The cartilage over the larynx is a defining characteristic of adult males, making the tracheal shave one of the most commonly requested facial feminization procedures.

Puberty is awkward for most, but absolutely alienating for some, as their bodies becomes increasingly out of line with their gender identity.

For trans women who benefit from hormone replacement therapy (HRT) at an early age, many of those changes can be averted. For those who transition after puberty has run its course, more invasive surgical procedures are often unavoidable.

While not all trans women opt for a tracheal shave — also known as chondrolaryngoplasty — it is one of the first of these gender confirmation procedures that many choose to undergo.

How Adam’s Apple Reduction Is Performed

A tracheal shave takes between 30 and 45 minutes under local or general anaesthesia. The procedure begins with scouting out the Adam’s apple in order to determine the amount of cartilage that needs to be removed. Tracheal shaves generally attempt to remove as much cartilage as possible, without damaging the voice box.

“The key to performing this procedure safely is to visualize the attachment of the vocal cords to the thyroid or tracheal cartilage,” says Dr. Kyle Keojampa, a facial plastic surgeon that performs facial feminization surgeries at the Del Rey Aesthetics Center in Marina Del Rey, California.

“Using a small 1-1.5 centimeter incision hidden underneath the chin, the thyroid cartilage is exposed after separating the overlying tissue,” says Keojampa. “Once exposed, a small needle is used to pierce through the thyroid cartilage to determine the attachment site of the vocal cords.”

Many specialists will use an endoscope to find the exact location of the vocal cord attachment. An endoscope consists of a small camera attached to the end of a long tube. The camera relays live footage from within the patient’s body, allowing surgeons to make informed and precise decisions.

“The attachment of the vocal cords is marked on the tracheal or thyroid cartilage,” Keojampa explains. “All the cartilage above this point can then be removed.”

While scarring may be a concern for some, the necessary incision for the procedure is made in the most strategic location possible — always below the chin, or where the head and neck meet, and not directly at the site of the Adam’s apple. To further reduce the appearance of scarring, mild topical steroids may be applied at the incision point.

Protecting the Vocal Chords

While not all specialists use an endoscope, Keojampa is a strong advocate for this technique. “In my opinion, it is very dangerous and negligent to guess the location of the vocal attachment without using an endoscope,” says Keojampa. “It’s critical that the surgeon performing the procedure explain in detail how they will visualize or check the location of the attachment of the vocal cords. Any cartilage removed at or below the vocal cords can cause permanent hoarseness, possible breathing problems, and destabilize the voice box,” says Keojampa.

Fortunately, such cases are quite rare. When performed by a professional taking the necessary steps to protect the vocal chords, the risk of complications or side effects stemming from tracheal shaves is essentially nonexistent. Nevertheless, “It is important to see a surgeon who is well trained in the surgery of vocal cords,” says Keojampa.

Post-Surgery: Tracheal Shave Recovery and Results

Following the procedure, short term irritation may arise during the healing process. “There is minimal discomfort or pain,” says Keojampa. “Some patients may experience a sore throat for several days, but this pain is controlled with over-the-counter medications such as Tylenol.”

Keeping ice on the area during the first few days following the procedure may also help reduce discomfort. Roughly a week following the procedure, most patients are able to return to their normal daily activities.

The results of chondrolaryngoplasty vary depending on vocal chord attachment, but significant size reduction is often possible. However, it is generally recommended to reduce the Adam’s apple conservatively to avoid potential damage.

Unlike other parts of the human body, cartilage essentially doesn’t heal itself because it lacks the necessary blood vessels and structures needed to do so. While this causes difficulty in certain circumstances, it benefits patients who undergo tracheal shaves, as the procedure is permanent.

Related Procedures: FFS and Voice Feminization

If performed correctly, chondrolaryngoplasty will not have any effect on the voice. Vocal chords, and not the Adam’s apple itself, are what produce the lower masculine voice. Options for vocal feminization range from vocal training to the surgical option of feminization laryngoplasty. Feminization laryngoplasty can also improve voice quality if the vocal chords are damaged during chondrolaryngoplasty.

Trans-women may opt to undergo a tracheal shave in conjunction with other procedures. “Tracheal shave is usually performed at the same time as Facial Feminization Surgery, which is a constellation of surgeries,” says Keojampa.

Facial Feminization Surgery commonly includes forehead contourplasty, rhinoplasty, and, or course, chondrolaringoplasty. Other procedures such as genioplasty and lip augmentation may also be performed on the lower area of the face.

Non-Trans Women and Adam’s Apple Reduction

Tracheal shaves are not exclusively requested by transitioning women. Occasionally, cisgender women also undergo the procedure.

The sharp angle found between the thyroid cartilage and surrounding larynx is what makes the Adam’s apple visible. In men, this angle is of approximately 90 degrees, whereas in women it’s closer to 120 degrees, making it appear less pronounced.

In some cases however, the cartilage may be more prominent and masculine-looking. Cisgender women do not necessarily exhibit any other “masculine” traits when this occurs, and may undergo chondrolaryngoplasty as a standalone procedure, using the same techniques as transitioning patients.

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