Feminization Laryngoplasty (continued)
Thyrohyoid elevation: Muscles are elevated from the anterior inferior half of the hyoid bone with electrocautery. Strap muscles are divided at their insertion along the inferior edge of the hyoid bone for 15 mm either side of midline.
Drilling holes for closure: Two, 1-mm holes are drilled in the new anterior edge of each thyroid cartilage, one inferior at the level of the subglottis, one superior at the level of the false vocal cords. Each hole is angled toward the midline internally. To create the thyrohyoid elevation, two additional holes are placed along each superior border of the thyroid cartilage where the upper wings were removed. The softer the cartilage, the further from the upper cut edge of thyroid cartilage I place these holes to avoid tear-out later when tightening. Four holes are drilled into the hyoid bone, two either side of midline. These are angled slightly inferiorly to allow passage of the large needle on 0-Ethibond sutures.
Four braided, 0-Ethibond sutures are individually passed through each hole in the superior edge of the thyroid cartilage and passed through a corresponding hole in the hyoid bone. No sutures are tied yet.
Originally I placed 4-0 nylon sutures through the upper holes in the superior thyroid cartilage and internally includes the cut edges of the false vocal cords with the intent of pulling this up against the inner thyroid lamina during closure. For the past few years I have changed to 4-0 monocryl sutures for this which are dissolvable. Another 4-0 suture is passed through the inferior holes and includes the cut edge of the subglottic mucosa, again with the intent that the mucosa will reattach to the inner thyroid perichondrium and that there will be an airtight seal in the immediate postoperative period. I leave this needle attached temporarily.
With all sutures in place, closure commences by bringing the cut edges of the thyroid cartilage together.
The lower nylon suture is tied while an assistant squeezes the thyroid cartilage alae together with a forceps (above left photo). The upper suture is then tied securing the thyroid cartilage. With the needle still on this upper suture, I pass the needle through the tissue near the base of the epiglottis at the superior edge of the thyroid cartilage and secure it to the thyroid cartilage.
A 4-hole, dogbone shaped plate is bent to the shape of the newly angled anterior thyroid cartilage. It is placed preferably at the same level as the original attachment of the anterior commissure. I prefer self-tapping screws, which are placed bilaterally.
At this point the slipperiness of the Gore-Tex suture presents it’s advantage, the ability to slide between the coapted edges of the thyroid cartilage. The Gore-Tex sutures are tightened and tied around the plate to pull the anterior commissure against the inner thyroid perichondrium. I have tried unsuccessfully to monitor the tensioning during this portion of the procedure with a flexible endoscope, but with the patient paralyzed, the soft tissues of the pharynx and larynx collapse onto the end of the endoscope precluded an adequate view of the glottis during the tightening.
The 0-Ethibond sutures are then tightened and tied, pulling the larynx superiorly in the neck. Typically the thyroid cartilage does not quite reach the hyoid bone.
The wound is irrigated with saline solution containing Bacitracin. The strap muscles are reapproximated and can be slightly plicated, pulled superiorly and reattached to the hyoid bone under some tension. Subcutaneous tissues are closed with 4-0 Monocryl.
The skin is closed with a running subcuticular suture, either 4-0 Monocryl.
I place some form of cyanoacrylate on the skin.
She is extubated deep and awakened.
Surgery is performed as an outpatient. Each patient is discharged after approximately one-hour into the care of a friend, family or a professional caregiver. Because of the general anesthetic, she must remain with someone for the first 24 hours postoperatively. Most stay in a nearby hotel of their choosing. Postoperatively each patient is examined with flexible laryngoscopy every day for three days. I see them again six days postoperatively and then she is free to return home if there are no complications.
Two weeks of complete voice rest are suggested. Pain is typically fairly minimal (though individually variable). A narcotic is prescribed for use as either pain or cough suppression. My postoperative instructions include instructions to avoid coughing. Nothing heavier than 10 pounds is to be lifted for one month. Other forms of straining, such as Valsalva maneuver, are strongly discouraged. I ask that she not be electively intubated for a period of three months. If intubated for general anesthesia she should request a number 6 endotracheal tube be used.
