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Feminization of Transgender Women with Thyroid Chondroplasty and Laryngoplasty

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Feminization of Transgender Women with Thyroid Chondroplasty and Laryngoplasty ORIGINAL ARTICLE Feminization of Transgender Women With Thyroid Chondroplasty and Laryngoplasty Sarah E. Hammond, MD,Ã Erin Cohen, MD,y and David Rosow, MDy that a piece of forbidden fruit eaten by Adam lodged in his throat as a Abstract: In recent years, gender affirmation surgery has broad- reminder of his disobedience.5 Accomplished linguist Alexander ened significantly from its previous focus on genital conformation Gode theorizes that the phrase originated even earlier; he speculates only to include other areas of the body as well. As society that the Latin pomum Adami is a misinterpretation of the Hebrew reconsiders its interpretations of masculinity, femininity, and gen- tappuach ha adam, which means simply ‘‘bump of man,’’ not 6 der definitions, transgender individuals have realized that they will ‘‘Adam’s apple.’’ Regardless of the etymology, the anatomical only be able to truly transition if they are recognized by the public in structure clearly has strong implications as a defining male charac- their chosen societal role. The authors review the literature and teristic and retains that qualification even in modern times. Often- times while others may view the thyroid cartilage of a transgender describe their own techniques for feminizing thyroid chondroplasty woman as a subtle prominence, the patient herself sees the feature as and laryngoplasty. conspicuous and a significant factor in her gender dysphoria. Key Words: Chondrolaryngoplasty, facial feminization, THYROID CARTILAGE ANATOMY feminizing laryngoplasty, gender affirmation surgery, thyroid The male larynx enlarges significantly at puberty, almost doubling chondroplasty, transgender in size anteroposteriorly.7 In men and women, the larynx consists of 9 cartilage subunits, 1 of which is the thyroid cartilage.7 The thyroid (J Craniofac Surg 2019;30: 1409–1413) cartilage is the longest laryngeal cartilage; 2 lateral laminae fuse in the midline over the deeper structures of the larynx, giving a shield- n the last 3 to 4 decades, gender affirmation surgery has broad- like shape and function. The male thyroid cartilage forms a 908 I ened significantly from its previous focus on genital conforma- angle with greater median projection anteriorly.8 This smaller angle tion only to include other areas of the body as well.1 As society results in longer vocal cords and a lower-pitched male voice.9 In reconsiders its interpretations of masculinity, femininity, and gen- contrast, the female thyroid cartilage has a more obtuse 1208 angle. der definitions, transgender individuals have realized that they will The female thyroid gland is larger, covering the thyroid cartilage only be able to truly transition in the public sphere if they are able to and creating a smoother silhouette. Overall, the effect is a more interact in every-day life in their chosen societal role. In fact, many slender and smoother neck contour that is recognized as feminine. transgender patients are satisfied with these more recognizable Originally reported by Wolfort and Parry in 1975,8 alteration of facial transitions and do not go on to seek bottom surgery. the thyroid cartilage can be done to achieve a more masculine or more The neck is an area of the body where sexual differences can be feminine contour.10 However, a thorough knowledge of the pertinent easily identified. Studies on intergender differences in neck height anatomy is crucial to maintain normal phonation and respiration and and length by Vasavada et al2 showed that neck anthropometry to prevent complications. The extrinsic muscles of the larynx attach to parameters in females were 9% to 16% smaller than in males, with the posterolateral surfaces of the thyroid cartilage. The epiglottis only a 3% to 6% gender-related decrease in head anthropometric attaches to the deep surface of the thyroid cartilage in the midline via parameters. The female third through seventh cervical vertebrae the thyroepiglottic ligament. The intrinsic laryngeal muscles attach (C3–C7) were significantly smaller when compared with the same inferior to this ligament and function to close the glottis or tense and male cervical vertebrae.2 Female neck muscles were also found to relax the vocal cords, allowing deglutition or inspiration and produc- be 20% weaker in extension and 32% weaker in flexion when ing phonation, respectively.7 The intrinsic muscles are innervated by compared with male counterparts.2 the recurrent laryngeal nerve with the exception of the cricothyr- A masculine neck is characterized by increased muscle volume,3 oideus which is innervated by the external branch of the