Feminization laryngoplasty

Feminization laryngoplasty
Before and after images of a feminization laryngoplasty patient
Pronunciation/ləˈrɪŋɡəˌplæsti/[1]
Other namesFemLar
SpecialtyLaryngology
MeSHD058753

Feminization laryngoplasty (also known as FL or FemLar/Femlar) is a reconstructive surgery surgical procedure that attempts to increase the baseline pitch of a patient, making the voice sound higher and more feminine. It is a heavily modified Type 4 thyroplasty that is distinct in critically avoiding a cricothyroid approximation. Instead, as a form of open laryngoplasty a partial laryngectomy of the anterior portion of the larynx is removed, diminishing the diameter of the larynx to cisgender female proportions. The surgery can be categorized into two main steps: Incision and vocal fold modification followed by thyrohyoid elevation. A reduction in larynx diameter modifies vocal weight or resonance quality of the voice while allowing more vocal range access than a type 4 thyroplasty usually allows, as the function of cricothyroid muscle is preserved. Risks and complications include granuloma, dysphonia and tracheostomy. Patients are recommended to follow perioperative management such as voice rest and antibiotics to hasten recovery.

The operation will also diminish the masculine neck profile caused by "Adam's apple" after the removal of anterior cartilage, achieving a more feminine neck appearance.[2] This effect is more pronounced than the reduction that can be typically achieved with a tracheal shave as it explicitly goes further than a tracheal shave and removes tissue that should be avoided by the surgeon during a tracheal shave. Thus, if a patient opts for this procedure, they will typically not need a tracheal shave.

The procedure is less popular and well-known than other forms of voice feminization surgery and is currently performed by a limited set of surgeons due to the need for specialized sutures and training. This includes, but is not limited to several surgeons in the US,[3] Thailand,[4][5] and Australia.[6] There are doctors using this term (FemLar) generically to describe their suite of voice and larynx feminization procedures, that do not perform this particular procedure, but rather other procedures such as glottoplasty, cricothyroid approximation, and tracheal shaves.[7]

Background

Transgender women

During puberty, testosterone, causes the diameter of the larynx to increase and the vocal folds to thicken and lengthen. This change is irreversible even with the help of feminizing hormone therapy. The fundamental and resonant frequency of their voice decreases and they no longer match to the desired vocal range that suits their gender identity.[8]

Nonbinary people and cisgender women

Cisgender women with an abnormally low voice and gender nonconforming individuals may also seek feminization laryngoplasty. However, the target pitch for nonbinary people may be different from people who identify solely as women. For instance, some would hope to achieve an androgynous voice rather than a completely feminine voice.[9] Therefore, laryngologists should work closely with patients to tailor to their personal needs to maximize satisfaction.[10]

Voice therapy

Individuals who sought vocal alterations are first recommended to undergo voice therapy to generate a desirable vocal pitch and resonance. Some individuals could substantially achieve a more feminine voice by adapting to a new habitual coordination of muscles in their vocal cords. However, results vary greatly from person to person and often require an active effort to maintain.[3] A persistent effort of using a more feminine voice could lead to straining and other pathological issues in vocal cords.[11] Surgical means of voice feminization such as feminization laryngoplasty can be an alternative to vocal therapy when effects from training alone are unsatisfactory, allowing patients to permanently modify their comfortable speaking pitch and resonance.[12]

It is estimated that about 1% of transgender women have opted for a surgical procedure of voice feminization, while a larger proportion of transgender women (14%) opted for non-surgical means of voice feminization (i.e. voice therapy).[13]

History

Transgender surgery in general has gained its initial momentum in the early 1950s after the attention brought by American transgender woman Christine Jorgensen.[14][15] Sexual reassignment surgeries have seen an exponential increase in public awareness during that period of time. However, it was not until a few decades ago had voice feminization garnered its own recognition from public audience.

History of voice feminization

Previously, gender affirmation surgery has put great emphasis on genital conformation only. In the last few decades, as the interpretations of gender identity in society shifts, gender affirmation surgery has expanded to the territories of secondary sex characteristics, in a way that voice feminization has seen unprecedented attention. Study notes that throughout the decades, there has been an increasing trend of emphasis on social recognition (i.e. interacting with other people in the community under their own preferred gender identity) rather than sexual recognition alone. Several cosmetic surgeons have claimed that most of their patients are satisfied with alterations on secondary sexual characteristics and are not tempted to seek additional genital surgery.[11][16]

Traditional techniques

The first experimental study to surgically raise the speaking pitch was performed by Japanese otorhinolaryngologist Kazutomo Kitajima and his colleagues in 1979. They together discovered the inverse linear relationship between the vocal pitch and the distance between the thyroid cartilage and cricoid cartilage.[17] Based on this principle, the first surgical procedure for voice feminization, cricothyroid approximation (CTA) was developed to achieve pitch increase by reducing the separation between the two cartilages. This procedure remains the most well known among transgender women seeking surgical voice feminization.[18] However the results are often unsatisfactory with CTA due to the unnatural falsetto quality of the voice.[19][20] Other surgical solutions were also developed, including Wendler (Web) Glottoplasty (also known as anterior web glottal formation, newer versions of this surgery are also occasionally referred to as VFSRAC, Vocal Fold Shortening with Retrodisplacement of the Anterior Commissure), and a variant of it, laser reduction glottoplasty (LRG), as well as laser tuning, including laser assisted voice adjustment (LAVA) and vocal fold muscle reduction (VFMR).[21] The glottoplasty and laser tuning options do not have this falsetto issue, unlike CTA. However, they generally have a longer and more complex recovery.[22]