Acoustic data is taken from patients who subsequently return for scheduled follow-ups beyond the 2-week window. Voice samples are also accepted from patients who complete a recording by reading a voice analysis script. Recordings have been accepted on a wide range of media including computer files, video hi-8 tapes, cassettes, microcassettes, CD’s and DVD’s. Quality and background noise is variable. I have utilized software with Skype if the patient does not have recording capabilities, although cell phones and Skype seem to have automatic volume dampening that hampers assessment of some of the vocal parameters.
Caveats and thoughts
Anesthesia: My initial FemLar procedure was performed under local anesthesia. Although this is a feasible approach in terms of minimal pain during and after the surgery, the seeming risk of tearing the vocal cords while suturing them, if the patient tries to speak at an inappropriate moment, seems to outweigh the benefits of this approach. After the first patient, general endotracheal anesthesia was used largely to prevent vocal cord movement at an inappropriate time.
Dividing the cartilage: The thyroid cartilage is not calcified in some young patients and a knife may be used. Over a number of patients, I placed the cuts further and further laterally trying to further narrow the larynx, until in one patient, after removing 10 mm either side of midline, I could not approximate the inferior cut edge of the thyroid cartilage. The upper edge of the cricoid cartilage lies internal to the lower thyroid cartilage and the external diameter of the cricoid cartilage precluded complete closure.
Currently, the vertical incisions in the thyroid cartilage are generally placed about five to six millimeters either side of the midline. The amount removed varies with the perceived size of the thyroid cartilage. In very large thyroid cartilages and in cartilages with a very acute anterior angle the vertical thyroid cartilage incision tends toward seven or eight millimeters from the midline. In small or very flat thyroid cartilages, perhaps only five or six millimeters are removed. At the typical beveled angle, in the average person, this removed piece of cartilage measures about ten millimeters in width across the outer table of the thyroid cartilage and about five millimeters in width on the inner table. The width or kerf of the saw blade itself is about 1 mm.
Revisions: Revisions are possible. In my first patient I conservatively removed additional vocal cord over three surgeries until we reached the pitch that she desired. I presently consider about 50% of membranous cord to be the appropriate amount to remove.
Prior CTA surgery: If a patient has had a prior CTA surgery, the cricoid and thyroid cartilage are typically fused. Even if they can be pried apart or even if they are sawed apart, in my experience, the cricothyroid joint has typically been immobilized long enough that the joint is non-functional. The cricothyroid muscle can no longer modify the vocal cord length. Dissecting apart this fusion sometimes lowers the pitch back into a male speaking range: certainly not desirable in most cases. Consequently, if there has been a prior cricothyroid approximation, I now leave the approximation intact. I utilize a midline thyrotomy division and do not remove any additional thyroid cartilage. The cricothyroid fusion limits opening of the thyroid cartilage and surgical exposure. I try to gain additional pitch elevation solely through removal of anterior membranous vocal cord and typically remove about 20% of the length.
Taking apart a cricothyroid fusion from a prior CTA however, may not be a reliable way to lower the pitch, again because of cricothyroid joint fixation. There is an uncommon patient wishing to return to a lower or male speaking pitch. If after taking apart a cricothyroid fusion under local anesthesia, there is no or insufficient pitch drop, I place two vertical thyrotomy incisions and remove one to 3 mm of cartilage from one or both sides which drops the tension in the vocal cords.
This issue of cricothyroid joint fusion is also the reason I discourage “trying the CTA surgery first”. The CTA procedure causes loss of use of one of the most important muscles for elevating pitch. The postoperative CTA patient has only the thyroarytenoid muscle remaining to change pitch. The postoperative FemLar patient has both a shortened thyroarytenoid muscle available as well as a cricothyroid muscle available to alter pitch.
Dividing the vocal cords: In early cases, I divided the anterior commissure early in the procedure so that I could widely open the larynx for a view. The very first time I cut the membranous vocal cords, the mucosa contracted all the way back to the vocal process, an unsettling maneuver that makes the vocal cord seem to disappear. It is possible to re-grasp the mucosa and the vocal ligament. However, resecting the anterior vocal cord one at a time seemed also to be a possible contribution to the likelihood of postoperative asymmetry between the vocal cords.
