present technique was performed through a primary presternal incision of 1.5 cm length and two secondary 0.5 cm incisions in the superior verge of both areolas. In the ET group, significantly superior cosmetic results were noted compared to the CT group in the first month postoperatively.

Jiang et al. ¹⁶ also reported the notable advantage of the ET regarding the appearance of the wound at the 3‐month follow‐up. Twenty‐five patients with thyroid nodules of various sizes were treated with breast approach ET with CO₂ insufflation through a right parasternal incision on the nipple level for the 10‐mm trocar and two smaller incisions for the 5‐mm trocars on the superior margin of both areolas. ¹⁹

Tae et al. ¹⁸ reported 31 patients with PTMC and a maximum diameter of around 1 cm who were treated with ET using a gasless unilateral axillary approach (six patients) or a gasless unilateral axillo‐breast approach (GUABA in 25 patients). A 5–6 cm skin incision was made originally in the axillary fossa in both techniques and a second 0.5 cm incision followed just inferior to the axillary incision for a 5‐mm trocar in the first approach. On the contrary, in GUABA, the second incision was located on the upper circumareolar margin of the breast. Satisfaction with the cosmetic outcome was significantly superior compared to that in the open group at all the different time‐points from postoperative 1 week to 6 months.

Transoral ET versus CT

Tae et al. ²⁰ compared retrospectively the cosmetic outcomes in a total of 307 patients between use of transoral endoscopic or robotic thyroidectomy and CT (Table 3). Transoral vestibular approach ET was completed in 29 patients with thyroid lesions less than 5 cm in diameter through a 1.5–2 cm horizontal incision at the lower lip frenulum and two lateral incisions near the oral commissure with CO₂ insufflation. Postoperative cosmesis was assessed using a questionnaire about the neck scar and the contour of the neck at the 3‐month follow‐up. In the ET group the appearance of the neck was evaluated significantly superior compared to the CT group, despite the high incidence (6%) of surgical‐site infection in transoral thyroidectomy. Tae et al. ²⁰ reported that surgical‐site infection was mild in all patients and could be treated successfully with antibiotics and aspiration.

Table 3.

ET transoral approach versus CT

Author (year)	Study design	Number of patients	ET surgical approach	Scar assessment tool	Assessor	Timing of scar assessment (postop)	Satisfaction with the cosmetic outcome	P value
Tae et al. (2020)	Retrospective nRCT	236 (CT = 207, ET = 29)	Transoral approach with CO2 insufflation	VRS: 0–4	Patient	3 months	CT < ET	<0.05

Note: The bold values simplify the result of the reference papers.

Abbreviations: CT, conventional thyroidectomy; ET, endoscopic thyroidectomy; nRCT, nonrandomized‐controlled trial; VRS, Verbal Response Scale.

Retroauricular ET versus CT

One study ²¹ of 94 patients was published in Korea and evaluated the esthetic results of ET via a retroauricular approach against CT (Table 4). Chung et al. ²¹ reported that 47 patients with thyroid lesion less than 4 cm in diameter underwent ET, which was performed through a single skin incision located behind the earlobe near the postauricular crease and extending into the occipital hairline. A 4‐point Visual Analog Scale was used to self‐evaluate the appearance of the wound at various time points. At the first week of follow‐up, scar appearance was marginally better in the ET group, although this difference was not statistically significant. From postoperative 1 month to 1 year, cosmetic satisfaction increased steadily over time in the ET patients and presented eventually a significant dominance over the open thyroidectomy.

Table 4.

ET retroauricular approach versus CT

Author (year)	Study design	Number of patients	ET surgical approach	Scar assessment tool	Assessor	Timing of scar assessment (postop)	Satisfaction with the cosmetic outcome	P value
Chung et al. (2015)	Prospective cohort	94 (CT = 47, ET = 47)	Retroauricular approach	VAS: 0–3	Patient	1 week	CT < ET	>0.05
						1, 3, 6 months, and 1 year	CT < ET	<0.05

Note: The bold values simplify the result of the reference papers.

Abbreviations: CT, conventional thyroidectomy; ET, endoscopic thyroidectomy; VAS, Visual Analog Scale.

DISCUSSION

The present paper represents a narrative review of comparative studies published since 2010 aiming to compare the cosmetic outcomes between the use of extracervical endoscopic and CT. The superiority of the esthetic appearance of the neck and the high patient satisfaction with the cosmetic outcome after remote‐access techniques were demonstrated clearly by the current study; likewise, this finding has been reported in previous reviews in the literature. ¹ , ⁴ , ²² , ²³ , ²⁴

CT through a skin‐crease incision in the lower anterior neck has been established as the gold standard technique for thyroid resection and throughout all these years, a variety of skin closure techniques have become available and have been widely utilized. ¹ , ³ , ¹⁷ Mahalingam et al. ³ reported that subcuticular sutures ensured better cosmesis as opposed to clips and tissue adhesives, at least in the short term.

However, the standard anterior neck cervicotomy resulted in a horizontal incision above the sternal notch, which, regardless of the severity or the length of the scar, was located in an exposed and prominent position and therefore was an issue of major concern to the patients after the thyroid surgery. Some scars are camouflaged well with the skin crease and provide an acceptable cosmetic outcome, while others may heal with hypertrophy or keloid formation and affect the patients' postoperative quality of life even further, leaving a permanent defect. ¹ , ¹⁵ , ²⁰ , ²⁴ , ²⁵ , ²⁶

The emergence of endoscopic neck surgery has enabled the resection of the thyroid gland from a remote site incision, where the scar can be hidden with regular clothing or even when the arm is in the neutral position. Because of the high incidence of thyroid diseases in young people and especially in female patients, the cosmetic requirements increased and the option of a scarless outcome in the neck was more frequently preferred. ⁴ , ¹⁵ , ¹⁸ , ²⁰ , ²⁵

This inference was strongly stated by the notably greater satisfaction with the cosmetic outcome accomplished after transoral, transaxillary, and postauricular thyroidectomy compared to the conventional method. ²⁷ , ²⁸ Lee et al. ²⁷ reported slight superiority of the transoral and transaxillary approaches over the postauricular facelift technique; however, no statistically significant differences were detected.

