[Quick note, if you haven’t already read my other article, I previously got a Hair Transplant and also wrote an article about that]
It goes by many names: The tracheal bone aka the lyringeal prominence aka your “Adam’s Apple” (official designation— thyroid cartilage), is the bone in your neck that protects your vocal chords (technically they’re skin folds).
CN: Descriptions of the physical sensations related to a surgical procedure. A couple of post-op photos included below. No photos were taken of the actual surgery in progress.
Here’s what we’re dealing with:
For this article I’m going to use two shorthands: AMAB and AFAB.
AMAB = Assigned Male At Birth, and AFAB = Assigned Female At Birth.
So why do AMABs tend to have a larger and more prominent tracheal bone? Well, as I have learned as a trans person, it’s because when normal puberty starts for an AMAB, their body begins to release a lot of testosterone.
What does testosterone do to a body? A number of things.
Testosterone triggers body and facial hair growth (great if you like beards, not if you don’t!). It also triggers increased muscle growth. It’s literally easier for people with testosterone dominant hormone balances to build muscle than for their counterparts.
And in case you didn’t know, your vocal folds are a muscle.
As they thicken, their resonant frequency drops, resulting in a deeper and lower pitch. This is why typically AMABs voices drop during puberty, and AFABs don’t. Of course it varies from person to person as there are AFABs who have naturally deeper voices and AMABs who have naturally less deep voices.
The body’s natural response to this thickening of the vocal muscles tends to be a thickening of the thyroid cartilage which protects them. Theoretically the thicker the vocal muscles become, the thicker the tracheal bone would try to grow to compensate. But again, it varies.
The visible prominence of the bone can also vary depending on things like how much body fat padding a person has around their neck area. Someone who is tall and skinny is likely going to have a more visible/prominent laryngeal prominence than someone who is shorter and has more fat padding around their body.
Fun Fact #1: If an AMAB person were to determine that they were anything other than a cis male before their natural teenage puberty kicked in, and they were to go on puberty blockers (aka anti-androgens), provided they stayed on the puberty blockers and pursued hormone replacement therapy, their voice would likely never drop. And as a result, it’s also likely that their tracheal bone would not increase in size either.
However, as many trans women or AMAB non-binary people do not begin transitioning before their initial natural teenage puberty begins, it’s “too late” to prevent this growth, and for some of these people, their large and/or prominent tracheal bone “gives them away” once they have transitioned.
But hey, there’s a surgery for that!
[PS In case you missed it, 2 months ago I had another surgery and I wrote about that here: “I Got A Hair Transplant, Here’s What It Was Like”.]
I ended up basically doing 2 consults for this procedure.
Initially I went to a plastic surgeon as I was also inquiring about a variety of “facial feminization surgeries” that trans women often seek or least consider. Facial feminization surgeries tend to be pretty expensive (plastic surgery in general is) so it’s not accessible to many.
The plastic surgeon I met with quoted about $10,000 for the procedure. This surgeon specifically mentioned getting a dedicated operating room, having me fully unconscious for the procedure, and would make a special effort to make the incision higher up under my chin so that there wouldn’t be a visible scar on my neck.
The second consult, which I sought out through a referral from a fellow trans person was with an Ear, Nose, and Throat (ENT) Specialist at a local hospital. The quote in that case was only $1,000, and would be done simply with local anesthetic, and in the hospital but not in an operating room. The scar would more likely be visible this way but they could still make the incision as small as possible. (it ended up only being about 2cm wide which is totally fine)
Here are 2 before photos for reference.
Fun Fact #2: Depending on how old a person is (as well as variable genetic factors), your bones can be more or less “calcified” (aka more solid). Some parts of your body structure are actually cartilage, not solid bone. The bridge of your nose and parts of your ear are examples. They’re “solid”, but not “rock solid”.
I kind of knew this before my procedure, but I hadn’t realized that it could be a significant factor in this surgery. As the surgeon was doing the initial assessment and beginning to administer the localized freezing, they mentioned that while it’s uncommon for it to be an issue for this procedure, once a person reaches their mid to late 30s (again, it varies), the tracheal bone may have “calcified” more, and may not be “shaveable” (or not as shaveable).
The doctor had a clever idea though, they used a needle tip to poke into the tip of the laryngeal cartilage in a few spots to see how rigid it felt. They said it seemed soft enough that they “wouldn’t need to use a drill instead”.
That was the first I’d heard of the possibility of a drill being used! That was the first time I was a little bit freaked out.
