Letter
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Published Online: 27 September 2022

Clinical Feasibility and Efficacy of the Externally Scarless Transoral Chondrolaryngoplasty

Publication: Facial Plastic Surgery & Aesthetic Medicine
Volume 24, Issue Number S2

Introduction

Feminizing chondrolaryngoplasty improves the neck appearance of trans women by effectively reducing the thyroid cartilage prominence and is often performed through a transcervical incision.1 Regardless of neck incision placement, the scar itself can serve as an undesirable “mark” and a source of continued misgendering.2
Khafif et al. recently developed a scarless endoscopic chondrolaryngoplasty technique.3 The need for specialized endoscopic instrumentation and training could limit its widespread adoption. Facial feminization surgery (FFS) recipients often undergo mandible contouring through an intraoral incision,4 and this approach could be leveraged for a transoral chondrolaryngoplasty (TOC).

Methods

Surgical technique

An incision is created within the gingivobuccal sulcus extending to the retromolar trigone bilaterally exposing the buccal and inferior mandible surfaces. The mental nerves are identified and protected (Fig. 1A). Dissection transitions to the neck subplatysmal plane toward the thyroid prominence (Fig. 1B, C). Mandible reduction can be performed before or after chondrolaryngoplasty. Visualization is achieved entirely with headlights and retractors. The strap muscles are divided in the midline raphe revealing the thyroid cartilage.
Fig. 1. (A) Operative photo demonstrating the exposure of the mandible, larynx, and bilateral mental nerves; (B) cadaveric dissection and (C) illustration demonstrating the exposure of the thyroid prominence; (D) exposure and access for cartilage resection with a knife (Illustration by Abel P. David).
A flexible laryngoscope or bronchoscope is passed through an laryngeal mask airway to localize the insertion of Broyle's ligament, denoting the inferior extent of cartilage removal.5 With both the endolarynx and the thyroid surface in view, a 22-gauge needle is passed through skin to mark the thyroid cartilage.6 Perichondrium is elevated off the thyroid cartilage designated for removal (Fig. 1D), and sharp excision is performed.
Closure begins with reapproximating the perichondrial flaps and strap muscles. A round low-profile drain is placed and exits in the submentum. The vestibular incision is then sutured. The dissection and thyroid exposure were performed by facial plastic surgeons (R.S. or P.D.K.) and thyroid cartilage removal by laryngologists (C.A.R. or V.N.Y.). Patients are then observed in the hospital for 24 h after surgery. A compression dressing was used for 5 days. This procedure was initially designed and assessed on cadaveric heads by R.S.

Patient outcome surveys and analysis

Two validated surveys were administered at least 1 month after surgery (Supplemental Methods and Supplementary Tables S1 and S2). Patient consent was obtained and the study received institutional review board approval from the University of California, San Francisco (IRB #20-32699).

Results

TOC was performed in six patients between August 2019 and May 2021. All patients refused transcervical chondrolaryngoplasty due to the associated scar. Patient demographic and perioperative variables are shown in Supplementary Table S3. Median follow-up was 198.5 days. Five patients underwent concurrent mandible reduction. Time to perform TOC was ∼45 min. An obvious reduction in laryngeal prominence was apparent (Fig. 2).
Fig. 2. Results of transoral chondrolaryngoplasty: (A) preoperative and (B) postoperative photos on frontal view; (C) preoperative and (D) postoperative photos in lateral view. (E) Postoperative results on lateral view with neck extension. Postoperative photos were taken at 3 months after surgery.

Survey results

The distribution of scores for each question was depicted in a diverging stacked bar chart, and indicate a high degree of aesthetic satisfaction and quality of life (QOL) benefit (Supplementary Fig. S1, Supplemental Results, Supplementary Tables S4 and S5). Only one patient described negative outcomes; they were initially satisfied, but TOC results diminished after a subsequent neck lift.

Adverse events

None of the patients had voice complaints, dyspnea, or dysphagia after surgery. Temporary numbness of the lower lip was experienced by all patients, with eventual return to full sensation. No patients had a hematoma or need for reoperation. One patient developed a 1-cm intraoral wound dehiscence treated successfully with conservative management. The patient had withheld being an active smoker.

Discussion

We demonstrated technical feasibility and clinical efficacy of the novel scarless TOC procedure in a limited series of patients. Our preliminary experience demonstrates safety and similar aesthetic and QOL outcomes as reported in transcervical chondrolaryngoplasty.1,2 Notably, TOC leaves the patient without a revealing scar, requires no specialized endoscopic equipment, enables wide instrument access, and allows for simultaneous mandible alterations often required in comprehensive FFS.

Supplementary Material

File (supp_figs1.docx)
File (supp_methods.docx)
File (supp_results.docx)
File (supp_tables1.docx)
File (supp_tables2.docx)
File (supp_tables3.docx)
File (supp_tables4.docx)
File (supp_tables5.docx)

References

1. Cohen MB, Insalaco LF, Tonn CR, et al. Patient satisfaction after aesthetic chondrolaryngoplasty. Plast Reconstr Surg Glob Open 2018;6:e1877.
2. Tang CG. Evaluating patient benefit from laryngochondroplasty. Laryngoscope 2020;130 Suppl 5:S1–S14.
3. Khafif A, Shoffel-Havakuk H, Yaish I, et al. Scarless neck feminization: transoral transvestibular approach chondrolaryngoplasty. Facial Plast Surg Aesthet Med 2020;22:172–180.
4. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg 2016;137:438–448.
5. Carrau RL, Herlich A, Rosen CA. Visualization of the glottis through a laryngeal mask during medialization laryngoplasty. Laryngoscope 1998;108:769–771.
6. Spiegel JH, Rodriguez G. Chondrolaryngoplasty under general anesthesia using a flexible fiberoptic laryngoscope and laryngeal mask airway. Arch Otolaryngol Head Neck Surg 2008;134:704–708.

Information & Authors

Information

Published In

cover image Facial Plastic Surgery & Aesthetic Medicine
Facial Plastic Surgery & Aesthetic Medicine
Volume 24Issue Number S2November/December 2022
Pages: S-41 - S-43
PubMed: 35506892

History

Published in print: November/December 2022
Published online: 27 September 2022
Published ahead of print: 2 May 2022

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Authors

Affiliations

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
P. Daniel Knott
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
Clark A. Rosen
UCSF Voice & Swallowing Center, Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
VyVy N. Young
UCSF Voice & Swallowing Center, Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
Andrea M. Park
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.

Notes

*
Address correspondence to: Rahul Seth, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, 2233 Post Street, Third Floor, San Francisco, CA 94115, USA. [email protected]

Authors' Contributions

All authors have reviewed and approved the article for submission. Furthermore, all authors provided substantial contributions, drafting, and revising of the study, providing approval of the article, and are accountable for all aspects of the study.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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