VOICE FEMINIZATION

For a high percentage of transgender women, the voice represents a very important feature to consider in the journey undertaken in their transition. The fact that their voices do not reflect the vocal tone that they consider appropriate for their outward appearance may potentially influence their social, professional and personal life.

Therefore, the first question patients should ask themselves before beginning the process of voice feminization is: Do I feel that my voice reflects my true self?

The first thing to know is that hormone therapy with oestrogen has been shown to have very little effect on the voice quality. Therefore, to rise the vocal tone we would need to act on the larynx and the vocal behaviour.

Although normally the largest group of people that choose the voice feminization surgery are transgender women. We can also find this surgery being performed on cisgender women that suffer androphonia (lower voice tone,  stereotypically manly voice) due to the excessive consumption of androgens or different diseases that are testosterone producers like polycystic ovary syndrome or Klinefelter’s syndrome. Today, there is an increasing demand in actors, singers, humourists and other professions that belong to the showbiz.

At the beginning, people opted for vocal therapy (speech therapy) as the sole and exclusive method to feminize the voice. This built up due to different reasons:

• The technique is safe and non-invasive.
• Lack of experience in the different surgical techniques.
• Bad on-line reputation concerning the voice feminization surgery, only the negative results where published, probably due to an economic interest.

Nevertheless, in the last years there has been a substantial change in this philosophy thanks to the documents published by different groups of researches like Dr. Rihkanen in Helsinki (Finland), Dr. Remacle in Brussels (Belgium), Dr. Thomas in Portland (USA), Dr. Anderson in Toronto (Canada) and Dr. Casado in Marbella (Spain).

Thanks to all these clinicians and researchers, they have come to different conclusions:

• There are currently different surgical techniques to increase vocal tone; some are performed by external cervical approach and other by endoscopic approach (through the mouth, without leaving any type of external scar). All of these contribute with very favourable results, with a high degree of satisfaction by the patient and, at the same time, with very little possibility of difficulties during the surgery.
• Like any surgical activity is not assured without risk or with no negative vocal results. With the experience gained over the years. We can say today that the risk has minimized to anecdotal figures. With respect to the negative results, they are very rare and the ones that appear on the web are usually old due to the little definition of the surgical technique. However, if we have a negative result, what can we do? Faced with poor postoperative vocal outcome, specialists can now intervene to correct the defect healing and, at the same time, have a complementary speech therapy.
  We should not forget that in the process of voice feminization a multidisciplinary team intervenes, the team is formed by the ENT surgeon and specialist speech therapist, they both collaborate closely to obtain positive results.
• Vocal therapy (speech therapy) is not exclusive but complementary to the surgery and must be essential after this.

Many surgical techniques have been proposed to increase the vocal tone. All are based on three fundamental principles:

1. Increase the tension of the vocal cords
2. Alter the consistency of the vocal cords
3. Lower the mass of the vocal cords

There are many surgical techniques, each with advantages and drawbacks. We will know them briefly.

The most currently used is called Wendler’s Glotoplasty, which our team has added some personal modifications based on experience and previous results.

Classically more intervention has been made since it was described by Isshiki in 1983, subsequently amended by Lee (1986) and Sataloff (1997)

Through a cervical incision, cartilage cricoid is displaced backwards and upwards; and thyroid cartilage, downward and forward. Thus the two cartilages approach and tension of the vocal cords increases. Normally vocal tone remains high by the contraction of the cricothyroid muscle, and this is what is intended with this surgical technique, which over the years has been partially modified from the original described by Isshiki (see Figure 1).

One of the disadvantages of this surgery is that the thyroid cartilage tends to be more prominent, which is a proper secondary male sexual character. It is what is usually done in conjunction with thyroid Chondroplasty. The Chondroplasty Thyroid is a simple surgical technique in which through a cervical incision the anterior prominence (commonly called Adam’s apple) thyroid cartilage is removed.

Other disadvantages of this technique is that it requires a cervical incision, with the aesthetic problem of (although this same cervical incision can take advantage to make a Chondroplasty Thyroid) and long-term results are inconsistent and contradictory. Often produce good short-term results that would follow a period of decline vocal tone in the following 6-8 months. Furthermore, the maximum increase in tonal range achieved is one octave or less and cannot be performed in patients with ossification of the laryngeal cartilages.

It can be concluded that the cricothyroid is a viable approach to increase the vocal tone MFT option, but produces uncertain long-term results.

This technique was developed by Lejeune in 1983 and subsequently modified by Tucker in 1985.

The procedure is performed under general anaesthesia and involves the anterior commissure forward by placing a splint on the thyroid cartilage.

These techniques currently used only by the uncertain results obtained.

