Keywords
thyroidectomy - cervicotomy - scar
Thyroid and parathyroid surgery are common procedures with more than 16,000 operations
performed last year in the United Kingdom alone, with this figure continuing to increase.[1]
[2] Thyroid carcinoma is a common indication for surgery and is more frequent in women
than in men. The traditional anterior neck can be exposed, hence cosmesis is a priority
for surgeons and patients.[3]
Recently, various surgical approaches including minimally invasive and robotic surgery
have been advocated as they were thought to offer better cosmesis. However, these
techniques can be significantly more expensive, often involve a longer duration of
surgery, and potentially increased risk of complications, such as brachial plexus
injury. Interestingly, a recent review of literature suggested that minimally invasive
surgery did not offer long-term cosmetic outcomes.[4] Furthermore, it has been shown that a small incision does not necessarily result
in overall patient satisfaction.[5]
[6]
Hence, thyroid surgery through the standard anterior neck cervicotomy approach is
still practiced by the majority of thyroid surgeons.[7] However, what does vary is the way in which the skin is approximated. The commonly
employed methods include the use of clips, subcuticular suture, and tissue adhesive.
It is questionable as to whether the technique for skin closure has an impact on the
cosmesis of the scar and no previous systematic reviews have been conducted in this
subject.
Aim
Our aim is to review the literature to determine the optimal closure technique to
enhance cosmetic outcomes for patients undergoing thyroid and parathyroid surgery
through the conventional approach.
Material and Methods
A systematic review was undertaken of all published studies of thyroid and parathyroid
surgery performed using the conventional anterior cervicotomy approach in accordance
with preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines
similar to previously described methodology.[4]
[8] The MEDLINE, Embase, and Cochrane databases were searched for relevant articles
in the English language using the following terms: thyroid scar/wound, closure, cosmesis,
suture, clips, staples, and tissue adhesive. Studies assessing minimally invasive
surgery and robotic surgery were excluded.
All studies comparing scar cosmesis of two different closure techniques and making
use of an assessment scale were included. Articles were reviewed to ensure no duplication
of results.
Results
Sutures versus Clips
Three studies (including 200 patients) compared cosmetic outcomes in scar quality
between subcuticular sutures and metal clips ([Table 1]). All three included an assessment by the patient, surgeon, and an independent observer.
None of these used a validated tool to assess cosmetic outcome. Two studies used a
visual analog scale (VAS).
Table 1
Comparison between sutures and clips (n = 200)
|
n
|
Suture
|
Clips
|
Assessment
|
Assessor
|
Time of assessment
|
Cosmetic results
|
|
Selvadurai et al (1997)
|
80
|
3′0 polypropylene (42)
|
12 mm metal (38)
|
VAS
|
Patient, surgeon, independent observer
|
Discharge
|
Suture significantly better
|
|
3 and 6 months
|
No significant differences but suture outcomes better
|
|
Verbal response
|
Discharge
|
At discharge suture significantly better
|
|
3 and 6 months
|
No significant differences but suture outcomes better
|
|
Iqbal et al (2014)
|
100
|
3′0 prolene (52)
|
12 mm metal (48)
|
Satisfaction levels
|
Patient, surgeon, independent observer
|
Discharge
|
Suture outcomes superior
|
|
3 and 6 months
|
No significant differences but suture outcomes better
|
|
Guarino et al (2014)
|
20
|
Absorbable monofilament (10)
|
Metal (10)
|
VAS
|
Patient, surgeon, independent assessor
|
6 months
|
No differences
|
Selvadurai et al[9] assessed cosmetic appearance through VAS and verbal response (four options: poor,
fair, good, and excellent). They found that the appearance of the wound was significantly
better with subcuticular sutures than metal clips at time of discharge post surgery.
At three and six months following the procedure, although there were no significant
differences, VAS scores remained better with subcuticular suture. Interestingly, three
patients developed hypertrophic scars (clips were used in two and subcuticular sutures
in one). Furthermore, they noticed that pain experienced on removal was significantly
worse with clips.
Iqbal et al[10] also found that satisfaction with scar quality was significantly better with subcuticular
sutures than metal clips at the time of patient discharge, once again at three and
six months; although no significant differences were noted, results were marginally
better with subcuticular suture.
On the other hand, Guarino et al[11] detected no differences in VAS scores between subcuticular sutures and clips in
a small study of 20 patients 6 months post surgery. They report that two patients
in whom suture was used developed a subcutaneous hematoma.
Sutures versus Tissue adhesive
Three studies (including 213 patients) compared cosmetic outcomes between subcuticular
sutures and tissue adhesive ([Table 2]).
