Feminizing voice surgery

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 Glotoplasty.

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-epithelialised 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.

Absolute vocal rest of ten days is necessary. This period is entirely empirical, to avoid dehiscence of the sutures. Post-operative treatment consists of antibiotic coverage for one week, inhaled corticosteroids for one week and proton pump inhibitors for six weeks.

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.