We are seeing an increasing need for creation of a permanent tracheal fest administration. One indication is laryngeal fibrosis which can occur as a result of injury, infection or irradiation treatment. The latter as radiation therapy has assumed a greater role in the treatment of laryngeal cancer treatment. For the syndrome of sleep apnea requires a permanent tracheostomy. Some patients with bilateral vocal cord paralysis with aspiration and those with chronic obstructive pulmonary disease require a permanent tracheal opening. Although the long term placement of the tracheostomy tube may result in a permanent fest administration. The time interval is long and associated with considerable inconvenience to the patient and physician given a choice. Most patients prefer not to wear or care for a tracheostomy appliance. The technique of permanent tracheal fest administration will be shown graphically and then demonstrated surgically. The placement of the incisions should be as inferior in the neck as possible. Allowing finger effusion for speaking and the cosmetic advantage of being hidden by a shirt or scarf in the obese. However, a more superior placement of the stoma offers technical advantages. The dimensions for the cervical skin flaps are variable but average 2 to 3 centimeters horizontally and 1 to 1.5 centimeters vertically. One should allow for approximately 30 to 40% ultimate narrowing of the stoma. The tracheal flaps are created in such a fashion that the inferior flap is longer than the superior one due to the posterior inferior direction that the trachea assumes the average dimensions of the tracheal flaps are 1.5 centimeters wide and 1.5 centimeters long for the inferior flap and 1.5 centimeters wide and one centimeter long. For the superior flap, the flaps are then advanced appropriately and sewn in place with 40 woven nylon suture and removed on the 10th to 14th, post operative day or when healing is judged to be sufficient. A custom made button can be fashioned for sleep apnea patients or those with chronic obstructive pulmonary disease that require an intermittent tracheostomy made from room temperature, vulcanizing Silastic. The button is created for daytime use to seal the stoma. It is then removed in the evening or whenever necessary for suctioning or ventilation. The advantages of the technique of permanent tracheal fest administration are that it is a quick, simple one stage procedure that can be performed under local or general anesthesia because no skin or tracheal tissue is excised. This technique has the additional advantage of being reversible should conditions change allowing tracheostomy closure. This patient is 15 years, post resection of a cerebellar astrocytoma and six years post resection of a benign cerebellar cyst A tracheostomy had been closed several years before with resultant upper airway obstruction and intermittent aspiration of liquids. These laryngeal photos show a right vocal chord paralysis and a left vocal chord peres. The skin incisions are marked and the tracheostomy scar will be excised, requiring extension of the incisions. The skin incisions are made and the previous trays are excised. The flaps are then elevated in a plane superficial to the plasma muscle. This patient has a moderate amount of subcutaneous fat and thus wide undermining is accomplished to facilitate advancement of the cervical skin. The skin flaps are retracted with 40 woven nylon sutures as necessary excess, subcutaneous fat is excised to further enhance advancement of the flaps. At the conclusion of the procedure, fascia in the midline is divided using the electric scalpel because in this patient, considerable scar tissue is encountered from the previous tracheostomy. The isthmus of the thyroid is mobilized superiorly when encountered or more commonly excised. In this patient, it was simply mobilized superiorly. The tracheal flap incisions are made with the electric scalpel having ensured adequate anesthesia of the tracheal mucosa care should be taken if there is residual vocal cord mobility to avoid placing the vertical incisions too far laterally with resultant recurrent nerve damage. The tracheal flap is advanced towards the skin and sewn in place with 40 woven nylon suture. The superior tracheal flap is sewn to the superior skin incisions creating the dimensions for the ultimate vertical length of the permanent trachea stone. The skin flap is sewn to the tracheal mucosa and the flap is advanced into position as this is accomplished. The final tracheostoma begins to take form when performed under local anesthesia. Tracheal mucosal anesthesia is necessary to inhibit reflex coughing. The advantages of minimal blood loss and absence of an obstructive endotracheal tube make local anesthesia preferable. The sutures are left long and shortened at the termination of the procedure. In order to prevent suture tags from obstructing the closure. A bland ointment is applied in order to prevent crusting and to retract the sutures away from the tracheal mucosa, digital closure of the stoma is performed at the conclusion of surgery to reassure the patient that vocal function is intact. 12, three, our patient is now six months postoperative and enjoyed an uneventful recovery. Cora, could you tell us what kind of difficulties did you have before your surgery? Some, uh, I would get tired fast walking up the stairs or those kind of start breathing. Did you have trouble swallowing before your surgery? Yes, I did. What kind of trouble did you have? I would start coughing and I would have to stop eating because, uh, I would cough a lot. And what kind of problems have you had since your surgery? Well, now I do all sorts of things. I don't get tired like I used to. And how about trouble breathing? No, I haven't. Are you able to climb stairs. Now, I see socially. Were you incapacitated before you had your operation? Uh, yes. So I didn't want, I didn't like nobody to listen at me because I was pretty tired and I would be embarrassed. And how about, since surgery? Well, since my surgery, I don't really care that they look at me because I, well, I've been doing pretty good and I don't really care if they dare me because I cover my throat. I see. Do you have any, do you go to parties now? Whereas before you did not? No, I do before. I didn't go. Could we take a look at your stoma? Yes. Now take a deep breath in for us. Blow it out, deep breath again. Blow it out. Now, count to three, 12, three. The next patient is an attorney who developed progressive laryngeal fibrosis and edema for 6.5 years after high dose radiation for an extensive laryngeal cancer. These laryngeal photos show an immobile larynx with an inadequate airway. This patient is now over a year post operative and healed uneventfully despite his high dose of irradiation, Ralph, can you tell us what kind of problems you had before your surgery? I had a lot of difficulty in breathing, um, especially if I try to walk fast or climb stairs. And about 18 months ago, it got worse than that. It got to the point where occasionally I was feeling like I was gonna black out. Uh, my voice was about one half the strength it is now, give that much and I couldn't, uh, project my voice at all. So I found it difficult to do my work and eventually the swelling became so bad that I'd have trouble breathing while driving. And on a couple of occasions nearly blacked out in a freeway which, uh, sent me to you. What kind of problems have you had since your surgery? Well, the problems have decreased considerably. I've gotten off pregnizone lost about £30. I can breathe again. Um, I do have a problem with mucus. The more I talk toward the end of the day I get more and more collection of mucus. Hi. Don't think I could run a marathon but, uh, I can run again, which I couldn't before in your work as an attorney. How do you function in court? Uh, primarily my work is limited now to managing, uh, attorneys and other claims people. And, uh, but that requires a lot of public speaking and, uh, similar work to courtroom work. And, uh, I manage well, as long as I have a microphone in a big crowd, Ralph, we'd like to take a look at your stone. If we could please take a deep breath in for me, blow it out, deep breath in. Bought out. Now, would you say 123 for me? 123? I want to ask one more question. Are you able to whistle at pretty girls. No.