Feminization Laryngoplasty: 17‐Year Review on Long‐Term Outcomes, Safety, and Technique

Abstract

Objectives Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL’s long-term voice outcomes across a 17-year review period. Study Design Level III, retrospective study and description of technique. Setting A single-institution transfeminine voice clinic. Methods Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented. Results The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up. Conclusion FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…Two types of laryngeal surgeries are relevant for TGD populations: those for raising voice pitch (e.g., glottoplasty with retro-displacement of the anterior commissure, cricothyroid approximation (CTA), feminization laryngoplasty, laser-assisted voice adjustment (LAVA)) (Anderson, 2007 ; Anderson, 2014 ; Brown, 2000 ; Casado, 2017 ; Geneid, 2015 ; Gross, 1999 ; Kelly et al., 2018 ; Kanagalingam, 2005 ; Kim, 2017 ; Kim, 2020 ; Kocak, 2010; Kunachak, 2000 ; Mastronikolis, 2013 ; Mastronikolis et al., 2013 ; Matai, 2003 ; Meister, 2017; Mora, 2018 ; Neumann, 2004; Nuyen et al., 2022 ; Orloff, 2006 ; Pickuth, 2000 ; Remacle, 2011 ; Thomas & MacMillan, 2013 ; Tschan, 2016 ; Van Borsel, 2008 ; Wagner, 2003 ; Wendler, 1990 ; Yang, 2002 ) and for lowering voice pitch (e.g., thyroplasty type III, vocal fold injection augmentation) (Bultynck et al, 2020 ; Isshiki et al., 1983 ; Kojima, et al. 2008 ; Webb et al., 2021).…”

“…TGD people’s self-rating ratings show general satisfaction with voice postsurgery, although individuals who are interested in more comprehensive changes to vocal self-presentation may need to engage in behavioral interventions with a voice and communication specialist in addition to laryngeal surgery (Brown, Chang et al. 2021 ; Kelly et al., 2018 ; Nuyen et al., 2022 ). Potential harms of pitch-raising surgery can be assessed and addressed in voice training by a voice and communication specialist.…”

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention

“…There are limited descriptions of anterior commissure advancement surgery, and more recently, feminization laryngoplasty (FemLar). [45][46][47] The FemLar procedure involves a laryngofissure (surgical midline division of the larynx) and subsequent reconstruction to shorten the length of the vocal folds and alter the supraglottic resonating chamber. The former surgery involves "stretching" or "lengthening" the vocal fold by surgically moving the anterior commissure into a more anterior position.…”

“…47 In comparison, the only other study reporting on this procedure quoted a revision rate of 7%, and 41% required in office KTP laser treatment to smooth or further feminize the voice. 46 Revision surgery with Wendler glottoplasty, VFSRAC, and LAVA following cricothyroid have been reported on numerous occasions in the literature, 33,37,40 though exact revision rate following this surgery is largely unknown. Meta-analysis also suggests this procedure most likely to fail for elevating pitch, and there was lowering of the pitch over time.…”

“…33 Nuyen et al found no difference in voice outcomes following open FemLar procedure whether patients had previous cosmetic chondrolaryngoplasty. 46 Further studies are needed to confirm the influence of chondrolaryngoplasty on vocal pitch outcomes following phonosurgery, and ideal timing thereof.…”