10.14639/0392-100X-N1141
Objective. With the introduction of remote access thyroidectomy questions regarding patient satisfaction after trans-cervical thyroidectomy has been raised in several publications. As far as neck scars are concerned, patient satisfaction in the early post-operative period and long term are different. This study assessed patient satisfaction regarding their neck scar in the early post-operative period and at long term follow-up. Methods. Retrospective study. Patients underwent total thyroidectomy by single surgeon. Scar satisfaction scores assessed at different time intervals (&lt; 6 weeks, 6 months, 2 years and 5 years after procedure). Scores of patients aged &lt; 35 years and &gt; 35 years were compared. Patient and observer scar assessment scales (PSAS, OSAS) and patient satisfaction score (PSS) were used. Results. 595 patients were included (443 females and 152 males, age 19-77 years). Improvement was observed in the PSAS (13.5 ± 2.3 at 6 weeks; to 4.32 ± 1.37 at 5 years; p &lt; 0.05) and OSAS (7.32 ± 1.35 to 4.18 ± 1.51; p &lt; 0.05). PSS improved over time from 1.8 ± 0.8 to 0.92 ± 0.66 (p &lt; 0.05). The satisfaction scores were higher in patients &lt; 35 years (p = 0.003). The scores indicated excellent patient satisfaction and are similar to those published in the literature regarding minimally invasive surgery (MIS). Conclusions. Proper incision placement and suturing resulted in excellent patient satisfaction regarding scars after conventional thyroidectomy.
application/xml
1827-675X
1141
en
Puthen Veetil Pradeep
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
scar assessment scale
Scar satisfaction assessment after conventional thyroidectomy: follow-up results
Text.Serial.Journal
https://www.actaitalica.it/
41
Thyroid
2021-03-19
2020-09-27
2021-03-19
2021-03-24
39-42
1
Puthen Veetil Pradeep
2021/03/19
10.14639/0392-100X-N1141
39
Department of Endocrine Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India 673004
1827-675X
scar assessment scale
42
Scar satisfaction assessment after conventional thyroidectomy: follow-up results
https://www.actaitalica.it/article/download/1141/535
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:39-42; doi: 10.14639/0392-100X-N1141




Thyroid


Scar satisfaction assessment after conventional
thyroidectomy: follow-up results
Il livello di soddisfazione riguardante la cicatrice dopo intervento di tiroidectomia:
risultati a distanza
Puthen Veetil Pradeep
Department of Endocrine Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India 673004


