Conventional thyroidectomy is associated with an anterior neck scar ranging from 1 to 2 inches in length—a highly visible reminder to patients of their thyroid disease and a marker to others about their medical histories. Although thyroidectomy has been performed for 150 years, surgeons have only recently begun to apply endoscopic tools to tunnel to the thyroid from other locations to avoid the visible scar on the lower neck.

Initially pioneered in Asia, these endoscopic techniques include the TOETVA (transoral endoscopic thyroidectomy vestibular approach). “The TOETVA procedure was a milestone in that it eliminated a skin incision and scar from thyroidectomy by putting the incisions inside the mouth under the lower lip area,” says Insoo Suh, MD, associate professor of surgery at NYU Grossman School of Medicine. Dr. Suh was among the first U.S. surgeons to travel to Asia to study this technique and introduce it on the West Coast through a program at the University of California San Francisco. “However, the original TOETVA technique may have limitations, including the size of the specimen that can be removed through the middle incision without disruption as well as prolonged discomfort at the chin.”

Now at NYU Langone Health, Dr. Suh is continuing to pioneer the application of endoscopic techniques to thyroidectomy and to research the subject of surgical innovation more broadly. “My major research interests focus on innovative surgical techniques and alternative treatment technologies. I believe that we’re at the forefront of innovating upon the current techniques to make them even safer, better tolerated, and faster.”

TOaST: A Modified Transoral Approach

Dr. Suh and his colleagues have developed a modified transoral procedure that eliminates the need for significant dissection of the chin by creating an effectively invisible submental incision. The new approach, known as the transoral and submental technique (TOaST), reduces the potential for dissection-related complications of the type associated with TOETVA and shortens the path from the incision to the thyroid gland by substituting the submental incision for the central intraoral incision used in the TOETVA procedure.

In an article in the Journal of Surgical Research, Dr. Suh reported on the initial experience of 14 TOaST procedures between 2017 and 2018. Subjects included five patients with benign thyroid nodules, three with cytologically indeterminate nodules, three with papillary thyroid cancers, two with Graves’ disease, and one patient with a multinodular goiter. The technique was demonstrated to be safe in this series, with an extremely low rate of complications overall and no permanent complications such as recurrent laryngeal nerve injury and neck hematoma. The cosmetic results were outstanding.

Dr. Suh’s subsequent, larger experience with this technique has confirmed the safety and efficacy results from this initial case series as well as its potential broader applicability to selected patients. “About half of patients in a typical high-volume endocrine practice would be candidates for the procedure under currently accepted selection criteria,” Dr. Suh says.

Scarring Not a “Minor Concern” for Patients

Although the TOaST procedure does leave a scar, it is functionally invisible, placed in the submental area that is often the incision site for aesthetic procedures such as neck lifts and liposuction. “The idea of a visible scar is not a minor concern,” says Dr. Suh, who is a fierce patient advocate concerning the scar associated with conventional thyroidectomy and the impact it can have on patient satisfaction and self-perception.

“There’s a common theme that comes out of my conversations with most of these patients: it’s not about vanity, but rather about seeing the scar every day in the mirror, reminding the patient of the disease and unavoidably sharing private health information so visibly with the world,” says Dr. Suh. He likens the extra effort to avoid scarring as analogous to reconstructive breast surgery after a mastectomy rather than to other types of aesthetic surgery.

In a recent discrete choice experiment published in Thyroid, Dr. Suh and his colleagues found that, while the risk of nerve injury, travel distance, and cost remain the most important factors for patients choosing among various surgical approaches for thyroidectomy, cosmetic considerations also influence choices depending on patient age. Younger patients (defined as up to 60 years old) are significantly more likely to choose surgical approaches with no visible neck scar and are actually willing to accept significant trade-offs to achieve this outcome, such as more than $2,000 in increased out-of-pocket cost, nearly 700 miles in extra travel distance for surgery, and even a slightly higher rate of complications.

Despite the significance of the study, Dr. Suh cautions against overinterpretation of some of the findings. “For example, patients may be willing to tolerate an increased risk of complications, but that doesn’t necessarily mean that we should as surgeons,” he says. “Thankfully, this is a moot point because these techniques appear to be very safe. I think the most important takeaway here is that visible scars matter to many people, and so it is our duty to respect that by working to address this issue for our patients.”