Discussion
Spiegel7, in a retrospective study, indicated that 60% of the 31 patients who underwent chondrolaryngoplasty were ”very” or ”completely” satisfied. In our sample, all patients demonstrated aesthetic satisfaction after surgery, whereby 80% of the VAS scores were between 9 and 10. We introduced the use of the diamond burrto flatten the remaining thyroid cartilage, thereby enabling major remodeling without a temerarious resection,perhaps one of the key points for surgical success.
It was demonstrated, prospectively and objectively, that there was no permanent vocal change in any of the patientsduring the postoperative period. Two patients reported hoarseness in the first week, possibly due to transient laryngeal edema from surgical manipulation or even by orotracheal intubation, which was resolved itself without the need for any specific treatment. The variation observed in the F0 and in the GRBAS had no statisticalsignificance and is probably part of the daily changes within the normal range of each individual.8
Chondrolaryngoplasty represents a challenge for the surgeon in seeking a balance between aesthetics and function: a very conservative resection of the thyroid cartilage may lead to aesthetic dissatisfaction, while excessive resection may destabilize the anterior commissure tendon, thereby signifying permanent vocal damage, with hoarseness and decrease in vocal pitch, which would be tragic for a transgender woman.
Spiegel5, in 2008, described a surgical approach using a laryngeal mask airway combined with intra-operative fiberoptic laryngoscopy examination to mark the implantation height of the anterior commissure in the thyroid cartilage with a 22-gauge needle, and consequently at the safe limit of the resection of the thyroid cartilage.In our study, the midpoint of the height of the thyroid cartilage was used as a parameter for insertionof the anterior commissure, with an additional safety margin of 3 mm. This parameter had already been employed since Isshiki type I thyroplasty and was objectively measured by Sagiv9 in 2016. It proved to be simple, easy to perform and safe. Furthermore, unlike Spiegel’s technique, it can be executed under general anesthesia with endotracheal tube, especially when performing another sex reassignment proceduresimultaneously.
This study has several limitations. Initially, the number of participants was small, and might not have reliably represented the population. Secondly, due to the study design and ethical aspects, it was not possible to establish a control group to eliminate the influence of the placebo effect. Moreover, there was no objective measurement of the laryngeal prominence before and after surgery, demonstrating in fact that there was a significant reduction.