Cosmesis and Body Image after Minimally Invasiveor Open Thyroid Surgery

Therezia Bokor • Erhard Kiffner • Bibiana Kotrikova •

Franck Billmann

Published online: 10 March 2012

� Societe Internationale de Chirurgie 2012

Abstract

Background Minimally invasive techniques, such as

laparoscopic appendectomy or minimally invasive thyroid

surgery, are thought to produce better cosmetic results.

However, cosmesis in thyroid surgery was rarely investi-

gated using a standardized approach. The objectives of this

study were to evaluate body image and cosmesis in patients

who had either minimally invasive (MI) or conventional

open (CO) thyroid surgery.

Methods Two hundred fifty patients of 540 participated

(46.3 %): 50 patients (20.0 %) had MI thyroid surgery and

200 (80.0 %) had CO thyroid surgery. The patients filled

out a body image questionnaire that investigated body

image, cosmesis, and self-confidence. SPSS 19.0 software

was used for statistical analysis.

Results Although the mean incision size was significantly

shorter in the MI group than in the CO group (2.8 vs.

3.5 cm), the mean scores from the body image question-

naire (body image score, cosmetic score, and self-confi-

dence score) were similar for both groups (p [ 0.05). No

significant differences in postoperative complications were

observed in these groups (p [ 0.05).

Conclusions Studies in the literature that evaluate body

image and cosmesis in thyroid surgery using standardized

methods are scarce. In our department, the results of a

questionnaire showed that the MI approach has no advan-

tage for body image and cosmesis over the CO approach.

Further prospective randomized studies using different

tools with a larger sample size are needed to investigate the

use of MI procedures for thyroid surgery.

Introduction

Most patients with thyroid disease could be effectively

treated surgically by experienced endocrine surgeons.

Although thyroid surgery can lead to postoperative dis-

comfort, with pain and paresthesia [1–3], it has few com-

plications. As a result, many patients undergoing thyroid

surgery are concerned about the postoperative cosmetic

appearance of the neck. Thus, in recent years, there has

been a surge of interest in developing alternative surgical

approaches to the thyroid gland with a focus on cosmesis.

A recent study documented 20 different (open or minimally

invasive) approaches to the thyroid [4, 5]. Most of the

minimally invasive approaches can be categorized as either

completely endoscopic or endoscopy-assisted approaches.

Surgical incisions vary from small cervical incisions to

larger incisions at distant access sites (e.g., axilla or breast).

Beyond cosmesis, and according to the literature, mini-

mally invasive approaches are thought to reduce the

operative trauma for the patient [6–8]. However, exces-

sively reducing the incision length for thyroid surgery in

order to improve cosmesis may increase the likelihood of

complications [7].

Little is known about the subjective feelings and cos-

metic consequences of scarring in patients who undergo

either conventional open (CO) or minimally invasive (MI)

thyroid surgery. Surgeons assume that MI approaches yield

better cosmesis due to smaller scars. However, studies

rarely investigate the point of view of the patient. Those

that have dealt with a small number of patients or were

T. Bokor � E. Kiffner � F. Billmann (&)

Department of Abdominal, Endocrine and Vascular Surgery,

St. Vincentius Kliniken, Sudendstraße 32, 76137 Karlsruhe,

Germany

e-mail: franck.billmann@wanadoo.fr

B. Kotrikova

MKG Klinik, Sophienstraße 4, 76530 Baden, Germany

123

World J Surg (2012) 36:1279–1285

DOI 10.1007/s00268-012-1563-7

lacking a standardized way to evaluate cosmesis. Body

image is defined as a person’s perception of, satisfaction

with, and attitudes toward his or her body. Body image

questionnaires (with a body image score and a cosmetic

score) are widely used with cancer patients, particularly

after damaging operations such as mastectomy [9–11] or in

affections like Crohn’s disease [12], as a standardized way

to evaluate the cosmetic result of an operation in the

patient’s point of view.

We theorized that (1) shorter scars do not necessarily

improve a patient’s satisfaction, and (2) CO procedures

could have the same outcome when compared to MI pro-

cedures in terms of cosmesis, body image, and self-confi-

dence. In order to test this hypothesis, this study evaluated

cosmetic results and body image in surgically treated

patients with thyroid pathologies using a standardized

method (body image questionnaire). This enabled us to

measure the patient’s cosmetic satisfaction and to put it

into balance with the clinical and surgical outcomes of both

types of approach.