SUMMARY
Objective. With the introduction of remote access thyroidectomy questions regarding pa-
tient satisfaction after trans-cervical thyroidectomy has been raised in several publications.
As far as neck scars are concerned, patient satisfaction in the early post-operative period
and long term are different. This study assessed patient satisfaction regarding their neck
scar in the early post-operative period and at long term follow-up.
Methods. Retrospective study. Patients underwent total thyroidectomy by single surgeon.
Scar satisfaction scores assessed at different time intervals (< 6 weeks, 6 months, 2 years
and 5 years after procedure). Scores of patients aged < 35 years and > 35 years were com-
pared. Patient and observer scar assessment scales (PSAS, OSAS) and patient satisfaction
score (PSS) were used.
Results. 595 patients were included (443 females and 152 males, age 19-77 years). Im-
provement was observed in the PSAS (13.5 ± 2.3 at 6 weeks; to 4.32 ± 1.37 at 5 years;
p < 0.05) and OSAS (7.32 ± 1.35 to 4.18 ± 1.51; p < 0.05). PSS improved over time from
1.8 ± 0.8 to 0.92 ± 0.66 (p < 0.05). The satisfaction scores were higher in patients < 35
years (p = 0.003). The scores indicated excellent patient satisfaction and are similar to those    Received: September 27, 2020
published in the literature regarding minimally invasive surgery (MIS).                            Accepted: November 17, 2020
Conclusions. Proper incision placement and suturing resulted in excellent patient satisfac-
tion regarding scars after conventional thyroidectomy.                                             Correspondence
                                                                                                   Puthen Veetil Pradeep
KEY WORDS: thyroidectomy scar, patient satisfaction, scar assessment scale                         Department of Endocrine Surgery, Baby Memorial
                                                                                                   Hospital, Kozhikode, Kerala, India 673004
                                                                                                   Tel. +91 8281021234, +91 495 2988234
RIASSUNTO
                                                                                                   E-mail: pradeepputhenveetil@yahoo.co.in
Obiettivo. Con l’introduzione delle interviste telematiche da accesso remoto, sono emerse
diverse perplessità circa il grado di soddisfazione dei pazienti sottoposti a tiroidectomia.
Per quanto riguarda le cicatrici sul collo, vi sono diversi livelli di soddisfazione del pazien-   Funding
te nel primo periodo post operatorio rispetto al lungo periodo. Questo studio si propone di        None.
valutare la soddisfazione del paziente in relazione alla cicatrice sul collo nel primo periodo
post-operatorio e nel follow-up a lungo termine.                                                   Conflict of interest
Metodi. Studio retrospettivo. 595 pazienti sono stati sottoposti a tiroidectomia totale da         The Authors declare no conflict of interest.
parte dello stesso chirurgo. Sono stati assegnati diversi punteggi di soddisfazione della ci-
catrice, valutati a diversi intervalli di tempo (< 6 settimane, a 6 mesi, 2 anni e 5 anni dopo       How to cite this article: Pradeep PV. Scar sat-
la procedura). Sono stati confrontati i punteggi dei pazienti di età < 35 anni e > 35 anni.          isfaction assessment after conventional thy-
Sono state utilizzate le scale di valutazione della cicatrice del paziente e dell’osservatore        roidectomy: follow-up results. Acta Otorhi-
(PSAS, OSAS) e il punteggio di soddisfazione del paziente (PSS).                                     nolaryngol Ital 2021;41:39-42. https://doi.
Risultati. 595 pazienti sono stati inclusi nel presente studio (443 femmine e 152 maschi,            org/10.14639/0392-100X-N1141
età 19-77 anni). Il miglioramento è stato osservato nel PSAS (13,5 ± 2,3 a 6 settimane; a
4,32 ± 1,37 a 5 anni; p < 0,05) e OSAS (7,32 ± 1,35 a 4,18 ± 1,51; p < 0,05). La PSS               © Società Italiana di Otorinolaringoiatria
è migliorata nel tempo da 1,8 ± 0,8 a 0,92 ± 0,66 (p < 0,05). I punteggi di soddisfazione          e Chirurgia Cervico-Facciale
erano più alti nei pazienti con età inferiore ai 35 anni (p = 0,003). I punteggi hanno indi-
cato un’eccellente grado di soddisfazione del campione esaminato, i punteggi sono simili a                        OPEN ACCESS
quelli pubblicati in letteratura per quanto riguarda la chirurgia mininvasiva (MIS).
                                                                                                   This is an open access article distributed in accordance with
Conclusioni. L’adeguata pianificazione dell’incisione e adeguata sutura chirurgica produ-
                                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
ce un’eccellente grado di soddisfazione del paziente riguardo alle cicatrici dopo la tiroi-        Commercial-NoDerivatives 4.0 International) license. The
dectomia convenzionale.                                                                            article can be used by giving appropriate credit and mentio-
                                                                                                   ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: cicatrice tiroidectomia, soddisfazione del paziente, scala di valutazione           only in the original version. For further information: https://
della cicatrice                                                                                    creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                             39
P.V. Pradeep




