Quality of life after remote access thyroid surgery: a narrative review

Introduction

Over the past 30 years, the rate of thyroid surgery has shown a steady increase and is now one of the most common surgeries performed in the United States (1). This is largely due to increase in thyroid cancer diagnoses and detection of thyroid nodules in North America (2-4). Given that the mortality risk of thyroid cancer has not increased within the same time frame, the increase in incidence is attributed to greater detection with medical imaging and access to health care resulting in an overdiagnosis of thyroid cancer (2,5).

Fortunately, differentiated thyroid cancer carries an excellent prognosis, with 5-year survival in the United States >98% for all stages (6). Given this data, it is imperative to balance the low morbidity of the pathology with the potential morbidity of thyroid surgery. Although the overall surgical complication rate is as low as 5.7% in high-volume centers (7), it is important to consider that there are many factors that influence quality of life (QoL) after thyroid surgery other than the generally reported complications. Decreases in QoL may impact return to work or employment status, cause financial or psychological hardship, and even increase rates of bankruptcy (8). Given the long survivorship of thyroid cancer patients, QoL differences between this group and the general population have the potential to be long-lasting. Therefore, it is critical to examine the factors that affect QoL to determine ways in which negative effects may be mitigated or eliminated. The aim of this review is to examine the published data on QoL after remote access thyroid surgery, to determine if avoidance of a cervical incision influences post-operative QoL. We present the following article in accordance with the Narrative Review reporting checklist (available at https://aot.amegroups.com/article/view/10.21037/aot-22-15/rc).

Methods

A systemic literature review was conducted to identify the published QoL outcomes in traditional and remote access thyroid surgery. Utilizing PubMed, SCOPUS and Google Scholar, the terms “thyroidectomy” or “thyroid surgery” were combined with “remote access” or “endoscopic” as well as “quality of life,” “outcomes,” “complications,” “cosmesis,” or “scar”” to identify studies published prior to February 1, 2022 (Table 1).

Methods to assess QoL

Multiple tools have been validated to quantify QoL scores, such as the SF-36 (Short Form Survey) (9), THYCA-QoL (Thyroid Cancer Quality of Life) (10), PROMIS (Patient Reported Outcome Measurement Information System) (11), and others. These instruments examine domains such as physical functioning, pain, general health, vitality, social function, emotional well-being, and mental health. Tools that are more specific to skin or cosmetic outcomes include the DLQI (Dermatology Life Quality Index) (12), BIS (Body Image Scale) (13), VSS (Vancouver Scar Scale) (14), and SCAR (Scar Cosmesis Assessment and Rating) (15).

Factors that impact QoL

One factor that holds an important influence on QoL after thyroid surgery is the preoperative diagnosis. In patients who undergo surgery for benign goiters, several studies found an improvement in post-operative QoL (16-19). Additionally, Promberger et al. found that those with histologically confirmed Hashimoto’s thyroiditis also experienced an improvement in QoL after surgery compared to preoperative baseline (20). However, this trend is not demonstrated in thyroidectomy performed for malignancy. Despite the excellent prognosis and high long-term survival rates (21), patients treated for differentiated thyroid cancer tend to have poorer health-related QoL (HRQoL) compared to the general public (22-24) as well as those who undergo thyroid surgery for benign pathology (25). In fact, overall QoL in patients with thyroid cancer is comparable to those with malignancies conferring poorer prognoses such as colon cancer, glioma, and gynecological cancer, and worse than those with breast cancer (26,27). Depending on the tool utilized, cancer patients have been found to score lower in sleep/fatigue, role functioning, cognitive functioning, social functioning, and financial stability (22). Likewise, Lubitz et al. found the domains of emotional and social impacts of treatment to be the most affected in the thyroid cancer population (24).