Table 2
Comparison between sutures and tissue adhesive (n = 213)
|
n
|
Suture
|
Tissue adhesive
|
Assessment
|
Assessor
|
Time of assessment
|
Cosmetic results
|
|
Consorti et al (2013)
|
50
|
3′0 polyglactin (25)
|
Octyl-cyanoacrylate (25)
|
OSAS
|
2 independent observers
|
6 weeks
|
Suture significantly better
|
|
PSAS
|
Patient
|
6 weeks
|
No significant differences
|
|
Ciufelli et al (2014)
|
89
|
Caprosyn (47)
|
2-octyl-cyanoacrylate (42)
|
Wound registry scale
|
Plastic surgeon (blinded)
|
10 days
|
Suture significantly better
|
|
SBSES
|
3 months
|
No significant difference
|
|
Rao et al (2015)
|
74
|
3′0 ethilon (38)
|
Octyl-cyanoacrylate (36)
|
SBSES
|
Not stated
|
1 and 3 weeks
|
No significant differences but suture marginally better
|
Abbreviations: OSAS, observer scar assessment scale; PSAS, patient scar assessment
scale; SBSES, Stony Brook Scar Evaluation Scale.
Consorti et al[12] used a validated measure—the patient and observer scar assessment scale (POSAS)[13]—to assess cosmetic outcomes at 6 weeks post surgery. This tool used a combination
of an observer scar assessment scale (OSAS) and a patient scar assessment scale (PSAS).
Their results showed that subcuticular sutures had overall more favorable outcomes
on the OSAS, with significantly better vascularity, pigmentation, and relief scores.
In the remaining 3 domains of the OSAS (thickness, pliability, and surface), scores
were still better with sutures but with no significant differences. In the PSAS, tissue
adhesive showed slightly worse cosmetic outcomes in the domains of itching, color,
stiffness, and thickness, while subcuticular sutures had worse scores in the domains
of pain and irregularity of scar; none of these differences were significant.
Ciufelli et al[14] used the 6-point wound registry scale[15] to assess cosmetic outcomes at 10 days, and the Stony Brook Scar Evaluation Scale
(SBSES) at 3 months after surgery (both of which are validated tools). At 10 days,
the scar quality was noted to be significantly better with subcuticular sutures. This
was attributed to significant differences in the following domains: step-off of the
margins, margin separation, margin eversion, and overall appearance. At 3 months,
however, no statistically significant differences were detected.
Rao et al[16] also evaluated scar quality on the first and third postoperative week for appearances
using the SBSES. It is unclear as to who the assessors were in this study but scar
appearance was marginally better with sutures, although these differences were not
statistically significant. One patient in whom tissue adhesive was used developed
immediate postoperative wound dehiscence. Postoperative pain was also assessed using
the VAS and was noted to be significantly worse with tissue adhesive at week 1. At
week 3, although pain scores were higher with tissue adhesive, this difference was
no longer significant.
It is important to note that both Consorti and Ciufelli used a deep subcutaneous suture
for approximation, while with Rao this was unclear.
Tissue Adhesive versus Clips
Two studies (including 202 patients) compared cosmetic outcomes between tissue adhesive
and clips ([Table 3]).
Table 3
Comparison between tissue adhesive and clips (n = 202)
|
n
|
Tissue adhesive
|
Clips
|
Assessment
|
Assessor
|
Time of assessment
|
Cosmetic results
|
|
Pronio et al (2011)
|
70
|
Octyl-2-cyanoacrylate (32)
|
Proximate skin staples (38)
|
Patient satisfaction
|
Patient
|
7 days
|
Higher patient satisfaction with tissue adhesive
|
|
Self-aesthetic evaluation scores
|
Patient
|
7 and 15 days; 1, 3, 6, and 12 months
|
Staple group showed higher percentage of excellent results
|
|
Appearance of scar
|
Not stated
|
7 and 15 days; 1, 3, 6, and 12 months
|
7 days: edema around wound significantly higher with tissue adhesive
1 month: higher incidence of edema with tissue adhesive
3, 6, and 12 months: no significant differences
|
|
SBSES
|
Not stated
|
1 and 12 months
|
Overall appearance in both groups good
|
|
Yang et al (2013)
|
132
|
Butyl cyanoacrylate (65)
|
Stainless steel (67)
|
Manchester scar scale
|
Surgeon not involved in treatment
|
1 and 3 months
|
At 1 month, tissue adhesive significantly better; at 3 months, no significant difference
|
Pronio and colleagues[17] assessed the difference between octyl-2-cyanoacrylate and skin staples in 70 patients.