The length of the vocal cords determines the vocal tone; so vocal cords produces a shorter, sharper higher vocal tone.

For all the above it is reasonable to think that the vocal tone could rise by creating an anterior synechiae to shorten the length of vibration of the vocal cords.

This method of shortening the strings can be done by different surgical approach (through the mouth or endoscopic and externally)

a) Endoscopic approach with voice suture

Described by Gross in 1999 based on previous work Wendler similar idea in 1989. It has been popularized by the name of Wendler’s Glotoplasty.

It is the technique used by us, we will develop in the chapter of our working method

b) Endoscopic approach with chordal injection:

Very easy to perform technique proposed by Anderson in 2007.

The goal is to shorten the length of the vocal cords but in this case, without performing suture. injection is made in the anterior commissure of 1-2 cc calcium hydroxyapatite gel. With this injection is achieved desepitelizados bring the free edges of both vocal cords without suture.

Obviously a period of 2 weeks of complete vocal rest and exercise is required.

c) External Approach:

Described by Donald in 1982. It aims to achieve the same as the two previous technique but using a wide incision and posterior cervical opening “in the book” thyroid cartilage.

Being much bloodier than the last, specify cervical incision and potentially more iatrogenic practically not used.

Technique described by Orloff in 2006 under the name Laser-Assited Voice Adjustment (LAVA).

It involves incising side cordotomy (1-2 mm from the free edge) on the upper surface of both vocal cords, from the voice arytenoid process as close as possible to the anterior commissure. For this CO2 lasser or lasser diode is used.

We believe it can be useful in case of professional voice as first surgery to feminize her voicevoz

Thomas and McMillan have posted this technique called feminization laryngoplasty.

It is a complex technique performed by cervical incision which that aims to reduce the vocal tract resonance and improve women.

I personally believe it is very aggressive. The anterior segment of the thyroid wing, vocal cord and ventricular band is resected; a new anterior commissure and complete the intervention cricothyroid approximation.

Our team used for 10 years the technique of shortening suture anterior commissure by oral suture and endoscopic approach. It is called Wendler’s Glotoplasty, but with personal modifications.

The procedure is performed under general anesthesia. The endolarynx is exposed by direct laryngoscopy. The free edge, the upper surface and the lower anterior third of both vocal cords are deepithelialized with cold instruments or lasser. Special care must be taken not to injure the vocal ligament. The two vocal cords are firmly sutured to get a new V in anterior commissure. It is very useful to use a special needle holder and a “knot pusher” that allows us to tie sutures hard. We use a 4-0 Vicryl suture 19 mm. in length and with a special thread 70 cm. two stitches that can be reinforced by fibrin are made. (See Figure 8)

We strengthen through the stitches applying thereon biological glue (fibrin glue).

To end the intervention performed a longitudinal Cordotomy (from the anterior commissure to arytenoid process) or diode lasser or scalpel electrocoagulation, similar to the technique introduced by Orloff (which will be discussed later), but with the deepest incision to thyroarytenoid muscle level. The purpose of this is twofold cordotomy; on the one hand, reduce tension Vocal mucosa sutured to allow gluing the edges of the faster; and secondly, to heal the incision made stiffness of the vocal cord will increase.

An absolute vocal rest for 10 days is necessary. Postoperative treatment consists of antibiotic coverage for 1 week, inhaled corticosteroids for one week and proton-pump inhibitor for 6 weeks.
Using this technique the vocal cords are shortened and the mass of vibration thereof is reduced.

Has the disadvantage that acts on the same vocal cord altering integrity and vibration surface thereof, thus requiring very accurate and conservative be

It has the advantage of avoiding making incision in the neck and good long-term results (shown by a recently published work Remacle, 2011; Casado 2016). This is why what is now probably the technique used to increase the vocal tone.

The videos 1, 2 and 3 show the steps of the surgical procedure:

The perception of the voice as stereotypically masculine or feminine depends on the speaking fundamental frequency, but, although it is the most important factor, other aspects of the language intervene like the intonation, vocal resonance, laryngeal joints, breathiness, modulation etc.; in other words, to obtain a more feminine voice, we should act on the frequency or the tone as well as the vocal behaviour.

To increase the vocal tone we use a surgical technique called Wendler Glottoplasty with personal modifications or vocal lasser techniques.

To change the vocal behaviour, we use vocal therapy (speech therapy).
This is why our method consists of the union of surgery and postsurgical speech therapy.

However, a transgender woman can come to our clinic, and after completing a laryngoscopy, speech therapy and acoustic study we could conclude that the patient has a sufficiently high vocal tone to be exempt from any type of surgical intervention.

