Voice feminization surgery

For many trans women, having a deep voice can be uncomfortable, especially in terms of their social projection. Voice feminization surgery involves increasing your voice’s fundamental frequency combined with post-operative speech therapy to optimise results.


Voice feminization is a surgical procedure aimed at altering the voice to sound more feminine. This type of surgery is often search by transgender women as part of their gender transition. There are different surgical techniques used to achieve this goal. Some of these techniques involve adjusting the tension of the vocal cords, changing the shape and size of the vocal tract, or modifying the pitch of the voice. The specific method chosen depends on the voice and the desired outcome. 



    Different surgical techniques

    Nowadays there are different surgical techniques to increase vocal tone. Some are performed through an external cervical approach and others through an endoscopic approach, that is, through the mouth, without leaving external scars. All of them provide good results, with a high degree of satisfaction on the part of the trans woman and, at the same time, with little possibility of complications.


    Two surgical techniques

    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 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.

    The Cricothyroid approach technique

    It is also known in Anglo-Saxon literature as CTA (Cryco-Thyroid Approximation). 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.


    Results after surgery

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

    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 feminisation in trans women. Complementing the surgery with vocal therapy is essential so as to permanently modify vocal behaviour. This means that, after surgery, post-operative speech therapy is recommended.

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    IM GENDER team

    At IM GENDER we have been specialising in the care of transgender people for more than 20 years. Two decades of experience, professionalism, research and training endorse our medical team.

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