This single-center, prospective observational study was conducted from October 2011 to March 2012 at the Department of Dermatology, Gangnam Severance Hospital, Korea. Informed consent was obtained from all participants after providing extensive written and oral information about the study. The study protocol was approved by the ethics committee of Gangnam Severance Hospital (Registration No. 3-2011-0193).

Thyroid cancer patients who underwent traditional thyroidectomy surgery at the Department of Surgery in Gangnam Severance Hospital, Yonsei University were assessed for inclusion. The criteria for patient selection were as follows: patients with thyroid cancer who had undergone traditional thyroidectomy procedures at least 2 months before the survey; able to provide written informed consent; aged 16 years or older; able to read the Korean language; and did not have any severe dermatological, mental, or physical illnesses.

The DLQI is one of the most frequently used QoL measure in dermatology6. It consists of 10 questions and is designed for use in patients older than 16 years. The questions are classified to subscales: symptoms and feelings (questions 1 and 2), daily activities (questions 3 and 4), leisure (questions 5 and 6), personal relationships (questions 8 and 9), work and school (question 7), and treatment (question 10) (Appendix). The total DLQI score is calculated by summing the scores of the 10 questions with a maximum score of 30 and a minimum score of 0. The higher the score, the more the QoL is impaired. Grade 1 (0~1) indicates no effect, grade 2 (2~5) indicates a small effect, grade 3 (6~10) indicates a moderate effect, grade 4 (11~20) indicates a very large effect, and grade 5 (21~30) indicates an extremely large effect.7 In this study, we used a validated Korean translation of the DLQI.

Photographs of all scars were taken by using identical camera settings, patient positioning, and room lighting. Two dermatologists blinded to other study parameters performed the clinical assessment of scars by using a modified Vancouver scar scale (VSS) composed of four parameters: vascularity, thickness, pliability, and pigmentation8. To evaluate vascularity more precisely, dermoscopic examination was performed. Postthyroidectomy scar lesions present for ≤1 year were classified as active scars, whereas those present for >1 year were classified as mature scars.

Statistical analyses were performed by using SAS version 9.2 software (SAS Institute, Cary, NC, USA). Descriptive data are presented as counts with percentages and means with standard deviations. Logistic regression was used to identify relations between DLQI scores and clinical, social, and demographic factors. Risk factors with p<0.05 were considered statistically significant in a univariate model. Results are presented with p-values.

Ninety-seven patients (8 men, 89 women) were recruited for the study. The demographic and clinical characteristics of the participants are given in Table 1. The median age was 36.9 years (range, 16~64 years). The mean time that had elapsed from the thyroidectomy to the survey was 12.9 months.

The classification and definition of postthyroidectomy scars were as follows (Fig. 1): (i) linear flat scars, flat scars with linear configuration; (ii) linear bulging scars, similar to linear flat scars but with bulging on the upper portion of the scar; (iii) hypertrophic scars, elevated scars that are typically raised and stiffer than the surrounding skin; and (iv) adhesive scars, immovable by manual inspection, and exhibiting fixation to the underlying skin.

The postthyroidectomy scars were classified as linear flat scars in 32 patients (33.0%), linear bulging scars in 9 patients (9.3%), hypertrophic scars in 41 patients (42.3%), and adhesive scars in 15 patients (15.5%).

Symptoms associated with postthyroidectomy scars were present in 64 patients (66.0%), including pruritus (n=37, 38.1%), tightening (n=29, 29.9%), pain (n=12, 12.4%), and burning sensation (n=3, 3.1%). After traditional thyroidectomy, the obtained specimens were diagnosed as papillary microcarcinoma in 67 patients (69.1%), papillary carcinoma in 24 patients (24.7%), adenomatous hyperplasia in 3 patients (3.1%), follicular adenoma in 2 patients (2.1%), and thyroid goiter in 1 patient (1.0%), according to postoperative pathological evaluation.

The VSS scores differed significantly among the types of scars (Table 2, Fig. 2; p<0.05). The mean VSS score was 5.18±2.24; the VSS scores were as follows: 3.09 for linear flat scars, 6.89 for linear bulging scars, 6.29 for hypertrophic scars, and 5.60 for adhesive scars.

DLQI indicated that postthyroidectomy scars impaired QoL in thyroid cancer patients (Table 3). The mean DLQI score was 9.02±5.79 (minimum=0, maximum=12). Domain 2 (daily activities, 2.87 points) was the most greatly affected among patients with postthyroidectomy scars. The lowest mean DLQI individual score was for item 7 (work and school, 0.36 points), whereas the highest mean DLQI score was for item 4 (clothing, 1.95 points) (Fig. 3). The relations between DLQI scores and clinical, social, and demographic factors were analyzed by using logistic regression analyses (Table 4). A univariate analysis showed that patients with associated symptoms such as pruritus, pain, burning, or tightening (ratio of mean DLQI differences in scores of patients without the symptom to patients with the symptom=6.45 : 10.34) showed greater QoL impairment. Scores were not associated with age, body mass index (BMI), employment, marital status, number of children, smoking, type of scar, time elapsed after surgery, or VSS score.