Introduction
Gender dysphoria is estimated to
occur in over 1 millionpeople in the United States.1The laryngeal prominence demarcated in the cervical region, commonly
known as the “Adam’s apple”, is one of the stigmatizing secondary
sexual characteristics of men and it is a notable obstacle to the full
exercise of transgender women’s social and professional
role.2
Chondrolaryngoplasty or “tracheal
shaving” is cosmetic surgery to reduce the cervical projection of the
laryngeal prominence, initially described by Wolfort and
Parry2 in 1975.In retrospective studies, around 85%
of patients submitted to chondrolaryngoplasty report improvements in the
appearance of the laryngeal prominence and satisfaction with the
scar.3 Complications, although rare, may include
damage to the vocal folds and epiglottic
destabilization.4
To the best of our knowledge, to date, there has been no prospective
study in the literature that analyzes the aesthetic and functional
results of chondrolaryngoplasty. Thus, the objectives of this research
were to assess safety, consequence on voice quality, and effectiveness
(i.e., subjective aesthetic satisfaction) of chondrolaryngoplasty in
transgender women.
Materials and methods
Ethical considerations
This study was conducted in accordance with the Helsinki Declaration
and was approvedby theethics committee of [Removed for blind
review]. Informed consent was obtained from each patient.
Study design and patients
This was a prospective interventional cohort, conducted at the Hospital
das Clínicas da UFPE, Recife, Brazil. The recruitment period was from
March 2018 to October 2019.The population consisted of consecutive
transgender women diagnosed with gender identity disorder, according to
the criteria of the World Professional Association for Transgender
Health Inc.,5monitored for at least 2 years in the
hospital,with aesthetic dissatisfaction regarding the laryngeal
prominence. The exclusion criteria establishedwere: presenting with
clinical or psychiatric comorbidity prohibiting surgical treatmentor
inappropriate physical characteristics for the procedure.
Pre- and Postoperative Assessment
Eligible patients were assessed by photographic records of the laryngeal
prominence and laryngostroboscopyby a senior laryngologist (B.T.M). For
subjective analysis of the laryngeal prominence, we useda visual
analogue scale (VAS) for aesthetic satisfaction, graded from 0 (very
ugly) to 10 (very beautiful), applied at the preoperative consultation
and in the sixth postoperative month, based on the Utrecht questionnaire
validated for aesthetic rhinoplasty.6
To assess the effects of the surgical procedure on vocal quality, voice
recordings were made in the immediate preoperative period and on the
thirtieth postoperative day,using Voxmetria® (CTS
Play). The voice of each patient was recordedin an individual sound file
and anonymously labeled. These samples were randomized, and voice
assessment was performed blindly by one experienced listener, who did
not participate in the research. We analyzed the fundamental frequency
(F0) and the auditory-perceptual voice assessment with the Hirano GRBAS
scale.
Technique
All patients were submitted to chondrolaryngoplasty under general
anesthesia and orotracheal intubation, by the same team of
otolaryngologists (B.T.M., M.M.A.C.), using the same surgical technique.
A median transverse anterior cervical incision of 3cm was made in a
previous cervical cutaneous fold over the larynx and an upper and lower
subplatysmal flap was created. After dieresis of the muscle planes, the
thyroid cartilage was exposed. The external and internal perichondrium
from the region of the laryngeal prominence to be resectioned were
detached. The height of the thyroid cartilage was then measured and the
midpoint of the distance between the thyroid notch and the lower margin
of the thyroid cartilage (projection of the anterior commissure of the
vocal folds) was identified, an area that must be preserved to avoid
disinsertion of the vocal folds. After delimiting a safe margin of 3 mm
above the midpoint of the height of the thyroid cartilage, the laryngeal
prominence and the upper portion of the cartilage were resectioned in a
”V” shape, also including the upper border along the thyroid notch. For
this resection, a scalpel blade number 15 and/or a 2 mm surgical cutting
burrwas used (if calcified cartilage, especially in patients aged over
40). After resection, a crucial step in this procedure was to smooth the
edges and flatten the residual laryngeal prominence with a 4 mm diamond
burr. Finally, the planes were then closed,followed by intradermal
suture, without placing a drain (Figure 1).
Statistical Analysis
Statistical analysis was performed using SPSS®23.0
(IBM, Armonk, NY). Statistical significance was compared using a
Wilcoxon signed rank test. Statistical significance was fixed at α =
0.05.