Feminization laryngoplasty surgery

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 male's voice box smaller and vocal cords shorter in an attempt to raise the comfortable speaking pitch. It has also cut off the lower range and sometimes adds a few notes on the upper end of the range based on my experience thus far.

Indications

The surgery is for patients whose voice pitch is consistently interpreted as male, despite concerted efforts at altering pitch such as speech therapy. 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 undergoing transgender surgeries and wishes to change the voice pitch and potentially other qualities of the voice as well. Having a previous voice surgery such as a CTA does not preclude performing this procedure, in fact, this procedure may work even if the CTA procedure has failed.

Alternatives

This surgery doesn’t work or meet the needs of everyone. It is new and carries with it some significant risks. A more common and traditional surgery would be cricothyroid approximation (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 am just speculating on this as I do not have enough follow up on patients who have had the 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, so I don't plan on trying this procedure myself at this point in time.

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 positive vocal effect, some of the time. 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.

The 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 occured 1 or 2 days later, which is why I ask you to stay in the area. If you need to go to the hospital, it 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 from 1 to 3 days later. Overall, including the preoperative exam you will be in town about 5-7 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 ENT's 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 chose to stay. If you cannot bring someone with you, there is the TLC, "Temporary Living Center" located in a medical facility about 10 miles away. A private room there presently includes a bath, meals and assistance with care and medication. You can make the reservation for this care. You will be charged by the TLC and payment is made at the time of discharge. We will arrange for transport to the living center for you. After that time 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.

Title: Thyroid cartilage and vocal fold reduction: a new phonosurgical method for male-to-female transsexuals.

Authors: Kunachak S, Prakunhungsit S, Sujjalak K.

Journal: Ann Otol Rhinol Laryngol. 2000 Nov;109(11):1082-6.

Location: Department of Otolaryngology, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand.

Abstract: To date, there is a paucity of literature on surgery to alter vocal pitch in male-to-female transsexuals. The currently available pitch-raising surgical techniques yield neither a good long-term result nor a high enough pitch to simulate a female voice. We investigated a new procedure to alter vocal pitch in 6 male-to-female transsexuals. The principle is to shorten and increase tension on both vocal folds by composite resection of a vertical strip of the anterior thyroid cartilage along with a segment of vocal fold. This resulted in a satisfactory pitch alteration from an average of 147 Hz before operation to 315 Hz afterward. In addition to a marked pitch elevation, all patients were particularly pleased with the softness of the voice and the simultaneous loss of the prominentia laryngea (Adam's apple). The longest follow-up was 6 years. In conclusion, thyroid cartilage and vocal fold reduction is an effective method for long-term alteration of voice in male-to-female transsexuals.

I have performed 45 cases (as of 4/2/2007). You may listen to the results of several cases at http://www.voicedoctor.net/media/cases/pitch/index.html. 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.

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.

Pitch altering surgeries: Feminization laryngoplasty