Voice feminization surgery

Voice feminization surgery

What is voice feminisation surgery?

Voice feminisation surgery is a surgical technique used to raise the pitch of the voice. We use the technique called Wendler glottoplasty, similar to the VFSRAC technique used by Yeson Voice center. One of the differences is that the VFSRAC technique doesn’t use laser.

FAQs about this procedure

Pros

• Very good results
• Very safe procedure
• No visible scar

Cons

• A 15-day complete vocal rest period is necessary.

What is the difference between a masculine and feminine voice?

The first step is understanding the differences between “pitch” versus “voice” versus “speech.”

  • Pitch—Pitch is the rate at which the vocal cords vibrate, and determines the frequency of a sound produced. Pitch is essentially ALL that the voicebox (larynx) does. The rage is the array of pitches that our larynx can produce. An untrained male voice usually has a little over an octave of range, which are 12 notes on a piano. Voice is what results as we mold that sound.
  • Voice—Voice is shaped by the size and shape of our throats, mouth, nose and sinuses, giving it resonance, just like the size and shape of a piano gives that sound character. The “voice” or sound of an upright piano would sound different than that of a concert grand piano even if the same note is being played. It is important to understand that the resonators of your voice, the shape of the throat, mouth, and sinuses, can not be changed in feminisation laryngoplasty. Even gender reassignment surgery and/or facial feminisation cosmetic surgery can not change these resonators. Assessing these areas pre-operatively are vital to predicting how the voice might sound, and be perceived, afterwards.
  • Speech—Next, voice is shaped into words and sentences. This is speech. A genetic female uses a different part of the brain to produce speech than a genetic male, and has a certain sing-song quality called prosody. Prosody is why the brain of someone listening to you will subconsciously perceive the voice as being female versus a high-pitched male voice. (Visual cues are also very important, but for the purposes of this discussion, visual cues are assumed absent, such as during telephone conversation). Prosody can not be changed with hormones or surgery. It must be learned, the way an actor would acquire the skills to take on another’s personality of sorts. It requires a speech therapist who is very, very experienced in transgender voice changes. For most, years of practice are required to perfect female prosody and have it sound natural and effortless. Perfecting female prosody is 50% of the final result. This is why a genetic female with a very low speaking voice is still perceived as female, even when in the male speaking fundamental frequency (such as many female television reporters).

Voice feminisation surgery only addresses the pitch (vibrating rate, frequency). The average female speaking fundamental frequency is right around middle “C” on a piano (the normal range is within the pink arrows). The average male SFF is in a range about an octave lower than female, within the blue arrows in the picture. An octave is 12 notes on the piano (including the black keys!).

piano_keyboard2-580

The average female speaking fundamental frequency is right around middle “C” on a piano (the normal range is within the pink arrows). The average male SFF is in a range about an octave lower than female, within the blue arrows in the picture. An octave is 12 notes on the piano.

How does a voice feminisation surgery work?

If you look at a real piano, the higher notes have the shorter, thinner, tighter strings. This is what voice feminisation surgery aims to achieve with your vocal cords.

What can a voice feminisation surgery do for you?

Many transwomen are stigmatized by their deep, male-sounding voices. The main desire of the patient is a naturally feminine voice 
rather than constant acting efforts to sound feminine.

Even when speech therapy is capable of feminizing 
the voice and vocal behavior by changing breathiness, intonation, articulation, word choice, and inflection, the male voice 
appears in uncontrolled situations, such as yawning, coughing, and laughing.
The voice in many cases gives the impression of hyperfunctional dysphonia (Voice dysfunctioning as a result of overuse of the laryngeal muscles and ,occasionally, use of the false vocal folds) and produces subjective complaints such as hoarseness, globus feeling (feeling of a lump in the throat when actually there is no lump present) and vocal fatigue.

By voice feminisation surgery pitch can be raised 2/3 of an octave, or 8 notes, on average and in most cases. Some patients may get as little as 1/2 of an octave (6 notes) and others more than a full octave (12-14 notes). The goal, however, is to end up with a SFF in an appropriate part of the normal female range. There are many things that help predict the degree of expected pitch elevation, such as whether you ever smoked; have vocal fold polyps or scarring from voice abuse; limited range to begin with; age, or a shorter, fatter neck. In general, the lower your voice starts, the lower you will likely end up. A thorough pre-operative, in-person evaluation will help predict the degree the voice could be raised under ideal conditions.

The most frequently used method is the cricothyroid approximation (CTA), first described by Isshiki . However, its main drawbacks are external incision, majoration of the thyroid notch, and inconsistent long-term results. Wendler in 1989 described an endoscopic technique that has the advantage of the absence of an external incision in the neck and more stable long-term results. The Wendler glottoplasty for raising the 
pitch, is based on three fundamental principles: increasing the vocal 
folds tension, altering the vocal folds consistency, and 
decreasing the vocal folds mass.

How is a voice feminisation surgery performed?