superior decreased subcutaneous tissue,4 and a more prominent thyroid carti- laryngeal nerve. The external branch travels deep to the superior lage as compared with a feminine neck. In fact, the more protruding thyroid artery to enter the cricothyroid muscle. Injury to this nerve can thyroid cartilage is a defining secondary sexual characteristic in occur if dissection is done too posteriorly, causing a decrease in voice males. This anatomic feature is known in popular culture as an pitch and strength. The internal branch of the superior laryngeal nerve ‘‘Adams apple,’’ or pomum Adami. The origin of this term is provides sensory innervation to the laryngeal mucosa and enters the obscure—medieval Judeo-Christian writers handed down the legend larynx through the thyrohyoid membrane. Injury to this structure can cause loss of the laryngeal cough reflex and increased risk of aspiration pneumonia. Both recurrent laryngeal nerves travel in From the ÃDivision of Plastic Surgery; and yDepartment of Otorhinolaryn- the tracheoesophageal groove to the larynx, entering just posterior gology, University of Miami, Miami, FL. to the cricothyroid joint. These nerves innervate the remainder of the Received March 12, 2019 Address correspondence and reprint requests to Sarah E. Hammond, MD, intrinsic laryngeal muscles and can be injured in the course of lateral Division of Plastic Surgery, University of Miami, 1120 NW 14th Street cartilage dissection. 4th Floor, Miami, FL 33136; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD CHONDROLARYNGOPLASTY TECHNIQUE ISSN: 1049-2275 In our own practice, we have frequently performed feminization DOI: 10.1097/SCS.0000000000005569 thyroid chondroplasty in conjunction with a feminizing The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 1409 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Hammond et al The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 and the anterior protrusion approximately 5 to 6 mm beyond the native cartilage. Once satisfied with the appearance, they secured the graft to the patient’s existing thyroid cartilage using permanent sutures. They then closed the wound with a standard layered closure and did not leave a drain. In their report, they recommended obtaining plain films of the chest to rule out a pneumothorax postoperatively. They reported the patient to be well at 6 months follow-up, with free mobility of the laryngeal prominence and no resorption of the cartilage graft.14 Although this is not often requested by transgender men, it may be considered as an option for facial masculinization. FIGURE 1. (A) Intraoperative thyroid cartilage exposure via submental incision. FEMINIZING LARYNGOPLASTY (B) Intraoperative thyroid cartilage resection specimen. Many individuals in the transgender community place just as much if not more importance on their transformation as effected by secondary sex characteristics, and rightly so. Humans both perceive laryngoplasty done by our otolaryngology colleagues. We ask our others and present themselves through largely visual and tactile transgender female patients to hold all hormone supplements for 4 communication. However, research shows that the most accurate weeks prior to surgery. An incision directly over the thyroid and effective communication is achieved with solely one’s voice.15 cartilage should be avoided. We prefer to utilize a 2 cm submental While androgen use can lower the voice in female-to-male trans- incision unless the patient has an obvious scar or rhytid overlying gender patients, estrogens have no significant effect on the physical the thyroid cartilage that can be used instead. In general, an incision properties of the vocal folds or the laryngeal framework, and thus 3 to 5 cm cephalad to the superior aspect of the thyroid cartilage will more extensive interventions must be performed. allow for access with sufficient downward traction of the skin. The Male-to-female (MTF) individuals commonly undergo consid- strap muscles are divided in the midline raphe and retracted erable voice therapy to generate a more feminine voice. Whether laterally, exposing the underlying thyroid cartilage. The thyroid somewhat learned from societal expectations or purely biologic, a gland itself can be retracted superiorly, or divided if necessary for ‘‘feminine’’ voice is characterized by a certain cadence, intonation, adequate exposure. Care should be taken to maintain a midline articulation, inflection, breathiness, lower volume, and most impor- dissection to avoid nerve injuries more laterally and to maintain an tantly, increased pitch.16,17 As shown by Spencer in 1988 and Wolfe avascular field. After adequate, safe exposure of the thyroid carti- et al in 1990, fundamental frequency (F0) is the most important lage is achieved, the perichondrium is incised
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