Furthermore, use of endoscopic instruments has led to overcoming of the limited visualization provided by smaller incisions and the restricted workspace of the cervical area using focused illumination and magnification. Further application of robotic technology aims to facilitate surgeons' manipulations and refine these remote‐access approaches. ¹ , ⁴ , ²⁴ The disadvantages of the high cost and long learning curve that accompany these technical alternatives represent barriers that still need to be conquered. ²⁰ , ²⁵  On the contrary, these extracervical remote techniques were considered to be more invasive than direct cervical thyroidectomy due to the extensive dissection required to reach the thyroid gland. The operating space was then maintained by either CO₂ insufflation or external retraction by specially designed flap retractors. In the case of CO₂ insufflation, two related complications were reported, namely, CO₂ embolism and subcutaneous emphysema. Therefore, the operative time as well as the CO₂ insufflation pressure should be reduced to limit the incidence of corresponding adverse events. ²⁰

The incision translocation during ET may result in prolongation of the operating time and greater postoperative pain. Moreover, the broad subcutaneous dissection might result in several postoperative complications such as mild hypesthesia, paresthesia, hematoma, and seroma in the cervical region and slight discomfort while swallowing, although the respective incidence rates were almost comparable to those with the use of CT. ¹ , ⁴ , ¹⁸ , ²³ , ²⁴ Jiang et al. ¹⁶ reported that the trauma induced by the wide dissection of the skin flaps to the anterior neck did not exacerbate the inflammatory response and no functional defect developed on the anterior neck. Consequently, this feature did not necessarily constitute a disadvantage of the remote‐access techniques. Further improvements in the surgical instruments used and more experience would significantly decrease the operating time and the incidence of postoperative complications of ET. ⁴ , ¹⁶ , ²⁴

From the viewpoint of surgeons, the most important parameter in evaluating and adopting a new surgical technique is its safety. ²⁰ Although studies have shown that both conventional and remote‐access thyroidectomy may result in postoperative adverse events, including bleeding, recurrent laryngeal nerve palsy, hypocalcemia, hypoparathyroidism, hematoma, and seroma, however, a higher incidence of surgical‐site infection, skin burn, or CO₂‐related complications was correlated with the endoscopic or robotic approach. ²⁰ , ²⁴

Therefore, besides the expectations in terms of the cosmetic outcome and patients' preferences, additional factors such as age, sex, clinicopathologic characteristics, and oncological safety have to be considered to provide patients with the most accurate and suitable surgical approach. Strict patient selection and recognition of the possibility of unusual complications in combination with growing experience are important for the safety of patients and the success of the surgery. ¹⁵ , ²⁰ , ²⁴

Despite our findings, this study had several limitations. First, only one RCT ¹¹ fulfilled the inclusion criteria and was considered suitable for data extraction, whereas the rest of the eight cohorts were prospective or retrospective nonrandomized. Additionally, available data were only narratively reported together with crucial data and no statistical analysis was conducted.

Another restriction was the difficulty of evaluating patient satisfaction, given the fact that all the included studies were based on the subjective judgment of the patient and not on an objective assessment index, while the majority of them did not use a validated scar assessment tool. Dordea et al. ²⁶ reported that scar assessment tools should include not only objective physical features of the scar, scar esthetics, and symptoms but also a measurement of the sensation and satisfaction of the patient. Appearance alone was not considered the principal factor that affected patient satisfaction.

Last but not the least, only one study ²¹ assessed satisfaction with the cosmetic outcome at various time points until the first year postsurgery, while in the rest, the latest evaluation took place at the 6‐month follow‐up, an interval that corresponded to the early stages of scar maturation. Considering the finding that healing and remodeling are completed mainly by 8–12 months and scar esthetics continue to improve with time, the ideal duration of the follow‐up for assessment of the appearance of a surgical incision and patient satisfaction should have been at least 1 year postoperatively. ¹¹

CONCLUSION

In conclusion, use of extracervical ET led to a scarless appearance of the neck and was found to be superior to the conventional approach in terms of cosmetic outcome and patient satisfaction. With growing experience and use of newer surgical instruments, ET could offer more benefits and satisfy the high esthetic requirements of patients with thyroid pathology. In the meantime, minimally invasive nonendoscopic thyroidectomy could be proposed since the results obtained with this technique are similar to those obtained with open thyroidectomy, with the major advantage of a minimal neck wound and shorter hospital stay. ²⁹

AUTHOR CONTRIBUTIONS

Anna Kasouli evaluated and wrote the paper. All authors contributed to manuscript revisions and approved the final version of the manuscript.

CONFLICTS OF INTEREST

The authors declare that there are no conflicts of interest.

ETHICS STATEMENT

This material is the authors' own original work, which has not been published elsewhere. The paper is not currently being considered for publication elsewhere. The paper reflects the authors' own research and analysis in a truthful and complete manner.

Kasouli A, Spartalis E, Giannakodimos A, Tsourouflis G, Dimitroulis D, Nikiteas NI. Comparison of cosmetic outcomes between remote‐access and conventional thyroidectomy: a review of the current literature. World J Otorhinolaryngol Head Neck Surg. 2023;9:1‐8. 10.1002/wjo2.65

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available in the PubMed/Medline database.