Open Feminization Laryngoplasty, Cricothyroid Approximation (CTA), Thyroplasty type IV
To create a person's voice, the vocal cords act as a sound generator. The pitch of the voice relies on vocal cord vibrations. The shape and size of the mouth, nose, throat, and even sinuses also contribute to the way the voice sounds.
Men tend to have lower voices while female voices are usually higher. Through the voice feminization procedure, transgender patients seek to increase the resonant frequency of a male voice to a more female one.
But the procedure alone is not enough to make a full vocal change. Once completed, patients need to work with a speech therapist experienced in transgender procedures to ensure a successful vocal outcome and comfort in speaking. Going through therapy after the procedure will help patients learn to properly use their new vocal pitch.
There are two surgical options used to raise a person's voice pitch. One such surgery is the anterior glottal web formation. This procedure creates a web of scar bands at the front of the vocal cords, shortening it to raise the pitch. Another way to raise the vocal pitch is by shortening the vocal folds and configuring the vocal tract through surgery.
One thing to remember is that the pitch is just one component that makes up how a feminine voice sounds. Rest assured, this surgical procedure can help patients achieve the voice sound they desire.
Before the Operation
There are some important steps a patient must remember before undergoing voice feminization surgery. First, they must stop smoking a minimum of two weeks before the first doctor's consultation. In most cases, the patient would also be advised to drink plenty of water proper to the procedure to maintain good vocal hygiene. Having good vocal hygiene goes a long way towards ensuring a successful surgery.
Then the patient must undergo a very careful acoustic study of their voice (voice analysis). This is done to be able to fully understand the potential results of the pitch elevation surgery. The study is called a videolaryngostroboscopy.
The videolaryngostroboscopy lasts for an hour including consultation and the procedure proper. When it is completed, patients can discuss potential results, bring up any risk factors, and ask all their questions, such as when they get to hear their final voice.
After the initial exam and discussion, patients are asked to work with a speech therapist for one-hour sessions at least 2-3 times a week before the surgery to help retrain their voice and prepare for the operation. If the patient has already had a prior voice change surgery using a different technique, the surgical team may need to assess the case further to ensure success.
Vocal Feminization Surgical Technique
During the voice feminization procedure, the surgeon moves thyroid cartilage near the patient’s cricoid using absorbable stitches. A 2 cm transverse incision is used, usually done in a skin crease to minimize scar visibility, at the level of the vertical midpoint of the thyroid cartilage.
A patient’s vocal cords aren’t directly touched or manipulated to prevent damage. The change in pitch occurs because the vocal cords are passively stretched through the surgery. The stretching causes the rise in vocal pitch through surgically stimulating cricothyroid muscle contraction with sutures.
This simulation helps increase the space between vocal fold attachments which causes the vocal fold tension to increase. Thyroid and cricoid cartilage are brought as close to each other as possible to mitigate potential post-surgery reversion to a lower pitch when the swelling decreases.
The voice feminization procedure is done under general anesthesia for approximately 40-50 minutes. It is often done in tandem with Adam's apple/tracheal shaving in patients wishing to do both feminization procedures.
If a patient is just doing the voice feminization surgery, there is generally minimal pain afterwards. Any pain can be managed with painkillers. However, if doing both procedures, the tracheal shave procedure may cause some post-operative pain.
Advantages and Disadvantages of Procedure
The advantages of voice feminization surgery include:
- No direct manipulation of the patient’s vocal cords that might lead to voice damage and permanent hoarseness.
- It is reversible.
- This procedure can be done in tandem with tracheal shaving.
The disadvantages include:
- surgery will require a small neck incision which may scar. This varies per patient;
- long-term success and results of this procedure are not available as it is still relatively new.
What are the risks associated with voice feminization surgery?
Risks of getting voice surgery include:
- Dysphonia, such as voice breaks and tremors
- Edema or fluid buildup in the voice cords
- Enlarged Adam's apple
- The pitch remains low even after voice feminization surgery and therapy
- Scarring inside the voice box or on the outside of the throat
- Voice sounds unnaturally high
- Vocal cord dysfunction
- Vocal cord lesions
- Vocal fold paralysis
Post-surgery reminders to follow include:
- Day 1-7 – Patients must stay in absolute silence. Patients won't have food and beverage restrictions although to prevent acid reflux it is recommended to avoid caffeine, chocolate, fatty food, soda, peppermint, and alcohol.
- Day 3-7 – Patients should lubricate vocal cords with water and simultaneously nebulize using a saline solution.
- Day 8-10 – After the patient's allocated rest time, a new videolaryngostroboscopy will be conducted. Outer stitches will be removed and wound dressing will be replaced. This is also when speech rehabilitation with speech-language pathologists or voice feminization therapy may begin. This helps patients learn the eye contact and timing needed to support the female voice. Undergoing therapy can also help patients get used to their transgender voice.
Note: Usually only a week off work is required if the patient can follow voice restrictions while at work. If the patient's voice is needed at work, a minimum of two weeks is required to ensure proper healing.
Female-to-Male (FTM) Voice Surgery/Vocal Masculinization
The procedure can be done for transgender men seeking to lower their vocal pitch to make it more masculine. This is usually considered if patients are dissatisfied with the changes to their voice using just male hormone therapy.
The preoperative process is similar. Patients need to undergo a videolaryngostroboscopy to be able to plot out how best to meet their goals through surgery and voice therapy.
To help patients get a deeper lower voice, the mass of the vocal cords is increased by using an intra-cords injection of biocompatible materials. This increase in mass helps lower the fundamental voice frequency.
Usually, one injection of biocompatible material (autologous fat or hydroxyl apatite depending on each individual case) is enough to reach desired lower pitch. However, each patient is unique and this could differ. The operation is not permanent and may need to be repeated after several years.
The FTM operation is done with general anesthesia. It lasts for approximately 20-30 minutes. Patients do not experience postoperative pain and have no food restrictions after surgery.
After the operation, patients must remain silent for 2 days. Then a second videolaryngostroboscopy will be conducted to evaluate the results. When this is completed, patients then proceed with speech therapy.
Once the voice feminization or masculinization procedure is complete, speech therapy is required to ensure optimal long-term results. Having a pitch closer to a patient's gender identity is empowering but, without proper speech therapy, patients may not fully understand how to use their new voice.
Speech therapy helps patients communicate naturally with their new and authentic voices. Therapists help patients learn proper ways to balance control frequency, tone, intonation, and resonance through exercises that include posture adjustments, facial expressions, and even breathing exercises. Exercises can usually be done in just 10 minutes per day.
Through these guided exercises and evaluations, patients learn to better understand their new vocal tone, how their voice works, and how they can better utilize their new pitch.
Voice Training Programs in Thailand
We have fully-trained speech therapists ready to work with Transgender Thailand patients. Each patient's voice and speech patterns will be assessed one week before their voice feminization or masculinization surgery. In these pre-operation sessions, therapists will help patients plot out a path forward with their surgeons.
After the procedure, patients again meet speech therapists to assess new vocal cord functions and speech. Patients should attend speech therapy for at least 2-4 weeks post-surgery. Patients are also usually given daily exercises to do on their own in tandem with the therapy.
Monthly follow-ups will be arranged online to ensure steady progress.