Patients and methods

Patients

Patients were recruited using the records of the Department

of Abdominal, Endocrine and Vascular Surgery of the St.

Vincentius Kliniken (Karlsruhe, Germany). Our study ran

from January 2010 to October 2010. Patients were included

if they had a thyroid pathology. All patients were told

about the operative approaches proposed in our depart-

ment. Patients with a thyroid volume exceeding 35 ml were

operated with the CO approach, and patients with a thyroid

volume 35 ml or less could choose between the CO and MI

approaches. Exclusion criteria ruled out patients with

malignancy, thyroiditis, prior vocal fold paralysis, or lar-

yngeal disease requiring therapy. The extent of thyroid

resection was determined for each patient using the

American Thyroid Association guidelines [13].

Methods

On the day of the clinic visit, patients were asked to fill out

our body image questionnaire (German version) before the

surgical procedure (item 8 alone) and 6 months after the

procedure (the complete questionnaire without item 8). All

intraoperative and postoperative complications were

recorded and analyzed for each group of patients (CO and

MI).

Surgical techniques

The surgical techniques for CO and MI procedures were

precisely defined using the guidelines of the ‘‘Deutsche

Gesellschaft fur Allgemein- und Viszeralchirurgie’’

(German Society for General and Visceral Surgery) and

the ‘‘Chirurgische Arbeitsgemeinschaft Endokrinologie’’

(Surgical Working Group Endocrinology) (Table 1). These

standardized procedures are used by all the surgeons in our

department. The CO approach used a modified Kocher

incision; the MI approach used the MIVAT technique. In

our department, the following technical characteristics

were introduced, before this study was started, in order to

improve the CO approach: (1) mark the incision site with

the patient in the supine and sitting positions before the

operation, (2) make the incision in skin wrinkles, (3) pro-

tect the skin during the procedure, (4) excise traumatized

skin at the end of the procedure, (5) use intracutaneous

suture, and (6) use silicone plaster or silicone gel

postoperatively.

Table 1 Summary of the German guidelines edited by the AWMF, DGAV, and CAEK for the surgical procedure in thyroid surgery, translated

from the German language

E10 Nervus laryngeus recurrens and Nervus laryngeus superior

The operation should be performed with gentle preparation of the Nervus laryngeus recurrens. That means that the vascular supply of the

nerve has to be maintained. The visualized nerve has to be tested by neuromonitoring before and after thyroid resection.

In order to avoid dysphonia the surgeon should preserve the Ramus externus of the superior laryngeal nerve. Thus, the upper pole vessels

should be divided just above the upper pole of thyroid gland.

E11 Preparation of the parathyroid glands

For the case of thyroid resections in which parathyroid glands could be injured, particular attention should be put on finding these glands in

order to preserve their functional integrity by preserving their vascularisation in situ. If this vascularisation is compromised, or if a

parathyroid gland is accidentally resected, this gland should be cut up and autotransplanted in the neck musculature.

E12 Frozen section examinations

If there is a preoperative suspicion of malignant thyroid tumor, a frozen section should be performed pre- and intraoperatively. If this is not

possible, the patient should be informed preoperatively of the possibility of a secondary completing procedure.

E13 Minimally invasive techniques

For minimally invasive techniques one should apply the same basic rules than those used for conventional open procedures.

1280 World J Surg (2012) 36:1279–1285

123

Clinical and surgical outcomes

Surgical outcomes include operating time, intraoperative

blood loss, length of hospital stay, and postoperative

complications (transient hypocalcemia, transient hoarse-

ness, laryngeal nerve palsy, hematoma, seroma). Operating

time was defined as the interval from skin incision to

closure. Mobility of vocal cords was assessed by video-

strobolaryngoscopic examination performed 1 day before

the operation and 6 months after the operation, if neces-

sary. Vocal cord palsy was defined as permanent when no

evidence of recovery was observed after 6 months.

Body image questionnaire

The body image questionnaire (Table 2) is a standardized

instrument validated in studies that investigated cosmesis

in patients with breast cancer or Crohn’s disease and

ulcerative colitis [9–11, 14, 15]. The questionnaire consists

of three parts (9 items): (1) a body image score after sur-

gery, (2) a cosmetic score after surgery, and (3) a self-

confidence score before and after surgery. To assess the

effect of the surgical procedure (CO or MI) on body image

and cosmetic scores within gender, this study analyzed the

male and female patients separately.