Many studies have aimed to characterize the factors contributing to decreased QoL in thyroid cancer survivors, which have been found to include age, sex, extent of surgery, education level, and radioactive iodine therapy (28-30). Goldfarb examined factors impacting the HRQoL of young adult survivors of thyroid cancer, and found that patients aged 17–39 years had significantly more complaints related to their scar, anxiety, and overall psychological state than their older counterparts (31). Females also had poorer QoL scores, as well as more concerns regarding their scar than men (32). This is particularly applicable considering that thyroid cancer is the most common cancer in 16–33 years old (33), and that approximately 75% of all thyroid cancers occur in women (34). Likewise, a large scale study of 1,743 patients by Goswami et al. demonstrated that along with the previously reported factors, concerns regarding scar appearance had a significant impact on post-operative QoL in the domains of anxiety, social function, and depression (35). Moreover, 77.4% of respondents had concerns regarding their scar appearance, which was greater than the portion of patients with dysphagia, dysphonia, or hypocalcemia. The mean length of time since surgery in this cohort was 7 years, which suggests that these effects can be long standing. In contrast, other studies have found that the detriment to QoL is in fact diminished with time, with QoL scores returning to baseline anywhere from 6 months (36) to 2 years (30).

Remote access approaches

Traditionally, thyroid surgery has been performed through a cervical incision which results in a visible anterior neck scar. Given the potential patient aversion to an appreciable scar, there have been multiple surgical approaches applied an effort to move this scar to less conspicuous areas. Ohgami et al. first described an endoscopic thyroidectomy which utilized two peri-areolar incisions as well as a parasternal incision within the breast tissue (37). Modifications on this approach include a combination of axillary and areolar incisions, in order to avoid a parasternal scar as well as improve viewing angles (38,39). Other authors describe a solely axillary approach, in order to avoid breast incisions altogether (40). However, complications encountered in the axilla such as injury to the brachial plexus and esophagus prompted further novel techniques. The retroauricular or “facelift” approach was described in 2011 as an alternative path to the thyroid bed that could avoid challenges associated the axillary approach (41). However, this approach also involves potentially unfamiliar tissue planes and the risk of novel complications including hypesthesia in the greater auricular nerve distribution and risk of flap necrosis. Although these various methods avoid an anterior neck incision, they still require a cutaneous scar. Further efforts to eliminate visible scarring resulted in publication of a sublingual approach to the thyroid bed (42,43). In 2011, Richmon et al. described a transoral endoscopic thyroidectomy vestibular approach (TOETVA) which utilizes three incisions in the gingivobuccal sulcus in order to perform a truly “scarless” procedure and avoid injury to the floor of the mouth (44). Since TOETVA was first described, there have been over 2,000 cases published in the literature (45). This method has had the most rapid adoption compared to other approaches (46), possibly due to a relatively short learning curve (47), ready access to the bilateral thyroid beds, and ability to use standard laparoscopic instruments.

QoL outcomes

A primary aim of remote access approaches is to mitigate the effect of a visible scar. Therefore, QoL outcomes have been measured in an effort to compare the traditional transcervical approach to various remote access approaches, utilizing the metrics and scales discussed above. A study by Lee et al. examined 75 patients who underwent endoscopic thyroid lobectomy [surgical methods included bilateral axillo-breast approach (BABA) and unilateral axillo-breast approach (UABA), with and without insufflation] and 233 patients who underwent a traditional cervical thyroid lobectomy (36). QoL measures were assessed using the EORTC-QLQ-C30 (European organization for Research Treatment of Thyroid Cancer core quality of life questionnaire) preoperatively and at regular intervals post operatively, up to 6 months. Although pain was greater in the endoscopic patients, these patients had significantly greater improvement in emotional and physical function in the early (1 and 3 months) post-operative period. This effect was mitigated by 6 months post-operatively, when the endoscopic and open patient groups had no significant difference in QoL scores. Similarly, Kurumety et al. found that although there was a significant correlation between self-perception of neck appearance and anxiety, depression, social function and fatigue, these effects return to baseline 2 years after surgery (30). However, the authors admit that populations more at risk for hypertrophic or keloid scarring were underrepresented in their study, as 95% of the study population was Caucasian. In a more diverse population where nearly 50% of the respondents were of Asian, Afro-Caribbean or Hispanic descent, 15% had a scar-related complication including hypertrophic or keloid scarring (25). For those that did experience dissatisfaction with their scar, this factor had a significantly greater effect on their QoL than their counterparts who did not have a poor cosmetic outcome. This showcases the importance of consideration of one’s patient population and their risk of scar complications relative to other races or ethnicities. Within this same study population, the patient’s subjective rating of their scar appearance was significantly worse in patients with a diagnosis of cancer compared to those who underwent surgery for benign disease (25). The scar itself should not grossly differ based on the surgical pathology, and therefore this raises the possibility that a visible scar may serve as a reminder of a cancer diagnosis for these patients.

