Feminization laryngoplasty

Information intended for patients considering a Feminization laryngoplasty procedure with or without a Thyrohyoid elevation. Patients are typically male-to-female transgender patients.

• Definition
• Indications
• Alternatives
• Presurgery
• Risks
• Procedure
• Recovery
• Instructions during healing
• Benefits

The following is meant for my patients and is based on my experience. There certainly are regional and individual surgeon variations in style, especially for surgery in the transgender patient.

Definition

Feminization laryngoplasty is a procedure designed to make a genetic males voice box smaller and vocal cords shorter in an attempt to raise the comfortable speaking pitch. I almost always try to alter the resonance as well by adding in a thyrohyoid elevation at the same time. The thyrohyoid elevation attempts to shorten the pharynx (the throat) to improve the resonance of the higher pitches. In general the procedure cuts off the lower range and sometimes adds a few notes on the upper end of the range and sometimes removes some notes from the upper end.

Indications

The surgery is for patients whose voice pitch is consistently interpreted as male, despite concerted efforts at altering pitch such as speech therapy and training. For instance, a person who might be faring well in person, but is still typically perceived as male when on the telephone. The typical patient will be a male who has or is, or may yet be undergoing transgender surgeries and wishes to change the voice pitch and potentially other qualities of the voice as well. However, other genetic females or intersex individuals have had the procedure as well. Having a previous voice surgery such as a cricothyroid approximation (CTA) does not preclude performing this procedure. In fact, this procedure may work even if the CTA procedure has failed. It also is a very good way of correcting the complication of a trach shave where the pitch was inadvertently lowered.

Alternatives

This surgery doesn’t work or meet the needs of everyone. It is new (I have been performing it for 8 years in 2011) and carries with it some significant risks. A more common and traditional surgery would be CTA.

Other approaches include reducing the size of the vocal cord, perhaps with a laser. The theory is that the thinner vocal cord will vibrate at a higher pitch. Women’s vocal cords are both thinner and shorter than men's vocal cords. The surgery might also increase the tension of the cords from some pulling and retraction after the surgery and thus alter the vocal quality. I have been using an office laser (presently the KTP) to add some tension to vocal cords since early 2009. I have found it to be ideal to correct asymmetries in tension that may have resulted from FemLar surgery.

Some other surgeons have tried creating a web on the vocal cords. I have continued to see people with webs from other conditions and I am still not impressed with their voices though the pitch does go up.

As pitch elevation in both males and females involves changes in the diameter and length of the throat during speech, there may be a way to surgically reduce the diameter or length of the throat (or pharynx) that would change the resonance of the voice. I have surgically elevated the voice box in an attempt to accomplish this. It seems to have some beneficial effect on feminine resonance. See the thyrohyoid elevation procedure for further information.

Presurgery

Before the surgery/procedure, I evaluate your larynx with a videoendoscopy and I hold a PARQ conference with you.

An evaluation and examination of your voice box is essential. During the typical examination I record a number of your vocal parameters. I then film your vocal cords in motion. The complete examination of your voice takes about an hour. Our speech therapist will also spend about an hour with you.

PARQ is an acronym for Procedures, Alternatives, Risks and Questions. It means that your surgeon has discussed with you in full detail the reasons for the procedure, the alternative treatments to the procedure, the risks of the procedure and that you have been given ample time to ask questions and are satisfied with those reasons and answers.

Risks

The general risks of surgery are discussed on the informed consent page. The risks specific to this procedure are similar to those for a cricothyroid approximation though there are some additional ones as well, that would need to be discussed in person.

I have had a number of granulomas form on the inside of the voice box. So far all have either been coughed out or have been able to be removed, though primarily I prefer to inject them with steroids and they will fall off. While present, the granuloma could cause a soft whispery voice depending on its location inside the voice box.

I have had a number of infections ranging from mild redness, to more prolonged infection that have required surgical removal of the infected suture or infected plate. Before I placed drains in the neck, I had one infection that caused enough swelling that I placed a temporary tracheostomy for a few days.

Procedure

The surgery is performed in an outpatient setting under general anesthesia. After you are asleep, an incision is placed parallel to or in a skin crease of your neck over the Adam’s apple. The front of the voice box is removed thus making the voice box smaller. (This removes the projection of the Adam's apple at the same time so it is not necessary to have a separate “trach shave” procedure.) The vocal cords are then stretched and the front third to half of the cords are removed to shorten them. A tiny metal plate may be used over the voice box to maintain the tension on the vocal cords as well as hold the incised cartilage together during the healing period. It is a small plate and remains in place even when everything is healed.