Thus, I now place the marking suture in the mid-portion of the vocal cords in everyone before removing the anterior vocal cords. It acts as a marker for where I intend to place a cut as well as the suture to maintain symmetry. I place the cut just anterior to the marking suture. Then I place the first horizontal mattress suture, defining the new anterior commissure before removing the marking suture. This also defines for me the area of the vocal ligament. When the vocal cord is cut, it not only contracts posteriorly toward the vocal ligament, it flattens out against the lateral aspect of the thyroid cartilage. It can be difficult to locate the vertical level of the vocal ligament after releasing it.
Currently, while holding the vocal cords tense, I am also placing a plicating suture of 5-O fast absorbing gut from the superior vocal cord’s surface into the subglottis and back in the same direction (in each vocal cord), again to further define and highlight the vocal ligament and vibratory margin while I am re-creating the new anterior commissure.
Suturing the new anterior commissure: In early cases I placed an additional suture into each vocal cord in order to tension the thyroarytenoid muscle separately from the new anterior commissure. Before placing the opposing horizontal mattress sutures which create the new anterior commissure, I drilled two additional holes into the thyroid cartilage at the level of the anterior commissure. I passed a nylon suture through the cut anterior end of the thyroarytenoid muscle. This was brought out of the glottis and passed into the thyroid cartilage from externally to internally, then back out of the thyroid cartilage via the other hole. As this suture was tightened, the central portion of the thyroarytenoid muscle was pulled up to the cut edge of the inner thyroid lamina. If there was too much thyroarytenoid muscle, such that it could be pulled out along the cut edge of the thyroid cartilage, then the suture was cut and more thyroarytenoid muscle resected. This type of suturing made further work internally more difficult since if the thyroid alae were pulled laterally for exposure after suturing the thyroarytenoid muscle, this suture would tear out of the muscle. I remain unconvinced that it added any pitch gain and it added time and technical difficulty to the procedure.
Voice rest: With the initial patients I did not suggest any voice rest. Many patients when they initially speak have a deeper comfortable speaking pitch, presumably because of the easily visualized swelling of the transected vocal cords. Some patients seem to have tight enough vocal cords with minimal swelling and have a higher pitch even the first week after surgery. One patient, with an initial great result, began singing one week after surgery. She felt a pop and noted that her comfortable speaking pitch dropped. Since that time, I have requested two weeks of voice rest and a number of patients have voluntarily undergone three weeks of voice rest if their occupation allowed.
Subcutaneous emphysema: This might result from lack of an airtight closure or from an aggressive cough. Some patients will feel a need to cough from a tickle, or to clear secretions, or to clear a blood clot from the internal incision or even from a sensory illusion, the result of the swelling that places the anterior cords in apposition to each other. Isolated or infrequent coughing does not necessarily cause a problem. However, heavy or ongoing coughing may lead to subcutaneous emphysema. I have managed this with expectant waiting or on an occasion with placement of a drain. If air is leaking from internally, there also seems to be a higher associated rate of infection.
Postoperative airway compromise: All of the iatrogenic airway compromise I have seen has been from supraglottic edema and principally from edema on the posterior aspect of the arytenoids. I believe there are two probable etiologies for this edema. One is infectious. The other seems to be from extension of the resection along the superior edge of the thyroid cartilage toward the superior thyroid cornu. After realizing that some supraglottic edema is a result of surgical dissection posteriorly along the superior border of the thyroid cartilage, I began to remove only the anterior two thirds of the upper thyroid ala. I feel that I can still elevate and suspend the larynx from the hyoid bone without removing thyroid cartilage all the way to the superior cornu.
Edema seems to peak on postoperative day number three. Infections seem to be identifiable by day three or else an infection tends not to occur. I have not seen any airway compromise from edema at the level of the glottis either early or late.
After one infection, where I inadequately drained a subcutaneous collection of purulence, the following day I placed a temporary tracheostomy and drained a deeper collection of purulence beneath the strap muscles. For a number of patients after this I then placed a drain at the time of skin closure. This drain seemed to make no positive difference in the rate of infection and perhaps increased the rate of infection, so I have not been placing drains since. After switching preoperative antibiotics to a combination of clindamycin and a third generation cefalosporin, combined with 7 days of postoperative cefuroxime or levofloxacin, I have encountered no severe infections.
