Voice Feminization Surgery (VFS)

This question is one of the most important and encompasses every point that is changing after surgery. Because voice is such a complex entity, we always have to find out what the individual’s expectations are – ranging from easily measurable F0 to personal favorable timbres and self perception. The expectations are not easily reduced to items in a questionnaire – that is why we thouroughly have to go through the individual’s history and (voicing) capabilities. That having said, we always try to find out if realistic expectations can be found. Otherwise, the indication for surgery should be thought over, or surgery should be cancelled.

Glottoplasty is one of the safest methods to raise the pitch, if the vocal folds can be accessed via direct microlaryngoscopy (which is frequently possible). However, the way of webbing and suturing can always lead to postoperative hoarseness and therefore this point has to be pointed out in the preoperative informed consent.

 

If the vocal folds have already been pretreated, then they can no longer vibrate symmetrically after a second intervention. That’s why good (first) surgery is so important. Improper surgery can cause hoarseness. However, there could be temporary complications such as pitch instability, foreign body sensation in the throat, rough voice – but these symptoms are all temporary.

Although we would be very happy to predict surgical outcome, each individual’s anatomy, physiology and voice technique and are so variable that we cannot predict the outcome. Still, our evidence comes from experience and systematic analysis. I do believe that – with time – we will come up with more reliable preoperative assessments that may predict better what will result from interventions of any kind. That’s why science is very helpful in medicine including voice therapy and vocal coaching.

After glotoplasty, the modulatory ability is preserved because the vocal fold tensioner (the so-called CT muscle) is not touched.

Yes, you can. But it narrows the airway to some degree. As a result, this surgery (glottoplasyty)  might be less appropriate for highly singing professionals (opera) and, perhaps, serious athletes.

Clearly: coughing, to clear one’s throat, sneezing and loud screaming. The techniques, to avoid these are trained by our speech therapist before the surgery.

Pitch is determined by the combination of length, mass and tension. You may look up the physics formula online. To whatever extent as surgery can change these parameters, the comfortable speaking pitch will be changed.

• Shorter cords lead to a higher pitch.
• Tighter cords lead to a higher pitch.
• Thinner vocal cords lead to a higher pitch.

It is the same as a string on a guitar.

 

A dehydration of the laryngeal mucous membranes by the narrowed glottis does not occur. The exhaled air has 100% humidity. Much more, normal nasal breathing plays a role with its three functions of dirt filtration, heating and humidification.

Glottoplasty and swallowing: none of my patients that ai recall reported of swallowing problems in terms of aspiration (fluids or solid food goes into the trachea). Postoperative discomfort and rarely pain in the first days after surgery result from the laryngoscope placed into the larynx. But this is not related to the webbing and therefore not the cause.
Deep breathing: In terms of deep breathing, all patients are able to inhale and exhale the same air volume as before. In terms of rapid (maximum) flow there surely is a limitation after both procedures. Fortunately, airflow is (physiologically) mainly directed in the posterior larynx and even behind the vocal processes. However, if maximum and high effort breathing is an extremely important part of life, both surgeries should not be performed. But in the vast majority of our patients this is not the case.
Loud screaming: There is a restriction for loudest voice after glottoplasty.

James Thomas:

Dr. Kim is an outstanding surgeon. However, I don’t believe the tools make the surgeon. The surgeon should use a scalpel or a laser based on their comfort with the tool. If I were a patient, I would not make a decision based on the tool that the surgeon uses. The idea of making the web connect lower along the anterior margin so the air flows more smoothly is an interesting theory. In the individuals I have examined, I haven’t seen any difference in the subglottic area between different surgeons, including Dr. Kim’s patients.

 

Markus Hess

In our daily phonosurgical practice patients very often ask for ‘laser’ surgery, as if the laser was ‘magic’. The laser is an instrument and only as good as the hands controlling it. Although lasers are very important for phonosurgery, I must say that the patient should rather ask for the best technique and equiment that is on the market for a specific task and then ask if the surgeon has experience with this best technique – including the question if the surgeon has the specific tools. In highly specialised centers these tools will be available. So, in essence, surgeons think different to achieve best results: they choose from a spectrum of different instruments within their armamentarium, and if lasers work better for them than ‘cold steel instruments’, then its fine – and probably the best choice for their patient as well.
The concept and hope, that less turbulence due to ramping the air flow at the anterior subglottic site would result in clearer voice outcome, is compelling. If this concept were adequate and correct, it would make sense to put a lot of effort into this surgical step of the glottoplasty procedure. From our own experiences and from subglottic laryngoscopies in postoperative patients who had glottoplasties performed from other surgeons we could not see big differences, if any, from their subglottic anatomy that would prove that this funnel effect is actually achieved, and this also includes patients that I saw who were operated by Dr. Kim. At any rate, aerodynamics of phonation are very complex and there is at this stage of scientific research no method that can prove of disprove this concept.

 

When comparing these two surgical approaches, one must bare in mind that all individuals have – more or less – different voice boxes (laryx anatomy varies a lot interindividually). The angulation of the thyroid cartilages and the lengths of vocal folds as well as their thick are very different. It is like the shape and consistency of our faces, noses, ears etc.. Therefore, a technically exactly similar performed surgery can turn into a great result in one female and in others there might be only favourable results.

 

If one wants to start with a less invasive surgery, it seems clear that surgery only addressing the length and shape of vocal folds is less invasive and risky than doing an open neck surgery. Most females decide to have a glottoplasty and preserving the laryngeal framework anatomy and supplement with phonatory and voice therapy as well as vocal coaching for improvement of voice feminization.

However, a comparison of these two methods is not ‘fair’ in terms of what these technique aim for: FemLar attempts resonance changes as well as fundamental frequency (F0) changes and adds the Adam’s apple reduction, whereas glottoplasty and vocal fold shortening and retrodisplacement of the anterior commissure (VFSRAC) does not.

 

In general, singing styles differ significantly (classic to non-classic, hobby to high professional). And even for a surgically untreated larynx professionality in singing is still in most cases an enormous challenge. The more the singing is relying on a perfect, clear voicing and soprano-like easy onset in highest pitches, one might not go for any feminization surgery risk. One of the challenges is that the vocal fold mass, tension, length and tissue characteristics not only change with surgery, but also change with hormones and voice use. Too many variables to reliably predict outcome yet. But many researchers are working on this, including us.