I was given the local freezing, and left for perhaps around 45 mins for it to fully kick in. It was honestly a little bit like getting a freezing needle at the dentist before having a cavity fixed. My chin and neck both got numb. I could still feel sensation, but presumably more from the inside than the outside.
Before the actual procedure began, I asked “what am I likely to feel?”
The surgeon said that the freezing could only really affect pain sensors but not as much pressure sensors, so I would feel pressure, but I shouldn’t feel much (if any) pain. They said “if you DO feel pain, tell us and we’ll give you more freezing”.
Okay before I go any further this is likely the point where some of the sensations I will describe might gross some people out, so once again, IF YOU ARE SQUEAMISH, READ AHEAD MINDFULLY.
I did not feel the incision at all.
However, once the incision was made, I did feel the sensation of what was obviously the surgeon’s assistant grabbing the skin flap on the bottom half of the incision site and basically pulling it up and out away from my neck to create space for the surgeon to get into where they needed to. The closest comparable I can think of to how it felt was like wearing a pair of pants with an elastic waistband, sticking one finger behind the waistband and pulling outward. Like this:
Basically, I knew that’s what was happening because I could feel the skin of my lower neck and side of my neck being stretched. It didn’t hurt at all, but it was a very strange feeling.
I worried in that moment “are they going to stretch out my neck skin so that it’s droopy afterward?” and “is the incision site going to tear more from the pressure?”
The answer to both was no (they’re medical professionals, they know what they’re doing) but that didn’t stop me from worrying about it.
I really had no idea what they were doing for the most part. They had a cauterizing gun that they were using kind of like a mini welder to stop bleeds around the incision site (at least that’s what I assume they were doing).
The surgeon had told me at my initial consult that the procedure only takes 15–20 mins typically. I had assumed they cut you open, get in there quickly and shave the bone, and then sew you back up. I did see a brief clip of the procedure in a documentary a couple years ago but had not looked at anything else since.
So as I said, I could feel my neck skin being held out and open, and it felt like the surgeon was going in from the top down. I had assumed the incision had been made probably an inch higher up on my neck than was actually the case. I was wondering how they could see the bone given the physics I thought were taking place in my mind’s eye of what was happening. They weren’t using any mirrors (like dentists use), or cameras.
The incision was actually almost right on top of the bone, which explains why no cameras or mirrors were needed.
I was swallowing a lot the first 10 or 15 minutes (the doctor had to scold me gently at one point), which was partly a stress reaction and partly a habit/instinct.
It felt like about half way through that the surgeon’s assistant seemed to be holding down my tracheal bone with their hand (or a tool) as it became harder to swallow even when I gave into the feeling of needing to (but I was much better in the latter half, especially once I knew they were actually using sharp objects on the bone).
For the first 10 or so minutes I was doing OK.
But probably by about the mid point (mind you I had no concept of how much time had passed) I was starting to really feel like “damn, it would be really nice to have someone I know here with me for emotional support”.
Unsurprisingly, having your neck cut open (even a small hole) can remind you of your own mortality. At least for my hair transplant I was not fully lucid.
At one point my nerves were getting tense and my leg started to shake a bit, and I had to do my best to hold it down with my right hand. Eventually adrenaline fully kicked in and I just white knuckled the rest of it (which meant that I had a decent sized emotional response afterwards).
I couldn’t feel much, mostly just the pressure of stretched skin. The only time I could tell they were actually cutting anything, aside from a slight rocking/sawing motion of the action, was two times I could feel a very slight, faint sharp sensation. I guess it was a bit similar to when a dentist is drilling your frozen tooth and they get really close to the nerve and you can feel that but it doesn’t really hurt. I’m not sure if the faint sharp feeling was initial cuts, or if that was when they were getting down to the barrier between the cartilage and the calcified bone underneath.
Towards the end the surgeon did say “yeah this part is too hard, I can’t cut that”.
The surgeon mentioned that they had tried to cut an even amount from both sides (mine was slightly more prominent on the right side than the left). They said they were able to take a decent amount off. The surgeon actually said that they were pleased with how much they were able to do.
Once I was stitched and bandaged up, the surgeon said it was safe to touch the area and feel the difference. I could tell just from feel that it was smaller.
I had to fight back tears in the cab ride home. I had been holding some emotional weight from something else earlier which was part of it, but there was definitely some trauma from the procedure. It hadn’t hurt but it was a lot of unfamiliar and unpleasant sensations and feeling very vulnerable for an extended period of time.
