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Archive for the ‘tracheal shave’ Category

Case Study – Transgender Tracheal Shave Based on Head Extension

Monday, November 20th, 2017

 

Background: The  prominence of the Adam’s apple (hyroid cartilage) in the neck is a distinct gender-associated feature. In males, just like the brow bones, it is more protrusive than females due to the growth influence of testosterone on its cartilaginous development. This is why in facial feminization surgery, particularly in the male to female transgender patient, a tracheal shave is often done.

But not all tracheal cartilage protrusions are seen in a normal head posture position. Its prominence may be partially or fully masked by a low cervicomental angle, a fatty neck or a highly positioned thyroid cartilage. In some cases it is not fully revealed until the head is extended. While this always makes any Adam’s apple more prominent as the neck tissues are pulled back around it, the revealed prominent thyroid cartilage in the transgender patient can still be bothersome.

Most tracheal reductions or tracheal shaves are done through a small horizontal skin incision over it. In this operation it is the laryngeal prominence (this is what makes up the true Adam’s apple) of the paired thyroid cartilages that is removed. The laryngeal incisura is the most anterior part of the laryngeal prominence and this must be flattened through cartilage shaving. It usually can not be reduced  back to the same horizontal projection as the inferior thyroid notch to prevent cartilage instability and potential mucosal violation and even disruption of the vocal cords.

Case Study: This young transgender male to female patient was bothered by the prominence of the Adam’s apple which was most noticeable when the head was extended. It was such less obvious with the head in neutral position and was largely naked by the lower cervicomental angle.

Under general anesthesia a small horizontal skin incision was made over the greatest prominence of the Adam’s apple. The strap muscles were separated in the midline and the Adam’s apple cartilages exposed. Their horizontal projection was reduced by vertical  cartilage shaving almost back to the level of the projection of the cricoid cartilage. The strap muscles were reapproximated and the skin closed.

The immediate intraperative result was apparent. Even though the neck profile was not completely flat its forward projection was similar to what a female’s neck with their head in extension would look like.

Highlights:

1) A prominent Adam’s apple can only be fully revealed in some patients by neck extension.

2) In the transgender tracheal shave patient any prominent neck protrusion, neck extended included, may appear masculinizing.

3) In surgery the neck is extended to maximize the amount of tracheal reduction done.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Submental Tracheal Reduction

Saturday, August 5th, 2017

 

The reduction of a prominent Adam’s Apple is known as a tracheal shave. Done directly over the tracheal prominence through a small skin incision the V-shaped thyroid cartilage is reduced, as the name indicates, by shaving it down with a scalpel blade. Since the prominence is composed of cartilage it can be reduced in layers with the sharp edge of a blade. As patients age the thyroid cartilage becomes stiffer and more calcified and may have to be burred down for an effective reduction.

While the skin incision for a tracheal shave is small and often heals exceedingly well, the risk of a visible scar always exists. While the procedure will always require a skin incision, an alternative location would be higher in the submental region under the chin. This distant incision location requires the creation of a subcutaneous tunnel down the midline from the chin to the thyroid prominence. Using a fiberoptic retractor the prominent cartilage can be seen and dissected free of overlying tissues.

Because the thyroid cartilage is a mobile structure, trying to shave it down with a scalpel blade from a remote incision is difficult. For this reason I prefer to use a handpiece and drill and burr the cartilage prominence down. This works just as well on soft cartilage as it does on harder cartilage. A small round or tapered carbide burr removes cartilage structure rapidly. Within the tight space of this subcutaneous tunnel it is important to be careful with a rapidly rotating burr to not inadvertently engage the surrounding soft tissues.

Because of the more limited visibility from this remote incision, a submental reduction should not be used when larger tracheal shaves are needed. Better control of the shape of thyroid prominence can be obtained by a direct incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Tracheal Shave by Burring Reduction

Wednesday, August 12th, 2015

 

A tracheal shave or Adam’s Apple reduction (technically a thyrochondroplasty) is a well known neck contouring procedure to reduce a thyroid cartilage prominence. While it is most commonly perceived to be a male to female transgender procedure, it is actually done just as commonly for men or women who have a prominent thyroid bulge and are not undergoing a facial feminization procedure.