Modern technique

The concept of feminization laryngoplasty originated from the open laryngoplasty technique proposed by cosmetic surgeon Somyos Kunachak.[23] The first operation was then performed by James P. Thomas in 2003.[3] Compared to other surgeries, feminization laryngoplasty could be undergone as one single surgery for thyroid chondroplasty to reduce the prominence of the "Adam's apple", while the other solutions had to perform chondroplasty separately.[11]

Modern Procedure

Presurgical management

Before the operation, antibiotics such as clindamycin and ceftriaxone are administered intravenously to reduce surgical infection. Dexamethasone is also given to reduce edema.[24]

To better analyze the change in voice pitch and quality after the surgical operation, voice recordings are also taken before and after the laryngoplasty.[25]

Incision and vocal fold modification

The horizontal cross section of thyroid cartilage before and after feminization laryngoplasty. The thyroid cartilage is cut along the red line (left), with the part in between the lines removed and the remaining parts sutured together (right).

General anesthesia would be administered beforehand. A 5 cm long horizontal incision would then be made at a skin crease above the thyroid notch, allowing the postoperative scar to be hidden under the crease. After flaps have been created under the platysma, the strap muscles would be separated along the midline to expose the thyroid cartilage. This allows a strip of the anterior thyroid cartilage to be removed to effectively reduce the contour of the Adam's apple and the diameter of the laryngeal opening.[24][26]

A quarter of the anterior false folds would also be removed to further reduce the diameter of the upper larynx and to provide a better view of the true vocal folds. Subsequently, up to 50% of the anterior vocal folds is removed and the length of pharynx is shortened to raise the speaking pitch. The overall size of glottal region is also reduced, which diminishes the thyroid notch.[11][26]

Thyrohyoid elevation

By elevating the thyrohyoid muscle, the distance between the thyroid cartilage and the hyoid bone can be decreased. This may be further facilitated by removing upper thyroid alae in the operating room to provide additional room to elevate the larynx.[27]

At last, eight holes are drilled on the thyroid cartilage and hyoid bone for the placement of sutures and screws, securing and suspending the structure of the larynx higher in the neck, but still allowing it to move up and down to facilitate functions such as swallowing. The strap muscles are then reattached and the skin is closed with sutures.[26]

Postsurgical management

Following surgery completion, patients are prescribed acetaminophen with narcotic pain medication for pain relief and cefpodoxime or levofloxacin for 7 days to minimize infection.[24]

Risks and complications

Granuloma of the vocal cord

After feminization laryngoplasty, most patients would experience a drop in voice volume and some may experience a decreased vocal pitch. Continuity of range might also be negatively affected. Therefore, the surgery might be less suited for vocal performance professionals. Vocal Fold Muscle Reduction, a standalone laser tuning procedure, can also be considered for professional voice users as well.[28]

Granuloma in the vocal cords is also a possible complication, which may cause a soft and whispery voice. The granuloma should eventually be coughed out, or in some case be removed manually.[24] Dysphonia is another common symptom in the first two months of recovery, but the issue gradually resolves in most patients. Further treatment or revision surgery might be needed for some patients with serious unresolved sound hoarseness after extended periods of recovery.[20] If the vocal cords heal with asymmetrical tension, laser treatment is generally required to correct the defect.

In some rare cases, severe swelling could lead to difficulty in breathing, which may require tracheostomy to bypass the area of obstruction.[27]

Post-operative care

Following feminization laryngoplasty, patients are usually discharged without the need for overnight stay. Exceptions would be made when complications have occurred, during which the patient would have to stay in a hospital for up to a week.[29]

Complete voice rest after the surgery is also necessary for fast healing as the vocal cords are only supported by a few sutures. Those who have undergone the procedure are advised to have vocal rest for at least 2 weeks, no aerobic activity for 3 weeks and no weight lifting for a month to give time for scar tissue to develop and support the larynx.[2] It is also advised to refrain from having surgery requiring intubation for at least 6 months.[27]

To maximize the effects of the surgery and to adapt to the new feminine voice, patients are also highly recommended to undergo vocal therapy, during which patients could learn to feminize their voice intonation, volume, resonance and non-verbal communication such as gesture and articulation.[13]

For patients who are still unsatisfied with the pitch increase after the surgery, revision surgery or laser tuning could be considered to improve results. However, a revision is generally not recommended to patient with medical records of voice surgery prior to feminization laryngoplasty.[30]

