30%-50% of the vocal folds, which are only a few millimeters long, are gently thinned out with the finest microsurgical instruments sutured together with a hair-thin, resistant thread (6-0 permanet .
Under general anaesthesia, a metal tube (laryngoscope) is placed through the mouth to lift the tongue out of the way and visualize the vocal cords directly. Using a microscope, the lining of the vibrating portion of the vocal cords is removed from the front half of the vocal cords. The vocal folds are surgically shortened by anterior suturing and subsequent permanent union, so that a higher fundamental frequency is enforced in the posterior remaining, oscillating segment. An additional combination with anterior-lateral augmentation, btx injection and thinning of the inferior vocal folds may be useful.
Because in gender recognition our ear also responds to the resonance spectrum in the vocal tract (‘timbre’) , the surgical suppression of the supraglottic resonance chambers usually provides an additional supportive effect of voice feminization. The surgery is performed under general anaesthesia and through the mouth. Consequently, there is no external incision. The whole procedure can be done in about 1 1/2 hour and the patient is able to go home the same day.