A thyrohyoid elevation may also be performed at the same time to try raising the voice box in the neck. This attempts to shorten the pharynx to feminize a portion of the resonance chamber (pharynx). A thyrohyoid elevation consists of passing sutures around the hyoid bone to hold the voice box in an elevated position in the neck.

Recovery

I have not kept anyone in the hospital overnight. When a complication has occured, such as infection, the complication has typically occurred two or three days later, which is why I ask you to stay in the area for one week. If you need to go to the hospital, the cost is not covered by the surgical fee. It is your responsibility. I say this because some patients choose not to be insured. I do not offer insurance.

I will see you back in the office frequently. Overall, including the preoperative exam you will be in town about five to seven days. I cannot emphasize how valuable it is to remain in the Portland metropolitan area immediately after the surgery. This is because problems that might arise are typically easily handled by myself since I performed the surgery and I understand what is going on inside your neck. Few, if any other ENTs have ever performed this type of surgery and small problems can become big ones if people are not comfortable.

Because of the wide range of choices patients make regarding post operative housing, the cost for housing is not included in the surgical fee. For the first 24 hours after surgery, you must stay with an adult where ever you choose to stay. If you cannot bring someone with you, there is a service where you can pay someone to stay with you for the first night after surgery. Although you could stay at a local hospital it is very expensive and to date no one has opted to spend that much money. After that first surgery night, you may stay in a number of facilities near the office ranging from hotels to hostels. We maintain a list based on feedback from previous patients.

In the initial post-surgery weeks, your speaking pitch will likely be lower than before surgery. This is because the surgery opens the voice box and creates a lot of swelling (when compared to other procedures such as the CTA). Swollen vocal cords vibrate at a lower pitch, just like the last time you had laryngitis. Your voice will often seem quite soft, tight or effortful to use. It will likely get worse before it gets better and you may have a roughness that changes over several months. There will be initial pain or discomfort from the procedure. It is common to describe a sore throat sensation and to have some initial difficulty with swallowing. I do not expect your voice to be approaching it's new pitch for at least 6 weeks.

Instructions during healing

Complete voice rest is mandatory for two weeks after the procedure. I initially specified one week and then I had a patient start singing because their voice felt so good after one week. Then they felt a tear and a drop in pitch. All forms of verbal communication are not allowed, including whispering. Remember, there are only a few sutures holding the vocal cords in place and until your body's own scar tissue helps support the procedure, the sutures could theoretically pull out. Sedentary work can be resumed in a few days. Speaking may begin gradually after two weeks - but should be at the absolute minimum for the third week (I have had patients try to use their voice too much and become hoarse or drop their pitch). Aerobic activity may be resumed after three weeks. No weight lifting for one month. It would be best not to have surgery requiring intubation (a breathing tube) for three months and if you must have surgery you should request a size 6 or smaller endotracheal tube to be safe. That is the tube I use for almost every patient. You may have your anesthesiologist call Dr. Thomas at any time if there are any questions.

Benefits

There is a report of six cases performed in Thailand referenced with abstract below.

I have performed 105 cases (as of 12/30/2010) on 79 patients. Eighteen of the first 40 cases were revised. Six of the second 40 cases were revised. In the past two years, I have been touching up some of the results with an office laser procedure. At present, I am reviewing the outcomes. Of 56 patients for whom I have both before and after recordings, the mean pitch elevation is six semi-tones with a standard deviation of 3 semi-tones. The lowest pitch is up seven semi-tones (s.d. = four semi-tones) and the highest pitch is down three semi-tones (s.d. = seven semitones). This review is in the process of being submitted to a peer reviewed journal.

You may listen to the results of some cases at http://www.voicedoctor.net/audio-files-current. The patients have provided some feedback on this procedure as well. I especially appreciate all of their efforts in working with me on this procedure.

For another viewpoint see Anne Lawrence who reviews a number of surgeries.

In a brief summary of my current opinion, I would say that this procedure offers more potential gain than cricothryoid approximation and more potential risks. When the outcome has been good, the quality of the voice is far better than the quality of cricothyroid approximation. When there has been a complication, the outcome has been poor. If the outcome was a rough voice and there had been no previous pitch surgery, I have been able to revise and improve the voice. There are a number of variables that I am still altering trying to get the procedure optimized. These will be discussed with prospective patients.