Single-Port Hairline Approach Thyroidectomy in Male Patients: A Retrospective Analysis of Cosmetic and Surgical Outcomes

Abstract

Objectives

Although concerns regarding visible scars have traditionally been associated with female patients, male patients are increasingly placing value on cosmetic outcomes in surgical procedures. Single-port robotic thyroidectomy utilizing a hairline approach has proven feasible in female patients. This study aims to evaluate the safety, utility, and cosmetic results of single-port hairline approach thyroidectomy (SPHAT), with a focus on minimizing visible scarring in male patients.

Methods

Thirty-one male patients underwent SPHAT performed by a single surgeon between February 2020 and February 2024. We analyzed operative time, complication rates, pain scores (numeric rating scale [NRS]), and cosmetic outcomes in these male patients.

Results

Among the cases, 27 were diagnosed with papillary thyroid carcinoma, 1 with follicular thyroid carcinoma, 2 with non-invasive follicular neoplasms exhibiting papillary-like nuclear features, and 1 with follicular adenoma. The median age of patients was 62 years (range, 34–73 years). Hemithyroidectomy was conducted in 28 cases and total thyroidectomy in 3 cases. Central neck dissection was performed in 26 cases. The median total operative time was 89 minutes (range, 55–160 minutes), with a median console time of 49 minutes (range, 26–125 minutes). All patients were discharged without major complications on the second or third postoperative day. Postoperative pain NRS scores were 3.71±1.56 on the day of surgery and 2.86±0.35 on the first postoperative day. Six months after surgery, the mean cosmetic satisfaction score on a visual analog scale was 8.51±1.62.

Conclusion

SPHAT is a viable and safe approach for male patients, offering excellent cosmetic results.

INTRODUCTION

Concerns regarding postoperative appearance have driven the advancement of robotic thyroidectomy techniques over the past two decades [1-3]. Robotic surgery for thyroid cancer and other thyroid neoplasms is now commonly performed using a variety of minimally invasive approaches, including the transaxillary, bilateral axillo-breast approach, transoral, and retroauricular methods [1-3]. The recent introduction of single-port (SP) robotic systems (Intuitive Surgical) addresses technical difficulties encountered in operating within smaller anatomical spaces [4]. As surgeons gain experience, their proficiency in robotic thyroidectomy continues to improve. Nevertheless, the specific indications and contraindications for robotic thyroidectomy remain to be fully established, and technically challenging cases can result in longer operative times and increased risk of complications [5-7]. Therefore, identifying factors that contribute to prolonged operative time may offer valuable guidance for optimizing patient selection in robotic thyroidectomy. At our institution, we exclude patients from robotic thyroidectomy if they have (1) recurrent thyroid tumors, (2) thyroid carcinomas with clear invasion of vital structures such as the trachea or esophagus on preoperative imaging, or (3) Graves’ disease [8].

An increasing number of male patients are seeking robotic thyroidectomy to minimize visible scars. Previous studies examining operative time with the bilateral axillo-breast approach have identified male sex as a predictor of longer surgery duration; however, these findings were based on limited samples of male patients [9]. It is noteworthy that, in these complex cases, the incidence of other postoperative complications does not necessarily exceed that observed in less technically demanding procedures. In male patients, flap creation typically requires more time, and the limited range of motion of robotic arms is further constrained by increased skin and sternocleidomastoid muscle (SCM) thickness [9]. Despite these challenges, the literature contains very few studies evaluating the efficacy of robotic surgical approaches specifically in male patients [1].

Our institution is actively developing safe and practical techniques for single-port hairline approach thyroidectomy (SPHAT), which enables access to deep, narrow anatomical regions through a small incision concealed along the hairline. We have previously demonstrated that SPHAT is technically safe and feasible for female patients [8]. Given the limited data on robotic thyroidectomy in male patients, we evaluated the feasibility and safety of SPHAT specifically in the male population.

MATERIALS AND METHODS

This study was conducted with approval from the Institutional Review Board of Ulsan University Hospital (No. 2021-09-010). The need for informed consent was waived due to the study’s retrospective design. The photograph of the patient in Fig. 1 was published with the consent of publication.

Fig. 1.

Docking after flap elevation and closure. (A) Design for hairline incision. (B) Retraction for the working space using a Koh retractor. (C) Skin closure with skin bond. (D) Invisible scar at 6 months after single-port hairline approach thyroidectomy in male patients.

