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.