Tracheal Cartilage (Adam’s Apple) Augmentation

The Adam’s apple is formed by the angle of the thyroid cartilage in the larynx. While cisgender men typically have a sharp, protruding laryngeal angle that creates this external prominence, this feature may be subtle or absent in individuals assigned female at birth. Thyroid cartilage augmentation creates a visible and palpable Adam’s apple to bring the external appearance of the neck into alignment with a patient’s gender identity and goals.

The procedure involves the placement of cartilage grafts over the thyroid cartilage to build a natural-looking prominence. There are two primary sources for the cartilage graft:

• Autologous rib cartilage: A small piece of the patient’s own rib cartilage is harvested and sculpted to conform to the underlying thyroid cartilage. When the patient is undergoing top surgery at the same time, the graft can often be harvested through the same chest incision, avoiding additional scars.
• Cadaveric (allograft) cartilage: Sterile, processed donor cartilage may be used in patients who prefer not to undergo rib harvest or in cases where previous surgeries preclude autologous use.
  

The cartilage graft is meticulously shaped and secured over the thyroid cartilage with sutures. The incision is placed in a natural skin crease at the neck-chin junction.

The procedure may be performed on its own or in combination with other facial masculinization surgeries, including jaw augmentation, brow augmentation, or malar implants.

Adam’s apple augmentation is an excellent option for facial masculinization patients who wish to reshape neck facial profile to better reflect their unique individuality and gender expression. It can be performed on FTM, nonbinary, and gender nonconforming individuals seeking a more masculine neck contour and profile. Multiple variables are involved in determining candidacy for the procedure. You may be a strong candidate for thyroid cartilage augmentation if you:

• Desire a more prominent Adam’s apple
  
• Have little to no natural tracheal prominence
  
• Are undergoing other masculinizing facial or chest procedures and wish to combine surgeries
  
• Are in good general health, with well-managed medical or mental health conditions
  
• Have non-smoking status or are willing to stop nicotine use preoperatively
  

This procedure can be a powerful affirming choice for transmasculine individuals of any age but is particularly impactful for those whose neck profile does not match their gender identity. Candidates should also be in good general health, have well-controlled medical or mental health conditions, and meet WPATH criteria for gender-affirming surgery. Dr. Marano and Dr. Keith will conduct a private consultation that includes a detailed physical assessment and medical review to ensure no contraindications are present and that the surgery will be safe, successful, and rewarding for you. 

The first step in facial masculinization is to meet with Dr. Marano or Dr. Keith for a private consultation at GAMMA in New York City or New Jersey. During this time, you will discuss your goals and medical history with our team, who will then create a customized treatment plan according to your unique anatomy, comfort levels, and goals. Prior to consultation, you should ensure the following:

• Provide Mental Health Letter – Many insurance providers and surgical guidelines require a letter from a qualified mental health professional confirming a diagnosis of gender dysphoria and the patient’s readiness for surgery. This letter should follow WPATH (World Professional Association for Transgender Health) standards and address the patient’s understanding of the procedure and its implications. Our team will assist in ensuring the proper language is used and the provider is appropriately credentialed
• Quit Smoking – Nicotine constricts blood vessels and significantly increases the risk of complications, including poor wound healing and tissue loss. Patients must stop using all nicotine products—including cigarettes, vapes, nicotine patches, and gum—at least 4-6 weeks before and after surgery.
• Manage Medications – You may be asked to discontinue certain medications that increase surgical risks.
• Well-Controlled Medical or Mental Health Issues / Medical Clearance – To ensure safe surgery and recovery, patients with underlying medical conditions such as diabetes, high blood pressure, or psychiatric conditions should have them well-managed. Medical clearance from a primary care provider or specialist is required.
• BMI Cutoff – There is no strict BMI cutoff for facial masculinization at GAMMA. Every patient is evaluated individually, considering overall health and surgical goals rather than BMI alone.
• Insurance Coverage – GAMMA works with various insurance providers to help patients access gender-affirming surgery. Our team assists with insurance verification, prior authorization, and necessary documentation. Patients should check with their insurance carrier regarding coverage criteria, including mental health letters and medical clearance requirements.
• Complete Your Consultation – You will undergo a detailed consultation with Dr. Marano or Dr. Keith to ensure your expectations are realistic and your health supports the treatment process. Our team will discuss the risks and benefits, recovery and results, of facial masculinization.

On the day of surgery, you will arrive early for preoperative check-in, and the surgeon will review the surgical plan. The procedure is performed under general anesthesia. In many cases, thyroid cartilage augmentation is performed in conjunction with other facial gender surgery procedures, and you may require an overnight hospital stay for monitoring.

Recovery time varies for each patient and depends on several factors, including the individual’s healing ability, the specific techniques utilized, and whether thyroid cartilage augmentation is combined with other treatments or procedures.