The tracheal shave is one of those plastic surgery operations that is not really misnamed. In its name is exactly how it is done. The usually soft nature of the thyroid cartilage is exposed and shaved down with a scalpel reducing the laryngeal prominence at the thyroid notch and the anterior rim of the paired lamina. With the scalpel the reduction is shaved down in layers until the desired level is obtained.

Tracheal Reduction by Burring Dr Barry Eppley IndianapolisBut as patients get older the thyroid cartilages become stiffer and partially ossified. Around the age of 50 and older a scalpel will usually not cut into the cartilage and a true tracheal shave is not possible. It becomes necessary to change from the reduction method from a scalpel to a burring technique using a handpiece and drill. This mechanical rotary reduction method allows for a very precise laryngeal prominence reduction and also makes the cartilage edges very smooth.

Tracheal Shave by Burring Reduction Dr Barry Eppley IndianapolisIn older patients a tracheal shave becomes a tracheal burring reduction. The result with mechanical burring is just as effective. Given the need for a handpiece the tracheal reduction is best done through a small overlying skin incision rather than a more distant submental incision higher up under the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Submental Incision for Tracheal Shave

Saturday, August 23rd, 2014

 

Reduction of a prominent Adam’s apple is a neck contouring procedure that is known as a tracheal shave or, technically, a chondrolaryngoplasty. It is a very effective procedure that is most commonly done through a small skin incision directly over the tracheal prominence. Through this approach the elevated ridges of the thyroid cartilages are literally shaved down using a scalpel and occasionally a rotary burr if the cartilage is very stiff or ossified.

The skin incision in the neck for a tracheal shave is positioned in a horizontal orientation. As a result it usually heals exceptionally well, often being virtually invisible. But in some patients who have concerns about the neck scar for a tracheal shave, there is an alternative incision location.

Submental Approach for Tracheal Shave Dr Barry Eppley IndianapolisSubmental Tracheal Shave Dr Barry Eppley IndianapolisA submental approach can be taken for the neck contouring procedure. Through an inch long incision in the submental skin crease, a skin flap can be raised down to and over the tracheal prominence. It is some distance away but the elevation of such a skin flap in the neck is common, frequently done as part of many facelift procedures. Using special retractors made for working under narrow skin tunnels, the trachea can be shaved down with a scalpel.

The submental tracheal shave produces offers a ‘scarless’ method to do the procedure. While it is effective, I have found that it can be difficult to get as much reduction as that which can be done through a direct skin incisional approach.  This is particularly so if a rotary burring technique may be needed for maximal reduction as the narrow skin tunnel limits instrument access. Thus the submental approach must be used selectively in the right tracheal shave patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Transgender Tracheal Shave

Sunday, June 15th, 2014

 

Background: The bulge in the center of just about any neck is the result of the laryngeal prominences. These are two large plates of paired cartilages who have a primary function to provide protection of the very important vocal cords from injury The size or prominence of these cartilages is highly influenced by hormones which is why men have larger laryngeal cartilages than women. As a secondary sexual characteristic, its presence is highly associated with being a male feature.

As an aside, the neck laryngeal prominence is commonly called the ‘Adam’s Apple. It is a commonly held belief that this term comes from a piece of forbidden fruit embedded in the first man’s (Adam ) throat. This sounds somewhat logical but there is no mention of any such reference of it happening in the Bible. It is postulated that a far more likely explanation are translation errors. Latin translation from Hebrew confuses the word ‘bump’ to be ‘apple’ and the word ‘man’ to be ‘Adam’. Hence ‘man bump’ has become ‘Adam’s Apple’.

Adam's Apple Surgery Dr Barry Eppley IndianapolisBecause the Adam’s Apple is a highly recognized male feature, it has become an important area of treatment in facial feminization surgery. Getting rid of an obvious and prominent neck bulge and creating a smooth more feminine neck line is a small but important change. Known more commonly as a tracheal shave, technically a reduction chondrolaryngoplasty, it is a fairly simple and uncomplicated procedure.

While a tracheal shave is most commonly recognized as a transgender facial feminization surgery procedure, it is done just about as often in non-transgender men. The difference in treating these two patient populations for tracheal shave reduction is a matter of degree. In facial feminization patients, an aggressive and maximal reduction of the neck bulge is needed to achieve a flat and smooth as neckline as possible. The reduction needs to be less aggressive in other men who still want to leave some semblence of an identifiable male neck bulge.

