Reply to: Long-term cosmetic results after minimally invasive video-assisted thyroidectomy

Abstract

Dear Dr. Mangano, We have read your very interesting article about the important evolution in endocrine surgery over the last few years, especially regarding video-assisted technology in thyroid surgery. The aim of the constant development of all procedures is to increase the patients’ satisfaction. The advantages of minimally invasive video-assisted thyroidectomy (MIVAT) over conventional thyroidectomy are described in terms of postoperative pain and cosmetic results [1, 2]. Improved patient satisfaction in having a smaller neck scar has been the main argument for implementation of this approach. The small incision is the major difference, as well as the measuring criterion in comparison between minimally invasive and conventional thyroid surgery. I completely agree that the standardized operative technique is an important step for successful results. The procedure of skin closure is of the same importance comparing minimally invasive surgery versus conventional thyroid surgery. In this regard, it might be highly interesting to become familiar with your unpublished data relating to the influence of the kind of surgical technique and the type and diameter of the suturing wire on the cosmetic results. In our study, a standardized procedure was shown by using an absorbable suture (Dexon 4x0; Dexon; B. Braun Melsungen AG, Germany) [3]. In this regard, I would like to add that we performed an inverting suture. Your idea that skin closures are done by the same surgeon seems hardly realizable in the present supply situation. Your remarks concerning the use of an ultrasonic scalpel with intraoperative cooling of the tip of the instruments in physiologic water are very important. Thermal injuries on the skin incision due to the increased temperature of the tip of the instruments during the surgical procedures are a well-known problem. We cover the lower edge of the wound by an operation cloth to avoid thermal injuries of the skin. Also in this regard, it is worthwhile to find out the influence of the different procedures. Furthermore, it is important to impose the cosmetic results of thyroid surgery by a standardized evaluation. Only that way are results really comparable. The Patient and Observer Scar Assessment Scale we used is a complete scar evaluation tool developed by plastic surgeons [4]. In this regard, it is important to gather the results by follow-up examination. Using this method we have been able to compare our results with a Canadian study referring to the comparison of minimal access and conventional access [5]. Another fact is the time at which the post-surgery examination is performed. The scar analysis needs longterm follow-up at a minimum of 6 months because the healing and remodeling process is a long procedure [6]. In our study, the average follow-up period was 22.4 months. Another issue associated with the use of the MIVAT technique is the problem of keloid. In our study, we showed that ten women (with an average age of 38 years), who make up 10.4 % of all MIVAT patients, experienced keloid [3]. Furthermore, these results can only be shown by using long-term follow-up examination. Further exaltations are necessary in this regard. In your article you mentioned the genetic influence and interpersonal variability among patients, such as age, skin or phototype, as being influential M. Sahm (&) M. Pross Department of Surgery, DRK Kliniken Berlin Kopenick, Berlin, Germany e-mail: m.sahm@drk-kliniken-berlin.de