Voice feminization surgery

Before treatment, your doctor will do a blood test, evaluate your general health, and ask you about your medical history. It is important also to know if you are taking some medication. You should give up smoking and drinking for a correct and quick recovery and avoid complications during the postoperative period.

Our medical team will explain to you all the details about the procedure, postoperative care, the possible risks and the results that you can expect.

There are two types of surgery for gender-affirming voice therapy. Dr. Casado, an otorhinolaryngologist who has been dedicated to caring for the voice of trans people for over a decade, performs two surgical techniques to increase vocal tone. Both involve personal modifications to achieve the best results.

• Wendler Glottoplasty Technique

Wendler’s glottoplasty is a surgical procedure to feminise the voice, using the technique of shortening the anterior commissure by suturing the vocal cord using an endoscopic approach. Dr Casado performs this technique with modifications carried out after more than ten years of study and experience. In this way he achieves highly satisfactory results. This technique, described by Gross in 1999 and based on previous work on a similar idea by Wendler in 1989, has become popular under the name of Wendler’s Glottoplasty.

For about three years, based on Dr Kim’s work, he has been modifying the original technique. The aim is to create a more oval glottis, a more anatomically feminine larynx by “retropositioning” the anterior commissure.

This technique has very good medium-term results and no major medical complications. The procedure is performed under general anaesthesia with an endoscopic approach with vocal suture.

The endolarynx is exposed by direct laryngoscopy. The free edge and the upper and lower surface of the anterior third of both vocal folds are de-epithelialized either using cold instruments or with a laser. Special care must be taken not to injure the vocal ligament. The two vocal folds are firmly sutured to obtain a new V in the anterior commissure. It is highly useful to use a special needle holder and a “knot pusher” that allows us to knot the sutures tightly.

At first we used a 4–0 Vicryl suture 19 mm long with a special 70 cm thread; nowadays we have changed this for permanent nylon sutures, which give more stability to the new larynx. To finish the operation, we perform a longitudinal cordotomy (from the anterior commissure to the arytenoid process) either using a diode laser or with an electrocoagulation scalpel, up to the level of the thyroarytenoid muscle. The aim of this cordotomy is twofold: on the one hand, to reduce the tension of the sutured vocal mucosa to allow the edges of the vocal cord to be joined together more quickly; and on the other hand, the healing of the incision will increase the vocal cord’s rigidity.

With this technique, the vocal folds are shortened and their vibrating mass is reduced. It has the disadvantage that it acts on the vocal cord itself, altering its integrity and vibration surface, and therefore requires great precision and conservatism. However, it has the advantage of avoiding neck incision and good long-term results (demonstrated in a recently published paper by Remacle, 2011; Casado, 2016). This is probably why it is currently the most widely used technique for increasing vocal tone.

• Cricothyroid Approach Technique (CTA)

It is also known in Anglo-Saxon literature as cricothyroid approximation CTA. Dr. Casado performs it in the case of trans women over 50 years old. In these cases, due to the loss of elasticity of the vocal cords, a worse result is assumed with the glottoplasty technique.

The approach is through a cervical incision in the skin and consists of bringing the thyroid cartilage closer to the cricoid cartilage through 4 permanent suture points. In this way, the activation of the cricothyroid muscle is simulated and there is an increase in the tension of the vocal cords.

Absolute vocal rest of ten days is necessary for a complete recovery. This period is entirely empirical, to avoid dehiscence of the sutures. It is also recommended to avoid any physical effort or exercise for approximately 3 weeks.

Postoperative treatment consists of antibiotic coverage for one week, inhaled corticosteroids for one week and proton pump inhibitors for six weeks. Your doctor will follow up after 6 months to monitor your progress. 

Once a transgender woman’s larynx has been surgically modified, it becomes an anatomically female larynx. As a result, there is a higher pitch.

Vocal therapy is also important to secure this definitive change without needing to worry or concentrate before each phonation. However, vocal cord surgery is only one part of voice feminization in trans women. Complementing the surgery with vocal therapy is essential so as to permanently modify vocal behaviour. This means that, after surgery, postoperative speech therapy is recommended.

After voice surgery, long-term changes occur in the voice. This makes it necessary to learn to use your voice to avoid vocal fatigue and discomfort. It must also be taken into account that this surgery also reduces the volume of the voice. Your surgeon may recommend to you to attend to voice therapy after the feminizing voice surgery.

Swelling in the Adam’s apple and larynx area is normal and subsides over time. As with any operation, sometimes the patient may suffer a reaction to the anesthesia.