“Minimally-Invasive Feminization Laryngoplasty”, “Endoscopic Suture Glottoplasty”, “Laser-Assisted Vocal Fold Webbing”, “Anterior Commisure Retrodisplacement” “Wendler glottoplasty”. These are different terms for shortening the vocal cords via an endoscopic, minimally-invasive, laser-assisted procedure. The terms are descriptive and essentially synonymous in intent, which is to shorten the functional length of the vocal cord, thereby raising the pitch. The laser assists in controlling the degree of webbing, as well as the amount of anterior commisure retrodisplacement, and the final length of the vocal cords.

  • A Wendler glottoplasty is performed under general anesthesia, with jet –ventilation.
  • The endolarynx is exposed via direct laryngoscopy. The anterior part of the vocal folds is deepithelized using the CO2 laser with Acublade system (Lumenis, Santa Clara, CA) with a 10-W intensity, repeat mode, and a 2-mm beam.
  • The free edge and the superior and inferior surfaces of the vocal folds are deepithelized. Care is taken not to injure the vocal ligament.
  • The corresponding tissue of the vocal folds is firmly sutured with 2 knots of slowly resorbable threads (3-0 vicryl) to obtain a V shaped anterior commissure
  • At the end of the procedure, fibrin sealant is used to strengthen the suture.

wendler glotto yeson

Notice how much shorter is the functional length of the post-op vocal folds (blue arrow) on the right. The yellow arrow marks the suture. The suture will dissolve in 3 months, however, the vocal fold shortening is considered permanent and irreversible.

wendler glottoplasty yeson after 6 months

Before, and 6 months after glottoplasty alone. Notice the controlled webbing where the yellow arrow is pointing, and that the suture has dissolved.

What to expect and do during the recovery period after a voice feminisation surgery?

  • A 15-day complete vocal rest period is necessary. This vocal rest period is empirical and is meant to limit tension forces to prevent the dehiscence of suture points.
  • Patients are treated with antibiotics (amoxicilline + clavulanic acid: 1 g three times daily) for 1 week, double-dose proton pump inhibitors for 6 weeks, and inhaled steroids twice daily for 1 week.
  • Temporary hoarseness for 3-4 weeks can be observed but this disappears spontaneously o with a few session of speech therapy.
  • Subglottic pressure is augmented because of the more important work to perform after reduction of the surface of the glottic aperture. However, the vocal effort tends to decrease with time. As most of the patients are young and not vocal performers, they are not bothered by the temporary rise of vocal effort and the decrease in vocal range.
  • The comparison between the preoperative and the last postoperative measurements shows a significant improvement of the fundamental frequency from 150 Hz to 190 Hz. The mean frequency range had a tendency to decrease after the surgery from a preoperative mean range of 430 Hz to a postoperative mean range of 240 Hz

Which are the risks of a voice feminisation surgery?

The 2 complications observed so far are
• a breakage of the knots
• an insufficient web.

Both can be corrected by performing a second procedure to re-suture the vocal cords and extend the web.

How long can I expect the results of voice feminisation surgery to last?

  • Basically for ever.
  • The Wendler glottoplasty however is only a part of voice feminisation. It contributes to the feminisation of the voice. Speech therapy must be added to modify the vocal behavior.
  • Counseling is a very important part of the preoperative process. We send all our patients first to our specialised voice therapist Katrien Eerdekens because she will guide you through the operative process.

Make an appointment with our voice therapist to discuss your voice surgery

FAQ

What is CHL?

The surgery is performed in CHL, the major institution of Luxembourg

Here the information about where the ENT department is located:
Prof Marc Remacle
Voice and Swallowing center
Department of ORL-Head & Neck surgery
CHL-Eich
Rue d’Eich 78
L-1460 Luxembourg

What about the “conventional” cricothyroid approximation

The “conventional” procedure called cricothyroid approximation ( type IV of the Isshiki classification) doesn’t give any long-term good result because this is based on the stretching of the cord. This stretching like any stretching doesn’t last long . Moreover this based on the stable position of the arytenoid (cartilage of the vocal cord) what doesn’t happen. This why I prefer the Wendler glottoplasty that is based on reduction of the mass and the length of the vocal cord. The Wendler glottoplasty is also purely transoral. The approximation necessitates an incision in front of the larynx.

Should the voice surgery be my last surgery? I heard if I have surgery after the voice surgery, the new created voice box can be damaged when the intubilator is put trough the throat for breathing?

During a surgery in general anesthesia (FFS, SRS, BFS) the patient needs to be intubated. That means a tube will be placed in between the vocal cords to ventilate the patient during surgery. The voice feminization surgery with the best long term results is the Wendler glottoplasty (the technique the Yeson Centre uses). A Wendler glottoplasty will reduce the space in between the vocal cords, which means it will be more difficult for the anaesthesiologist to put a tube in between the vocal cords without damaging them. On the other hand this should be no problem ifs done with care by an experienced anesthesiologist with a small size tube.

So in the end it doesn’t make a lot of difference: first other surgery or the voice cord surgery. But doing the voice cord surgery at the end of your transition will make things easier for the anaesthesiologist. It will also make your voice feminization cord surgeon sleep more quietly.

You still have another question? Feel free to ask! We will answer your question and if generally applicable add it to the FAQ of this page.