Feminization Laryngoplasty

Feminization laryngoplasty is a surgical procedure that results in the increase of the pitch of a patient, making the voice sound higher and more feminine. It is a type of voice feminization surgery (VFS) and an alternative to vocal therapy. Feminization laryngoplasty is performed as a treatment for both transgender women and non-binary people as part of their gender transition, and women with androphonia. The surgery can be categorized into two main steps: Incision and vocal fold modification followed by thyrohyoid elevation. Risks and complications include granuloma, dysphonia and tracheostomy. Patients are recommended to follow perioperative management such as voice rest to hasten recovery.

Feminization laryngoplasty
Before and after images of a feminization laryngoplasty patient
Pronunciation	/ˌfɛmɪnaɪˈzeɪʃən/ /ˌlɛr.ɪŋˈɡɒˌplæsti/
Other names	FemLar
Specialty	Laryngology
MeSH	D058753

Japanese otorhinolaryngologist Kazutomo Kitajima and his colleagues in 1979. They together discovered the inverse linear relationship between the vocal pitch and the distance between the thyroid cartilage and cricoid cartilage. Based on this principle, the first surgical procedure for voice feminization, cricothyroid approximation (CTA) was developed to achieve pitch increase by reducing the separation between the two cartilages. To this date, this procedure remains the most popular among transgender women seeking surgical voice feminization. However the results are often unsatisfactory due to the unnatural falsetto quality of the voice. Other surgical solutions were also developed, including Web Glottoplasty (also known as anterior web glottal formation), laser assisted voice adjustment (LAVA) and laser reduction glottoplasty (LRG).

Modern technique

The concept of feminization laryngoplasty originated from the open laryngoplasty technique proposed by cosmetic surgeon Somyos Kunachak. The first operation was then performed by James P. Thomas in 2003. As opposed to previous efforts, feminization laryngoplasty results in a more significant and long-lasting pitch increase along with a more feminine voice quality. The function of cricothyroid muscle is also preserved, allowing the use of the falsetto range when needed. In addition, compared to other surgeries, feminization laryngoplasty could be undergone as one single surgery for thyroid chondroplasty to reduce the prominence of the "Adam's apple", while the other solutions had to perform chondroplasty separately.

The first few surgeries were performed under local anesthesia. However, general anesthesia is now preferred over local anesthesia to prevent patients from attempting to talk during the surgery, which may lead to complications such as the tearing of sutures

shortened to raise the speaking pitch. The overall size of glottal region is also reduced, which diminishes the thyroid notch.

Thyrohyoid elevation

By elevating the thyrohyoid muscle, the distance between the thyroid cartilage and the hyoid bone can be decreased.

At last, eight holes are drilled on the thyroid cartilage and hyoid bone for the placement of sutures and screws, securing the structure of the larynx. The strap muscles are then reattached and the skin is closed with sutures.

Postsurgical management

Following surgery completion, patients are prescribed acetaminophen with narcotic pain medication for pain relief and cefpodoxime or levofloxacin for 7 days to minimize infection.

Risks and complications

Granuloma of the vocal cord

After feminization laryngoplasty, most patients would experience a drop in voice volume and some may experience a decreased vocal pitch. Continuity of range might also be negatively affected. Therefore, the surgery might be less suited for vocal performance professionals. Instead, an alternative procedure, Vocal Fold Shortening and Retrodisplacement of the Anterior Commissure (VFSRAC) is generally recommended as it preserves the ability to sing.

Granuloma in the vocal cords is also a possible complication, which may cause a soft and whispery voice. The granuloma should eventually be coughed out, or in some case be removed manually. Dysphonia is another common symptom in the first two months of recovery, but the issue gradually resolves in most patients. Further treatment or revision surgery might be needed for some patients with serious unresolved sound hoarseness after extended periods of recovery. If the vocal cords heal with asymmetrical tension, laser treatment is generally required to correct the defect.

In some rare cases, severe swelling could lead to difficulty in breathing, which may require tracheostomy to bypass the area of obstruction.

Post-operative care

Following feminization laryngoplasty, patients are usually discharged without the need for overnight stay. Exceptions would be made when complications have occurred, during which the patient would have to stay in a hospital for up to a week.

Complete voice rest after the surgery is also necessary for fast healing as the vocal cords are only supported by a few sutures. Those who have undergone the procedure are advised to have vocal rest for at least 2 weeks, no aerobic activity for 3 weeks and no weight lifting for a month to give time for scar tissue to develop and support the larynx. It is also advised to refrain from having surgery requiring intubation for at least 3 months.

To maximize the effects of the surgery and to adapt to the new feminine voice, patients are also highly recommended to undergo vocal therapy, during which patients could learn to feminize their voice intonation, volume, resonance and non-verbal communication such as gesture and articulation.

For patients who are still unsatisfied with the pitch increase after the surgery, revision surgery could be considered to improve results. However, a revision is generally not recommended to patient with medical records of voice surgery prior to feminization laryngoplasty.