Performing A Safe “Tracheal Shave” Procedure In The Male-To-Female Transsexual

Although the tracheal shave (aka laryngeal shave) procedure, removal of the thyroid notch (Adam’s apple), is usually considered to be cosmetic, often it is psychologically and socially important to the male-to-female (MtoF) transsexual patient.  In performing this procedure, there is a surgical paradox. If the surgeon takes too much cartilage, she or he risks destabilizing the anterior commissure tendon (Broyle’s ligament), which can have devastating effects on the voice. Conversely, if the surgeon is too conservative in removing cartilage, the result will be suboptimal. Presented is a technique that allows the surgeon to routinely achieve an optimal result.

 

 

INTRODUCTION

In performing the tracheal shave procedure, there is a surgical paradox. If the surgeon takes too much cartilage, she or he risks destabilizing the anterior commissure tendon (Broyle’s ligament) , which can have devastating effects on the voice. Conversely, if the surgeon is too conservative in removing cartilage, the result will be suboptimal. Presented is a technique that allows the surgeon to routinely achieve an optimal result.

SURGICAL TECHNIQUE

Like most other laryngeal framework procedures, the author performs the tracheal shave procedure under local anesthesia with IV sedation because intraoperative visualization of the endolarynx is important. (Prior to prepping and draping, a fiberscope is passed through the nose and secured using a holder.) Anesthesia is accomplished by the local infiltration of 1% xylocaine with epinephrine 1:100,000.

The incision is not made over the thyroid cartilage, but rather it is placed superiorly, so that it is hidden up under the chin. This is because MtoF transsexual patients do not want to have a telltale tracheal shave scar right over the Adam’s apple. Next, subplatysmal flaps are raised and the strap muscles area are separated in the midline exposing the thyroid notch . Using an oscillating saw, the uppermost, flared portion of the notch is removed.

Next, a 25g or 27g needle is passed through the anterior soft tissue in the notch and into the laryngeal lumen. At this point, the needle usually appears well above the level of the anterior commissure. Using a drill with a medium/large diamond burr, additional thyroid cartilage is then removed in a stepwise fashion. The needle may be replaced several times during the procedure so that the surgeon can always know the level of the anterior commissure; and therefore, she or he can remove all of the thyroid notch (down to the needle when it is positioned just above the anterior commissure).

 

SUMMARY & CONCLUSIONS

For transsexual patients the tracheal shave operation is an important component of the transsexual transformation. Without identifying the level of the anterior commissure

tendon (Broyle’s ligament), the surgeon cannot confidently do a complete removal of the thyroid notch because of concern for destabilization of the vocal folds’ anterior attachment. Herein presented is a targeted solution.

With direct visualization of the anterior commissure, the surgeon can safely remove the maximum amount of protruding thyroid cartilage to achieve an optimal cosmetic result without putting the patient’s voice in jeopardy.

Presented at the Annual Meeting of the American Laryngological Association, April 30 – May 2, 2004, Scottsdale, Arizona by Jamie Koufman, M.D., F.A.C.S.

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