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“Dropping Acid” Blog

Tracheal Shave

Ideally, this procedure should be performed by a laryngologist, not a plastic surgeon, with direct visualization of the vocal cords during the surgery. This technique allows maximum cartilage removal while minimizing the risk to the voice (vocal cord) damage.



This article is about how to avoid a dreaded and preventable surgical complication, severe and irrevocable vocal cord (voice) damage. Figure 1 shows Broyle’s ligament in cadaver dissection (it is like a band of fibrous tissue).

Figure 1: The Anterior Commissure Tendon (Broyle's ligament) (cadaver dissection)

Figure 2 shows the appearance of the vocal cords after destabilization of Broyle’s ligament from a botched tracheal shave. Note that the vocal cords are lax (crooked). On examination, they do not vibrate normally, and the patient’s voice is low-pitched like a frog. Presented here is Dr. Jamie Koufman’s surgical technique, one that virtually guarantees an optimal result.

Figure 2: Appearance of "too loose" vocal cords (after a botched tracheal shave)

Surgical Technique

Like other laryngeal framework procedures performed to straighten bowed vocal cords, Dr. Koufman performs the tracheal shave under local anesthesia with IV sedation. This is because intraoperative visualization of the larynx is important (Figure 3).

Figure 3: Appearance of the larynx (vocal cords) by transnasal flexible laryngoscopy

A small, flexible endoscope is passed through the nose and secured using a scope holder for continuous visualization of the vocal cords during the surgery. Anesthesia of the neck area is accomplished by the local infiltration of 1% xylocaine with epinephrine 1:100,000 by the surgeon.

The incision is purposely not made over the larynx (thyroid cartilage), but rather it is placed superiorly (much higher), so that it is hidden up under the chin. This is because tracheal shave patients do not want a telltale scar right below the Adam’s apple area. Next, flaps are raised and the strap muscles area are separated in the midline exposing the thyroid notch (Figure 4A).

Figure 4-A: Thyroid cartilage from the side

Figure 4-B: The uppermost portion of the thyroid (cartilage) notch is removed

Next, a 25g needle is passed through the anterior soft tissue in the notch and into the laryngeal lumen; see Figures 3C. At this point, the needle usually appears somewhat above the level of the anterior commissure. Using a drill with a diamond burr, additional thyroid cartilage is then carefully removed.

Figure 4-C: Needle locates Broyle's ligament

Figure 4-D: When the needle is at the vocal cords, no more cartilage should be removed

The needle is inserted a few times during the procedure so that the surgeon can always know the level of the anterior commissure; therefore, s/he can remove all of the thyroid notch down to the needle when it is positioned just above the anterior commissure; see Figure 4D & 5.

Figure 5: When the needle is at this level, it is not safe to remove any more cartilage

The landmark of the anterior commissure (tendon), where the vocal cords attach to the thyroid cartilage allows safe and complete removal of the protruding parts of the thyroid cartilage.  The tracheal shave procedure performed in this way in the awake and comfortable patient is safe!