Gender-Affirming Facial Surgery: Lower Third of the Face

This article is intended to give the reader an overview of facial gender-affirming procedures applicable to the lower face and neck. A review of facial analysis in the context of masculine versus feminine facial features and the contributions of both soft tissue and bone to this anatomy is provided. The use of systematic facial evaluation and patient-driven concerns as a guide for presurgical planning is reviewed. Detailed descriptions of the unique surgical interventions to feminize the soft tissues and the skeletal framework of the lower face and neck are provided.

Combined genioplasty, chondrolaryngoplasty, and glottoplasty: A novel scarless procedure in facial feminization surgery

Facial feminization is a long process with multiple surgical steps that is known to improve quality of life in transgender patients. Visible scars are a frequent complaint by this community as it adds to the stigmatization in this population. Combined procedures have been shown to be effective, by reducing the number of hospitalizations and the total length of recovery periods. In this context, we propose a novel scarless procedure combining a chondrolaryngoplasty, a glottoplasty, and a genioplasty using solely a transoral approach. First, we perform a glottoplasty according to the technique described by Wendler et al. and then a contraction genioplasty. Finally, the thyroid cartilage is approached by a subplatysmal dissection, between the mandibular osteotomy fragments. For now, 15 patients have benefited from this procedure in our department. Preliminary results demonstrate that this is an easy and safe procedure with good esthetic results and good patient satisfaction.

Complications and Functional Voice Limitations Following Gender-Affirming Laryngeal Surgery (GALS)

OBJECTIVE

Gender-affirming laryngeal surgery (GALS) procedures are effective, with high rates of patient satisfaction following endoscopic vocal fold shortening (glottoplasty) or chondrolaryngoplasty. Despite this, complications and functional limitations in voice use following GALS are not well described. The current study aims to visually characterize the clinical and laryngoscopic features of complications following GALS.

METHODS

Patients who presented with complications or subjective dysphonia following glottoplasty or chondrolaryngoplasty across three tertiary care centers were included. Medical charts were reviewed for demographics, surgical history, the primary outcomes of short- and long-term surgical complications, and the secondary outcome of subjective difficulty in daily voice use unrelated to pitch or gender congruence. Postoperative videostroboscopy exams were reviewed for correlating features.

RESULTS

Eighteen patients with complications after glottoplasty, chondrolaryngoplasty, or both were identified. Complications after chondrolaryngoplasty occurred in three patients and included skin tethering, late-stage infection with fistula, and voice change. Short-term complications following glottoplasty occurred in four patients and included persistent granulation at the neocommissure (n = 3) and suture dehiscence (n = 1). Persistent dysphonia or voice limitations greater than 6 months following glottoplasty were described by eight patients; associated stroboscopy findings included excessive web formation of greater than 50% (n = 4), incomplete web formation with opening anterior to the neocommissure (n = 2), and scarring of the remaining membranous vocal fold (n = 5). Dysphonia complaints were consistent with observed glottic insufficiency in seven of eight of these patients, with incomplete membranous vocal fold closure posterior to the neocommissure or anterior air escape.

CONCLUSION

While chondrolaryngoplasty and glottoplasty have high success rates, complications related to healing, granulation, and web length are not uncommon. Long-term dysphonia appears to be related to postprocedural glottic insufficiency. These data should be used to counsel patients preoperatively about the risks and benefits of GALS.

Chondrolaryngoplasty

Chondrolaryngoplasty is a surgical procedure that reduces the prominence of the thyroid notch. Although frequently performed on transgender (man to woman) women, anyone wishing to reduce the prominence of their thyroid notch for aesthetic purposes may consider undergoing a chondrolaryngoplasty. Direct visualization of the vocal cords with flexible laryngoscopy and intraoperative needle localization of the anterior commissure directs the extent of resection, helps increase safety, and avoids devastating postoperative voice complications. This procedure can be safely performed in combination with other facial feminization surgeries.

Chondrolaryngoplasty

Chondrolaryngoplasty is a well-described surgical procedure most commonly performed as part of facial feminization surgery for transgender patients with a diagnosis of gender dysphoria. A complete understanding of relevant neck anatomy and laryngeal function is critical to optimizing surgical outcomes. The overall goal of the procedure is to maximally reduce the thyroid cartilage prominence while preserving laryngeal integrity and minimizing the risk of external scarring. Among available approaches, the bronchoscopic-assisted technique with intraoperative needle localization has been demonstrated to reliably lead to safe and effective surgical outcomes while minimizing the risk of postoperative complications.

Chondrolaryngoplasty for transgender patients: feasibility of a scar-free approach

PURPOSE

Adult male-to-female transgender patients with a prominent thyroid notch can benefit from chondrolaryngoplasty with high satisfaction rates. It is a safe, effective, and established procedure with only minor and temporary complications. Until now, only external approaches have been described, leaving the patient with a cervical scar, which remains a frequent complaint. The goal of this study is to assess the feasibility of a transvestibular endoscopic chondrolaryngoplasty.

METHODS

Transvestibular endoscopic chondrolaryngoplasty was conducted on six fresh adult male cadavers. The thyroid cartilage approach was similar to the one described in cases of transvestibular endoscopic thyroidectomy. After thyroid notch exposition, the laryngeal prominence was shaved down using an endoscopic burr until the desired aesthetic result was achieved.

RESULTS

Laryngeal prominence volume was significantly reduced without any cutaneous scar.

CONCLUSION

We have demonstrated that this novel approach is feasible and has the advantage of leaving the patient's neck scar-free.

Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty

Background

The transgender patient seeking transition from male to female suffers a significant stigma from the prominent male thyroid cartilage. Natal men and women may seek elective reduction of the “Adam's apple” as well. There are various techniques for performing chondrolaryngoplasty, but these techniques and their associated outcomes are poorly described in the literature.

Methods

A literature review was performed for articles related to esthetic chondrolaryngoplasty. Data related to outcomes and complications were extracted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The authors also present the case of a transgender 58 year-old male-to-female patient who underwent chondrolaryngoplasty.

Results

Four case series, including 69 patients who had esthetic chondrolaryngoplasty, were identified that met inclusion criteria. Qualitative assessment of patient satisfaction was reported in two studies (n = 62), with a 98.4% satisfaction rate. The most common complications were odynophagia in 20.3% of patients, hoarseness in 36.2% of patients, and laryngospasm in 1.4% of patients. Of patients that had postoperative hoarseness, 96% had resolution within 20 days. In our patient's case, chondrolaryngoplasty was performed with a tracheal shave in combination with high-speed burring for fine contouring. The patient experienced hoarseness for 1 week postoperatively that self-resolved.

Conclusion

Overall, chondrolaryngoplasty for reduction of the thyroid cartilage appears to be a safe and effective procedure. The complications that occurred in identified case series were mild and self-limiting. Although serious complications are certainly possible, we were not able to identify their occurrence in the literature. Recent modifications in chondrolaryngoplasty involve protecting the anterior commissure tendon to prevent iatrogenic voice modification.