UCSF Surgeons Develop Effective Scarless Adam’s Apple Surgery

Promotes Patient Satisfaction and Avoids Misgendering after Facial Feminization Surgery

By Jess Berthold and Melinda Krigel

Side-by-side before-and-after photos of a transgender woman who had adam's apple surgically removed. The left photo shows the patient with the adam's apple, and the right photo shows the patient without the adam's apple after surgery, with no residual scar.
Before (left) and after (right) photos of a patient who udnerwent a scarless transoral chondrolaryngoplasty (TOC) procedure. Images by Rahul Seth

Feminizing chondrolaryngoplasty, also known as “tracheal shave,” improves the neck appearance of trans women by effectively reducing the prominence of the Adam’s apple and is performed through an incision across the front of the neck. Regardless of the incision placement or its length, the scar itself can serve as an undesirable ‘‘mark’’ and a source of continued misgendering for the patient.

UC San Francisco surgeons have developed and demonstrated the technical feasibility and clinical efficacy of a novel scarless transoral chondrolaryngoplasty (TOC) procedure. This innovative technique approaches the thyroid cartilage through an incision in the mouth, instead of requiring a neck incision. The preliminary outcomes, published May 4 in Facial Plastic Surgery & Aesthetic Medicine, demonstrate surgical safety as well as similar aesthetic and quality of life outcomes compared to the standard neck incision chondrolaryngoplasty. Most notably, TOC surgery leaves the patient without a revealing scar.

Additionally, this new procedure does not require specialized endoscopic equipment, enables wide instrument access, and allows for simultaneous jaw (mandible) alterations, such as reduction and contouring, often required in comprehensive facial feminization surgery.

Side by side view of patient who underwent adam's apple surgery. Left image is before surgery, and the right image is after. There is no neck incision scar.
Images by Rahul Seth

“By using transoral chondrolaryngoplasty, we can reduce thyroid cartilage prominence, which is the main source of the Adam’s apple’s size, from the mouth without needing to make an incision on the neck,” said senior author and innovator of the approach Rahul Seth, MD, associate professor in Facial Plastic and Reconstructive Surgery in the UCSF Department of Otolaryngology-Head and Neck Surgery. “We can give patients an appearance that more closely matches their identity without leaving a telling scar that they must live with.”

The TOC surgery starts with an incision in the mouth at the lower gums to uncover the jawbone. Under the upper neck skin, a tunnel is continued down to the nearby thyroid cartilage. By using a scope camera passed through the mouth, the location of the vocal cords within the thyroid cartilage is determined. It is essential to leave the vocal cords undamaged and intact so that the voice does not deepen or change. Once accurately marked, the cartilage above vocal cords is then safely removed. With the thyroid cartilage removed, the neck is feminized. At this point, the jawbone can be reduced and contoured, if the patient desires. The incision in the mouth is closed with suture, leaving no external scars.

We can give patients an appearance that more closely matches their identity without leaving a telling scar that they must live with.

Rahul Seth, MD

The surgery was performed in six patients between August 2019 and May 2021. All the patients had refused transcervical chondrolaryngoplasty due to the associated neck scar. Five patients also underwent concurrent jaw reduction. Patients were surveyed at least one month after the surgery and indicated a high degree of aesthetic satisfaction and quality of life associated with the TOC.

Authors: Abel David, MD; P. Daniel Knott, MD; Clark A. Rosen, MD; Vyvy Young, MD; Andrea M. Park, MD, and Rahul Seth, MD.