Voice feminisation

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



Raising your voice’s fundamental frequency (feminisation) is an operation that many transsexual women require for their voice to have a naturally high vocal pitch without having to think about how to make it more stereotypically feminine in each phonation; that means without having permanently to imitate a female voice.


La cirugía de feminización de la voz

Actualmente existen diferentes técnicas quirúrgicas para aumentar el tono vocal. Unas se realizan mediante abordaje externo cervical y otras mediante abordaje endoscópico, es decir, a través de la boca, sin dejar cicatrices externas. Todas ellas aportan unos resultados muy favorables, con un alto grado de satisfacción por parte de la mujer transexual y, al mismo tiempo, con escasa posibilidad de complicaciones.



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

Es también conocida en la literatura anglosajona como CTA (Cryco-Thyroid Aproximation). El Dr. Casado la realiza en el caso de mujeres trans de edad superior a 50 años. En estos casos debido a la pérdida de la elasticidad de las cuerdas vocales se presupone un peor resultado con la técnica Glotoplastia.
El abordaje es a través de una incisión cervical en la piel y consiste en aproximar el cartílago tiroides al cartílago cricoides mediante 4 puntos de sutura permanente; de esta forma, se simula la actiación del músculo cricotiroideo y se produce un aumento de la tensión de las cuerdas vocales.



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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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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