The initial first hour after getting out was definitely unpleasant. Until I got my hands on the prescribed painkillers, talking (and to a minor extent breathing) was difficult and uncomfortable. Swallowing was very uncomfortable.
Almost as soon as I’d gotten some painkillers into my system though, I began to feel much more human. I’d been warned that the painkillers I was getting would make me drowsy, but have actually found they seem to have the opposite effect. (They did end up affecting my stomach over the next few days though)
I get the stitches out in 5 days.
DAY ONE RECOVERY
I woke up feeling like how I imagine a fish must feel when it has a hook stuck in it’s mouth and is being reeled in (except the hook was in my neck, and I don’t know if fish can feel stuff in their mouth). But only initially.
I slept fine (aside from being awake much later due to the meds), and today basically swallowing is the only really unpleasant part. Yes, my neck is tender and sore, but I’m not in horrible pain and I feel reasonably normal.
DAY TWO RECOVERY
On the second morning I didn’t have nearly the same hook in neck feeling (pretty much only when I first got out of bed, but after I’d brushed my teeth and moved my head around a bit, it was fine).
Swallowing still hurts and is uncomfortable, but the pain is only about 75% of what it was yesterday. I didn’t take any painkillers to start the day. It was mostly just uncomfortable… until the late afternoon. For some reason by late afternoon it became much more painful to swallow again. I resorted to taking one painkiller around 5pm which helped take the edge off a bit, but I’m still trying to avoid swallowing as much as I can. Even liquid hurts to swallow. Just the muscle action at all is uncomfortable.
My energy has felt pretty good, as in I haven’t felt the need to lay around and sleep all the time, but I have found (similar to recovering from my last surgery, or even just recovering from a flu) that “normal output” for a couple of hours will lead me to feeling the need to lay down for a bit. Maybe a half hour. So I’m just trying to pace myself.
DAY THREE RECOVERY
Today ended up being the most uncomfortable and painful so far.
My entire tracheal area had become bruised today (and the swelling finally seemed to be fully setting in) and forced me to take another painkiller, otherwise it was difficult to swallow. The pain in general was worse today than even the first day. Around mid day I ended up feeling similarly to when recovering from a flu, but thankfully laying down for a bit helped clear that. I’ve still been feeling off and on all day.
It’s now evening and clearly the painkiller has worn off, swallowing is still painful but now tolerable on its own.
Given the progress made in physical feeling, I hope that tomorrow will be better and today will have been the worst.
DAY FOUR RECOVERY
Today is back to work.
Feeling better this morning than yesterday. Still hurts/uncomfortable to swallow, but I don’t think I’ll need my painkillers today.
After being awake for 2 hours, I’m definitely feeling better overall. Swallowing is actually somewhat bearable now (still not fun but not as painful). I think my vocal chords are still swollen though as my default voice is rather deep this morning (I can still talk normally but if I do zero effort at changing pitch and basically just hum talk it’s a really deep bassy sound, for the moment.
Now at work, several hours after waking up, swallowing is getting progressively easier. Very little pain, now mainly just uncomfortable. Vocal chords definitely seem kind of swollen, but I am still able to speak in a slightly higher register if I really want to (it’s just uncomfortable at the moment).
Neck muscles felt very tight still by end of day.
DAY FIVE RECOVERY
Well this morning my voice sounds like I swallowed a muffler.
I recorded a short video of it:
I actually tested it with a guitar tuner and I can hit a low C2 (as in 2 whole steps down from the lowest note on a standard tuned guitar). My natural voice is typically around an F/F#3 (so 1st/2nd fret on lowest string on standard 6 strong guitar).
I had an 8:50am appointment to have my stitches out. It was a quick and mostly painless procedure. The doctor said everything looked and felt good.
I’m still not supposed to touch the wound for the next 9 days (2 weeks from the date of the surgery), but I am allowed to shower and let water run over it and gently use a towel to pat-dry afterwards.
Swallowing is still uncomfortable, but as the swelling gradually lessens, it’s getting easier bit by bit. Right now it’s just my swollen vocal chords that are uncomfortable (and I kind of sound like I’m dying lol).
The scar is quite minimal. They had told me it was barely 2cm which is quite small. Once it fully heals up and blends in with the rest of my skin I do think it will barely be visible except really up close.
Swallowing has been getting easier all day. It’s now 7:30pm as I write this and swallowing is actually almost back to normal. My super bassy voice is also subsiding. My neck muscles don’t feel as tight anymore. That said, I still have quite the swollen bump right around the surgery site:
Given the rate i’ve healed between yesterday and today, I’m optimistic that by tomorrow evening I’ll be mostly back to normal. But as is often the case with healing, the first 90% is relatively easy, it’s the final 10% that takes a long time.
