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Cosmesis in Thyroid and Parathyroid Surgery: A Matter of Perspective

Cosmesis in Thyroid and Parathyroid Surgery: A Matter of Perspective I read with interest the article by O’Connell et al1 that concludes “improved scar cosmesis should not be acknowledged as an advantage of performing MA-T [minimal access thyroid] or MA-P [minimal access parathyroid] surgery.” While I applaud the authors for their efforts to quantify the cosmetic value of minimal access surgery, their report suffers from serious limitations. These limitations bear scrutiny lest readers be left with an impression that patients are not interested in smaller, more cosmetic scars, which would conflict with the experience of most minimally invasive thyroid surgeons. I would draw particular attention to the offering of definitive conclusions based on the responses of fewer than a dozen geriatric-aged women as to whether they are dissatisfied with their scar result and the unsubstantiated extrapolation of parathyroid surgery to thyroid surgery. The findings were quite predictable: 10 women and 1 man (mean age, 70 years) who underwent either conventional thyroidectomy or parathyroidectomy expressed no more dissatisfaction with their scar than eleven 70-year-olds who underwent minimally invasive parathyroidectomy (MIP), while untrained observers made clear note of a difference in cosmesis. Yes, it is undoubtedly true that elderly women are not very concerned with the appearance of their scars. However, youthful women place supreme importance on this very same outcome. Of note, the age of the patients in the study by O’Connell and colleagues (originating in Canada) is significantly more advanced than that of the typical American parathyroid population (eg, a mean age of 52 years in one such study2), possibly reflecting a fundamental difference between the Canadian and American health systems. Second, the report represents a fundamentally flawed comparison of patients who underwent MIP through a lateral incision (resulting in immediate asymmetry) to a mixed population of patients who underwent either parathyroid or thyroid surgery through a central incision. The authors further assert that patients who undergo minimally invasive thyroidectomy derive no cosmetic advantage over conventional surgery. Not only did no patients undergo minimally invasive thyroidectomy, but also the discussion of quality-of-life outcomes ignores other important downstream benefits of minimally invasive thyroidectomy, including reduced pain3 and superior voice quality.4 Finally, patients who undergo thyroidectomy are substantially younger than those who undergo parathyroidectomy (eg, 49 years of age in previously published data from the same surgical group5). O’Connell and coauthors are encouraged to expand their investigation of minimally invasive endocrine surgery to a more youthful and informed population, which will assign importance to cosmesis, and to identify a more appropriate control group undergoing conventional surgery. Correspondence: Dr Terris, MCG Thyroid Center, Department of Otolaryngology, Medical College of Georgia, 120 15th St, Augusta, GA 30912-4060 (dterris@mcg.edu). References 1. O’Connell DADiamond CSeikaly HHarris JR Objective and subjective scar aesthetics in minimal access vs conventional access parathyroidectomy and thyroidectomy surgical procedures: a paired cohort study. Arch Otolaryngol Head Neck Surg 2008;134 (1) 85- 93PubMedGoogle ScholarCrossref 2. Pellitteri PK Directed parathyroid exploration: evolution and evaluation of this approach in a single-institution review of 346 patients. Laryngoscope 2003;113 (11) 1857- 1869PubMedGoogle ScholarCrossref 3. Miccoli PBerti PRaffaelli MMaterazzi GBaldacci SRossi G Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 2001;130 (6) 1039- 1043PubMedGoogle ScholarCrossref 4. Lombardi CPRaffaelli MD'alatri L et al. Video-assisted thyroidectomy significantly reduces the risk of early postthyroidectomy voice and swallowing symptoms. World J Surg 2008;32 (5) 693- 700PubMedGoogle ScholarCrossref 5. Uwiera TCUwiera RRSeikaly HHarris JR Tisseel and its effects on wound drainage post-thyroidectomy: prospective, randomized, blinded, controlled study. J Otolaryngol 2005;34 (6) 374- 378PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Cosmesis in Thyroid and Parathyroid Surgery: A Matter of Perspective

