Otolaryngologists increasingly must think about the cosmetic outcomes of patients undergoing head and neck surgery. Consequently, physicians are incorporating more cosmetic and reconstructive techniques into their procedures, according to experts interviewed for this article.
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October 2007The increased demand for cosmesis may be driven by culture or patient awareness that cosmetic and reconstructive techniques are available, said Brendan J. Stack Jr., MD, Vice Chairman of the Department of Otolaryngology-Head and Neck Surgery and Director of the Divisions of Head and Neck Oncology and Clinical Research at the University of Arkansas College of Medicine in Little Rock. Regardless, people want the best treatment possible, he said.
Squamous Cell Cancer
Traditionally, larger head and neck surgeries are usually performed to treat patients with squamous cell cancer, said Dr. Stack. These people as a group have generally not done well, and cosmesis has often been sacrificed for an attempt at cure, he said. However, the need to perform some of this surgery is changing with diagnostic technology, he said.
For example, physicians used to routinely perform neck dissections if they suspected the possibility of metastases to the neck, explained Dr. Stack. Now, however, many otolaryngologists use positron emission tomography (PET) scans to determine if the patient has metastasis to the neck. The scan may show that the patient is cancer-free, making routine neck dissection unnecessary.
Or we can do a sentinel lymph node biopsy, a minimally invasive procedure, to see if the patient has cancer, he said.
To treat squamous cell cancer, which occurs mainly in the throat or tonsils, minimally invasive surgery is not often applicable, said David J. Terris, MD, Porubsky Professor and Chairman of the Department of Otolaryngology at the Medical College of Georgia in Augusta.
Rather, surgeons will use ablative surgery followed by state-of-the-art microvascular free flap reconstruction, which involves taking tissue from other parts of the body-for example, the anterolateral thigh flap or the inferior epigastric cutaneous flap-to fill in holes left by cancer surgery, he said.
Typically, patients are either referred to a reconstructive surgeon or the surgeon performing the excision also does same-day reconstruction, said Dr. Stack. Many major university medical schools are training otolaryngologists to perform reconstructive head and neck surgery using microvascular free flap transfer, he explained.
In addition to reconstructive surgery, the patient may need cosmetic touch-ups or enhancements at some point in the future because of the way incisions heal, said Dr. Stack. Postoperative radiation treatment can also cause tissue damage, which may eventually need to be surgically revised, he said.
Some patients may also require osseointegrated implants and dental prostheses for dental restoration, although an oral surgeon and maxillofacial prosthodontist generally performs these procedures, said Dr. Stack.
Parotid Disease
While patients with head and neck cancer may require reconstructive surgery, those with parotid disease may benefit cosmetically from incisions most often used for facelifts, said Dr. Terris.
To help minimize scarring in patients who need parotidectomy, surgeons can cut in front of the ear and then behind it into the hairline to access the gland. We used to make the incision continue down on the neck, which could produce an obvious scar, Dr. Terris said.
For this procedure, surgeons may also consider using a harmonic scalpel, which uses frictional energy to break down proteins and seal tissue and blood vessels, said Dr. Terris.
Harmonic scalpel technology may eventually be used in other facial surgeries because the tool allows the surgeon to dissect and ligate vessels in one cut, he explained. It could also be useful for neck dissection and laryngectomy, he added.
Sinus Tumors
To help maintain cosmesis when approaching tumors in the skull base sinuses, surgeons can use facial degloving, which avoids the use of open incisions, said Dr. Terris.
This procedure involves creating an incision under the lip and gum and pulling the facial skin above the nose and sinuses allowing access to these areas, said Dr. Terris. Once tumors are removed, the skin is placed in its original position using absorbable sutures, he explained.
The skull base is increasingly being approached endoscopically, added Dr. Stack.
Also of mention is endoscopic image-guided sinus surgery, which allows head and neck surgeons to remove tumors of the nose and sinuses without open facial incisions, said Dr. Stack.
Endoscopic sinus surgery has essentially replaced making incisions on the face to access tumors in the nasal and sinus passages, agreed Dr. Terris.