I also noticed that being out in the cold air for about half an hour really bothered my throat.
DAY SIX RECOVERY
Definitely the best morning so far. My voice still started out nice and bassy, but it gets better as the day wears on. Still have that nice big bump around my trachea, but I think it’s a bit smaller today.
Swallowing is a lot easier, and there’s not really any pain anymore. The muscles still feel disoriented and a bit weak but definitely feeling closer to normal.
I had a full-on shower this morning, and as per doctor’s orders I only washed above and below the wound and just let water rinse over it, then patted dry.
The scar definitely looks minimal. Especially once the swelling goes down it should look really nice.
DAY SEVEN RECOVERY
Today was the first day where my voice didn’t start out completely bassy. My voice is still strained but starting to get closer to normal. The less I speak, the better, for now.
By end of day, I’ve also noticed that the swelling of my neck has visibly begun to reduce. Perhaps by the end of the weekend (three more days), the swelling will have gone away completely. Fingers crossed.
(It took nearly a full month for the swelling to completely go away)
DAY EIGHT RECOVERY
Last night I had a minor setback. Apparently I did something in the evening that upset my surgery area as I woke up around 2am with my neck having swollen back up again. It was painful enough that I resorted to taking another painkiller (which helped with the pain but now has me stuck wide awake at 4 in the morning on a Friday), and put an ice pack on it (which seems to have helped).
I’ve been using an ice pack on and off today. I’ve noticed that if I am sitting and not moving for an extended period of time (ie 1hr or more) that the swelling seems to settle, but once I start moving (or eating and using my neck muscles to swallow), the swelling increases more again.
This is pretty much where I’m at:
I’m hoping that bulge settles down soon. (It did, but took several days more than I was expecting)
DAY NINE & TEN RECOVERY
This weekend I really buckled down and get stuff done, namely, research and writing, and cooking. So not a lot of moving or high octane activity, which was good. The less I move, the faster my neck seems to heal. My voice is mostly back to normal now, and swallowing still feels a bit weird but I suspect that’s due to the remaining swelling.
It’s Monday, I was back to work today so another pretty calm day. My throat is much less bulge-y but still have a bit more to go. I have my next follow up on Friday, so hopefully by then all of the swelling will be gone.
I still can’t exactly tell how much smaller my Adam’s Apple is, but I’m starting to get a bit of a sense.
Here’s a closeup of the area today:
Bit by bit, the bulge is shrinking. It still feels like there is a decent amount of something under the skin (internal scar tissue?)
BEYOND DAY TWELVE — 2 MONTHS LATER
So I have a confession.
I fully meant to write short daily updates, but I think I got busy, or got sick, I don’t know, but I stopped doing them, and now it’s over 2 months later.
The good news is I’m pretty much 99% healed now. Like, actually 99% healed.
I had my next post-surgery follow up after the stitches removal, where they told me to start using Vitamin E cream and massaging the surgery site for 10 minutes every day. I did as told, and found that each day, the internal scar tissue under the scar would reduce bit by bit.
I had another post surgery follow up 2 weeks after that, and was told everything looked “normal” and as expected. Keep doing what I’m doing they said, it takes time. They said it can take up to 3 months for the healing to fully complete.
It took several weeks to get an actual sense of the reduction of the bone. It’s definitely smaller, mostly at the sides, but also at the front.
Here is a side by side of how it is right now. As you can see on one side it’s almost completely flat, while on the other it’s still a bit of a bump, but honestly unless you’re looking really close it doesn’t stand out significantly.
And here’s the front, close-up. There’s only a tiny bit of scar tissue left, which is still slowly fading with daily use of vitamin E cream and gentle massaging. I suspect in another week or two, you won’t even be able to tell it was ever cut open.
I must admit, for this surgery I definitely did not do as much research as I should have, and while everything worked out OK, I was surprised by how long the recovery took and how intense it was. I know the neck and internal organs are pretty sensitive, but it was still kind of a slog for a little bit.
I don’t regret the surgery, but I probably would have if the results hadn’t been this good.
UPDATE: April 27, 2019 (5 months post-op)
There is still a tiny bit of scar healing left to do, but the results are quite good!
As you can see, the scar is barely noticeable (seems to stand out more in shadow, for some reason). The only time it’s particularly noticeable anymore is when I swallow:
I will try to remember to do another update after a full year.