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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.134.10.1120-a
Publisher site
See Article on Publisher Site

Abstract

I read with interest the article by O’Connell et al1 that concludes “improved scar cosmesis should not be acknowledged as an advantage of performing MA-T [minimal access thyroid] or MA-P [minimal access parathyroid] surgery.” While I applaud the authors for their efforts to quantify the cosmetic value of minimal access surgery, their report suffers from serious limitations. These limitations bear scrutiny lest readers be left with an impression that patients are not interested in smaller, more cosmetic scars, which would conflict with the experience of most minimally invasive thyroid surgeons. I would draw particular attention to the offering of definitive conclusions based on the responses of fewer than a dozen geriatric-aged women as to whether they are dissatisfied with their scar result and the unsubstantiated extrapolation of parathyroid surgery to thyroid surgery. The findings were quite predictable: 10 women and 1 man (mean age, 70 years) who underwent either conventional thyroidectomy or parathyroidectomy expressed no more dissatisfaction with their scar than eleven 70-year-olds who underwent minimally invasive parathyroidectomy (MIP), while untrained observers made clear note of a difference in cosmesis. Yes, it is undoubtedly true that elderly women are not very concerned with the appearance of their scars. However, youthful women place supreme importance on this very same outcome. Of note, the age of the patients in the study by O’Connell and colleagues (originating in Canada) is significantly more advanced than that of the typical American parathyroid population (eg, a mean age of 52 years in one such study2), possibly reflecting a fundamental difference between the Canadian and American health systems. Second, the report represents a fundamentally flawed comparison of patients who underwent MIP through a lateral incision (resulting in immediate asymmetry) to a mixed population of patients who underwent either parathyroid or thyroid surgery through a central incision. The authors further assert that patients who undergo minimally invasive thyroidectomy derive no cosmetic advantage over conventional surgery. Not only did no patients undergo minimally invasive thyroidectomy, but also the discussion of quality-of-life outcomes ignores other important downstream benefits of minimally invasive thyroidectomy, including reduced pain3 and superior voice quality.4 Finally, patients who undergo thyroidectomy are substantially younger than those who undergo parathyroidectomy (eg, 49 years of age in previously published data from the same surgical group5). O’Connell and coauthors are encouraged to expand their investigation of minimally invasive endocrine surgery to a more youthful and informed population, which will assign importance to cosmesis, and to identify a more appropriate control group undergoing conventional surgery. Correspondence: Dr Terris, MCG Thyroid Center, Department of Otolaryngology, Medical College of Georgia, 120 15th St, Augusta, GA 30912-4060 (dterris@mcg.edu). References 1. O’Connell DADiamond CSeikaly HHarris JR Objective and subjective scar aesthetics in minimal access vs conventional access parathyroidectomy and thyroidectomy surgical procedures: a paired cohort study. Arch Otolaryngol Head Neck Surg 2008;134 (1) 85- 93PubMedGoogle ScholarCrossref 2. Pellitteri PK Directed parathyroid exploration: evolution and evaluation of this approach in a single-institution review of 346 patients. Laryngoscope 2003;113 (11) 1857- 1869PubMedGoogle ScholarCrossref 3. Miccoli PBerti PRaffaelli MMaterazzi GBaldacci SRossi G Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 2001;130 (6) 1039- 1043PubMedGoogle ScholarCrossref 4. Lombardi CPRaffaelli MD'alatri L et al. Video-assisted thyroidectomy significantly reduces the risk of early postthyroidectomy voice and swallowing symptoms. World J Surg 2008;32 (5) 693- 700PubMedGoogle ScholarCrossref 5. Uwiera TCUwiera RRSeikaly HHarris JR Tisseel and its effects on wound drainage post-thyroidectomy: prospective, randomized, blinded, controlled study. J Otolaryngol 2005;34 (6) 374- 378PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Oct 20, 2008

References