Introduction                                                          Table I. Number of patients with duration of follow up.
                                                                       Follow-up duration            N = 595              Mean age (years)
Thyroid diseases are very common in India. Apart from hy-
                                                                       < 6 weeks                       16                   43 ± 11.2
pothyroidism and hyperthyroidism, patients also present with
                                                                       6 weeks to 6 months             101                   52 ± 9.8
goiters that can be benign or malignant. Malignant goiters and
                                                                       6 months-1 year                  93                  51 ± 12.3
a significant proportion of benign goiters need thyroidectomy.
Conventional neck surgery has stood the test of time and all           1-2 years                       105                  49 ± 11.6
surgeons are trained in this technique, even though outcomes           2- 5 years                      132                  54 ± 13.6
differ based on individual experience 1. One of the concerns           > 5 years                       148                  56 ± 14.8
raised with conventional thyroidectomy is related to the neck
scar, especially after the alternative procedures like remote ac-     The incision site is marked in one of the neck creases with the
cess and minimally invasive thyroidectomy (MIS) were intro-           patient in the sitting position prior to the anaesthesia. Sub-plat-
duced. As far as neck scars are concerned, patient satisfaction       ysmal flaps are raised. Straps are either cut/ divided depend-
in the early post-operative period and long term are different.       ing on the size/difficulty in surgery. The rest of the procedure
In this paper, the patient satisfaction regarding their scar in the   is as in standard thyroid surgery, preserving the recurrent and
neck in the early/late post-operative periods and at long term        external laryngeal nerves and the parathyroids. Since the oper-
follow-up were assessed in Indian subjects.                           ating team of assistants and nurses were the same, the traction
                                                                      on the skin edges was kept to the minimum. Closures of the
Methods                                                               wound in all cases included subcutaneous absorbable vicryl
                                                                      (3,’O’) followed by sub-cuticular suturing with 4 ‘O’ vicryl. A
We conducted a retrospective study in patients who under-             drain was kept in place on a case to case basis.
went thyroid surgery at two tertiary care centres in South            Statistical analysis was performed using the SPSS (version
India. A total of 2594 patients underwent thyroidectomy               16.0, SPSS, Inc., Chicago, IL). Continuous values were re-
during the period from 2008 to 2019. Patients who un-                 ported as mean ± standard deviation (SD). Differences in
derwent neck dissection, central compartment dissection,              continuous variables were assessed by the student t-test. A
hemi-thyroidectomy and foreign nationals were excluded.               p value of < 0.05 was considered statistically significant.
Patients who did not consent and those who did not present            Repeated measures ANOVA was applied to compare scar
for follow-up were excluded. Patients with diabetes melli-            satisfaction scores during follow-up.
tus, obesity, smokers and those with keloid tendency (n = 9)
were excluded. Cases of total thyroidectomy performed for
benign or malignant goiters were included (Tab. I).
                                                                      Results
Patients were divided into groups based on duration of follow-        The number of patients available for follow-up after applying
up (< 6 weeks, 6 weeks to 6 months, 6 months to 2 years, 2            the exclusion/inclusion criteria is shown in Table I (n = 595).
to 5 years and more than 5 years). It is well known that heal-        These were further divided into subgroups depending on the
ing and scarring is different in younger and older individuals,       duration of follow-up as shown in Table I. Table I also shows
especially in the long term. Hence, scoring was also assessed         the age distribution. The age and sex distribution did not show
in patients who were < 35 years and > 35 years where the              any significant differences. There were 443 females and 152
follow-up was > 1 year. In these subgroups, the age and sex           males. All patients were between 19 years to 77 years. Pa-
distribution did not show any significant differences.                tients who had more than 1 year follow-up were further sub-
The standard patient and observer scar assessment scale               grouped by age less than 35 years and more than 35 years.
was used in this study (POSAS) 2. This scale is shown in              Among patients who had follow up of > 1 year, 210 were less
Table II. Observer scar assessment scale has five items and           than 35 years and 175 were more than 35 years. The mean
is scored 1-10, where a value of 1 indicates normal skin              length of the neck incision was 5.1 ± 1.8cm. Tables III and
and 10 the worst scar. The patient scar assessment scale              IV show the results of the scores in the various groups. Table
considers six items with scores from 1 to 10, with a score            III shows that the patient (PSAS) and observer (OSAS) scar
of 6 indicating normal skin and 60 the worst scar. Overall            assessment scale scores improved as the duration of follow-
satisfaction was assessed with the patient satisfaction score         up increased. Among patients with one year of follow-up the
(PSS). Very satisfied (1), satisfied (2), unsatisfied (3) and         PSAS and OSAS scores were comparable to the scores seen
very unsatisfied (4) was the scoring system used for PSS.             in the study by Ma et al. on minimally-invasive thyroidectomy
There are many different scar scales for assessing scar sat-          patients (PSAS: 13.27 ± 4.56 and OSAS 11.48 ± 3.6) 4. Ta-
isfaction, but the POSAS scale was used in this study 3.              ble IV shows that the PSAS showed better scores in patients
All surgeries were performed by a single endocrine surgeon.           who are more than 35 years old irrespective of the duration



