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June 17, 2026
Thyroid surgery no longer has to leave a scar on your neck. A technique called TOETVA — the Transoral Endoscopic Thyroidectomy Vestibular Approach — makes it possible to remove the thyroid gland entirely through small incisions inside the lower lip, leaving no visible mark anywhere on the body. Most patients are eligible.
Below are answers to the questions I hear most often.
"Scarless" thyroid surgery — formally called remote access thyroidectomy — is a category of thyroid surgery in which all incisions are placed far away from the visible front of the neck. The most advanced form, and the only one with zero skin incisions anywhere on the body, is TOETVA.
Three small openings are made inside the lower lip, within the oral vestibule. A thin camera and specialized instruments are passed through those openings to remove all or part of the thyroid gland. Because no cut is made on the skin, there is no visible scar after surgery — anywhere. Most patients are eligible for this approach.
Watch our animated overview here: https://www.youtube.com/watch?v=wEiir0vs0_A
Under general anesthesia, three small incisions are made inside the lower lip. A thin endoscopic camera and specialized instruments are inserted through these openings. The surgeon creates a working space under the skin of the chin and upper neck, then removes the thyroid gland. Incisions are closed with absorbable sutures that do not require removal.
Other remote access approaches — such as transaxillary (armpit), bilateral axillo-breast, or retroauricular ("facelift") thyroidectomy — avoid neck scars but still require incisions somewhere on the skin. TOETVA is the only approach with zero skin incisions, making it the only truly "scarless" option.
It also has practical advantages: a shorter operative path to the thyroid, no drain required, and a shorter learning curve than robotic approaches that depend on expensive platforms.
Most patients are eligible for "scarless" thyroid surgery. Research from Johns Hopkins, the University of Chicago, and UCSF has demonstrated that a majority of thyroid surgery patients qualify. Good candidates include patients with benign thyroid nodules, well-differentiated thyroid cancer, Graves' disease, or multinodular goiter.
Factors that may limit candidacy include a very large thyroid gland, prior central neck surgery with significant scarring, or advanced thyroid cancer requiring extensive nodal dissection. As surgeon experience has grown at high-volume centers, eligibility criteria have expanded well beyond early guidelines. If you have been told you are not eligible elsewhere, a second opinion is worthwhile — it is rare for a patient to truly be ineligible at the Russell Center.
Yes. Multiple published studies confirm that cancer-control outcomes with TOETVA are comparable to open thyroidectomy for appropriately selected patients with papillary thyroid cancer. Central neck dissection for cancer staging or treatment can also be performed through the same inner lip incisions — no neck incision required. Most patients with low- to intermediate-risk thyroid cancer are eligible for this approach.
For extensive lateral neck disease, conventional open surgery remains the standard.
Yes. The same approach can be applied to the parathyroid glands, referred to as TOEPVA (Transoral Endoscopic Parathyroidectomy Vestibular Approach). This is relevant for patients with primary hyperparathyroidism — the most common cause of elevated calcium — who wish to avoid a neck scar. Most patients needing parathyroid surgery are also eligible for this approach at experienced centers.
Yes — when performed by an experienced surgeon on an appropriate patient. Published systematic reviews find that the major complication rates — recurrent laryngeal nerve injury, low calcium from parathyroid disturbance, bleeding, and infection — are equivalent between TOETVA and conventional open thyroidectomy.
TOETVA may actually offer a safety advantage: the camera angle from below gives the surgeon an improved view of the recurrent laryngeal nerve as it enters the voice box, a perspective that is difficult to achieve from above. Outcomes are meaningfully better at high-volume centers.
In addition to the risks shared with all thyroid surgery, TOETVA carries two procedure-specific risks:
Mental nerve paresthesia: The mental nerve runs along the lower jaw near the incision sites. Temporary numbness or tingling of the chin and lower lip is the most common TOETVA-specific side effect. It is usually transient, resolving within weeks to months. Permanent injury is uncommon but has been reported.
Carbon dioxide (CO₂) embolism: CO₂ gas creates the working space for the instruments. In rare cases it can enter the bloodstream. This is a known but uncommon risk, managed with standard monitoring by an experienced anesthesia team.
Some temporary swelling and firmness in the chin and lower neck during healing is expected and resolves on its own.
Voice change is the most feared complication of any thyroid surgery. It results from injury to the recurrent laryngeal nerve, which controls the vocal cords. This risk exists with every surgical approach — open or "scarless."
