Scar-less Neck Surgery: Leaving no sign of thyroid, parathyroid, or neck lymph node surgery

By: 
Raymond Grogan, MD, MS, FACS
portrait of surgeon

Transoral “Scar-Free” Surgery

Transoral endocrine surgery is a new type of procedure that allows a surgeon to remove the thyroid, parathyroid glands, or neck lymph nodes in a truly scarless manner. While the surgery does leave scars, those scars are hidden on the inside of the lower lip, thus making it in all practical terms truly ”scar-free.” It is an operation that has been under development for nearly 12 years, and is now a viable alternative to traditional thyroid and parathyroid surgery for some patients.

We know significantly more today about transoral thyroid and parathyroid surgery procedures than we did just two years ago.

How does it work?

Traditionally, the surgeon makes an incision across the front of the neck. The size and exact location of that incision varies depending on the surgeon performing the operation as well as the size and location of either the thyroid or parathyroid gland. In the transoral approach, the surgeon makes three small incisions on the inside of the lower lip that are each 5 mm in length (2/10 of an inch). Small tunnels are then made between the skin and lower jaw down to the thyroid or parathyroid. Laparoscopic instruments and a high definition camera are then passed through these tunnels and the thyroid or parathyroid are removed with these instruments. Laparoscopic instruments are long, thin instruments that are about the diameter of a pen, and they take the place of traditional surgical instruments. At the end of the operation the thyroid or parathyroid is then placed in a bag and removed through the middle incision in the lower lip.

Is it safe and effective?

According to a large study from Bangkok, Thailand where there is the most experience, the risk of hurting either the nerve that controls the vocal cords or the parathyroid glands during transoral thyroid/parathyroid surgery is the same as with traditional thyroid/parathyroid surgery when done by experienced surgeons.

Are there any disadvantages of the transoral approach?

There is one additional surgical risk associated with the transoral approach that is not associated with the traditional approach, which is the possibility of hurting a nerve that controls sensation along the lower lip and chin. If this nerve is injured, the lower lip and chin could be numb. There is no functional consequence to this, meaning that smiling, eating, and facial expression are not affected. The risk of a permanent problem with sensation is <0.001%, meaning it happens less than once out of every 1,000 patients being operated upon. Another relative disadvantage is that the transoral approach typically adds 20-30 minutes of additional operative time to the traditional approach. However, it should be noted that an experienced transoral thyroid surgeon can do a thyroid operation faster than an inexperienced thyroid surgeon can do a traditional thyroid operation, so this disadvantage is relative.

Does a scar on the neck really matter?

The answer to this question is not simple. It is important to realize and understand that everyone has their own beliefs and reasons for what is important to them. Some people may not be bothered by the idea of a scar across the front of the neck, while for others avoiding such a scar is very important, and there is nothing wrong with either philosophy. It is actually quite normal to be worried about having a scar anywhere on the body and there is nothing wrong with wanting to avoid that scar if possible. Keep in mind though, that many patients have little to no scar once healing is complete after traditional thyroid/parathyroid surgery. Who develops a scar has to do with patient and surgeon factors as well as the extent of surgery. You should discuss these factors with your surgeon.

What is the recovery like?

The recovery from the transoral procedure takes about the same amount of time as the recovery from the traditional approach, but is a little different. We generally recommend for patients to take 1-2 weeks off from work and other strenuous activities. It is common to experience visible bruising and swelling of the lower lip, chin, and neck for 5-10 days. After that, the visible bruising and swelling will mostly resolve to the point where the casual observer would not be able to tell that someone has had the surgery. The majority of patients do not take prescription pain medication for more than 2-3 days.

Am I eligible for the operation?

The main eligibility criteria for transoral thyroid surgery are based on thyroid/nodule size. There are certain size limitations to the procedure, and at this time the size of a benign thyroid nodule cannot be more than 6 cm in diameter, and the overall size of the thyroid gland cannot be more than 10 cm in length. Thyroid cancer can be removed with the transoral approach, however currently the size of cancers being removed is typically limited to 2-2.5 cm in diameter and those well contained within the gland. For primary hyperparathyroidism, a condition involving enlargement of one or more parathyroid glands leading to hormone overproduction, the most well-suited type of operation for the transoral approach is a focused, single gland parathyroidectomy. Certain lymph nodes in the neck can also be removed with the transoral approach depending on their size and location. It is important to know that as new technologies emerge, more procedures are beginning to be safely accomplished with the transoral approach, thus what is possible today is likely to change in the near future. The only way to know for sure if you are eligible for the operation is to speak with a surgeon who routinely performs the procedure.

Should I consider this operation or the traditional approach?

This of course is a very personal decision, as is any decision relating to having a surgical procedure. In order to make this decision one must first have access to a surgeon who performs the operation, then have a candid discussion with that surgeon about your particular situation. Then, after that discussion, you have to carefully consider the pros and cons of all your options and use that information to make an informed decision. We know significantly more today about transoral thyroid and parathyroid surgery procedures than we did just two years ago, thus it is important to speak directly with a surgeon rather than relying only on information obtained on the internet or social media.

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