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Facial feminization surgery is a broad collection of facial reshaping procedures from the skull down to the neck. Most of the facial feminization procedures involve structural changes, most of which are reductive in nature. The one feminizing procedure that is not on the face is reduction of a prominent Adam’s apple or thyroid cartilage. Eliminating a prominent central neck bump is one of the most recognized and historic transgender feminizing facial change.

The most common approach to chondrolaryngoplasty or tracheal reduction is a direct one with a small horizontal incision over or just directly above the thyroid prominence. An alternative approach is to make an incision more indirectly right under the chin. (submental approach)

In the May 2020 issue of the journal Facial Plastic Surgery and Aesthetic Medicine an article was published on this topic entitled ‘Scarless Neck Feminization: Transoral Transvestibular Approach Chondrolaryngoplasty’. In this paper the authors describe a transoral endoscopic vestibular approach (TOEVA) to tracheal reduction which is a scarless technique. The procedure s done using a rotary reduction technique through a long handpick and burr. Four adult transgender women had the procedure after the technique was tried first on several cadavers. Total operative times were from 1.5 hrs to 2.5hrs. Of the four patients all had successful results with no complications. Vocal cord function remained unaffected.

A transoral approach to tracheal reduction offers a scar free technique that has proven safe and effective in a limited clinical series. While a wonderful demonstration of technical skill, I have never seen the very fine line scar in the neck from tracheal reduction to be an aesthetic detriment. The interesting question is whether taking a direct approach to tracheal reduction that can be done in 30 minutes or so into an operation that takes up to two hours or longer to perform raises the question of whether the added cost of the surgery is a worthy tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana

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