Given these findings, the impact of dermatologic and cosmetic outcomes on surgical patients’ QoL should not be discounted. In one series, the impact of a cervical incision was found to be comparable to that of patients with skin conditions such as psoriasis and atopic dermatitis (48) when utilizing the Dermatology Life Quality Index (DLQI). The DLQI is a 10-question survey instrument that assesses the impact of skin lesions or disease on patients’ QoL, in which the scores from each question are summed for a minimum score of 0 and a maximum score of 30. Russell et al. also used this survey to examine 15 patients who underwent thyroidectomy or parathyroidectomy via a remote access approach (49). DLQI scores were obtained at the patient’s first post-operative visit, with median and mean scores being 3.0 and 3.9 respectively. While there was no control group of open thyroidectomy patients, the authors compared the DLQI scores to a prior study (48) where the mean score for a traditional cervical thyroidectomy was 9.02. A score from 2–5 has been quantified as a “small effect” on the patient’s life, whereas a score from 6–10 shows a “moderate effect” (50). This data thus shows a substantially smaller impact of surgery on QoL for patients without a cervical incision compared to previously published data of patients with a cervical incision.

Interestingly, efforts to decrease the size of the scar have not been associated with improved patient satisfaction, suggesting that the mere presence of a scar is more impactful than the size of the scar (25,51,52). This may be due in part to visual attention being drawn towards any scar that is present, despite its size. Several studies utilizing eye-tracking technology have found that observers’ visual attention was drawn away from the peripheral face and towards the neck more frequently and for longer durations in open thyroidectomy patients than patients that had a transoral endoscopic thyroidectomy, suggesting that a cervical incision is noticeable and distracting to the casual observer (53,54). This brings forth the issue of patient privacy, as a cervical incision serves as a disclosure of a person’s surgical history regardless of their intent to share this information with others (55).

Body image is also closely related to one’s self perception of health and QoL in surgical patients (56). Therefore, the Body Image Scale (BIS) is another metric used to evaluate QoL outcomes. Lee et al. found that patients who avoided a cervical incision had improved body image perceptions in six out of ten categories, and a higher overall BIS score at final evaluation (57). Although the patients’ objective scar appearance improved (as evaluated by the Vancouver Scar Scale), they remained with lower body image scores compared to those with remote incisions. Similarly, Sethukumar et al. found that in their study of 123 patients with cervical incisions, high QoL scores correlated with better scar perception while negative body image correlated with a negative scar perception (52). These findings suggest that regardless of surgical outcome, patients’ perceptions of their cervical scar are correlated with their overall body perception and well-being. This result is confirmed by Song et al., in which patients who underwent a robotic thyroidectomy had higher cosmetic satisfaction, neck appearance, and physical competence scores than those patients who had a transcervical thyroidectomy (58). These findings are summarized in Table 2.

