Surgical technique

Under general anesthesia, each patient was placed in Rose position. A 4-6 cm long transverse cervical incision was made at the point half way between the superior thyriod notch and the inferior border of the thyroid cartilage. Superior and inferior skin flaps were then developed, the strap muscles were separated at midline, and the thyroid cartilage was exposed. Without elevation of the perichondrium, parallel vertical cuts were made on the sides of the thyroid alar at a point 4 mm away from midline, or the anterior commissure commencing from the superior border down to the inferior border of the thyroid cartilage. A strip of cartilage with Broyle¡¯s ligament attached to it was then obtained, and then pulled foreward, exposing the internal mucoperichondrium as well as the vocal ligament. A minimal undermining of true vocal cord at the medial surface of the thyroid cartilage at this stage facilitated stretching of the cord. The act of pulling the vocal cord taut before cutting is critical, as this enabled a longer segment of vocal cord than of the anterior thyroid cartilage commissure to be excised. The vocal cord was then cut bilaterally, so that the excised piece of tissue was composed of anterior thyroid cartilage with attached Brolye¡¯s ligament and the anterior part of the vocal cord

The length of vocal cord to be excised was approximately 6 mm on each side, which was approximately 2 mm longer than the excised anterior thyroid cartilage. Closure was accomplished by using 3-0 Nylon or Prolene, with the initial key suture placed at the vocal cord level so that the bite included both the rim of the remaining thyroid cartilage and the vocal cord. The remaining stitches completed thyroid cartilage closure, and a drain was inserted. Strap muscles was reapproximated at midline, and subcutaneous and skin closure was made layer by layer. The patients were instructed to rest their voices for at least 2 weeks. Follow up was made every 2 weeks for the first month after operation, and every 1-2 months thereafter.