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.