The speech therapy consists in changing the vocal gesture, the vocal behaviour that acts on the intonation, the modulation and the respiration with the use of exercises. Nearly every transgender woman that comes looking for solution have already performed speech therapy sessions in which they have learnt to daily altering their vocal and in many occasions they have felt embarrassed or frustrated if their voice comes back to its original tone, this can happen due to the vocal tiredness or during human physiologic reactions such as laughter, coughing, yawning, sneezing, screaming, pharyngeal clearance, etc.

In a literature review on the feminization of voice by speech therapy treatment (speech therapy) it can be concluded that there is no consensus either on the type of treatment, duration and effectiveness of it.

We think that it would be ideal if after all the transition process covered by these women, their voices could be naturally at a high pitch, without having to think about it on every phonation. Once the transgender woman’s larynx has transformed, with surgery, into a anatomically feminine larynx (the vocal tone has been increased), the vocal therapy will entrench this definitive change without having to worry or focus before each phonation.

The health professional must know that the voice can be improved to be more consistent to the physical aspect of the person.

If demand is for a lower pitch, a stereotypically male voice, this can be achieved by hormonal therapy (by a specialized endocrinologist). If what the patient wants is a more stereotypically feminine sharper voice, in this case the patient should refer to a specialized multidisciplinary team (an ENT surgeon and a specialized speech therapist) to decide, prior Laryngoscopy and acoustic studies, if the patient can get it by speech therapy, in cases where the patient has a sufficiently high tone; or by surgery and postoperative speech therapy (which is most preferred in the present).

We believe that the ideal, after all the transition process have come these women, would be that their voices had, naturally, a high vocal tone without having to think about how to make it more stereotypically feminine in every phonation, without having to be imitating permanently. Once the larynx of the transgender woman has been transformed by surgery in a female larynx, and consequently, the vocal tone has risen, vocal therapy entrench this definitive change if having to worry or focus before each phonation.

All surgical techniques have their advantages and disadvantages; the objective pursued is a more comfortable, stable and easy form to control voice. Patient satisfaction in the evaluation of results is not sufficient and should be used in combination of objective criteria (acoustic and spectrographic analysis of the voice).

With our experience and favorable results we conducted a glotoplastia Wendler, with personal modifications.

Therefore we conclude that vocal cord surgery is only part of the feminization of transsexuals voice and vocal therapy should be added to modify the vocal behavior. That is SURGERY + POSTOPERATIVE SPEECH THERAPY.

• Borsel JV, Eynde EV, Cupiere GD et al. Femenine alter cricothiroid approximation?. Journal of Voice. 2006;379-384
• Donald PJ. Voice change surgey in the transsexual. Head and Neck Surgery. 1982;4:433-437.
• Gross M. Pitch-Raising Surgery in Male-to-female transsexuals.Journal of Voice. 1999;13:246-250.
• Isshiki N, Taira Y, Tanabe M. Surgical alteration of the vocal pitch. The Journal of Otolaringology. 1983;2: 335-340.
• Koufman JA, Isaacson G. Laryngoplastic Phosurgery.  Otolaryngologic Clinic of North America. 1991;24:1151-1177.
• Kanagalingam J, GoergalasC, Wood GR et al. Cricothiroid approximation and subluxation in 21 male-to-female gtransexuals.Laryngoscope.2005;115:611-618.
• Kunachack S, Prakunhungsit S, Sujjalak K. Thyroid cartilage and vocal fold reduction: a new phonosurgical method for male-to-female transsexuals. Ann Otol Rhinol Laryngol. 2000;109:1082-1086.
• Lee SY;liao TT, Hsieh T. Extralatyngeal approach in functional phonosurgery. In: Proceeding if the 20^th Congress of the IALP. Tokio,1986;482-483.
• Sataloff RT. Professional Voice: The Science and Art of Clinical Care,2 nd. San Diego: Singualr Publishing Group;1997; 630-631.
• Sataloff RT, Spiegel JR, Carroll L et al. Male Soprtano Voice: A rare complication of thyroidectomy. Laryngoscope;102:90-93.
• Remacle M, Mater N, Morsommome D. el al.Glottoplasty for Male-toFemale Transexualim: Voice Results. Journal of Voice. 2011; 25:120-123.
• Tucker H. Anteriopr commissure laryngoplasty for adjustment of vocal  fold tension. Ann Otol Rhinol Laryngol. 1984;94:547-549.
• Wagner I, Fugain C, Monneron-Girad L et al. Pitch-raising surgery in fourteen male-to-female transsexuals. Laryngoscope. 2003; 113: 1157-1165.
• Casado JC; O´Connor C, Angulo S. Adrian JA. Glotoplastia de Wendler y tratamiento logopédico en la feminización de la voz en transexuales: resultados de la valoración pre- vs. poscirugía.  Acta Otorrinolaringólogica Española. 2016;67:83-92