Case Study: This 36 year-old transgender female wanted to reduce a very prominent Adam’s apple. Her overall face and neck was very thin with little subcutaneous fat but was strongly skeletonized with prominent bone and cartilage structures. As part of numerous other facial feminization procedures, a tracheal shave reduction was comboned with brow bone reduction and rhinoplasty surgery.

Transgender Tracheal Shave Surgery Dr Barry Eppley IndianapolisUnder general anesthesia, a 2.5 cm skin incision was made over the height of the larygneal prominence in a natural skin fold. The strap muscles were split vertically and the laryngeal cartilages exposed. The prominent cartilages were reduced by shaving them down with a scalpel until the inner lining mucosa was seen on the inside of each one. Because of the stiffness of the paired cartilages in the middle, a handpiece and burr was used to take down this area for maximal reduction. The strap muscles were sewn back together and the skin closed. A clear glue dressing was applied.

Transgender Tracheal Shave result side view Dr Barry Eppley IndianapolisRecovery from a tracheal shave is uncomplicated. The wound requires no care and the swelling is fairly minimal. Patients report only mild discomfort for a few days that is most evident on swallowing. The skin incision heals quite well and is rarely noticeable.

Transgender Tracheal Shave result oblique view Dr Barry Eppley IndianapolisThe tracheal shave can be done through either a direct skin incision over it or from a more remote submental incision under the chin. While the submental incision offers a hidden scar, it does not afford as much visualization of the cartilages and may compromise the amount of reduction obtained. Some surgeons prefer to do the procedure under local anesthesia and to visualize the vocal cords by laryngoscopy while doing the reduction to prevent injury to the vocal cords. While this approach offers theoretical benefits, it has not been necessary in my experience to have an uncomplicated tracheal shave outcome.

Case Highlights:

1) A tracheal shave can be done successfully and discretely through a small incision directly over the laryngeal prominence.

2) Significant tracheal reduction can be done without voce changes under general anesthesia.

3) Tracheal shave reduction is one of many facial feminization surgery procedures for transgender patients that can be combined with any number of other procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Tracheal Shave Neck Contouring

Sunday, February 23rd, 2014

 

The reduction of a prominent Adam’s Apple through a procedure known as a tracheal or laryngeal shave has been in the news lately. Former Olympic Gold Medalist Bruce Jenner has recently made headlines for purportedly undergoing the procedure and the tabloids have suggested that he may be in a transitional state to becoming a women. While I have no idea about whether he has that procedure and his motivation for doing so if he had, invariably a tracheal shave is almost always associated with facial feminization surgery. FFS()

The reality is, however, that tracheal shaves are not done exclusively in FFS. As many non-transgender patients, usually men, have them done as often as transgender patients. I have men with very large laryngeal prominences that have trouble buttoning a shirt or wearing a tie. Most are just bothered by this large unnatural looking projection in their neck. Less frequently, women may have it done for the same aesthetic concerns although their natural hormonal levels usually preclude it from ever developing that large.

Tracheal Reduction Indianapolis Dr Barry EppleyThe biggest challenge in tracheal shaves is to get it completely eliminated and the neck perfectly smooth/flat. This can be particularly difficult in very thin patients with large laryngeal prominences. In some patients getting a perfectly smooth neck with no bump may not be possible. There is balance between how much can be removed and avoiding entering the airway.

How aggressive one can be with tracheal shave reduction depends on how they balance the risk factors of entering the airway and destabilizing the larynx and causing voice changes. Some prefer to do it under fiberoptic larnygeal visualization of the vocal cords  and the anterior mucosal wall. Others use conservative intraoperative judgment and gently dissect off the mucosal lining and thyrohyoid ligament from the inner cartilage surface of the laryngeal prominence of the thyroid cartilage to allow for maximal reduction. Revisions of tracheal shaves are probably best done under visualization of teh airway.

Direct Tracheal Reduction Dr Barry Eppley IndianapolisThe surgical approach to a tracheal shave can be done either directly from more remotely. Most every one has some semblence of a horizontal skin crease near the laryngeal prominence and this can be used for direct access to the reduction As long as the incision does not exceed 2.5 to 3 cms and with good closure techniques, it can heal imperceptably.  The other approach is to make the incision high up under the chin in a submental neck crease. It is harder to get a good reduction this way but it can be done.

