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Background: A significant prominence in the center of the neck is that of the tracheal cartilages and it is an almost exclusive male feature. The tracheal cartilages become larger during development imen, like the deepening of the voice, due to hormone influences. While there are men, usually with thin necks, that desire tracheal reduction due to its prominence, tracheal or Adam’s apple reduction is most commonly associated with transgender facial feminization surgery.

The female neck, unlike that of the male, has a smooth contour in profile even with the neck extended. ThIs is because the two half of the thyroid cartilage meet at a less sharp angle from men, usually around 120 degrees as opposed to the male 90 degree angle. As a result there is less of a laryngeal prominences. (aka Adam’s apple) It is present but just less sharp and prominent.

Reduction of a laryngeal prominence (tracheal shave) requires taking down the anterior union of the two halfs of the thyroid cartilage. Because cartilage has the consistency of soap, it can be shaved down with a scalpel in younger patients. In older patients the cartilages becomes stiffer and partially calcified and requires reduction by high speed burring. Regardless of age the cartilage reduction must take into consideration that the origin of the paired vocal cords is just below the thyroid notch so the amount of reduction is not unlimited.

Case Study: This young transgender male to female patient was undergoing multiple facial reshaping procedures, one of which was the reduction of a significant laryngeal prominence.

Under general anesthesia and through a 2 cm skin incision in an overlying horizontal skin crease, the strap muscles were separated and the thyroid cartilage exposed. The most prominent anterior edges of the thyroid cartilage half were shaved down to the notch. While the notch was also reduced it was less so than its upper edges. Closure was done by reapproximation of the strap muscles and closing the skin.

While some laryngeal prominences can not be completely reduced, significant reductions are possible. Caution is given to safety to not disrupt or destabilize the vocal cord attachments. In addition to reduction of the neck bump the skin incisions usually heals In an near inconspicuous manner.

Highlights:

1) A tracheal shave is the ‘simplest’ of all facial feminization surgeries.

2) The direct incision over the laryngeal prominence provides the best reduction.

3) At younger ages the tracheal cartilage is soft enough that it can literally be shaved with a scalpel.

Dr. Barry Eppley

Indianapolis, Indiana

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