40
                                                                                                            Scar satisfaction after conventional thyroidectomy




Table II. The patient and observer scar assessment scales.
 Observer component                                               Normal skin                                         Worst scar imaginable
                                                 1           2        3             4        5          6             7         8           9         10
 Vascularity
 Pigmentation
 Thickness
 Relief
 Pliability
 Patient component                                                    No                                                       Yes
                                                 1           2        3             4        5          6             7         8           9         10
 Is the scar painful?
 Is the scar itching?
 Is the colour of the scar different?
 Is the scar more stiff?
 Is the thickness of the scar different?
 Is the scar irregular?

Table III. Scar satisfaction scores with duration of follow up.
 Follow-up duration                 N = 595                PSAS              P              OSAS                 P                  PSS               P
 < 6weeks                                  16         13.5 ± 2.3                          7.32 ± 1.35                           1.8 ± 0.8
 6 weeks to 6 months                       101         15.7 ± 2.1                         7.72 ± 2.24                           2.2 ± 1.1
 6 months -1 year                           93       11.36 ± 1.96                        10.12 ± 2.32                          2.1 ± 0.94
                                                                           < 0.05                             < 0.05                               < 0.05
 1-2 years                                 105       10.62 ± 2.37                        8.12 ± 1.76                           1.3 ± 0.52
 2-5 years                                 132        6.32 ± 1.97                         6.1 ± 1.86                           1.2 ± 0.36
 > 5 years                                 148       4.32 ± 1.37                         4.18 ± 1.51                          0.92 ± 0.66

Table IV. Scores in patients aged < 35 years and > 35 years.
 Follow-up duration                                        PSAS                   P              OSAS                                PSS              P
 1-2 years                        < 35 yr (n = 56)        11.13 ± 2.11                      8.88 ± 1.96                         1.6 ± 0.52
                                                                                 0.003                               0.01                          0.0001
 N = 105                          > 35 yr (n = 49)        10.11 ± 1.21                      7.91 ± 1.82                         1.1 ± 0.62
 2-5 years                        < 35 yr (n = 79)         6.88 ± 1.32                      6.46 ± 1.88                          1.4 ± 0.45
                                                                                 0.003                               0.09                          0.0001
 N = 132                          > 35 yr (n = 53)         6.11 ± 1.62                      5.95 ± 1.45                         1.01 ± 0.25
 > 5 years                        < 35 yr (n = 75)         4.66 ± 1.42                      4.46 ± 1.49                         0.98 ± 0.56
                                                                                 0.003                               0.05                            0.28
 N =148                           > 35 yr (n = 73)         4.02 ± 1.14                      4.03 ± 1.21                         0.87 ± 0.68



