October 16, 2013

An Overview of Surgical Techniques for Voice Feminization

A common view among transgender therapists, surgeons, and other “support” types, is that voice feminization surgery is a bad idea. They are dangerous; they are ineffective; they could scar the vocal cords; they could make your voice worse instead of better. I have yet to encounter anyone in real life who has had the surgery or who recommends one. Despite the negative connotations in the community at large, there must be a demand for the voice feminization because there are a number of surgical techniques out there, as well as practicing surgeons trained in each technique. Each comes with its own benefits and drawbacks.

Criticothyroid approximation (CTA) is one well-established and widely used technique. This alters the vocal muscles responsible for creating a falsetto. The surgery makes it so that the muscles cannot open the throat enough to speak in lower registers, in effect surgically trapping the voice in a higher pitch closer to falsetto. This surgery is effective in raising the pitch, but suffers from the problem of muscle stretching — to whit, the voice will eventually begin to drop again as the muscles are used. As such, CTA is often no longer considered the first choice for voice feminization. 

Another surgery, feminization laryngoplasty (FemLar), skips the vocal muscles and instead alters the voice box itself. By removing cartilage in the throat, the diameter of the voice box is reduced, creating a higher pitch range. The vocal chords are also sometimes shortened during a FemLar, allowing for higher pitch. Finally, FemLar often includes a thyrohyoid elevation, lifting the entire voice box and shortening the pharynx to improve resonance. When you hear someone talk about “voice feminization surgery,” they’re usually talking about FemLar. 

In recent years, laser reduction glottoplasty (LRG, sometimes called a Wendler glottoplasty) has gained popularity. In short, it is a technique by which a surgeon strips cell layers from the vocal folds using a laser, thinning them; the surgeon may also sutures some of the cords, making them shorter and tighter. In this technique neither the voice box itself nor the muscles around it are altered; only the folds and chords are changed. LRG is less invasive than either a CTA or FemLar, as it involves the least cutting and suturing; this also means it allows for a quicker recovery. However, the changes are usually less impressive than they may be with the other techniques. The variant of LRG called Wendlr Glottoplasty has received a handful of recent journal articles attesting to its effectiveness. 

Finally, we should mention the thyroid chondroplasty. This is not a technique for voice feminization, but a concurrent surgery that often happens in conjunction with voice feminization surgery (because, hey, they’ve already got the throat cut open). Thyroid chondroplasty is the clinical term for what most people know as “shaving the Adam’s apple.” It’s purely an aesthetic surgery; it has no effect on voice quality. 

So, is voice feminization surgery something you should pursue? Only you can answer that question, preferably in consultation with your doctor and a good, qualified surgeon. Each technique comes with risks, and none is a magic cure for the vocal problems many transwomen face. But there are many women out there who have found themselves much happier and much more likely to pass after having these surgeries. 

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