Finally, the SF-36 is a survey in which patients assess their well-being in eight dimensions of health. Wongwattana et al. examined the QoL outcomes for patients with Bethesda I−III nodules undergoing TOETVA and endoscopic thyroidectomy axillo-breast approach (ETABA) patients using the SF-36 (59). Although early post-operative pain scores were higher in the TOETVA group, overall post-operative QoL outcomes were equivalent between TOETVA patients and ETABA patients. Notably, there was no significant difference between pre-operative and post-operative QoL for either group. This data suggests that remote access approaches allow patients to return to the same QoL they had before surgery, at least in surgery for non-malignant nodules.

While cervical incision sparing techniques may have advantages, it is critical to recognize that remote access approaches are not indicated for all patients, nor should they be performed by surgeons who have not undergone extensive preparation. This preparation includes ensuring high thyroid volume, familiarity with existing literature, operative team/administration preparation, familiarity with the procedure, real-time observation of cases, cadaver dissection, and preceptor available for initial cases (60). Strict patient selection should be employed in accordance with published guidelines (49,61-65), particularly in cases of malignancy (45,66,67).

It should also be noted that many studies utilize generalized QoL questionnaires that are not specific thyroid cancer or thyroid surgery. The THYCA-QoL and QoL-TV (Quality of Life-Thyroid Version) were developed for this purpose and provide questions unique to thyroid cancer. Therefore, studies utilizing these metrics may provide stronger evidence towards conclusions regarding thyroid cancer survivors. Similar to QoL instruments, cosmetic or dermatologic scales such as the DLQI and BIS are not specific to scars and therefore may not consistently be generalizable to all patients. While studies utilizing the VAS, VSS, or SCAR metrics may offer more specific QoL data, these scales are not specific for cervical incisions. This variation in metrics utilized and non-specificity of the scales produces difficulty in drawing reliable and generalizable conclusions across an already limited QoL data field.

Conclusions

Despite excellent surgical outcomes, many thyroidectomy patients suffer from decreased post-operative QoL measures. This outcome is especially pronounced in patients undergoing surgery for thyroid malignancy. Remote access approaches aim to mitigate the effect that a visible cervical incision has on patient’s body image, self-perception, and overall well-being. Existing literature shows that cervical incisions do affect these domains and suggests that remote access approaches provide improved body image and self-perception. However, further large-scale research is needed to assess how these differences affect overall QoL and if improvements persist over time.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Vaninder Dhillon and Elizabeth Cottrill) for the series “Improved Quality of Life after Thyroid Surgery” published in Annals of Thyroid. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aot.amegroups.com/article/view/10.21037/aot-22-15/rc