of follow-up. The OSAS also showed better satisfaction in                         reduced to less than 1%. The closure of a neck incision
patients > 35 years during long term follow-up. The digital                       was given least importance and resulted in unsightly scars
images of scars shown in Figure 1 along with duration of                          in the neck due to poor placement of incisions and poor
follow-up.                                                                        suturing techniques (e.g. use of interrupted skin sutures).
                                                                                  At this point in time, two developments took place: a group
Discussion                                                                        of surgeons adopted an aesthetic way of skin closure which
                                                                                  included proper placement of incision in neck creases, and
On tracing the history of thyroid surgery in our depart-                          applying minimum traction on skin edges and closure us-
ment, the initial years showed high morbidity and even                            ing sub-cuticular absorbable sutures as do plastic surgeons.
mortality 1. With progress in anaesthesiology, the mortal-                        Another group introduced the evolving endoscopic surgery
ity became nil. However, the morbidity of hypocalcaemia                           into the thyroid area thereby taking the incision in the neck
and voice change persisted 1. As surgical techniques were                         to the axilla. Both these methods gave relief to patients who
refined and the experience of surgeons increased, this was                        were disturbed due to the scar in their neck.



                                                                                                                                                            41
P.V. Pradeep




                                                                    Studies have shown that scar maturation takes 6-18 months.
                                                                    Hence, the observation time is critical to judge outcomes
                                                                    of a surgical scar. Many factors influence patient satisfac-
                                                                    tion regarding their surgical scars. This includes the length,
                                                                    degree of hypertrophy, keloid formation, pigmentation and
                                                                    discomfort 6. It has been shown that skin and soft tissue
                                                                    damage are produced by high retractor pressure and hence
                                                                    cosmesis is poor 7. Thus, a small incision may not result is
                                                                    a good cosmetic result. Also, approaching a thyroidectomy
                                                                    through a small incision in the neck leads to a poor surgical
                                                                    field and increased risk of damage to structures like laryn-
Figure 1. Neck scars at different times during follow-up.           geal nerves and parathyroid, apart from poor cosmesis due
                                                                    to excessive traction 4. Our study has a large number of
Almost all Indian patients have creases in their neck, un-          patients and we have used a validated scoring system to
like the patients from Korea, Japan and Thailand. We have           assess patient satisfaction regarding neck scars. All publi-
used these skin creases in our patient population who un-           cations on endoscopic thyroidectomy highlight that a un-
dergo thyroid surgery to mask the neck incision and resultant       sightly scar in the neck and patient dissatisfaction as rea-
scar. However, whether this increases the patient satisfaction      sons to adopt endoscopic remote access thyroidectomy. In
with their neck scars has not been addressed extensively in         this paper, we share our extensive experience in scar-re-
various ethnic populations. In this study, we investigated          lated satisfaction (which is quite high) and also report that
the patient’s assessment of their scars and satisfaction us-        satisfaction improves as over long-term follow-up. Scar
ing the POSAS and OSAS scale 2. A number of scales are              satisfaction improvement over longer periods of time has
available for the assessment of scars 3. POSAS focuses on           not been published to date.
scar severity from the clinician’s and patient’s point of view,
although items represented in this scale may not adequately
express the patient’s perceptions and concerns 3. Scales like
                                                                    Conclusions
the Vancouver scar scale, visual analogue scale and Stony           Conventional thyroidectomy has stood the test of time in
Brook scar evaluation scales lack patient perception, while         terms of safety and adoption of the technique. Scar satisfac-
the latter two are photo-based without patient assessment           tion scores are excellent given the fact that the scar is in the
of the scar 3. Studies have shown that the POSAS is a reli-         anterior visible part of the neck. Scar satisfaction improves
able and complete scar evaluation tool 2. With the POSAS,           further with the longer duration of follow-up.
the consistency (internal) of the patient and observer scales
appeared to be most acceptable (Cronbach’s alpha 0.76 and
0.69 respectively) 2. It is well known that as time passes scars
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