Scar length

A photograph of the neck of every patient was taken on the first

postoperative day and 6 months after the surgical procedure

(Fig. 1). The scar was measured in both groups after 6 months.

Body image score

The body image score measures a patient’s perception of

and satisfaction with his/her own body and explores the

patient’s attitude toward his/her bodily appearance (items

1–4). This score varies between 4 and 16 points, with a low

score meaning a better body image.

Cosmetic score

The cosmetic score assesses the degree of patient satis-

faction with respect to the physical appearance of the scar

(items 5–7). This score varies between 3 and 24 points,

with a high score meaning a better cosmetic result.

Self-confidence score

The self-confidence score (items 8 and 9) explores self-

confidence of the patient before and after surgery. This

score varies between 2 and 20 points, with a high score

meaning a high self-confidence of the patient.

Statistical analysis

All data were checked for accuracy and analyzed using the

SPSS 19.0 statistical software (SPSS, Inc., Chicago, IL,

Table 2 Body image questionnaire as used in the present study,

translated from the German language

Body Image Questionnaire

(1) Are you less satisfied with your body since the operation?

1 = no, not at all

2 = a little bit

3 = quite a bit

4 = yes, extremely

(2) Do you think the operation has damaged your body?

1 = no, not at all

2 = a little bit

3 = quite a bit

4 = yes, extremely

(3) Do you feel less attractive as a result of your treatment?

1 = no, not at all

2 = a little bit

3 = quite a bit

4 = yes, extremely

(4) Do you feel less feminine/masculine as a result of your

treatment?

1 = no, not at all

2 = a little bit

3 = quite a bit

4 = yes, extremely

(5) On a scale from 1 to 7, how satisfied are you with your

incisional scar?

1 = very unsatisfied

[2, 3]

4 = not unsatisfied/not satisfied

[5, 6]

7 = very satisfied

(6) On a scale from 1 to 7, how would you describe your scar?

1 = revolting

[2, 3]

4 = not revolting/not beautiful

[5, 6]

7 = beautiful

(7) Could you score your own incisional scar on a scale from 1 to

10?

(8) How confident are you before your operation?

1 = not very confident

[2–9]

10 = very confident

(9) How confident are you after your operation?

1 = not very confident

[2–9]

10 = very confident

World J Surg (2012) 36:1279–1285 1281

123

USA). Differences between the groups were tested using

the v2 test or Student’s t-test as appropriate. A value of

p \ 0.05 was considered statistically significant.

Results

Patient characteristics

Group characteristics are given in Table 3. Five hundred

forty patients who were operated on for thyroid disease

between January 2010 and October 2010 were asked to

participate in the study; 250 (46.3 %) of them agreed.

There was no significant difference in the mean age of the

MI and CO groups: 40.1 years for the CO group and

38.1 years for the MI group. Of these 250 patients, 200 (80

%) had CO thyroid surgery and 50 (20 %) had MI thyroid

surgery (minimally invasive video-assisted thyroidectomy,

MIVAT). Since both groups did not differ significantly in

terms of clinical characteristics or pathological features,

these factors are not differentiated in the table.

Clinical and surgical outcomes

The clinical and surgical outcomes are summarized in

Table 4. Postoperative hospital stay and postoperative

complications were comparable in both groups. The gender

ratio between groups did not differ significantly. The mean

operating time for the MI procedure was 113.6 ± 31.4 min

compared with 81.3 ± 20.3 min for the CO procedure, a

statistically significant difference of 32.3 min

(p \ 0.0001).

Body image questionnaire

Scar length

The mean scar length was significantly smaller in the MI

group (2.8 cm, range = 2–4 cm) than in the CO group

(3.5 cm, range = 2–6 cm) (p \ 0.0001) (Table 5).

Body image score

The overall body image score showed no significant dif-

ference between the two groups (p = 0.22) (Table 5).

Since no significant differences were observed between

both sexes (males and females), this factor is not differ-

entiated in the table.