Facial Trauma
A degloving approach can also be used for patients with facial injuries from car accidents and other trauma, said Dr. Terris. Facial degloving initiated through the lip and gum area or further out in the cheek area can create access to facial fractures without creating open surgery incisions, he explained.
Sometimes surgeons access upper regions of the skull to repair trauma by making incisions around the eye area, he said.
Thyroid Disease
Thyroid surgery is another example of a procedure for which physicians can obtain good cosmesis and successful medical outcomes. Specific techniques for ensuring cosmesis were explored in a recent journal article (Laryngoscope 2007;117:1168-72) authored by Dr. Terris and his colleagues.
We’re beginning to blur the lines between plastic surgery and thyroid surgery, and otolaryngologists have the responsibility of thinking like plastic surgeons, said Dr. Terris.
The wound care principles addressed in the Terris et al. article, as well as many of the surgical techniques, are applicable to other head and neck surgeries, commented Dr. Stack.
The Data
To explore factors contributing to improved cosmesis in thyroid surgery, Dr. Terris and his colleagues conducted a prospective, nonrandomized study of 248 consecutive thyroid surgical patients undergoing a procedure between September 2003 and June 2006. The mean age of patients was 44.9 ± 14.6 years, and 198 were female.
Based on patient and disease parameters, 31% of individuals underwent conventional thyroidectomy, 48.4% had minimally invasive nonendoscopic thyroidectomy (MINET), and 20.6% endoscopic thyroidectomy. Incision lengths were 92.4 ± 22.3 mm, 46.4 ± 9.9 mm, and 24.3 ± 5.9 mm, respectively.
Researchers found that marking patients while they were sitting upright before undergoing surgery, resecting skin edges during closure, avoiding subplatysmal flap elevation and drains, and using liquid skin adhesive instead of sutures were among the factors that resulted in good cosmesis.
These techniques are pretty well-known, said Philip Miller, MD, an otolaryngologist and facial plastic surgeon in private practice in New York. The authors are using techniques used elsewhere for cosmesis and modifying them for thyroid surgery.
Preoperative Markings
Preoperatively, Dr. Terris finds that having patients sit upright, as opposed to lying down on the operating table, makes finding natural creases in the skin for incision much easier. This is similar to what would be done for someone having a facelift or cosmetic breast surgery, said Dr. Terris.
Careful incision planning that requires the patient to sit upright preoperatively for marking is a good idea because it can increase the visibility of natural creases and allow for an incision that is better hidden, said Steven Davis, MD, an otolayrngologist at Centinela Freeman Regional Medical Center in Inglewood, CA.
Incision Size
Because cosmesis is becoming increasingly important in thyroid surgery, surgeons may want to consider using smaller incisions to minimize scarring, but only if patient characteristics and nodule size allow, said Dr. Stack, adding that the surgical techniques described in the Terris et al. article can also be applied to parathyroid surgery. He suggests taking out a ruler and measuring the incision during surgery. A ruler can help you have some personal accountability, he said.
Overall, the small incisions discussed in the Terris et al. article are now being applied more broadly to head and neck surgery, noted Dr. Stack. We’re making smaller incisions or no incisions at all, in the case of nasal endoscopic procedures, he said.
The very smallest incisions for thyroid surgery are possible if the suspect nodule is 25 mm or less and the gland is not significantly enlarged, said Dr. Terris. To create smaller incisions, he uses the harmonic scalpel, he said, adding that endoscopic thyroid surgery can generally be done through a 15- to 20-mm cut.
With endoscopic surgery, physicians can often make smaller incisions and deliver the thyroid outside the body for excision, rather than making the long cut required during open surgery, explained Phillip Pellitteri, DO, a head and neck surgeon in the Department of Otolaryngology and Head and Neck Surgery at Geisinger Medical Center in Danville, PA.
However, pulling the thyroid gland through a small incision can cause maceration and trauma to the skin, increasing the risk of hypertrophic scarring, noted Dr. Terris. Trimming the skin edges can allow the wound to heal properly, he said.
If you take damaged tissue and sew it together, it’s not going to heal as well and may form an unattractive scar, commented Dr. Stack, adding that freshening skin edges may be useful for other head and neck procedures in which the skin is stretched to gain visualization.
