Voice Feminization Surgery

Introduction:

Vocal cords or vocal folds are bands of soft tissue present in the voice box (larynx). They vibrate when one takes in air and are responsible for controlling the pitch of the voice. In voice feminization surgery, the pitch of the voice is raised to make it sound higher. The length, size, or tightness of the vocal cords is manipulated during the surgery. Transfeminine people or gender-expansive folks prefer this surgery. The preference for voice feminization surgery is dependent on the individual’s will. Voice feminization surgery is also called gender-affirming voice care.

Why Is Voice Feminization Surgery Preferred?

It is preferred due to the following reasons:

• Some people prefer to modify their voices to suit their gender identity.

• Minimize the stress or discomfort arising from a difference between the voice and gender identity or sex-related physical characteristics (gender dysphoria).

• A voice that mismatches with the gender can evoke harassment issues in certain situations.

• Some people prefer gender-expansive voices in which one can switch between masculine, gender-neutral, and feminine voices.

• Presence of ovarian cancer where the tumors manufacture androgens.

• Those having disorders that require male sex hormone (androgen) therapy as treatment.

What Are the Different Types of Voice Feminization Surgery?

The following are the types of voice feminization surgery:

• Anterior Glottal Web Formation: In this procedure, the length of the vocal cords is shortened. It is also referred to as the Wendler glottoplasty and is most common.

• Cricothyroid Approximation (CTA): The tightness of the vocal cords is increased in this procedure.

• Laser-Assisted Voice Adjustment: In this procedure, a carbon dioxide laser knocks down pieces of vocal folds, making them small and tense.

• Laser Reduction Glottoplasty (LRG): In this procedure, the size or mass of the vocal cords is decreased.

Is Voice Feminization Surgery Common?

About 1% of transgender women undergo voice feminization surgery, and about 14 % of individuals prefer nonsurgical voice feminization therapy. A laryngologist who is an expert in performing throat and voice box surgeries performs the voice feminization surgery.

What Factors Determine the Type of Voice Feminization Surgery?

The following factors determine the type of voice feminization surgery:

• Age, anatomy, and overall health of the individual.

• Personal transition preferences.

• The current pitch of the voice.

• The experience and expertise of the surgeon.

The surgeon must clearly explain the method and the process of the procedure.

Who Are the Ideal Candidates for Voice Feminization Surgery?

The ideal candidates for the surgery are as follows:

• Those with other health conditions like heart disease should get an opinion from a primary physician before undergoing a voice feminization surgery.

• Some surgeries are not suitable for those over 40 years of age since there is a loss of elasticity in certain tissues which can delay and complicate the healing process. However, other options are available for such individuals.

• Smokers must refrain from such habits since smoking can delay the healing process.

• It is suggested that after voice feminization surgery, the person should not undergo any surgery requiring a breathing tube and a general anesthetic for a minimum of six months since this can have an impact on the healing of the vocal cords.

What Is Done Before a Voice Feminization Surgery?

Before undergoing surgery, one must discuss with the surgeon their medical and drug history, transition goals, get the current vocal cords examined, and customize a care plan, including speech therapy and a plan for the surgery. The vocal cords are assessed using a scope, and the procedure is called videostroboscopy.

One may be asked to quit smoking and alcohol and to drink plenty of water to keep the vocal cords healthy. A speech-language pathologist (an expert in diagnosing and treating communication and swallowing problems) ensures that one has no prevailing voice disorders that could affect a successful surgery. These experts help with the following:

• Vocal Function Exercises: The speech-language pathologist helps the individual expand and contract the vocal cords multiple times daily to facilitate easy movement. Exercises also aid in strengthening the voice box muscles and accelerate the recovery process.

• Vocal Hygiene: Keeping the voice healthy before the surgery is necessary. This can be done by quitting smoking and drinking plenty of water. A speech-language pathologist would also recommend one to refrain from drinking alcohol and caffeine as these can dry the vocal folds.

What Is Done During a Voice Feminization Surgery?

Voice feminization surgery is an outpatient procedure in which one can go home the same day after the procedure and usually does not require a stay at the hospital. However, this varies with each hospital. The procedure involved in voice feminization surgery is as follows:

• General anesthesia is given to put the patient to sleep so that he does not feel any pain during the procedure.

• The vocal cords are accessed using a small tube that traverses through the mouth called a laryngoscope or by making an incision on the throat to obtain direct access to the throat.

• Depending on the type of surgery that the individual and the surgeon had discussed and agreed upon, the cartilage will be stitched together in case of cricothyroid approximation, and the anterior vocal tissues will be stitched together in anterior commissure advancement or Wendler glottoplasty.

• In laser-assisted surgery, a carbon dioxide laser will knock down certain parts of the vocal folds to make them tense.

• The approximate time taken for the surgery is between one to three hours.

What Happens Following Voice Feminization Surgery?

The voice box might take several weeks to heal following the voice feminization surgery. Many people go ahead with voice feminization therapy after surgery. This therapy helps one to get accustomed to the changes in the voice. It is advisable to consult the surgeon and enquire when it would be safe to resume the therapy.

What Are the Risks and Complications Associated With Voice Feminization Surgery?

The following are the risks and complications:

• The person might find it difficult to speak for the first 6 to 12 months.

• The voice box can become scarred.

• There can be scarring on the outside of the throat.

• Increase in size of Adam’s apple.

• Abnormal growth or bumps in the vocal cords (vocal cord lesions).

• Hoarseness.

• Accumulation of fluid (edema) in the vocal cords.

• Paralysis and dysfunction of the vocal cords.

• The voice might sound too high or too low.

The sound of the voice can be influenced by one’s age and anatomy, postoperative recovery, the health of the vocal cords, whether speech therapy is initiated before or after the surgery, or both. Smoking also determines the sound of the voice. It might take 12 months for the vocal cords to heal completely and a new vocal pitch to emerge. If one prefers to alter other aspects of the voice, it is better to consult a speech therapist.

How Will the Recovery Process Be After Voice Feminization Surgery?

The following can be expected during the recovery process:

• The vocal cords should be given rest for about 30 days to heal properly. Talking, laughing, coughing, yelling, and singing should be avoided during this phase. Otherwise, there can be permanent damage to the vocal cords. One can use nonverbal methods of communication during this period.

• One cannot expect the voice to turn feminine immediately after the resting period. The voice might sound hoarse and strange, which can take about 12 weeks to resolve. This condition is called surgical laryngitis.

• The voice might be hoarse for six months and might continue to change up to one year after the surgery. It will be difficult to talk initially, but it will get corrected after 6 to 12 months.

• Taking soft foods and drinking liquids after the surgery for a few days is advisable. Spicy foods should be avoided for a certain period.

• Post-operative pain can be relieved by taking ibuprofen and acetaminophen. A cool compress can be used on the throat.

• Since the incision made during the surgery is usually small, scarring is minimal. One must be careful while washing and drying the scar and can take a shower after the removal of the stitch. Anti-scar cream can be used once the site heals completely.

Conclusion:

Voice feminization surgery is a procedure to alter the pitch of the voice and is preferred by transfeminine women or gender-expansive folks. There are various types of voice feminization surgeries that involve altering the length, size, or tightness of the voice box. Voice feminization therapy is indicated before and after the surgery. Sometimes, the desirable results may not be obtained in the first surgery, and one might require a second surgery. Steroid or Botox injections may be used after the surgery to treat dysphonia or vocal cord scarring.