Most laryngeal prominences can be reduced as the same implies (tracheal shave) by using           a scalpel to shave the prominences down. However, some patients will have stiffer cartilage that may be partially ossified. In these cases, scalpel will not make a dent in it. This usually occurs after some shaving has been done and the stiffer cartilage is revealed underneath. A handpiece and a small rotary burr can complete the reduction is a controlled manner.

The vast majority of tracheal shaves patients are satisfied with their initial operation. It does take a few months for all the laryngeal swelling goes down to see the final result. Some do wish that more could have been removed but accept that there are limits based on their anatomy and remain satisfied with an uncomplicated and improved neck result.

Dr. Barry Eppley

Indianapolis, Indiana

Adam’s Apple Reduction (Tracheal Shave) in Men

Sunday, December 15th, 2013

 

Recent internet postings report that Bruce Jenner is purportedly planning on reducing the size of his Adam’s Apple, an operation known as as tracheal shave. These reports also state that this neck operation is typically performed on patients in the initial stages of gender reassignment surgery. While I have no idea whether Bruce Jenner has any interest in this operation or not, it is not true today that those who seek a tracheal shave are in some phase of male-to-female transformation.

Thyroid Cartilage Anatomy Dr Barry Eppley IndianapolisA tracheal or laryngeal shave, technically known as a chondrolaryngoplasty, reduces the central bulge in the neck caused by the size of the thyroid cartilages. This is created by how large the paired thyroid cartilages are which come together in a V-shaped configuration surrounding the vocal cords, hence it is often called the voicebox. Males typically have larger thyroid cartilages due to the growth influence of the male hormones.

Tracheal Shave Dr Barry Eppley IndianapolisA tracheal shave is done through a small horizontal incision overlying the largest prominence of the thyroid cartilage. It is usually no bigger than 3 to 3.5 cms. Once past the skin, the vertical strap muscle of the neck are separated to expose the cartilage. It is not a very far distance from the skin to the cartilage as one can tell by feeling their on neck. The cartilage is then literally shaved down with a scalpel, reducing the V-shaped  prominence. In layers, the tissue is then closed over the reduced cartilages with dissolveable sutures for the skin.

Tracheal Shave and Vocal Cords Dr Barry Eppley IndianapolisA tracheal shave procedure can be done in less than one hour under either local or general anesthesia. Because of the potential risk of damaging the vocal cords and changing one’s voice, some surgeons prefer to do the reduction under local anesthesia. By so doing one can hear the patient’s voice or use a laryngoscope to locate the vocal cords by a percutaneous needle. Other surgeons, including myself, use IV sedation or general anesthesia and use judicious reduction to prevent vocal cord injury or change. While protection of the attachments of the vocal cords is important, they are usually below the level of the cartilage reduction.

Tracheal Shave Dr Barry Eppley IndianapolisWhile many people think this neck procedure is done only in transgender patients, it is not. That may be its history, but most of the patients that I do tracheal shaves on today simply want an unnaturally large Adam’s Apple reduced. These are often men with little subcutaneous fat in their necks and a very visible thyroid cartilage bulge that is unnaturally prominent.

Dr. Barry Eppley

Indianapolis, Indiana

 

Case Study: Tracheal Shave for Neck Feminization

Monday, April 1st, 2013

Background: The neck is generally a flat surface in youth that may have a bump or prominence in the middle about halfway between the jawline and the upper sternum of the chest. This laryngeal prominence, known more commonly as the Adam’s Apple, is formed by the size and angle of the thyroid cartilages that surround the larynx or voice box. This appears as a lump under the skin that is more prominent in men as the thyroid cartilages  form an acute angle where they meet in the middle. In women, this bump is much less visible, if at all, as the thyroid cartilage angle is more rounded rather than acute.

The laryngeal prominence has the name Adam’s apple for disputed reasons from a biblical  origin of an apple being stuck in Adam’s neck to a hebrew mistranslation of the words ‘man bump’. Regardless of what it is called, its purpose is to protect the larynx and the vocal cords which it contains. Its size also influences the depth of the voice. The bigger the laryngeal prominence the larger the voice box is creating a deeper toned voice.

Reducing the prominent Adam’s apple is a cosmetic neck surgery that has been done for decades. Know medically as a chondrolaryngoplasty, it is easier to call it by its more common name, a tracheal shave. While it is often thought as only being desired by transgender men to women conversions, that may be historically true but not accurate today. I done as many tracheal shaves in men who were merely bothered by its degree of prominence as that as part of facial femninization surgery.