I very aggressively try to ensure an airtight closure of the incision into the larynx. My present management approach is that if on endoscopic examination on postoperative day number two or number three there is any suggestion of infection including either supraglottic edema, supraglottic erythema, increasing pain, subcutaneous fullness or subcutaneous fluid collection then I will treat aggressively for presumed infection. This includes needle aspiration of any potential subcutaneous fluid collection, culture and I start oral antibiotics.
In all cases of infection persisting beyond ten days, I have ultimately returned the patient to surgery and removed the hardware or suture that was associated with the ongoing infection. The plate and GoreTex sutures, if removed after one month, are no longer needed and the anterior commissure remains well attached.
One patient felt moderately short of breath, yet had only typical mild supraglottic swelling, not enough to cause symptoms of an airway restriction. After a strong cough expectorated a clot, which must have been present in one of the bronchi, her sense of dyspnea resolved.
In one patient who had a previous tracheal shave followed by a cricothyroid approximation at a later date, noted a sudden drop in pitch 3 weeks after surgery. Her anterior commissure was detached. When I tightened the vocal cords, I believe that I placed the plate too low on the thyroid cartilage and the subglottic conus on both sides bulged into the airway on postoperative laryngoscopy restricting the airway.
Asymmetry: I noticed varying degrees of asymmetry of the vocal cords on stroboscopy of patients from my very first procedure. While sometimes asymptomatic, there can be some pitch where asymmetric cords cause dysphonia, specifically diplophonia. If this is at the comfortable speaking pitch, the patient may learn to elevate or lower the pitch slightly to avoid the rough spot. Initially, when severe enough, I tried to correct the asymmetric tension with a revision surgery. 15 of the first 69 patients received a revision surgery. This correction of asymmetry was difficult to accomplish with scar tissue from the initial surgery being present and it was difficult to judge the exact amount to remove.
On one patient with particularly severe dysphonia after an infection, I utilized an office laser to create a burn on the superior surface of the looser vocal cord, which tightened, correcting the dysphonia. It also raised the pitch slightly.
Since then, I have used the pulsed dye laser, but more recently have preferred a KTP laser for vocal cord tightening. Using a flexible laser fiber passed through a flexible laryngoscope has proven to be a very cost effective means of correcting surgical asymmetries.
The laser can also be applied bilaterally to raise the pitch. If I tighten both sides, I frequently can obtain an additional semi-tone of pitch elevation. This office laser procedure may be repeated after two to three months. I don’t know the limit of how much pitch elevation may be obtained with additional treatment(s).
Elevation of larynx: On the first patient which I tried a thyrohyoid elevation, I was able to elevate the larynx just by passing sutures through the upper thyroid cartilage and the hyoid bone, but in my second patient and in many patients since, the upper edge of the thyroid cartilage abuts the hyoid bone precluding additional elevation. I presently consistently remove one vertical centimeter of upper thyroid cartilage, which gives additional room to raise the larynx in the neck. It also gives the appearance during surgery of a more typical female sized thyroid cartilage.
Elevation of the larynx changes only one of several anatomical features that contribute to resonant frequency. Other anatomical differences that affect resonance (ie. the sinuses) cannot easily be surgically manipulated to produce a more feminine resonance. However, one anatomic area that might also be surgically manipulated is the diameter of the pharynx. There may be a way to plicate the pharyngeal walls and narrow the circumferential dimension of the pharynx, improving resonance of higher pitches. Or perhaps one might devise a subcutaneous augmentation to narrow the pharyngeal diameter in a way analogous to an obese person’s narrowed pharynx.
Most patients note a loss of volume, both in everyday speech and for a yell. In most cases she cannot replicate the volume of her previous voice. Subjectively, some patients are pleased with the softness of their new voice or may consider it a reasonable trade-off.
Numerous patients did not initially perceive a change in their voice after surgery. I suspect we are used to hearing our voices via internal bone conduction. Additionally FemLar does not change the accent nor character of the voice after surgery. While documentation is important in many respects (for the surgeon to learn what works, legal documentation, etc.), it is invaluable to the patient as well to hear the difference in pitch on a recording. After hearing the pre and post-operative recordings, many patients gain confidence in her new voice.
Feminization laryngoplasty, including a thyrohyoid elevation component and possibly a later postoperative laser tuning, is a surgical technique designed for individuals wishing to transition from a male to female voice by increasing the fundamental and resonant frequencies of her voice.
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