Voice Feminization and Masculinization

Abstract

Surgery for voice feminization is primarily aimed at altering the length and tension of the vocal fold through open procedures. These procedures are often combined with the laryngeal shave. The concept of tightening the vocal fold by stretching it and creating a response that was an exaggeration of the cricothyroid was the basis of Isshiki’s type IV thyroplasty. The initial results of this procedure did indeed raise the fundamental frequency, but medium- to long-term follow-up showed declination of pitch. Reduction of the vibrating mass of the vocal fold provided an alternative to raising tension and several procedures; both open and endoscopic have been used with varying success. Several procedures have been described with varying short- and long-term success. They include tension-increasing procedures (cricothyroid approximation, laser tightening and anterior commissure advancement); mass reduction procedures; laser debulking and vocal webbing and a combination of the two; and anterior partial laryngectomy.

Masculinization of the voice is reflected by the lowering of the fundamental frequency and is primarily caused by exposure to androgens—namely, testosterone. Surgery is rarely required but is nevertheless an important treatment consideration in trans males who have not responded adequately to androgen treatment. Isshiki’s type III B relaxation thyroplasty, based on the principle of pushing back the anterior commissure and relaxing the vocal folds, became the mainstay for pitch lowering surgery.