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.
But 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.
In 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.
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.
A 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.
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’.
Because 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.
Under 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.
Recovery 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.
The 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.
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.
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.
The 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.
The 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.
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.
A 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.
A 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.
A 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.
While 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.
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.
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.
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.
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.
There are no alternatives to reducing a prominent thyroid cartilage (adam’s apple) other than open surgical reduction.
The goal of a tracheal shave is to reduce the prominence of the neck bulge over the thyroid cartilage.
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 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.
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.
Should additional surgery be required for tracheal cartilage or scar revision, this will generate additional costs.
While the soft tissues dominate the surface area of the neck, they are not the only elements that give it its shape. Several hard tissue components comprised of bone and cartilage also make a contribution. The form of the jawline is on the upper edge of the neck and is the superior suspension point for most of the neck’s soft tissues. The thyroid cartilage sits in the midline of the lower neck and is barely noticeable unless it sticks out too far. The prominence of the thyroid cartilage also has gender significance in helping to define a male vs a female’s neck.
While manipulation of the hard tissues of the neck does not change the all-important cervicomental angle, it does help influence how that angle is seen. The stronger and more defined the jawline is, the greater is the perception of more youthful neck due to a longer upper limb of the cervicomental. If the thyroid cartilage is too prominent, the lower limb of the angle is disrupted creating an undesireable bump in the neckline. While for men this bump may be fine and even attractive, it is not so for women.
Chin Augmentation The jawline separates the neck from the face and is defined by both its length and it anterior projection. The chin is the most forward part of the jawline and its strength or weakness can help or hurt the appearance of the neck. The horizontal projection of the chin can be easily increased using a variety of implant styles and sizes. Chin implants can be placed through either the mouth or from under the chin. For many patients, putting the implant in from under the chin assures proper positioning on the most forward part of the chin bone. Chin augmentation can be a very useful adjunctive procedure with any of the neck contouring procedures, particularly isolated liposuction and facelifts.
Tracheal Shave The prominence of the thyroid cartilage often has little to do with one’s age. The size of the cartilages are genetically imprinted and not age-related. The one occasional exception is that seen after a facelift when the profile of the thyroid cartilage can become unmasked as the neck skin is tightened and pulled back. For those that have too strong of a neck bulge caused by the strength of the paired thyroid cartilages (more commonly known as an Adam’a apple), this can be reduced by shaving the prominence down. This is done through a small horizontal neck incision directly over the prominence. It is a virtually painless procedure with no recovery and a result that is immediate. Most patients obtain results where the size of the bulge is dramatically reduced and a few will get a completely smooth neckline in profile.
Tracheal Augmentation In rare cases, a more dominant or even an evident thyroid cartilage bulge is desired. This masculinizing neck procedure requires the placement of a specially-shaped implant on top of the thyroid cartilage to build out its projection where the paired cartilages meet in the midline. When combined with a submentoplasty above it, a more prominent tracheal bulge can be created.
The shape of the neck is an important aesthetic structure of the face. When it is well defined with a sharp angle definition (between 90 to 120 degrees in profile), it makes the chin and jawline more prominent and flattering. When the neck angle is obtuse or completely open (straight), the jawline becomes obscured and less aesthetically pleasing. The neck can be seen to have a major influence on how the entire lower third of the face looks. As one begins to age, the neck tissues become loose and begin to sag.For some, even at a young age, they have a naturally full with an obtuse angle due to a thicker fat layer and a lower positioned hyoid bone.
While genetics, gravity and time work against a shapely neck with a good angle, there are a number of plastic surgery procedures to improve the aesthetic appearance of the neck. First, however, a few comments on non-surgical reshaping methods. While creams and exercises are touted to improve the shape of the neck, none have been proven effective for making noticeable changes. Some modest changes can be made in the appearance of jowls and neck skin sagging in those who have good skin elasticity withvarious transcutaneous energy therapies. (e.g., BBL or Skin Tyte) These are not to be confused with surgical results but there can be visible improvement. Injectable Botox can also be used to treat prominent vertical platysmal neck bands. These are best viewed as treatments neck for those that don’t have enough of a problem to justify surgery or for those who do but prefer to try a non-surgical approach first.
Full thicker necks with good skin can be treated solely by liposuction. Removing fat allows the skin to shrink and tighten up to reveal the shape of the underlying platysma muscle. While traditional liposuction is effective,the additional use of a laser-assisted technique can help improve the results. Smartlipo, which uses a fiberoptic laser probe, creates heat which not only helps melt fat but can create a skin tightening effect as well. While neck Smartlipo is ideal for younger patients due to their better skin quality, I have seen a few older patients with impressive neck changes as well.
The next level beyond neck liposuction is a submentoplasty. This is a neck tightening operation that not only removes fat by liposuction but tightens the platysma muscle as well. It is performed through a submental incision in which some small amount of loose upper neck skin can also be removed. Also known as a submental tuckup, it can be effective for the very beginnings of neck sagging in younger patients with good skin. It is also historically used after a facelift when some submental skin sagging develops (rebound relaxation) in the first year after surgery.
Facelifts are the primary procedure that can create the most effective change for the aging neck. Facelifts, also called necklifts, can be thought of as being two fundamental types either a limited and full type. Both use incisions around the ear but the length of the incisions and what effects they create in the neck and jowls is different. A limited facelift, which goes by a lot of marketing names (Lifestyle Lift, Quicklift etc), has as its main effect the smoothing out of sagging jowls with a more limited effect in lifting neck skin. It is best used in patients whose primary complaints are about their droopy jowls and not their necks. Full facelifts are used when the neck problem is more significant and its improvement is the main objective of the surgery. It is the most powerful changer of both the neck and jowls and usually also incorporates liposuction of neck fat and tightening of the platysma neck muscles. Chin augmentation with a facelift can also be helpful in giving a more defined jawline.
One other approach to the sagging neck is that of the direct necklift. Unlike facelifts in which the incisions and the direction of skin lifting is based around the ears, the direct necklift removes loose neck skin by excising it down the center of the neck…directly if you will. This is a simpler approach to a necklift and is a very powerful reshaping method of the neck but it does so with the trade-off of a midline neck scar. This can be a preferred procedure for older men (greater than age 65) who prefer the least recovery and have large hanging neck wattles. Male beard skin heals remarkably well and I have not found the neck scar to be a visible concern after it heals.
The last area of neck reshaping, which has nothing to do with age, is the prominent Adam’s apple or thyroid cartilage. For those that have too strong of a neck bulge caused by the strength of the paired cartilages of the Adam’a apple, this can be reduced by shaving the prominence down. This is done through a small horizontal neck incision directly over the prominence. It is a virtually painless procedure with no recovery and a result that is immediate. Most patients obtain results where the size of the bulge is dramatically reduced and a few will end up with a completely smooth neckline.
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.