Peer Review File: Available at https://aot.amegroups.com/article/view/10.21037/aot-22-15/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aot.amegroups.com/article/view/10.21037/aot-22-15/coif). The series “Improved Quality of Life after Thyroid Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Sosa JA, Hanna JW, Robinson KA, et al. Increases in thyroid nodule fine-needle aspirations, operations, and diagnoses of thyroid cancer in the United States. Surgery 2013;154:1420-6; discussion 1426-7. [Crossref] [PubMed]
2. La Vecchia C, Malvezzi M, Bosetti C, et al. Thyroid cancer mortality and incidence: a global overview. Int J Cancer 2015;136:2187-95. [Crossref] [PubMed]
3. Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg 2014;140:317-22. [Crossref] [PubMed]
4. Kitahara CM, Sosa JA. The changing incidence of thyroid cancer. Nat Rev Endocrinol 2016;12:646-53. [Crossref] [PubMed]
5. Li M, Brito JP, Vaccarella S. Long-Term Declines of Thyroid Cancer Mortality: An International Age-Period-Cohort Analysis. Thyroid 2020;30:838-46. [Crossref] [PubMed]
6. Cancer Facts & Figures 2020 Atlanta: American Cancer Society, 2020. Available online: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf
7. Meltzer C, Klau M, Gurushanthaiah D, et al. Surgeon volume in thyroid surgery: Surgical efficiency, outcomes, and utilization. Laryngoscope 2016;126:2630-9. [Crossref] [PubMed]
8. Chan WL, Choi HC, Lang B, et al. Health-Related Quality of Life in Asian Differentiated Thyroid Cancer Survivors. Cancer Control 2021;28:10732748211029726. [Crossref] [PubMed]
9. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83. [Crossref] [PubMed]
10. Sturgeon C. The THYCA-QoL Questionnaire can be used to measure health-related quality of life in thyroid cancer survivors. Clin Thyroidol 2014;26:16-8. [Crossref]
11. Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Med Care 2007;45:S3-S11. [Crossref] [PubMed]
12. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. [Crossref] [PubMed]
13. Hopwood P, Fletcher I, Lee A, et al. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189-97. [Crossref] [PubMed]
14. Sullivan T, Smith J, Kermode J, et al. Rating the burn scar. J Burn Care Rehabil 1990;11:256-60. [Crossref] [PubMed]
15. Kantor J. Reliability and Photographic Equivalency of the Scar Cosmesis Assessment and Rating (SCAR) Scale, an Outcome Measure for Postoperative Scars. JAMA Dermatol 2017;153:55-60. [Crossref] [PubMed]
16. Bukvic BR, Zivaljevic VR, Sipetic SB, et al. Improvement of quality of life in patients with benign goitre after surgical treatment. Langenbecks Arch Surg 2014;399:755-64. [Crossref] [PubMed]
17. Mishra A, Sabaretnam M, Chand G, et al. Quality of life (QoL) in patients with benign thyroid goiters (pre- and post-thyroidectomy): a prospective study. World J Surg 2013;37:2322-9. [Crossref] [PubMed]
18. Sorensen JR, Watt T, Cramon P, et al. Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study. Head Neck 2017;39:2232-40. [Crossref] [PubMed]
19. Chew CR, Chin SL, Lam T, et al. How does thyroidectomy for benign thyroid disease impact upon quality of life? A prospective study. ANZ J Surg 2020;90:E177-82. [Crossref] [PubMed]
20. Promberger R, Hermann M, Pallikunnel SJ, et al. Quality of life after thyroid surgery in women with benign euthyroid goiter: influencing factors including Hashimoto's thyroiditis. Am J Surg 2014;207:974-9. [Crossref] [PubMed]
21. Brenner H. Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet 2002;360:1131-5. [Crossref] [PubMed]
22. Singer S, Lincke T, Gamper E, et al. Quality of life in patients with thyroid cancer compared with the general population. Thyroid 2012;22:117-24. [Crossref] [PubMed]
23. Rogers SN, Mepani V, Jackson S, et al. Health-related quality of life, fear of recurrence, and emotional distress in patients treated for thyroid cancer. Br J Oral Maxillofac Surg 2017;55:666-73. [Crossref] [PubMed]
