DISCUSSION
In today’s modern world perception of beauty and aesthetics is gradually
changing and getting more important. Popular social media platforms that
bring this perception to the front, positively support this situation.
Classical mid-cervical Kocher incision is often accepted as a standard
for thyroid surgical procedures. The aesthetic problems related that
incision may cause serious fear and anxiety. These concerns exist in
various societies around the world, particularly among Asian women and
these novel surgical procedures concerning in scar cosmesis are
performed more frequently in Asia compared to other parts of the world.
(9).
The vast majority of the patients included in our study were satisfied
with the appearance of their surgical scars. Only 3 of 77 patients
(3.9%) were found with a significant dissatisfaction level. Similar to
our results Bohm et al. reported the long-term cosmetic results after
traditional mid-cervical thyroid resection with a more than 90%
excellent or good cosmetic results (10).
There are several studies in the literature concerning about the
incision size and satisfaction. In the study by Miccoli et al. in the
postoperative 1st month, in another study by
Bellantone et al. in the postoperative 3-6th month
scar satisfactions were evaluated (2,11). They found that smaller
incision size reflected positively on patient satisfaction on their
studies. However, these were relatively short-term and relatively small
sample sized studies to assess the satisfaction of the patients
Wound healing and remodeling both are dynamic processes and last 8 to 12
months. Reasonably, scar evaluation before the 12 months may not reflect
the long-term satisfaction of patient (12). We designed our study to
evaluate our patients at least 1 year after the surgery in order to
assess the long-term quality of life more accurately. We didn’t find any
significant differences related with incision size and satisfaction.
Similar to our study, after the long-term evaluation of patients many
authors could not find any relation between the incision length and
patient satisfaction (13,14). As a result, in our study scar length does
not affect the scar appearance and patient satisfaction by itself. We
think that there are other factors affecting patient satisfaction
besides scar length such as asymmetry, vascularization, depression etc.
In our study we found secondary/completion surgery and radioactive
treatment as the significant factors for worse scar appearance and
unsatisfaction. Secondary surgeries were completion contralateral
thyroid lobectomies for malignant pathologies in early postoperative
period (generally in first month postoperatively). One might expect that
secondary operation during the healing and remodeling period may
negatively affect the scar appearance. Most of the patients who had
radioactive treatment, also required secondary/completion surgery. This
may be the reason for unsatisfactory scar appearance beyond the systemic
or local effect of the radioactive treatment. Reoperative thyroid
surgery especially completion surgery for residual disease is associated
with higher complication rates (15). The scar tissue due to previous
surgery makes it difficult to recognize and preserve the critical
structures such as recurrent laryngeal nerves or the parathyroid glands.
The poor scar appearance revealed by our study is one of the neglected
conditions of reoperative thyroid surgery.
In literature, there are many studies reporting the more unsatisfactory
scar results in females comparing with males (16,17). In our study also,
females have worse scar appearance scores, but this difference was not
statistically significant (p=0,069). Also, this study did not
demonstrate any significant relation between patient satisfaction and
age, histopathology, body mass index and comorbidities of the patients.
As a result, the classical mid-cervical incision has positive long-term
satisfactory results. Even a small number of patients complain about the
shape of their scars, we must take important precautions such as careful
positioning of incision, degree of retraction necessity, careful skin
closure by being gentle to the tissue for better results (14). Patients
required early secondary (completion) thyroidectomy should be informed
about the possible unsatisfactory results and surgeon should pay more
attention and act as careful as possible for skin closure. Patient
factors affecting the wound healing not covered in this study may be the
missing aspect and limitation of this study.