This page describes what to expect before, during, and after Feminization Laryngoplasty — from the presurgery evaluation through recovery and voice rest requirements.
Permit
Presurgery
Before the surgery I evaluate your larynx with a videoendoscopy and hold a PARQ conference with you. PARQ is an acronym for Procedure, Alternatives, Risks & Questions — an appropriate way of performing an informed consent discussion. It means your surgeon has discussed in full detail the reasons for the procedure, the alternative treatments, the risks, and that you have had ample time to ask questions and are satisfied with the answers. I typically perform this examination on a Monday, as many individuals make a single trip to Portland with surgery scheduled for the following day. A separate trip for the exam is also possible if you wish to have a thorough discussion before deciding on surgery.
I record your voice in a fairly extensive way and record on video your vocal cords in action at high and low pitch and during loud and soft sound. The complete voice examination takes about an hour.
Risks
The general risks of surgery on the neck are discussed on an informed consent page you receive at your visit.
Pitch
Risks specific to this procedure include a failure to raise the pitch of the voice. There will be a loss of vocal range — loss of the low end is expected and beneficial, but some patients have a small loss at the top end as well, some have a gain. More than a small loss at the top would be considered a complication.
Volume
There almost certainly will be some loss of volume.
Roughness
The vocal cords can heal with asymmetric tension, leading to a rough voice present throughout the range or only at certain pitches. This can be corrected but may require additional laser treatments to tighten a loose vocal cord, or uncommonly a revision surgery.
Granuloma
A granuloma may form on the inside of the voice box during healing. All granulomas so far have either been coughed out or successfully removed. While present, a granuloma could cause a soft whispery voice depending on its location. If one is seen at a follow up visit, I will often remove it in the office.
Infection
Infections have ranged from mild redness to more prolonged infection requiring surgical removal of an infected suture or the plate. My antibiotic protocol was changed in 2012 and this has significantly reduced the risk of infection.
Plate
A titanium plate holds the vocal cords in place after surgery. You do not need the plate for stability after 4-8 weeks, so it is quite safe to remove after that. It may need to be removed if a chronic infection develops around the plate (this has occurred less after switching from teflon sutures to absorbable sutures in 2025). It can be removed if you want it out with a separate surgery, typically under local anesthesia. Some individuals with little fat tissue in their neck can feel the plate or see a faint fullness.
Tracheostomy
If significant swelling occurs during the postoperative period, breathing can be impaired. Out of the first 108 patients, two tracheostomies were performed because of infection-related swelling. None have been performed since, I believe both because of a change in antibiotics used and because I am vigilant in examining the airway every morning for three days after surgery. After three days, I have not seen a serious infection in over 450 patients.
Procedure
The surgery is performed in an outpatient setting under general anesthesia. 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, making it smaller. (This removes the Adam’s apple projection at the same time, so a separate “trach shave” is not necessary.) The vocal cords are then stretched and the front third to half of the cords are removed to shorten them. A small titanium non-magnetic metal plate is placed over the voice box to maintain tension on the vocal cords and hold the cartilage together during healing. The plate remains in place after healing; it could be removed after 4–8 weeks if desired, but that would require a second surgery.
A thyrohyoid elevation is usually performed at the same time to raise the voice box in the neck, shortening the pharynx to feminize a portion of the resonance chamber. This involves passing sutures around the hyoid bone to hold the voice box in an elevated position.
Recovery
No one has been kept in the hospital overnight. When complications such as infection have occurred, they typically arise two or three days later — which is why I ask patients to stay in the area for 4-5 days after surgery. Any hospital costs beyond the surgical fee are the patient’s responsibility.
Overall, including the preoperative exam, you will be in the Portland area for approximately 4 to 7 days. It is valuable to remain nearby immediately after surgery because problems that might arise are most easily handled by the surgeon who performed the procedure. Few if any other ENTs have performed this surgery, and small problems can become large ones when the treating physician is unfamiliar with the procedure.
For the first 24 hours after surgery you must stay with an adult. If staying at a hotel or home in town, a friend or family member who can help with care is required. You may also arrange care through Select Home Care. For the first three nights after surgery you are required to stay within three miles of the office.
In the initial post-surgery weeks your speaking pitch will likely be lower than before surgery. The surgery opens the voice box and creates significant swelling — swollen vocal cords vibrate at a lower pitch, just as during laryngitis. Your voice will often seem soft, tight, or effortful, and may get worse before it gets better. Roughness may change over several months. A sore throat sensation and some initial difficulty swallowing are common. Do not expect the voice to approach its new pitch for at least 6 weeks.
Instructions During Healing
Complete voice rest is mandatory for two weeks after the procedure. All forms of verbal communication are prohibited, including whispering. Tecnically whispering does not stress the vocal cords, but some individuals who whisper tend to start talking too soon. Only a few sutures hold the vocal cords in place, and you have invested a lot, so until the body’s own scar tissue supports the new vocal cords, the sutures could theoretically pull out. One patient began singing after one week because their voice felt good, then felt a tear and a drop in pitch.
- Sedentary work may be resumed within a few days.
- Speaking may begin gradually after two weeks — at the absolute minimum during week three.
- Aerobic activity may be resumed after three weeks.
- No weight lifting for one month.
- Avoid surgery requiring intubation for three months. If intubation is necessary, request a size 6 or smaller endotracheal tube. Your anesthesiologist may contact Dr. Thomas with any questions.
Speech therapy
You may resume therapy one month after surgery if you wish to do so. It’s not a requirement, but it can be quite helpful. Most patients say that their voice has not settled in until about nine months after surgery. I think that swelling probably goes away within one to three months. However, I think it takes a while for your brain to adjust to the new angles inside the larynx. Perhaps Speech Therapy can speed up this process. I also think you need to re-tune your resonance. The surgery does not completely change the shape and size of your resonanting chamber. Your shorter vocal cords need a different tuning of the vocal tract to project your voice. I actually think voice lessons, a singing-voice specialist, or a speech therapist quite interested in gender work, can be beneficial.