24. Lubitz CC, De Gregorio L, Fingeret AL, et al. Measurement and Variation in Estimation of Quality of Life Effects of Patients Undergoing Treatment for Papillary Thyroid Carcinoma. Thyroid 2017;27:197-206. [Crossref] [PubMed]
25. Arora A, Swords C, Garas G, et al. The perception of scar cosmesis following thyroid and parathyroid surgery: A prospective cohort study. Int J Surg 2016;25:38-43. [Crossref] [PubMed]
26. Applewhite MK, James BC, Kaplan SP, et al. Quality of Life in Thyroid Cancer is Similar to That of Other Cancers with Worse Survival. World J Surg 2016;40:551-61. [Crossref] [PubMed]
27. Goswami S, Mongelli M, Peipert BJ, et al. Benchmarking health-related quality of life in thyroid cancer versus other cancers and United States normative data. Surgery 2018;164:986-92. [Crossref] [PubMed]
28. Aschebrook-Kilfoy B, James B, Nagar S, et al. Risk Factors for Decreased Quality of Life in Thyroid Cancer Survivors: Initial Findings from the North American Thyroid Cancer Survivorship Study. Thyroid 2015;25:1313-21. [Crossref] [PubMed]
29. Li J, Xue LB, Gong XY, et al. Risk Factors of Deterioration in Quality of Life Scores in Thyroid Cancer Patients After Thyroidectomy. Cancer Manag Res 2019;11:10593-8. [Crossref] [PubMed]
30. Kurumety SK, Helenowski IB, Goswami S, et al. Post-thyroidectomy neck appearance and impact on quality of life in thyroid cancer survivors. Surgery 2019;165:1217-21. [Crossref] [PubMed]
31. Goldfarb M, Casillas J. Thyroid Cancer-Specific Quality of Life and Health-Related Quality of Life in Young Adult Thyroid Cancer Survivors. Thyroid 2016;26:923-32. [Crossref] [PubMed]
32. Best AR, Shipchandler TZ, Cordes SR. Midcervical scar satisfaction in thyroidectomy patients. Laryngoscope 2017;127:1247-52. [Crossref] [PubMed]
33. Araque DVP, Bleyer A, Brito JP. Thyroid cancer in adolescents and young adults. Future Oncol 2017;13:1253-61. [Crossref] [PubMed]
34. Surveillance, Epidemiology, and End Results Program (SEER). Available online: www.seer.cancer.gov
35. Goswami S, Peipert BJ, Mongelli MN, et al. Clinical factors associated with worse quality-of-life scores in United States thyroid cancer survivors. Surgery 2019;166:69-74. [Crossref] [PubMed]
36. Lee MC, Park H, Lee BC, et al. Comparison of quality of life between open and endoscopic thyroidectomy for papillary thyroid cancer. Head Neck 2016;38:E827-31. [Crossref] [PubMed]
37. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000;10:1-4. [Crossref] [PubMed]
38. Ikeda Y, Takami H, Sasaki Y, et al. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-40. [Crossref] [PubMed]
39. Shimazu K, Shiba E, Tamaki Y, et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 2003;13:196-201. [Crossref] [PubMed]
40. Kang SW, Jeong JJ, Nam KH, et al. Robot-assisted endoscopic thyroidectomy for thyroid malignancies using a gasless transaxillary approach. J Am Coll Surg 2009;209:e1-7. [Crossref] [PubMed]
41. Singer MC, Seybt MW, Terris DJ. Robotic facelift thyroidectomy: I. Preclinical simulation and morphometric assessment. Laryngoscope 2011;121:1631-5. [Crossref] [PubMed]
42. Witzel K, von Rahden BH, Kaminski C, et al. Transoral access for endoscopic thyroid resection. Surg Endosc 2008;22:1871-5. [Crossref] [PubMed]
43. Benhidjeb T, Wilhelm T, Harlaar J, et al. Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method. Surg Endosc 2009;23:1119-20. [Crossref] [PubMed]
44. Richmon JD, Holsinger FC, Kandil E, et al. Transoral robotic-assisted thyroidectomy with central neck dissection: preclinical cadaver feasibility study and proposed surgical technique. J Robot Surg 2011;5:279-82. [Crossref] [PubMed]
45. Russell JO, Sahli ZT, Shaear M, et al. Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update. Gland Surg 2020;9:409-16. [Crossref] [PubMed]
46. Banuchi VE, Ballakur SS, Russell JO, et al. Benefits and risks of scarless thyroid surgery. Ann Thyroid 2020;5:24. [Crossref]
