Transverse submammary skin incision for thyroidectomy

Abstract

The low collar incision is the usual route for thyroidectomies because it allows excellent access to the thyroid gland and heals well. However, many African patients develop keloid scars. Moreover, such an overtly visible 'cut throat' scar in a young woman constitutes a taboo in many areas. Bilateral submammary skin incision with development of a flap that includes the subcutaneous tissue and the breasts allows good exposure of the thyroid for thyroidectomy.Our experience with this unique approach is presented. January 1985 and December 1987, 32 women between the ages of 19 and 35 years with simple goitre, had thyroidectomy through the submammary approach. The approach is started as described by William and Hanlon for median sternotomy using a transverse submammary skin incision' ; it was popularized by Bedard et a1. ' and Laks and Hammond3. Once the suprasternal space of Burns is reached, two Dever retractors are applied under the flap to aid in the dissection of the flap over the thyroid gland. Using both blunt and sharp dissection, the flap over the strap muscles is split in the median plane to expose the pretracheal fascia. Thyroidectomy is carried out in the usual fashion and haemostasis is secured. A long tube drain is inserted and passed out through the stab wound below the lower skin incision. The strap muscles are closed loosely above and left open below so that the thyroid cavity communicates freely with the space below the flap; two Redivac (O.E.C. Orthopaedic) drains are left under the flap. The flap is tagged onto the chest wall in three places on each side. Subcutaneous stitches must be placed in an interrupted fashion. Patients and methods Between ResultsThere were no hospital or late deaths. The mean follow-up is 21.4 months. Thyroidectomy was successfully done in all patients. All patients left hospital 5-7 days after operation. There was no major wound infection or necrosis of the flap.In 15 patients (47 per cent) hypertrophic scars started to develop; these were reduced by timely intralesional injection with triamcinolone. Two patients (6 per cent) had loss of cutaneous sensation around the lateral aspect of the skin incision. DiscussionThe low collar incision is the standard approach to the thyroid gland. It gives the quickest and most complete exposure for all thyroid and parathyroid operations. Unfortunately, in the African, ugly hypertrophic and keloid scars which are detrimental to the quality of life may develop after a low collar incision. This can be avoided by approaching the thyroid gland through a bilateral submammary incision which is feasible and without any added significant morbidity or mortality, while the scar, whether ugly or hypertrophic, is hidden under the breasts. The submammary approach has been used extensively in female patients undergoing sternotomy for cardiac operations with excellent results.This approach to the thyroid gland is recommended for the consenting cosmetically conscious female patient under 35 years who is likely to develop visible ugly or hypertrophic...