Feminization laryngoplasty

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Feminization laryngoplasty is a surgery designed for male-to-female transgender patients.

The procedure is designed to remodel the genetic male's voice box, to make it smaller and the 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, although I'm uncertain if resonance is significantly changed. 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.

The surgery is most optimal 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 (a somewhat frequent complication of aggressive reduction of the Adam's apple).

This surgery doesn’t work or meet the needs of everyone. It is new (I have been performing it for 10 years as of 2013) and carries with it some significant risks. 

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.  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 (PARQ is an acronym for Procedure, Alternatives, Risks & Questions and is considered an appropriate way of performing an informed consent discussion with a patient. 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.).

An evaluation and examination of your voice box is essential before surgery. During the typical examination I record a number of your vocal parameters and record on video your vocal cords in action. (For more about the exam, click here). The complete examination of your voice takes about an hour. A speech therapist will also spend about an hour with you.

Risks

The general risks of surgery are discussed on the informed consent page

Risks specific to this procedure include a failure to raise the pitch of the voice (3 out of the first 108 had no improvement in comfortable speaking pitch).

There will be a loss of vocal range. While loss of the low end is expected and beneficial, some patients have a small loss at the top end as well. More than a small loss of the top end would be considered a complication. There almost certainly will be some loss of volume.

The vocal cords can heal with an asymmetric tension. This would lead to a rough voice. This can be present throughout the vocal range or only at certain pitches. While this can be corrected, it would typically require additional visits for laser treatments to tighten a loose vocal cord or might require a revision surgery to correct the asymmetry.

I have had an occasional granulomas form on the inside of the voice box. So far all have either been coughed out or have been able to be removed. 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. During 2012, I have changed the types of antibiotics that I give during surgery trying to reduce this complication.

If significant swelling occurs during the postoperative period, breathing can be impaired. Out of the first 108 patients, I have performed two tracheostomies because of infection that caused swelling.

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 small non-magnetic metal plate is 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. It could safely be removed after 4-6 weeks if the patient wanted out since everything would be healed in place by that point. However, that would require a second surgery.

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 individuals 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.

There is a wide range of choices patients make regarding post operative housing. For the first 24 hours after surgery, you must stay with an adult where ever you choose to stay.

If patients choose to stay at a hotel or at a home in town, they will need to have a friend or family member who can help with their care.    It is easiest if you bring someone with you, or we can provide care through Select Home Care.  For the first three nights after surgery, you are required to stay within three miles of the office.

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 contact 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 Feminization Laryngoplasty 108 individuals (as of 1/29/2013). Eighteen of the first 40 cases were revised. I have continued to intermittently perform revisions when the resulting comfortable speaking pitch is not adequate. Six of the second 40 cases were revised. I have been touching up some of the results with an office laser procedure. At present, I am reviewing the outcomes. Of 81 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 of these results remain in the process of being reviewed by a peer reviewed journal (1/29/2013).

You may listen to the results of some cases here. 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 and a more nearly feminine voice than cricothryoid approximation and more potential risks. I have not heard enough Web Glottoplasty results to comment on a comparison. 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.