47. Razavi CR, Vasiliou E, Tufano RP, et al. Learning Curve for Transoral Endoscopic Thyroid Lobectomy. Otolaryngol Head Neck Surg 2018;159:625-9. [Crossref] [PubMed]
48. Choi Y, Lee JH, Kim YH, et al. Impact of postthyroidectomy scar on the quality of life of thyroid cancer patients. Ann Dermatol 2014;26:693-9. [Crossref] [PubMed]
49. Russell JO, Clark J, Noureldine SI, et al. Transoral thyroidectomy and parathyroidectomy - A North American series of robotic and endoscopic transoral approaches to the central neck. Oral Oncol 2017;71:75-80. [Crossref] [PubMed]
50. Hongbo Y, Thomas CL, Harrison MA, et al. Translating the science of quality of life into practice: What do dermatology life quality index scores mean? J Invest Dermatol 2005;125:659-64. [Crossref] [PubMed]
51. Kim SM, Chun KW, Chang HJ, et al. Reducing neck incision length during thyroid surgery does not improve satisfaction in patients. Eur Arch Otorhinolaryngol 2015;272:2433-8. [Crossref] [PubMed]
52. Sethukumar P, Ly D, Awad Z, et al. Scar satisfaction and body image in thyroidectomy patients: prospective study in a tertiary referral centre. J Laryngol Otol 2018;132:60-7. [Crossref] [PubMed]
53. Juarez MC, Ishii L, Nellis JC, et al. Objectively measuring social attention of thyroid neck scars and transoral surgery using eye tracking. Laryngoscope 2019;129:2789-94. [Crossref] [PubMed]
54. Liao D, Ishii LE, Chen LW, et al. Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery. Laryngoscope 2020;130:1603-8. [Crossref] [PubMed]
55. James BC, Angelos P, Grogan RH. Transoral endocrine surgery: Considerations for adopting a new technique. J Surg Oncol 2020;122:36-40. [Crossref] [PubMed]
56. DeFrank JT, Mehta CC, Stein KD, et al. Body image dissatisfaction in cancer survivors. Oncol Nurs Forum 2007;34:E36-41. [Crossref] [PubMed]
57. Lee S, Kim HY, Lee CR, et al. A prospective comparison of patient body image after robotic thyroidectomy and conventional open thyroidectomy in patients with papillary thyroid carcinoma. Surgery 2014;156:117-25. [Crossref] [PubMed]
58. Song CM, Ji YB, Bang HS, et al. Quality of life after robotic thyroidectomy by a gasless unilateral axillary approach. Ann Surg Oncol 2014;21:4188-94. [Crossref] [PubMed]
59. Wongwattana P, Laoveerakul P, Santeerapharp A. A comparison of efficacy and quality of life between transoral endoscopic thyroidectomy vestibular approach (TOETVA) and endoscopic thyroidectomy axillo-breast approach (ETABA) in thyroid surgery: non-randomized clinical trial. Eur Arch Otorhinolaryngol 2021;278:4043-9. [Crossref] [PubMed]
60. Russell JO, Anuwong A, Dionigi G, et al. Transoral Thyroid and Parathyroid Surgery Vestibular Approach: A Framework for Assessment and Safe Exploration. Thyroid 2018;28:825-9. [Crossref] [PubMed]
61. Anuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. World J Surg 2016;40:491-7. [Crossref] [PubMed]
62. Dionigi G, Lavazza M, Bacuzzi A, et al. Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z. Surg Technol Int 2017;30:103-12. [PubMed]
63. Grogan RH, Suh I, Chomsky-Higgins K, et al. Patient Eligibility for Transoral Endocrine Surgery Procedures in the United States. JAMA Netw Open 2019;2:e194829. [Crossref] [PubMed]
64. Jitpratoom P, Ketwong K, Sasanakietkul T, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy. Gland Surg 2016;5:546-52. [Crossref] [PubMed]
65. Wang C, Zhai H, Liu W, et al. Thyroidectomy: a novel endoscopic oral vestibular approach. Surgery 2014;155:33-8. [Crossref] [PubMed]
66. Wu YJ, Chi SY, Elsarawy A, et al. What is the Appropriate Nodular Diameter in Thyroid Cancer for Extraction by Transoral Endoscopic Thyroidectomy Vestibular Approach Without Breaking the Specimens? A Surgicopathologic Study. Surg Laparosc Endosc Percutan Tech 2018;28:390-3. [Crossref] [PubMed]
67. Razavi CR, Russell JO. Indications and contraindications to transoral thyroidectomy. Ann Thyroid 2017;2:12. [Crossref] [PubMed]