No subcutaneous sutures were used. Patient satisfaction was assessed using a numerical
score (0–10) and through a verbal rating response. The appearance of the scar was
also assessed with SBSES. Self-evaluation cosmetic scores in the early postoperative
period (7 days post surgery) showed significantly better results with staples. Results
at 3, 6, and 12 months did not show any statistically significant differences regarding
scar appearance between the two groups. SBSES scores were overall good for both groups
with no significant differences. The authors conclude that tissue adhesive has comparable
outcomes to staples.
Yang and colleagues[18] assessed differences in cosmesis between tissue adhesive containing butyl cyanoacrylate
and stainless steel clips in a supraclavicular approach at the first 24 hours postoperatively,
and the first and third month in 132 patients. All patients underwent subcutaneous
suture closure with 4/0 vicryl. The Manchester Scar assessment tool and VAS were used
at 1 and 3 months. In the first month, patients who were treated with adhesive had
significantly better scores, while at 3 months this difference was no longer significant.
Overall satisfaction levels were assessed through the VAS; in the first month patients
in whom tissue adhesive was used had significantly better scores, while at 3 months
this difference was no longer significant. They note that an important contributing
factor for patient comfort (noncosmetic) was the ability to shower immediately. Immediate
postoperative pain within the first 24 hours was noted to be significantly higher
with clips.
Discussion
Long-term cosmesis is an important outcome of wound repair, especially in areas of
the body where scars are readily visible. Here we have reviewed the literature to
help evaluate any differences in cosmetic outcomes between various forms of skin closure
after thyroid and parathyroid surgery. The outcomes of all closure techniques are
generally good and differences appear to be minimal; however, some conclusions can
be drawn from the data available.
Overall subcuticular sutures appear to have superior cosmetic outcomes in comparison
to clips. These findings are in agreement with studies comparing the two methods of
closure in other surgical specialties such as cardiothoracic surgery.[19] Subjectively, patients often find the initial appearance of clips disconcerting
and they can cause crosshatched scars.[9] The data also suggests that the removal of clips can be more painful than sutures
resulting in higher levels of anxiety; hence, overall sutures are preferable.
Subcuticular sutures also appear to give better cosmesis than tissue adhesive. Generally
it is thought that the use of glue does not facilitate precise apposition, which is
particularly important in the Head and Neck.[20] The latter does however appear to offer superior outcomes to clips in the initial
postoperative period, although after a period of 1 month there is no longer a significant
difference. This is in agreement with a study evaluating 72 patients who underwent
minimally invasive thyroid surgery which suggested no significant differences in cosmetic
outcomes between tissue adhesive and staples after 3 months; however, overall satisfaction
was higher with tissue adhesive, correlating with the ability to shower due to its
waterproof benefits.[21]
Interestingly, some studies have suggested that steristrips alone to approximate skin
edges may have good cosmetic outcomes.[22] However, it is questionable as to whether they may have a higher risk of wound dehiscence
in the initial postoperative period.
It is well known that minimizing skin tension enhances cosmesis. This can be achieved
by appropriate closure of the subplatysmal layer and some surgeons may place further
subcutaneous layer sutures to reduce the risk of railroad tracking. Lombardi et al,
however, found no advantage in cosmesis by using an intradermal double-layer suture
in comparison to a single-layer suture.[23] It is important to note, however, that in the majority of our studies in which tissue
adhesive was used, an absorbable suture was used for closure of the subcutaneous layer.
Not only does this extra layer of sutures relieve skin tension and the risk of wound
dehiscence, but also aids in the apposition of wound edge margins, ensures adequate
skin edge eversion, and prevents tissue adhesive from being deposited in the wound.[18]
There is limited data suggesting which specific sutures provide optimal cosmetic outcomes.
Parell et al have suggested that the ideal suture would be a flexible monofilament
with adequate tensile strength that holds knots well and absorbs in 7 to 10 days;
however, no such suture material is available today.[20] They have shown that the cosmetic outcomes of absorbable and nonabsorbable sutures
in the head and neck are similar.[20] Hence, absorbable sutures are preferred by many surgeons as they do not need to
be removed; however, this would be dependent on surgeon preference and individual
outcomes.
Conclusion
This is the first review of literature comparing cosmetic outcomes of various closure
techniques in thyroid and parathyroid surgery. It is clear that the evidence is overall
of limited quality with few studies using validated tools for scar assessment. Overall,
the cosmesis of surgical scars are good, no matter which method is used. However,
cosmesis with subcuticular sutures are more superior to other closure techniques,
especially in the short-term period. Thereafter the differences become minimal but
the evidence is still in favor of subcuticular sutures.
