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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

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