Case Study: This 35 year-old female had long been bothered by the size of her adam’s apple. She was a tall thin female with little subcutaneous fat. Her thyroid cartilages were very angular, coming to a sharp point that stuck out prominently.

Under general anesthesia, her prominent thyroid cartilages were approached through a 3 cm long in a horizontal neck skin crease adjacent to the bump. The strap muscles were split and separated and the cartilages exposed. The front edges of the cartilages were shaved done enough to eliminate the thyroid prominence. The strap muscles were reapposed over the cartilage and the skin closed with dissolveable sutures. Only small tapes were applied for dressing.

She had minimal pain and no bruising afterwards. There was some moderate swelling and firmness over the area for a few weeks. the scar took several months to completely fade. The result shows the elimination of the thyroid bump and a much smoother and more feminine neckline.

Tracheal shaves for the prominent adam’s apple is not new. In reading its history, it has been associated with a wide range of complications including voice changes and laryngeal nerve injury. In my experience, I have seen only aesthetic issues with tracheal shaves which revolve around under- resection. It is important to get the best reduction possible but one should not over weaken the cartilages or violate the mucosal lining in so doing. It is always better to leave a  much reduced hump with no complications than a completely flat one with a complication.

Case Highlights:

1) The prominent adam’s apple in the neck is the result of large paired thyroid cartilages and thin neck tissues.

2) Reduction of the prominent adam’s apple is through a shaved reduction of the anterior or front portion of the thyroid cartilages. (tracheal shave)

3) The prominence of the adam’s apple can be significantly reduced but can not always be reduced enough to make the neck completely flat.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Tracheal Shave (Adam’s Apple Reduction) Surgery

Wednesday, February 20th, 2013

 

A tracheal shave or Adam’s Apple reduction is the removal of the protruding portions of the paired thyroid cartilages that cover the larynx. This is done through a small horizontal neck incision directly over them in a natural neck skin crease. The cartilages are reduced by shaving or burring them down but without making them unduly weak or disrupting the attachments of the underlying vocal cords. How much reduction of the neck bulge that can be achieved highly depends on the thickness of the cartilages.

The following are typical after surgery tracheal shave instructions:

 

1)  Most tracheal shave procedures have virtually no pain after surgery. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, if any medication at all.

2) There  will be a flesh-colored tapes glued on over the incision. That will stay on for a week or so. It will either be removed by Dr. Eppley at the first postoperative follow-up (in town patients) or you may peel it off after a week for out-of-town patients.

3) There may or may be some spotting of blood on the tapes. This is normal and not a cause for concern.

4. The sutures used in the small neck incision are all under the skin and will dissolve on their own. There is NO need for suture removal.

5. You may shower and wash your hair as normal the following day. There is no harm in getting the  neck tapes wet.

6) There may be some mild neck stiffness and soreness when you extend your neck backwards after surgery. Avoid excessively stretching your neck backwards for a few weeks after surgery once the tapes are removed.

7) Once the neck tapes are removed, you may begin to apply any topical scar treatments if you desire.

8) There are no limitations to any physical activities after tracheal shave surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable.

9) There are no restrictions on what you can eat or drink after surgery. Swallowing has no adverse effects on neck healing.

10. If any neck redness, increased tenderness or swelling, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery – Tracheal Shave (Adam’s Apple Reduction)

Tuesday, February 19th, 2013

 

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the tracheal shave procedure. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

There are no alternatives to reducing a prominent thyroid cartilage (adam’s apple) other than open surgical reduction.

GOALS

The goal of a tracheal shave is to reduce the prominence of the neck bulge over the thyroid cartilage.

LIMITATIONS

The limitations of  a tracheal are in how much reduction can be achieved. How much reduction of the neck bulge that will result depends on the thickness of the cartilage and the overlying soft tissues.

EXPECTED OUTCOME

Expected recipient site outcomes include the following: temporary swelling and bruising of the neck area, mild temporary soreness and neck tightness, a small permanent heck scar and up to 3 months for all swelling to go down to see the final result.

RISKS

Significant complications from tracheal shaves are very rare. More likely risks include infection, undercorrection with some residual neck bulging and adverse neck scarring. Permanent voice changes have been reported in the medical literature by not seen by Dr. Eppley. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY

Should additional surgery be required for tracheal cartilage or scar revision, this will generate additional costs.


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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