Fig. 1 Photograph of a patient’s scar (arrow) (CO group), 3.2 cm

long, 6 months after the operation. This result was evaluated by the

patient with a cosmetic score of 22 points and a body image score of 4

points

Table 3 Patient characteristics in the present series

Thyroid procedure

Conventional

open (CO)

Minimally

invasive (MI)

No. patients ( %) 200 (80.0 %) 50 (20.0 %)

Male/female ratio 1/8 1/8

Mean age at operation (years) 40.1 ± 10.2 38.1 ± 11.0

Operation extent

Total thyroidectomy [n ( %)] 109 (54.5 %) 26 (52.0 %)

Subtotal thyroidectomy [n ( %)] 91 (45.5 %) 24 (48.0 %)

Table 4 Clinical and surgical outcomes in the present series

Thyroid procedure

Conventional

open

(CO) (n = 200)

Minimally

invasive

(MI) (n = 50)

Operating time (min) 81.3 ± 11.7* 113.6 ± 14.2*

Blood loss (ml) 3.7 ± 3.3 3.2 ± 3.1

Postoperative hospital

stay (days)

5.2 ± 0.8

(range = 4–7)

4.8 ± 1.0

(range = 3–7)

Postoperative

complications [n ( %)]

27 (13.5 %) 6 (12.0 %)

Transient hypocalcemia 18 (9.0 %) 3 (6.0 %)

Transient hoarseness 4 (2.0 %) 1 (2.0 %)

Laryngeal nerve palsy 0 (0.0 %) 0 (0.0 %)

Hematoma 1 (0.5 %) 0 (0.0 %)

Seroma 1 (0.5 %) 1 (2.0 %)

* p \ 0.05

1282 World J Surg (2012) 36:1279–1285

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Cosmetic score

The overall cosmetic score showed no significant differ-

ence between the two groups (p = 0.44) (Table 5). Since

no significant differences were observed between both

sexes (males and females), this factor is not differentiated

in the table.

Self-confidence score

No significant difference could be noted between the self-

confidence scores of the two groups before and after the

surgery (p = 0.27) (Table 5; only the postoperative score

is given in the table). Since no significant differences were

observed between both sexes (males and females), this

factor is not differentiated in the table.

Discussion

Minimally invasive procedures have become the gold

standard in many operations, including laparoscopic cho-

lecystectomy and laparoscopic appendectomy. Surgeons

continue to develop new applications for laparoscopy. The

first application of endoscopic procedures in endocrine

neck surgery was for the treatment of primary hyperpara-

thyroidism, described initially in 1996 [16]. Most authors

focus on the benefits of MI techniques in terms of reduction

in operative blood loss, shorter hospital stay, lower infec-

tion and complication rates, and less postoperative pain [6,

7, 17, 18]. Although cosmesis seems to be the only evi-

dence-based advantage of the MI approach [19–21], studies

are scarce. In contrast to cosmetic surgery, body image and

cosmesis are unconventional outcomes in the field of

general and endocrine surgery. We should also keep in

mind that these studies have several limitations, such as a

small number of observed patients or restrictive inclusion

criteria (small thyroid volume and small volume and

number of nodules, no malignancy). Moreover, the aspect

of body image has been widely ignored. Cosmesis has been

described in the point of view of the surgeon (scar length

only) rather than the patient. This leads to unstandardized

evaluations. The present study tries to overcome these

limitations by utilizing a standardized evaluation of body

image and cosmesis in a large group of patients operated on

for thyroid pathology. This allows the testing of the supe-

riority of MI approaches over CO approaches in terms of

body image and cosmesis.

Patient, clinical, and surgical outcomes

In this study, patients with a thyroid volume greater than

35 ml were excluded from the MI group. This is the rec-

ommended threshold volume for MI procedures by the

majority of endocrine surgery associations. However,

patients with a thyroid volume exceeding 35 ml are more

frequent than patients with small thyroid glands. This is

especially true in our region with its endemic iodine defi-

ciency. That is the reason for the small amount of MI

operated patients in this study.

In our study no significant difference between CO and

MI procedures in terms of complications (e.g., recurrent

laryngeal nerve palsy or postoperative hypoparathyroid-

ism) was noted, as demonstrated in previous studies [6, 7,

20, 22, 23]. Several studies have shown that patients who

undergo endoscopic thyroidectomy by the transaxillary

approach reported pain and discomfort in the neck or the

anterior chest wall [6, 7, 18, 24]. This may be caused by the

extent of the dissection required—from the axilla to the

anterior neck—to achieve an adequate working space. The

operating time for the MI group was significantly longer,

confirming the results of the outlined studies.

In addition, considering the narrow inclusion criteria of

MI approaches in thyroid surgery, surgeons and patients

should keep in mind that only 10 % of patients can undergo

a MI thyroid operation, even less in our iodine-deficiency

region.