• Swelling and bruising of the neck are common in the first 1–2 weeks
  
• Mild soreness at the neck incision site or rib donor site, if applicable
  
• Activity restrictions include avoiding heavy lifting, strenuous neck movements, or chest strain for 2–4 weeks
  
• Neck elevation while resting can help reduce swelling
  
• Most patients return to light activities and work within 1–2 weeks
  
• Final Results: The final aesthetic results of thyroid cartilage augmentation may take up to 12-18 months to fully manifest, as swelling continues to subside and tissues heal.

In terms of results, patients may notice a more Adam’s apple right away after surgery. Swelling and bruising can temporarily obscure your final results, however. Rest assured, within a few months, you will start seeing dramatic improvements that only improve with time as you heal.

Thyroid cartilage augmentation is generally safe when performed by an experienced gender-affirming surgeon. As with any surgery, there are potential risks and complications, which include:

• Bleeding or hematoma: Accumulation of blood under the skin may cause swelling or discomfort, sometimes requiring drainage.
  
• Infection at the graft or donor site: Rare, but may require antibiotics or, in severe cases, surgical drainage or removal of the graft.
  
• Graft displacement or resorption: The cartilage graft may shift slightly or be partially absorbed over time, which can affect the final appearance.
  
• Neck stiffness or temporary voice changes: Swelling or inflammation near the larynx may cause temporary hoarseness or discomfort when speaking, though this typically resolves.
  
• Donor site discomfort (if rib cartilage is used): Some patients experience soreness or numbness in the chest wall after rib harvest, which usually improves over several weeks.
  
• Hypertrophic or visible scarring: Most scars are minimal and well-hidden, but in rare cases, they may become raised or require scar treatment.
  

Your surgeon will take extensive measures to minimize these risks and will discuss them thoroughly during your consultation and pre-operative appointments.

Insurance carriers will typically cover gender affirmation surgery, including facial gender surgery, when it is performed to treat gender dysphoria, a condition in which the patient’s outer traits do not reflect their authentic gender identity. You’ll need a letter from a mental health provider detailing your decision to undergo facial gender surgery. Our team can go over the insurance requirements in greater detail during your consultation.

• Resources – For patients traveling to NYC for surgery, GAMMA provides recommendations for LGBTQ+ friendly accommodations, post-op caregivers, and recovery services. Our team can also assist with logistics such as medical transport and aftercare arrangements.
• Requirements – Out-of-town patients must plan to stay in NYC for at least two weeks after surgery to ensure proper healing and attend necessary post-operative appointments. We encourage having a trusted friend, family member, or professional caregiver for the first few days post-surgery.

Our team at Gender Affirming Medical and Microsurgical Associates (GAMMA) in New York City and New Jersey is known for providing the highest-level care in an affirming environment. We utilize today’s most progressive and cutting-edge techniques to provide the highest level of service possible. Our goal is to help transgender, nonbinary, and gender nonconforming individuals achieve their unique appearance goals and thrive with confidence, security, and peace of mind.

Dr. Drew Marano

Dr. Drew Marano is an accomplished, board- certified, and fellowship-trained plastic and reconstructive surgeon who has devoted his career to the art of gender affirmation surgery. He graduated from Rutgers New Jersey Medical School at the top of his class, receiving AOA honors before embarking on a competitive six-year Integrated Plastic and Reconstructive Surgery Residency at Columbia University/Cornell University in New York City. Following his residency, Dr. Marano was selected as the first-ever Harvard University Complex Gender and Microsurgery Fellow, during which time he underwent advanced training in groundbreaking and innovative surgical techniques. He is a prolific author, researcher, and lecturer who has contributed to over 40 publications and presentations at regional and national meetings. Dr. Marano offers ongoing support for transgender patients as they navigate their unique and rewarding journey of transitioning. 

Dr. Jonathan Keith

Dr. Jonathan Keith is a renowned, fellowship-trained, board-certified plastic surgeon known for his progressive approach to microvascular surgery. He is an active member of the World Professional Association for Transgender Health and the founder of the Rutgers Center for Transgender Health. In 2018, Dr. Keith created the first multidisciplinary clinical program for transgender patients in New Jersey and was the first surgeon in the state to perform a female-to-male phalloplasty for gender affirmation. Regarding his extensive educational background, Dr. Keith completed a demanding seven-year residency at the University of Pittsburgh, one of the nation’s most elite and well-regarded plastic surgery training programs. As a testament to his skill and artistry, in 2012, he received the Stephen S. Kroll Fellowship in microsurgery at the University Hospital of Gent, Belgium. Today, Dr. Ketih performs a range of complex and delicate procedures to assist transgender and nonbinary individuals in achieving their ideal appearance, including DIEP flaps for breast reconstruction, vaginoplasty, and phalloplasty.