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THE VISIBLE VOICE A Newsletter for Physicians, Speech-Language Pathologists, Professional Voice Users, and People with Voice Disorders
Monthly Newsletter of the Voice Institute of New York (VINY) www.voiceinstituteny.com Volume 1, Number 2 December 2007
TECHNIQUE FOR PERFORMING A SAFE “TRACHEAL SHAVE” PROCEDURE IN THE MtoF TRANSSEXUAL
This article is about how to avoid a dreadful and preventable surgical complication in trans-women. 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 is suboptimal. Presented is a technique that allows the surgeon to achieve the best results.
Jamie Koufman MD, Editor (jkoufman@aol.com)
TECHNIQUE FOR PERFORMING A SAFE “TRACHEAL SHAVE” PROCEDURE IN THE MALE-TO-FEMALE TRANSSEXUAL
Jamie Koufman, M.D., F.A.C.S.
Gender Identity Disorder (GID) is defined as incongruence between ones body and gender identity that is, the self-identification as male or female.1-5 Research has shown that Male-to-Female (MtF) transsexuals (aka trans-women) have brain findings that are different than heterosexual or homosexual men but similar to genetic women6 (Figure 1). Thus, it is now presumed that transsexualism is biologically determined; that is, being transsexual is not simply a lifestyle choice.
Figure 1: Structural Brain Findings The bed nucleus of the stria terminalis, that is responsible for sex/gender behavior, shown on post-mortem examinations in:
(A). Heterosexual man (B). Heterosexual woman (C). Homosexual man (D). Transsexual woman
Note that the nuclei of the heterosexual and the homosexual men are similar; and, that the nuclei of the heterosexual and the transsexual women are similar, but that the latter pair are different than those of the males.
Kruijver et al. Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus. J Clin Endocrinol Metabol 85:2034, 2000
There are hundreds of thousands of MtoF trans-women living in the United States. Many successfully pass (blend) in society. However, because a protuberant Adam’s apple is never seen in a genetic female, for many trans-women, surgical removal of the thyroid notch is essential.
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) (Figures 2 & 3), 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 (Figure 4A). (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.
Figure 2: Broyle’s Ligament Figure 3: Foreshortened Larynx Anterior thyroid cartilage removed. Result of detachment of the anterior The ligament suspends the vocal folds. commissure tendon (Broyle’s ligament).
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 (Figure 5A). Using an oscillating saw, the uppermost, flared portion of the notch is removed (Figure 5B).
Figure 4: Intraoperative Fiberoptic Laryngoscopy (The needle identifies the level of Broyle’s Ligament)
Next, a 25g or 27g needle is passed through the anterior soft tissue in the notch and into the laryngeal lumen; see Figures 4B and 5C. At this point, the needle usually appears well above the level of the anterior commissure. Using a drill with a large diamond burr, additional thyroid cartilage is then removed.The needle may be replaced several times during the procedure so that the surgeon can determine the level of the anterior commissure; and therefore can remove all of the thyroid notch (down to the needle when it is positioned just above the anterior commissure); see Figures 4B and Figure 5D.
Figure 5: Author’s Technique of Laryngeal Shave (See text)
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. 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.
COMING SOON: CASE OF THE MONTH SERIES
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