Cosmetic Inframandibular Hyoid-Level Incision, Ligatureless Thyroidectomy with Neck Lift: an Original Technique

Introduction

Most of our patients present late with large goitres that are not suitable for endoscopic thyroidectomy. The neck usually has 3 skin creases on the anterior aspect. The first and highest skin crease is at the level of the hyoid cartilage. The second is at the level of the cricoid cartilage. The classical Kocher’s incision is in the lowest skin crease and the scar is often visible as our people do not cover their neck due to hot weather. It is also prone to keloid formation. The scar of an incision in the second neck skin crease often straddles the thyroid cartilage prominence and is thus visible. Hence, an alternate high neck incision at the level of the hyoid was tried as this is a flexural area and is in the shadow of the face and chin and not seen. Addition of neck lift provides better cosmetic results than endoscopic thyroidectomy and surgery through incisions in second or third neck skin crease incisions. Radical neck dissection is difficult through this incision; hence, apron or hemi-apron incision is preferred by the author. This approach is not suitable for extended resection or if sternotomy is required. In patients with previous thyroid surgery, the old surgical scar is used.

Materials and Method

A preliminary study of skin creases of the anterior neck of the patient is done. For total or hemithyroidectomy, an incision is made at the level of the hyoid in the uppermost skin crease in the anterior aspect of the neck. Its size (5 to 10 cm) depends on the size of the goitre. The largest goitre weighed 775 g. No skin flap is raised thus avoiding postop anaesthesia or paraesthesia. Investing layer of the deep fascia is cut in the midline to increase the exposure. Strap muscles are retracted or cut with ultrasonic shears. The pyramidal lobe and the right or left upper pole of the thyroid are dissected first, using ultrasonic shears even for sealing the vessels, preserving the external branch of the superior laryngeal nerve (EBSLN), followed by division of the isthmus when uninvolved. The lobe is mobilized with identification of both parathyroids and the recurrent laryngeal nerve (RLN) at its entry into the larynx. Nerve monitoring is being used in recent years. Parathyroid autofluorescence has not been used yet to check vascularity of parathyroids as we have not yet acquired the fluorescence imaging device. The RLN, parathyroids, and their vascularity are preserved. The lower pole and any extension including any sub-manubrium-sternal extension are finally dissected using mild traction on the lobe. The other lobe is similarly dissected in an antegrade sequence. A flat suction drain is routinely used. For large goitres and those with lax neck skin, a classical neck lift is done by tightening the deep fascia in the midline and removing excess skin along incision margins during closure. Closure is completed in four layers—strap muscles, fascia, subcutaneous, subcuticular—with a 3-0 absorbable (poliglecaprone) suture with a cutting needle.

Results

In total, 340 total thyroidectomies (most of them large goitres, benign and malignant) have been performed by this technique over the past 12 years and the cosmetic and functional results have been excellent (less than 1% incidence of temporary vocal cord palsy), right pneumothorax in one patient, and residual thyroid needing re-exploration in only one patient. These have been the only complications. On postoperative radioactive iodine scan, minimal or no residual thyroid tissue is found suggesting complete or near complete removal is possible through this approach. Immediate and late follow-up photo images of the neck are available and show the excellent cosmetic results (Fig. 1). PTH and thyroglobulin levels are routinely checked before and after surgery to monitor safety and adequacy respectively of the procedure. Vocal cords are routinely checked by laryngoscopy before surgery. Any voice change after surgery is checked by laryngoscopy.

Fig. 1.

Thyroidectomy scar hidden in neck crease

Conclusion

The scar is so well hidden that it is virtually a scarless surgery (Fig. 1). It is safe and minimal or no residual tissue is left as per postoperative radioactive iodine scan and thyroglobulin estimates. Patients and relatives are surprised how their large goitres have been removed without visible scar and with a tightened neck and have been referring many patients for surgery by this technique. Two patients have even complained that they have received no sympathy as no one believes they have undergone thyroid surgery. It provides a complete single-piece specimen to the pathologist unlike in endoscopic surgery where large specimens are cut up.