Infiltration anesthesia was done using 1.5 mL of anesthetic solution (1% or 2% lidocaine with 1:100,000 epinephrine). Injection was done in the following sites bilaterally: intercartilaginous injection of the nasal dorsum from the region of the rhinion to the supratip region, and at the base of the columella and the nasal tip and this injection was extended into the floor of the nose.

The graft was obtained through a hemi-transfixion incision. Mucoperichondrial flaps were raised bilaterally to expose the quadrangular cartilage. Mucoperiosteal flaps were also raised over the vomer and the maxillary crest to provide maximum exposure. A vertical incision was made roughly 1.5 cm posterior to the caudal border of the quadrangular cartilage. A second cartilaginous incision was then made parallel to the dorsum about 1.5 cm below the nasal dorsum. The septal cartilage was harvested by disarticulating it from the maxillary crest, the vomer and the perpendicular plate of the ethmoid bone. To prevent damage to the nasal bridge and the development of a saddle nose, it was essential to be sure that at least 1 cm of cartilage remained both dorsally and below. The incision was sutured with silk. A nasal pack was applied as an internal splint to adapt the mucoeperichondrium to the nasoseptal cartilage and prevent formation of a hematoma.

Infiltration anesthesia was done through injecting 2 mL of anesthetic solution (1% or 2% lidocaine with 1:100,000 epinephrine) postero-laterally to the depth of the midpoint of the posterior border of the sternomastoid muscle (at the level of the cricoids cartilage). An additional 2 mL were injected superiorly and inferiorly to the point of the primary injection. The same procedure was repeated on the opposite side.

All the thyroplasties were performed by the same surgeon (Author #2). The technique used for medialization of the vocal fold has been previously reported by Isshiki et al. (4). The thyroplasty was applied in 8 patients on the right side and in 7 patients on the left side. A horizontal paramedian cervical incision was made over the middle of the thyroid cartilage. Dissection was carried out in a subplatysmal plane, the strap muscles were retracted and the thyroid lamina was exposed. A perichondrial rectangle (window) was made at the level of the vocal folds (6 mm from the midline) and it measured 5 mm (height)×12 mm (length). The cartilage window is subsequently cut (Fig. 1). With using a relatively blunt instrument, the inner perichondrium was circumferentially elevated in a careful way to avoid injuring it. A piece of the septal cartilage was cut and shaped into a rectangular graft with larger measurements than the window that was created in the thyroid lamina (Fig. 2). The cartilage graft was then carefully tucked into the window superficially to the inner perichondrium. To assess the best implant position intraoperatively, a perceptual evaluation of the patient's voices was done and further layers of the graft were inserted if needed to achieve the best voice quality the patient can produce. Intra-operative perceptual evaluation was carried out by asking the patient to count from 1-10 and rehearse a standardized passage that was memorized by all the patients. The patient's voice quality was judged by consensus agreement between the surgeon (YAK) and a phoniatrician (TAM), who attended the surgical procedures. All the patients received wound drainage for approximately 2 days and they were observed in the hospital after surgery for an average of 3 days. The patients were evaluated at 1 week after surgery and then at the 6 months follow-up.