Voice Feminization Surgery

Overview

Voice feminization surgery is a gender-affirming procedure aimed at elevating the pitch of the voice. It permanently modifies the vocal cords to achieve a higher sound. The vocal cords, or vocal folds, are soft tissue bands located in the larynx (voice box), and their pitch is influenced by their length and thickness. Typically, men and individuals Assigned Male at Birth (AMAB) have thicker and longer vocal cords, resulting in lower-pitched voices, whereas women and individuals Assigned Female at Birth (AFAB) have shorter, thinner cords that produce higher pitches. In this surgery, a laryngologist shortens, thins, or tightens the vocal cords to establish a lasting higher pitch.

Reasons for undergoing the procedure

Voice feminization surgery assists transgender women and transfeminine individuals in achieving a higher pitch that aligns more closely with their gender identity. This procedure can be pursued if you also wish to elevate your pitch for the following reasons:

• Suffer from a sex differentiation disorder.
• Require androgen (male sex hormone) therapy for certain conditions.
• Have ovarian cancer or other disorders that produce androgens from tumors.

Risks

Among the risks of voice feminization surgery are:

• Tremors or cracks in voice.
• A voice that sounds weak or strained, particularly in the higher range.
• A raspy, breathy, scratchy, or hoarse voice (dysphonia).
• Pitch rises too much, making the voice unusually high.
• Minimal or no change in pitch.
• Gradual lowering of the voice over time.
• The necessity for a second surgery.

Surgery might cause uncommon but potentially serious conditions like:

• Vocal cord lesions.
• Vocal fold paralysis.
• Vocal cord dysfunction.
• Abscesses in your airway.

Your risk of complications is lower if you work with a laryngologist who performs voice feminization surgery on a regular basis. Inquire with your doctor about any possible dangers associated with the procedure they have recommended for you.

Before the procedure

Prior to surgery, most patients undergo voice feminization therapy. Working with you, a Speech-Language Pathologist (SLP) addresses:

• Vocal function exercises: Performing exercises that stretch and contract your vocal cords multiple times a day can enhance their flexibility and strengthen the muscles in your voice box. These exercises can support your recovery process.
• Vocal hygiene: Maintaining optimal vocal health is crucial, especially before surgery. Your speech-language pathologist may recommend staying well-hydrated, quitting smoking if you smoke, and avoiding alcohol and caffeine, as these can dry out your vocal cords.

In order to ensure a successful surgery, your surgeon and SLP will also check to see if you currently have any vocal issues.

During the procedure

During certain procedures, your laryngologist may use a small, illuminated tube called a laryngoscope, which is inserted through your mouth and extends to your larynx. For other treatments, you might require incisions on the outside of your throat. Regardless of the procedure, general anesthesia will be administered to ensure you are asleep and pain-free during the surgery.

There are various methods for performing voice feminization surgery, such as:

• Anterior glottal web formation (Wendler glottoplasty): This procedure involves removing several layers of tissue from the front part of your vocal cords. Your laryngologist then uses stitches to connect the vocal cords in this area, effectively shortening the length of your voice box. This is the most common form of voice feminization surgery.
• Laser Reduction Glottoplasty (LRG): This technique uses laser light to eliminate the outer layers of your vocal cords, increasing their tension. It is a type of laser-assisted voice adjustment (LAVA) procedure.
• Cricothyroid Approximation (CTA): In this procedure, cartilage from the top and bottom of your voice box is stitched together to tighten the vocal cords. It was the original method for voice feminization surgery but is now used less frequently due to studies showing that its effects are not as enduring as other surgical options.
• Feminization laryngoplasty: This surgery involves removing cartilage from the thyroid gland and parts of the vocal cords, lifting the voice box, and shortening the vocal cords. Your laryngologist may perform this as a standalone procedure or combine it with other methods to achieve a higher pitch.

The exact technique will determine how long you spend in surgery. Anterior glottal web formation, the most prevalent type, usually takes one to three hours.

After the procedure

After your surgery, you will have regular follow-ups with your speech-language pathology (SLP) care team and laryngologist. Depending on the chosen method, you may require several minor procedures to achieve the best results. Following surgery, you will likely need to refrain from speaking for five to fourteen days. To maximize the benefits of the operation, additional SLP therapy may also be necessary.

Outpatient voice feminization surgery is standard, meaning you will likely be able to return home on the same day as your procedure.

Outcome

Voice feminization surgery can effectively raise your pitch, with anterior glottal web formation being the most effective at achieving the highest pitch increase. The final outcome will be influenced by your pitch level prior to the surgery.

However, success also depends on your individual goals. Pitch alone accounts for about 40% of how we perceive gender through speech and communication. The remaining 60% involves aspects learned through voice therapy, such as loudness, resonance, pitch variation, and nonverbal communication cues.

For this reason, it’s critical that you discuss what a good voice transition means for you with both your laryngologist and SLP prior to surgery.