Patients with larger nodules or those who are too obese for endoscopic surgery may need to undergo MINET, said Dr. Terris, adding that this procedure usually requires a 3- to 6-cm incision. Dysphagia, which can be a side effect of MINET due to cutting the strap muscles, has not been a problem in study patients. We repair these muscles at the end of the operation, he explained.
Fortunately, scarring can still be minimal when using MINET, or even conventional surgery, as long as the incision is well-planned and closed properly, said Dr. Davis. Of course, outcomes are best in patients who have a good intrinsic ability to heal.
The ability of a scar to heal is based primarily on the patient’s health and how the surgeon puts the tissues back together, said Dr. Pellitteri. Large incisions can heal just as well as small incisions, he said.
A small scar, even with minimally invasive surgery, can look worse than a large scar due to poor surgical technique or poor healing capability, Dr. Pellitteri added. No matter how skilled the surgeon, individuals with poor circulation, diabetes, or immunological disease, or those on steroid therapy, may form unsightly scars because of compromised wound healing, he said.
Other Surgical Techniques
In addition to freshening skin edges, not raising the subplatysmal flaps to gain access to the thyroid compartment reduces dissection and scar tissue and minimizes healing time, said Dr. Terris. Subplatysmal flaps were not raised in the open or minimally invasive surgeries in his study.
Avoiding drains is another way to minimize scarring because surgeons don’t have to create a second stab wound, said Dr. Terris. Compared with minimally invasive surgery, the chance of fluid collection is greater in open surgery due to increased tissue removal. Drains are supposed to prevent subsequent seroma or expanding hematoma, although data suggest they aren’t needed, he said.
Endoscopic techniques combined with the harmonic scalpel help to avoid the need for drains because the ultrasonic device’s hemostatic properties probably lower the risk of postoperative bleeding, added Dr. Terris.
Another strategy to reduce scarring is using medical glue to eliminate cross-hatching that may occur with traditional stitches, he said.
A sutureless closure that doesn’t pull or create traction lines in the upper layers of the skin can certainly help to avoid scars, agreed Dr. Pellitteri. The use of Dermabond is appropriate for small incisions.
Sutured skin for larger incisions does not have to result in an unsatisfactory scar either, he said. Location of the incision, avoidance of crossing the skin crease when suturing the wound, and burying the suture rather than placing it at the skin surface can minimize skin tension and scarring, explained Dr. Pellitteri.
Post-Surgery Management
Patients also play an important role obtaining good cosmetic results. For example, they can help reduce scarring by not pulling on the incision post-surgery, avoiding significant exercise that may aggravate the wound, and staying out of the sun and using sunscreen, said Dr. Terris. Sun exposure may cause a color mismatch between the scar and adjacent skin.
Massage may also be helpful for reducing scar tissue, although this technique should not be used until six weeks after surgery, he added.
Patients also need to keep the wound clean and dry, Dr. Stack noted. He also suggested using wound healing or antiscarring treatments, such as vitamin E capsules or an over-the-counter silicone gel a week or two post-surgery.
Individuals with hypertrophic scars that are not fading may want to consider injecting steroids to help soften and melt away damaged tissue, said Dr. Terris.
Excision of scars may also be an option. If healing is not satisfactory six months to a year after thyroid surgery, surgical removal of damaged tissue and freshening of the skin edges can help the wound heal properly, added Dr. Terris.
However, even if a scar is excised, this may not help prevent the reformation of hypertrophic scars or keloids, cautioned Dr. Davis.
Balancing Thyroid Cosmesis With Medical Outcomes
While scarring can be minimized in thyroid surgery, cosmesis should not outweigh the importance of medical outcomes, said Dr. Miller. For example, patients with thyroid cancer need to undergo full removal of their malignancy. Surgeons can make the scar look good, but they should not be wondering if they left anything behind, he said.
Moreover, further studies of thyroid surgery cosmesis need to demonstrate that long-term successful treatment is the same or better than conventional surgery, Dr. Miller added. In an attempt to improve cosmesis, you don’t want to interfere with the success of an operation, he concluded.
Whether the surgery is for thyroid disease or any other type of head and neck disease or injury, medical outcomes should always be the priority, concluded Drs. Stack and Terris.
©2007 The Triological Society