Patients

Between February 2020 and February 2024, a total of 220 patients underwent robotic thyroidectomy using the da Vinci SP robotic system through a hairline incision. This study is a retrospective, single-surgeon cohort analysis focusing on 31 male patients among the 220 individuals who underwent the SPHAT procedure utilizing with electromyography monitoring. One patient required completion thyroidectomy 2 years after the initial hemithyroidectomy due to the detection of a new lesion in the contralateral lobe. Vocal cord function was assessed preoperatively and postoperatively using flexible laryngoscopy in all cases.

The inclusion criteria for SPHAT were: (1) benign surgical lesions, such as benign tumors, or (2) thyroid carcinomas largely confined within the gland. Exclusion criteria included: (1) recurrent thyroid tumors; (2) thyroid carcinoma with clear extrathyroidal extension or invasion of vital structures like the trachea or esophagus, as indicated by preoperative imaging; and (3) Graves’ disease.

Preoperative diagnoses included papillary thyroid cancer in 26 cases and follicular neoplasm in five cases. All thyroid nodules were diagnosed through ultrasonography-guided fine-needle aspiration or core needle biopsy. Preoperative clinical staging and the extent of surgery were determined via ultrasonography and neck and chest computed tomography.

Operative procedure and technique

For surgical preparation, we adhered to the general principles of preparation and dissection described by outlined in our prior study (Fig. 1A) [8]. During the creation of the skin-subplatysmal flap, the anterior border of the SCM muscle was completely mobilized down to the clavicle, ensuring the preservation of the greater auricular nerve. The external jugular vein was carefully identified and preserved on the surface of the SCM muscle. A small-sized Chung’s or Koh’s retractor was introduced between the subcutaneous layer and the strap muscles to elevate the subcutaneous flap and maintain the working space. An additional fixed retractor was used to retract the flap inferiorly (Fig. 1B) [8].

After docking the robotic system, the optimal location and view were set in cobra mode using two Maryland forceps and one monoscissor. In male patients with thick skin or dense tissue, additional flap elevation was performed post-docking with Maryland forceps and monoscissors to separate the space between the SCM and strap muscles (Fig. 2A). The omohyoid muscle was identified and retracted ventrally or dorsally (Fig. 2B), exposing the sternohyoid and sternothyroid muscles, as well as the ipsilateral thyroid gland (Fig. 2C). Usually, in total thyroidectomy, the omohyoid muscle is retracted dorsally to facilitate better visibility for performing contralateral thyroid surgery.

Fig. 2.

Operative procedure. (A) Further flap elevation after docking around the strap muscle and the sternocleidomastoid muscle. (B) Elevation and traction of the strap muscle. (C) Exposure of the right thyroid and isthmus (arrow: right thyroid with thyroiditis). (D) Ligation of the right superior thyroid artery and preservation of the superior parathyroid gland at the superolateral aspect. (E) Identifying and exposing the recurrent laryngeal nerve (RLN; arrow) and dissection and detachment of Berry’s ligament with preservation of the RLN. (F) Resection of the isthmus in right hemithyroidectomy and central neck dissection (arrow: right central lymph nodes).

In SPHAT, all vessels were cauterized using Maryland forceps and cut with monopolar scissors. The robotic resection commenced with cauterizing the superior thyroid arterial pedicles using Maryland bipolar forceps (Fig. 2A). The upper pole of the thyroid gland was lifted ventrally and separated from the cricopharyngeal and cricothyroid muscles while preserving the external branch of the superior laryngeal nerve (Fig. 2D). The superior parathyroid gland was carefully dissected from the posterior surface of the thyroid gland and left intact (Fig. 2D). At this stage, the Maryland forceps were transferred from the left to the right arm for easier handling, and the middle pole of the thyroid gland was elevated superiorly and medially using the second arm of the Maryland forceps. The perithyroidal tissues were dissected to expose the recurrent laryngeal nerve (RLN) (Fig. 2E) using the second arm Maryland forceps. The inferior thyroid artery was coagulated and divided close to the thyroid gland with Maryland bipolar forceps to prevent injury to the branches supplying the inferior parathyroid gland. The course of the RLN was traced using Maryland bipolar forceps (Fig. 2E), dissecting along its path both superiorly and inferiorly to separate it from the thyroid gland. The Berry’s ligament was divided using monopolar scissors (Fig. 2F). During hemithyroidectomy, the isthmus was transected. For total thyroidectomy, the direction of dissection for the contralateral hemithyroidectomy proceeded from medial to lateral, opposite to the approach for ipsilateral hemithyroidectomy as described in a previous study [8]. Central compartment lymph nodes located between the hyoid bone superiorly and the innominate artery inferiorly were removed. Intraoperative monitoring ensured the integrity and functionality of the RLN, with amplitude assessments performed before and after RLN dissection. A closed suction drain was placed through the incision site, and the wound was closed in layers using subcutaneous sutures and skin bond (Fig. 1C). Fig. 1D showed the invisible scar at the 6 months after single port hairline approach thyroidectomy in male patients.

