Tracheomalacia (TM) is a disorder of the airway consisting of weakness of the anterior tracheal cartilaginous rings and laxity of the posterior membranous trachea, resulting in dynamic airway obstruction. The clinical symptoms range from chronic cough and wheezing to life-threatening apnea with cyanosis and profound airway obstruction (acute lifethreatening events). TM in infancy occurs either in isolation or in association with a variety of anatomic conditions, including a wide range of congenital heart lesions, as well as primary tracheal and esophageal disorders. TM is also associated with chromosomal abnormalities, such as 22q11.2 deletion syndrome, and trisomy 21. Severe TM is a life-threatening condition with reported mortality rates as high as 80%. Prolonged intubation and chronic positive pressure ventilation is particularly common in affected patients following reparative congenital heart surgery; in the most severe cases, tracheostomy is required. Although often life-saving in these patients, tracheostomy results in a high risk of medical, social, and developmental complications. Patients requiring tracheostomy are technology-bound until their anterior tracheal wall matures and they effectively outgrow their malacia. Most concerning, patients with tracheostomy and persistent severe TM remain at risk of sudden death, recurrent infections, and equipment failure. Aortopexy has been accepted as the standard surgical treatment to alleviate TM associated with congenital heart disease and carries a success rate of 85 to 90%. In our experience, innominate artery-pexy coupled with aortopexy has been particularly effective in relieving TM secondary to isolated innominate artery compression. However, it has also been our experience that aortopexy alone has failed to relieve symptoms in a number of cases of more complex TM and tracheobronchial malacia. Since March 2008, we have used anterior tracheal suspension for the treatment of severe refractory TM and tracheobronchial malacia in infants and children as an alternative to