Body image questionnaire

Although the number of patients investigated in the liter-

ature studies was relatively small, MI thyroid approaches

are described as utilizing smaller incisions, resulting in

increased cosmetic satisfaction [7, 20, 21]. While this may

reflect the opinion of the operator, it poorly renders the

point of view of the patient. However, no study in the

Table 5 Body image score, cosmetic score, self-confidence score, and scar length as observed in the present series

Thyroid procedure

Conventional open (CO) (n = 200) Minimally invasive (MI) (n = 50) p

Body image score (4–16) 4.8 ± 0.9 4.5 ± 0.7 0.22

Cosmetic score (3–24) 19.1 ± 3.2 18.5 ± 1.1 0.44

Self-confidence score (2–20) 18.0 ± 1.6 18.5 ± 1.7 0.27

Scar length (cm) 3.5 ± 0.7 (range = 2–6) 2.8 ± 0.5 (range = 2–4) \0.0001

World J Surg (2012) 36:1279–1285 1283

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literature validated the use of a body image questionnaire

for patients with thyroid disease, so we decided to focus the

present study on a standardized questionnaire, which could

be more rigorous than other outcome measures, investi-

gating the satisfaction of patients in terms of body image,

cosmesis, and self-confidence related to the scar length and

the postoperative course.

Even though after 6 months the scar length was signif-

icantly smaller in the MI group (2.8 cm) compared to CO

group (3.5 cm) (p \ 0.0001), surprisingly, no significant

difference could be noted in terms of body image, cos-

metic, and self-confidence scores between the groups.

However, even with a limited number of patients [25] or

considering that a laterocervical incision for parathyroid

adenoma was used [25], the studies presented by Toll et al.

[25] and O’Connell et al. [26] seem to confirm our results.

Thus, small scars do not seem mandatory for good cos-

metic results, making relative the supposed link between

small scars and good cosmesis described for MI approaches

in the literature [27]. Moreover, several MI approaches

show a high incidence of keloid scars or wound-healing

complications (e.g., anterior chest wall approach) [4],

impairing the cosmetic results. Furthermore, the retraction

required for adequate exposure and the augmented need for

preparation from incision sites far from the neck (e.g.,

axilla or breast) during these procedures may lead to aug-

mented skin and tissue damage. This can result in impaired

wound healing and, in some cases, poor cosmetic results

[28]. In a recent review, it was concluded that ‘‘scarless’’

(in the neck) endoscopic thyroid approaches via the axilla,

anterior/breast, and a hybrid (anterior combined with

axilla) comes at a steep price by being maximally invasive

in other areas and involving longer operative times and

greater postoperative pain [29].

There are several limitations to our study: (1) the

patients qualified for MIVAT could choose between CO

and MIVAT. The obligation of the surgeon to expose the

different medically equivalent therapy options and the

possibility for patients to choose among these enter in our

department’s quality-of-care guidelines. Because patients

select the procedure, this absence of randomization may

introduce bias. (2) However significantly smaller in the MI

group, the length of the incision in both groups (CO and

MI) is very similar; that is obviously a limitation that could

impact a patient’s satisfaction with cosmesis. (3) Unlike for

the CO group, the sample size of the MI group was unable

to fulfill the power requirement of 0.8 to detect small dif-

ferences in satisfaction. However, our study appears to be

larger than other studies in the literature. Nevertheless,

future investigations should take this in account.

In conclusion, MI approaches (MIVAT in our study)

show no significant advantage in terms of body image and

cosmesis over CO procedures. Thus, MI approaches are an

option and an adjunct in well selected patients, but we

recommend that thyroid surgery should not be performed

through exceedingly small incisions for only cosmetic

reasons and that we should improve conventional open

approaches to achieve optimal cosmetic results. We pro-

pose the following ways to improve open techniques: (1)

mark the incision site with the patient in the supine and

sitting positions before the operation, (2) make the incision

in skin wrinkles, (3) protect the skin during the procedure,

(4) excise traumatized skin at the end of the procedure, (5)

use intracutaneous suture, and (6) use silicone plaster or

silicone gel postoperatively. The limitations of the present

study should be kept in mind for future studies (ideally

prospective, randomized, conducted on a larger sample

size, and using different tools) in order to investigate the

use of minimally invasive procedures for thyroid surgery.

Disclosures Drs. Bokor, Kiffner, Kotrikova, and Billmann have no

conflicts of interest or financial ties to disclose.

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