Statistical analysis

Clinical and pathological characteristics, operation data, and complications were collected from our institutional database. All statistical analyses were conducted using IBM SPSS Statistics for Windows version 25.0 (IBM Corp.), with statistical significance set at P<0.05.

RESULTS

Baseline clinical characteristics

Table 1 summarizes the baseline clinical characteristics of male patients who underwent SPHAT. The median age was 62 years (range, 34–73 years), and the median body mass index (BMI) was 25.76 kg/m² (range, 20.02–32.10 kg/m²). The median tumor size was 8 mm (range, 4–50 mm). Hemithyroidectomy was performed in 28 cases, including one patient who underwent a right hemithyroidectomy for a new papillary thyroid carcinoma (PTC) in the right lobe after having left hemithyroidectomy 2 years earlier. Total thyroidectomy was performed in three patients with bilateral cancer. Central neck dissection was carried out prophylactically in 26 cases. The mean number of harvested lymph nodes was 3.2±1.2 (range, 1–6), and micrometastatic (size <3 mm) lymph node involvement was found in eight patients. Seven patients had multiple PTCs (including three cases of bilaterality), and micro-extrathyroidal extension was observed in nine patients.

Table 1.

Baseline clinical characteristics of male patients who underwent single-port hairline approach thyroidectomy

Variable	Value
Age (yr)	62 (34–73)
Male sex	31
BMI (kg/m2)	25.76 (20.02–32.10)
Tumor location
Right	18
Left	10
Both	3
Surgical extent
Hemithyroidectomy	28
Total thyroidectomy	3
CND (yes:no)	26:5
Median tumor size (mm)	8 (4–50)
Central lymph node metastasis (yes:no)	8:23
Pathological diagnosis
Papillary thyroid cancer	27
NIFTP	2
Follicular thyroid cancer	1
Follicular adenoma	1
Extrathyroidal extension (no:minimal:gross)	20:9:2
Extratnodal extension (yes:no)	2:29
Surgery time (min)
Flap time	30 (8–54)
Console time	49 (26–125)
Total operative time	89 (55–160)

Values are presented as median age (range) or number.

BMI, body mass index; CND, central neck dissection; NIFTP, non-invasive follicular neoplasm with papillary-like nuclear features.

Operation time

The median total operative time was 89 minutes (range, 55–160 minutes), with a median console time of 49 minutes (range, 26–125 minutes). For hemithyroidectomy, the mean operative time was 87.85±22.25 minutes, and the mean console time was 52.21±18.88 minutes. For total thyroidectomy, the mean operative time was 118.67±36.90 minutes, and the mean console time was 86.36±37.07 minutes.

Postoperative results

All patients were discharged on the second or third postoperative day without experiencing major complications such as bleeding or the need for reoperation. One patient developed a tracheal micro-perforation at Berry’s ligament 1 week after surgery, which was successfully managed with compression dressing and conservative measures, resulting in complete tracheal healing without infection. No cases of RLN palsy or hyperparathyroidism were observed. Paresthesia in the cutaneous area was reported by 20 patients, but resolved spontaneously within 1 to 3 months. The mean follow-up duration was 18.6 months (range, 6–38 months). One patient who had previously undergone left hemithyroidectomy required a right hemithyroidectomy for a new PTC 2 years later.

