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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘adam’s apple reduction’

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.

Options in Neck Reshaping and Contouring

Friday, October 21st, 2011

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

Indianapolis, Indiana

Case Study: Tracheal Shave in the Transgender Patient

Saturday, August 13th, 2011

Background:The central prominence of the neck is well recognized as the adam’s apple. It is largely a male feature although it can be prominent in some women as well. It is composed of paired cartilages which surround the larynx and is designed to protect the delicate voicebox from injuries. While often referred to as the thyroid cartilages, a more accurate name would be the larynx cartilages as that is what it actually guards.

The name adam’s apple is often believed to be a reference to the observation that it looks like a chunk of apple stuck in the throat, relating to the biblical story of Adam and the fruit from the Tree of Knowledge. More likely, however, it is the result of a mistranslation of the Hebrew words, tappuach ha adam, which means ‘male bump’.

Those patients who seek adam’s apple reduction generally fall into two categories, transgender conversion from male to female and males who simply desire less of a central neck prominence. It is widely believed that most tracheal reductions are done in the transgender patient but this has not been my experience. I find it to be about a 50:50 ratio. The aesthetic neck goals for each group are slightly different. The transgender patient would prefer a completely flat neck profile which is more feminizing. The male patient can live with some reduction and a visible remaining small neck bump is still acceptable.

Case Study: This 53 year-old male-to-female transgender patient wanted her thyroid cartilage eliminated if possible. It had an approximate 2 cm central profile and was located unusually low in the neck with a very obtuse cervicomental angle.

Under general anesthesia, it was approached through a 2.5 cm horizontal incision located directly over the prominence. After going through the strap muscles, the thyroid cartilage was identified and all soft tissues dissected off of it including the perichondrium. A scalpel was used to shave the wings of the thyroid cartilage down. At the anterior V of the thyroid cartilages, shaving was done until the cartilage became hard. A handpiece and burr was then used to thin out the central prominence done along the central box of the cartilages. The thyroid cartilages became thin In some areas but no complete through and through defects were created. The strap muscles were closed over the reduced areas but with minimal tension so as to not bunch up the muscles over the reduced area. The skin was closed with small dissolveable sutures. The difference in the neck profile was both immediate and dramatic. The incision was covered only with glue and tapes.

She could shower the next day and there were no restrictions from any activity. She reported minimal discomfort and swelling. By six weeks after surgery, most of the swelling had subsided. The scar already was very fine and nearly indiscernible.

Thyroid cartilage reduction is a simple but effective neck contouring procedure. While it is important to reduce the cartilage prominence as much as possible, it is critical to not destabilize the thyroid cartilage to avoid the risk of voice change due to alteration of the tension on the vocal cords. There is no exact way to know how much cartilage can be safely removed before this occurs so when in doubt, conservative reduction is best.

Case Highlights:

1) Tracheal shaves are done through a small horizontal neck incision with minimal recovery and discomfort.

2) Complete elimination of the thyroid cartilage profile is not always possible. The limiting factor is the thickness of the cartilage and the location of the vocal cords internally.

3) Adam apple reduction is largely done by cartilage shaving but more firm areas of cartilage may require mechanical burring reduction.

Dr. Barry Eppley

Indianapolis, Indiana

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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