Published data show that permanent nerve injury rates with TOETVA are comparable to conventional thyroidectomy, and some studies suggest voice outcomes may be slightly better due to the improved nerve visualization the transoral approach provides. At the Russell Center, Dr. Russell has zero permanent recurrent laryngeal nerve injuries with this approach. Intraoperative nerve monitoring is used routinely throughout the operation.
It is a reasonable concern, but published data show that infection rates after TOETVA are comparable to conventional open thyroidectomy. Perioperative antibiotics are standard.
None. The incisions are made entirely inside the lower lip and are nearly invisible within 7–10 days. There is no scar on the neck, chest, armpit, or anywhere else on the body.
Most patients go home the same day or after one overnight observation. In the first few days, patients commonly experience sore throat, mild voice hoarseness, temporary chin and lower lip numbness, and mild neck stiffness — all expected and usually short-lived. Patients eat a normal diet immediately after surgery. Most return to desk work within one to two weeks and full physical activity within two to three weeks. No surgical drain is required.
Yes, meaningfully so. Patients who have "scarless" thyroid surgery are more than three times less likely to feel self-conscious about their appearance after surgery compared to those with a conventional neck scar. Multiple studies report higher cosmetic satisfaction, better body image, and less postoperative pain. These advantages hold up in long-term follow-up studies.
At experienced centers, operative time is comparable to conventional thyroidectomy — roughly one to two hours depending on the extent of surgery.
No. TOETVA is performed with standard endoscopic instruments and does not require a surgical robot. This is a meaningful advantage over some other remote access approaches that depend on expensive robotic platforms.
It depends on how much thyroid is removed. If only one lobe is removed, many patients retain enough thyroid function and do not need medication. If the entire thyroid is removed, you will need a daily thyroid hormone replacement pill — typically levothyroxine — for life. This is a simple, once-daily medication and is unrelated to the surgical approach. Whether you have a scar or not has no bearing on this.
Coverage varies by insurer and plan. TOETVA is a recognized procedure with established billing codes, and many insurers cover it when medically indicated. The Russell Center for Endocrine Health does not participate with any insurance providers. However, anesthesia and hospital facility fees are usually covered by insurance — though patients should verify this with their insurer prior to scheduling. Our team can provide cost estimates and documentation to support reimbursement submissions.
It matters a great deal. TOETVA is a technique-dependent procedure, and outcomes — complication rates, operative time, and nerve preservation — are significantly better at high-volume centers. Surgeons typically reach consistent proficiency after approximately 30–50 cases. Dr. Russell has performed more TOETVA procedures than any other surgeon in the United States, which means the learning curve is long behind him.
When evaluating any surgeon for this procedure, ask directly: how many have you personally performed?
Do not hesitate to travel for expertise. "Scarless" thyroid surgery is a technique-dependent procedure where volume is strongly correlated with outcomes.
It means your doctor, at their specific location, does not offer it — or does not have sufficient experience to perform it in your case. Not all surgeons have the same training or volume in "scarless" thyroid surgery, and eligibility criteria vary enormously depending on the surgeon's experience.
The reality is that most patients are eligible. Research from Johns Hopkins, the University of Chicago, and UCSF has demonstrated that a majority of thyroid surgery patients qualify. Being told you are "not eligible" at one center is very common and simply reflects the limitations of that surgeon or program — not a universal verdict on your candidacy.
It is rare for a patient to be truly ineligible at the Russell Center for Endocrine Health. Dr. Russell regularly accepts patients who were turned away elsewhere. We encourage anyone who has been told they are not a candidate to contact us for a second opinion before accepting that conclusion.
TOETVA was first reported in large clinical series by Dr. Angkoon Anuwong in Thailand, with initial publications beginning in 2016. In the United States and Western Hemisphere, Jonathon O. Russell, MD, FACS — Director of the Russell Center for Endocrine Health in Columbia, Maryland — introduced and pioneered the technique. Dr. Russell has since performed more TOETVA procedures than any other surgeon in the US, trained surgeons at Stanford, NYU, MD Anderson, Harvard, UCLA, and the Clayman Thyroid Center, and co-authored the 2025 international consensus statement on remote access thyroid and parathyroid surgery from six major surgical societies.
Most patients are — even those who have been told otherwise elsewhere. Call 443-333-5233 or visit russell-center.com to request a consultation. We see patients from across the United States and internationally.
Russell Center for Endocrine Health 7226 Lee Deforest Dr, Suite 204 Columbia, MD 21046
This article is written for general educational purposes by Jonathon O. Russell, MD, FACS, and does not constitute medical advice. Individual candidacy, risks, and outcomes vary. Last reviewed: June 2026.
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World-class thyroid/parathyroid health and surgery center located in the greater DC/Baltimore area.