The average numeric rating scale (NRS) scores for postoperative pain, using a 0–10 scale (0=“no pain”, 10=“worst pain imaginable”), were 3.71±1.56 on the day of surgery and 2.86±0.35 on the first postoperative day. At 6 months after surgery, cosmetic satisfaction, assessed using a patient-reported visual analog scale ranging from 0 (very dissatisfied) to 10 (very satisfied), had a mean score of 8.51±1.62. Satisfaction with neck scarring and contour, evaluated on a 1–5 scale (very dissatisfied to very satisfied), had mean scores of 4.12±0.

DISCUSSION

This study demonstrates the feasibility, safety, and effectiveness of SPHAT in male patients. To our knowledge, increased skin thickness and muscle density in male patients can impede flap creation and limit robotic arm mobility, thereby prolonging surgery [7]. Therefore, the surgeon may require more operative time, and patients may face complications during or after surgery, as well as challenges such as postoperative scarring due to extended flap traction. In comparison to a previous study that included female patients undergoing SPHAT by a single surgeon from February 2020 to April 2021, the overall mean operative time reported was 140.2±50.7 minutes, with a mean console time of 74.0±42.7 minutes [8]. In the present study, which included male patients operated on between February 2020 and February 2024, the median operative time was 89 minutes, and the mean console time was 49 minutes. Song et al. [5] also demonstrated that male sex and BMI ≥23 kg/m² are independent risk factors for longer operative times in robotic thyroidectomy. These findings suggest that anatomical challenges specific to male patients may require adaptations in surgical technique or preoperative planning to optimize procedural efficiency.

Our study’s intraoperative and postoperative results align with existing literature that supports the safety of robotic thyroidectomy. No significant intraoperative complications or prolonged hospital stays were observed, consistent with earlier studies [10-12]. These studies emphasize that the incidence of complications such as RLN injury or hypocalcemia is not significantly higher with robotic approaches compared to open or endoscopic methods. This further reinforces the viability of SPHAT as a safe option, even for male patients who present additional technical challenges.

Similar to previous studies utilizing a hairline incision for endoscopic surgery and reporting favorable cosmetic outcomes [13], our study also found high cosmetic satisfaction scores. The hairline incision used in SPHAT creates a surgical field similar to that of the retroauricular incision described by Lee et al. [14] in their 2016 study on endoscopic thyroidectomy, but SPHAT offers a narrower field width, making the approach even less invasive. Furthermore, the cosmetic outcome is superior due to the absence of the horizontal segment required in the retroauricular incision. Blanco et al. [15] reported that robotic-assisted neck dissection with a pre- and post-auricular hairline incision is technically feasible, safe, and yields good cosmetic results for thyroid cancer involving the lateral and central neck compartments. In contrast, SPHAT provides an adequate surgical field without requiring a preauricular incision. These observations suggest that the use of a hairline incision in SP robotic thyroidectomy can offer significant cosmetic benefits and improve quality of life by producing an invisible scar.

Despite anatomical challenges such as thicker skin and more robust soft tissues in male patients, the procedure resulted in excellent surgical outcomes, minimal complications, and high cosmetic satisfaction. This study highlights the potential of SPHAT to address the unique surgical needs of male patients while preserving the advantages of minimal invasiveness and high aesthetic satisfaction. The increased operative time remains clinically tolerable and can be managed through surgical expertise and tailored techniques. These findings add to the growing body of evidence supporting robotic approaches as versatile, patient-centric options for thyroid surgery in male patients.

A limitation of this study is the absence of a direct comparison of operative time, complication rate, pain score (NRS), and cosmetic results between male and female patients when the same surgeon performed the procedure during the same study period. Future research should aim to objectively compare outcomes between male and female patients. Additionally, further studies could investigate specific modifications to the SP robotic technique to overcome operative challenges in male patients.

Despite anatomical challenges such as thicker skin and more robust soft tissues in male patients, SPHAT produced excellent surgical outcomes, minimal complications, and high cosmetic satisfaction. The observed difference in total operative time was clinically acceptable, indicating that these challenges can be effectively managed through surgical expertise. As this technique was first adopted in female patients and subsequently extended to male patients, the safe and effective implementation in both groups reflects the surgeon’s skill and mastery of the procedure.

HIGHLIGHTS

▪ Single-port hairline approach thyroidectomy is a viable and safe option for male patients, delivering excellent cosmetic outcomes.

▪ The difference in total operative time was clinically tolerable, indicating that surgeons with sufficient expertise can manage these challenges effectively.

▪ SPHAT provided high cosmetic satisfaction, effectively minimizing visible scars in male patients.