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Medical Rounds

Head and Neck Surgery: Completely Scarless Thyroidectomies

There’s no question that thyroidectomies can save function and lives. This technique has a long, safe history of removing both benign masses that threaten voice and breathing, and cancerous tumors whose spread can turn deadly. However, traditional thyroidectomies through a transcervical approach come with an unwanted addition that sometimes makes patients think twice about moving forward: a large, highly visible scar at the front of the neck.

That’s why Johns Hopkins recently began offering a new procedure for thyroidectomies and parathyroidectomies in select patients that allows resection with no visible scarring, say head and neck surgeons Jonathon Russell and Ralph Tufano. The team has now performed several of these surgeries, continually refining their technique to make this procedure more efficient.

“People don’t want this operation to define their lives,” says Russell. “We have the opportunity to intervene and take care of these patients without the average person knowing that they had surgery at all.”

Scarless thyroidectomies, performed through a transoral approach, got their start in Southeast Asia, where neck scarring is often stigmatized, Tufano says. “It’s an anathema, so patients can be reluctant to have thyroid or parathyroid tumors removed—even if it’s lifesaving.”

Surgeons there have worked for decades on developing approaches that minimize scarring. One such approach is transaxial, through the armpit. While this technique leaves a scar that’s not as visible, Tufano says, the path surgeons must take increases the risk of side effects, such as permanent arm weakness. Another technique that minimizes visible scarring involves using an approach similar to a face-lift. But because this technique can only access one side of the thyroid, it can be significantly more invasive than a traditional thyroidectomy if patients need the entire gland removed.

Nearly a decade ago, Tufano fortuitously met a German colleague who had begun studying a transoral technique. Soon after, Tufano and other Johns Hopkins colleagues began the first cadaveric studies of this in the United States. Through an incision in front of the mandible but behind the lip, they journey through the soft tissue of the neck, inflating it with carbon dioxide to create a working space. Once the thyroid is exposed, they then insert endoscopic or robotic instrumentation to perform the thyroidectomy.

Russell notes that efforts of surgeons thus far have shown there’s no difference in the safety profile of this procedure compared with transcervical thyroidectomies. And once the oral incision heals, he adds, no visible scar remains.

Currently, the procedure is restricted to a limited subset of thyroidectomy and parathyroidectomy patients. For example, qualifications include having a mass no greater than 4 centimeters in diameter that is of either benign or indeterminate pathology. However, as Tufano, Russell and other surgeons learn more about this technique, the population to whom it’s offered could expand.