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Reduction of Adam’ REDUCTION OF ADAM'S APPLE FOR APPEARANCE A H H Al-Jassim*, T H J Lesser** Keywords: Adams Apple, Gender Dysmorphia other male to females have undergone exactly the same procedure P4 RODUCIION with equally good results. We described a technique to reduce the profile of an Adam's apple for male-to-female transsexuals. We would like to bring The preoperative contour is demonstrated in Fig 2 (in this this technique to the attention of ENT surgeons. Five cases photograph there is a scar over the thyroid region. Which was have been done, one example is used to illustrate the technique. there preoperatively). The final contour is demonstrated in Fig 3. MATERIAL&METHODS DISCUSSION The first patient was a 49 year old male-to-female transsexual There is increasing demand for reduction and reshaping of patient referred from her GP for reduction of her prominent Adam's prominent thyroid cartilage among male transsexuals. Wolfort & apple. The patient has undergone, over the last six years, a series Parry were the first to describe a laryngeal chondroplasty in 1975, of operations to change sex from male to female. She was in 11 male transsexuals and obtained good results. They resected delighted with all the surgery she had, to achieve what she always the superior anterior segment of the cartilage without internal wanted. Her Adam's apple kept it's male prominence profile and thyroid dessection using rongeurs. Wolfort et al (1990) followed was the last contribution to gender dysmorphia. Four other up 31 patients over a 17 year period ranging from 4 months to 17 male to female transsexual case have since had the same years and found the results are effective and satisfying with few presentation and procedure. complications. The most frequent being a temporary mild voice TECHMQUE weakness, as it was seen in our case. Under general anaesthesia with endo-tracheal intubation the Wolfort et al (1990) also found that because the thyroid cartilage patient was put in a supine position on the operating table with becomes ossified with advancing age, it was difficult to resect a head ring and sandbag under the shoulder to extend the neck. with a blade. Hence resection was carried out using fine rongeurs A six centimetre transverse skin crease incision was made through and the edges smoothed with a burr to refine the contour. Giraldo the skin, subcutaneous tissue and platysmal layers. The middle et al (1997) used a number 11- blade scalpel to excise the cartilage. cervical fascia was then divided vertically in the midline. The stemohyoid and thyroid muscles were retracted laterally. The Our technique is modified from that described originally by anterior half of the thyroid cartilage was exposed. Perichondrial Wolfort & Parry. We found using shear cartilage cutting forceps flaps were raised via para midline incisions and a vertical incision more efficient and were able to resect and contour the cartilage made through the upper 3'd of the thyroid cartilage in the midline. more extensively. The perichondrium on the inner surface of the lamina likewise is dissected carefully to avoid damage to thyrohyoid membrane Cheesman (personal conversation) has extensive experience with and thyro-epiglottic ligament. The cartilage is then reduced by a very similar technique and has achieved good results. He has reported (Brown et al 2002) combining this procedure with crico using shear cartilage cutting forceps as shown in Fig 1. A full thyroid approximation for pitch changes. thickness "gull shaped" area is removed as seen in 2, then, as shown in Figure 1c, the cross hatched area only to pa'tial The main difference between the other operations and that thickness. Care was taken not to disrupt the internal attachments described here is the use of the shear cutting forceps which make to avoid blunting of the anterior commesure. Further reducing it easy to avoid internal damage. and smoothing was achieved with the shear cartilage cutting forceps and nasal rasps. The perichondrium was then closed Good knowledge of the anatomy and careful dissection is essential over the newly shaped thyroid cartilage. A fine drain was put in. to avoid complications. Damage to the thyrohyoid membrane may The wound was closed in two layers using absorbable 3/0 Vicryl damage the superior laryngeal nerve, which may cause aspiration to close the subcutaneous tissue and the skin closed with and anaesthesia of the larynx. Likewise damage to thyro-epiglottic subcuticular 4/0 Nylon, which was removed after five days. ligament petide can distabilise the epiglottis which need repair with non absorbable sutures to reconstruct the petiole (the points The patient made an uneventful recovery. She was discharged were the epiglottis attached to the inside of the thyroid cartilage). 24 hours later and reviewed a week later. Apart from a mild weak This was not necessary in this case. voice, which lasted for less than 48 hours, the patient has not experienced any other problems. As a result of this patient four aP * Associate Specialist in ENT, * *Consultant ENT / Skull Base Surgeon Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 2, April-June 2006 Clinical Reports Fig 1: Pre operative Fig 2: Post -operative CONCLUSION: A technique for reducing the profile of Adam's 2. Wolfort FG, Dejerine ES, Romas DJ and Parry RG (1990) apple for male to female transsexuals is described. Good knowledge Chondrolaryngoplasty for appearance. Plastic and of the anatomy and careful dissection is essential to produce a Reconstructive Surgery 86 (3); 464-69 good result with mild transient or no complications. We believe 3. this operation has a place among the techniques of ENT Surgeons Giraldo F, de Gardo J, Montes J, (1997) Aesthetic reductive and gives a pleasing profile which satisfies the needs of the patient. thyroid Chondroplasty. Int. J. oral maxillofacial surgery (26) 20-22 1A : DI IIMl1. 4. Brown M. , Perry A, Cheesman A.D., and Pring T. (2002) Int. We thank Ms J Elston for typing this paper and the photography J. Lang. Comm. Dis, 35(1); 129-136 department at University Hospital Aintree. Address for Correspondence I:7DIa11; DIzLei ^ MrA H HAl-Jassim 1. Wolfort FG & Parry RG (1975) Laryngeal Chondroplasty for ENT Directorate appearance. Plastic and Reconstructive Surgery 56; 371-4 University Hospital Aintree Trust Lower Lane Liverpool 9 7AL United Kingdom 173 Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 2, April-June 2006.
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