How To: Scarless Chondrolaryngoplasty Through Endoscopic Transoral Vestibular Approach

INTRODUCTION

Chondrolaryngoplasty is a procedure designed to reduce a conspicuous laryngeal prominence and feminize the neck. Traditionally, this procedure is performed through a transcervical incision, which may lead to an unsightly visible scar that can “out” the patient. To address this, indirect approaches have been employed utilizing a submental incision, which can be concealed by the chin. This approach nevertheless has the result of a visible neck scar and carries the risk of tethering to the underlying cartilage framework. To address this issue, Khafif et al. described scarless chondrolaryngoplasty through a transoral endoscopic vestibular approach (TOEVA) (Facial Plastic Surg Aesthet Med. 2020;22:172–180).

One of the key aspects of performing a safe chondrolaryngoplasty is the ability to identify the location of the anterior commissure tendon. Destabilizing the anterior commissure tendon by overaggressive resection can significantly and irreversibly affect the patient’s voice (Plast Reconstr Surg Glob Open. 2018;6:e1877). We describe a modification of the approach described by Khafif et al. in which we use a suture to mark the anterior commissure. We modified the technique described by Spiegel et al. in which a 22-gauge needle is used to mark a location 2 mm superior to the insertion of the anterior commissure tendon before performing the cartilage resection (Arch Otolaryngol Head Neck Surg. 2008;134:704–708). In our technique, we use a 22-gauge spinal needle and thread a 3-0 prolene suture through the needle lumen while directly visualizing the larynx. This allows precise localization of the inferior limit of resection of cartilage continuously throughout the procedure. Institutional review board sanction was obtained, and this case report was considered exempt from formal approval.

METHOD

A 21-year-old trans woman with no past medical history presented to our clinic with gender dysphoria. She had a history of facial feminization surgery including rhinoplasty and sliding genioplasty but remained dissatisfied with the appearance of her neck. Physical examination revealed a protuberant laryngeal prominence.

The patient was offered a chondrolaryngoplasty. We discussed the traditional transcervical approach, the submental incision approach, and the TOEVA. Given concerns over cosmetic appearance of a neck scar, the patient strongly preferred the scarless approach. The patient was intubated with a reinforced size 6-0 endotracheal tube. Unasyn was administered as intraoperative prophylaxis. A point midway between the thyroid notch and the inferior border of the thyroid cartilage was demarcated. A direct laryngoscopy was performed,and the patient was placed into suspension. The anterior commissure was visualized, and externally a 22-gauge spinal needle was used to puncture through the previously demarcated central portion of the thyroid cartilage and through the anterior commissure in the endolarynx. A size 3-0 prolene was passed through the needle lumen and grasped in the endolarynx. The laryngoscope was removed and the suture ends were secured externally using clamps.