See also

References

  1. ↑ "Medical Definition of LARYNGOPLASTY". www.merriam-webster.com. Retrieved 2026-06-18.
  2. 1 2 Thomas, JP; MacMillan, C (April 30, 2013). "Feminization laryngoplasty: assessment of surgical pitch elevation". European Archives of Oto-Rhino-Laryngology. 270 (10): 2695–700. doi:10.1007/s00405-013-2511-3. PMID 23632870. S2CID 23507643.
  3. 1 2 3 Thomas, JP. "Feminization laryngoplasty". Retrieved March 2, 2022.
  4. ↑ "Voice Feminization / VFS". Kamol Cosmetic Hospital. Retrieved 20 August 2023.
  5. ↑ "Voice Change Surgery". Voice Change Surgery - Dr. Ornouma. Retrieved 20 August 2023.
  6. ↑ "Larynx Reconstruction". Queensland Voice Centre - Larynx Reconstruction. 8 April 2016. Retrieved 20 August 2023.
  7. ↑ "Voice Feminization". Center for Care of the Professional Voice.
  8. ↑ Chen, Shitao; Han, Chengyang; Wang, Shuai; Liu, Xuanwen; Wang, Bin; Wei, Ran; Lei, Xue (2022-11-03). "Hearing the physical condition: The relationship between sexually dimorphic vocal traits and underlying physiology". Frontiers in Psychology. 13 983688. doi:10.3389/fpsyg.2022.983688. ISSN 1664-1078. PMC 9680725. PMID 36425833.
  9. ↑ Chadwick, Keith A.; Liao, David; Alter, Isaac L.; Coleman, Rachel; Andreadis, Katerina; Riekki, Rebecca; Waldman, Jack; Rives, Hal; Pitti, Mary; Rameau, Anaïs (January 2026). "Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series". Journal of Voice. 40 (1): 199–205. doi:10.1016/j.jvoice.2023.08.005. PMC 10909913. PMID 37673753.
  10. ↑ Davies, S; Papp, VG; Antoni, C (November 16, 2015). "Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside". International Journal of Transgenderism. 16 (3): 117–159. doi:10.1080/15532739.2015.1075931. S2CID 21705607. Retrieved March 24, 2022.
  11. 1 2 3 4 Hammond, Sarah E.; Cohen, Erin; Rosow, David (July 2019). "Feminization of Transgender Women With Thyroid Chondroplasty and Laryngoplasty". Journal of Craniofacial Surgery. 30 (5): 1409–1413. doi:10.1097/SCS.0000000000005569. ISSN 1049-2275. PMID 31299733.
  12. ↑ Chowdhury, Raisa; Silver, Jennifer A.; Philippopoulos, Eleni; Kost, Karen M. (July 2025). "Pitch Alteration Techniques for Transgender Women: A Systematic Review of Surgical and Nonsurgical Approaches". Journal of Voice. doi:10.1016/j.jvoice.2025.06.032. PMID 40681377.
  13. 1 2 "Voice Feminization Surgery: Transgender Voice Change Surgery". Cleveland Clinic. Retrieved March 2, 2022.
  14. ↑ Meyerowitz, J (2006). "Transforming Sex: Christine Jorgensen in the Postwar U.S.". OAH Magazine of History. 20 (2): 16–20. doi:10.1093/maghis/20.2.16. JSTOR 25162028.
  15. ↑ "From GI Joe to GI Jane: Christine Jorgensen's Story". The National WWII Museum | New Orleans. 2020-06-30. Retrieved 2026-06-29.
  16. ↑ Lab, Seattle Voice (2024-06-19). "The History of Voice Feminization". Seattle Voice Lab. Archived from the original on 2026-03-24. Retrieved 2026-06-29.
  17. ↑ Kitaijima, K; Tanabe, M; Isshiki, N (Jan 1979). "Cricothyroid distance and vocal pitch. Experimental surgical study to elevate the vocal pitch". Annals of Otology, Rhinology & Laryngology. 88 (1): 52–5. doi:10.1177/000348947908800109. PMID 426446. S2CID 36049428.
  18. ↑ Ornouma, S; Suthee, R; Egoy-Salvan, L (2013). "Expertise of Voice Feminization Surgery to 270 Diverse International Patients". Atlas of Operative Otorhinolaryngology and Head and Neck Surgery: Voice and Laryngotracheal Surgery (Volume 4). Jaypee Medical Publisher. p. 1252. doi:10.5005/jp/books/11961_30. ISBN 978-93-5090-482-4. Archived from the original on January 19, 2022. Retrieved March 22, 2022.
  19. ↑ Yang, CY; Palmer, AD; Murray, KD; Meltzer, TB; Cohen, JI (June 2020). "Cricothyroid approximation to elevate vocal pitch in male-to-female transsexuals: results of surgery". Annals of Otology, Rhinology & Laryngology. 111 (6): 477–85. doi:10.1177/000348940211100602. PMID 12090702. S2CID 8966461.
  20. 1 2 Kim, HT (February 12, 2020). "Vocal Feminization for Transgender Women: Current Strategies and Patient Perspectives". International Journal of General Medicine. 13: 43–52. doi:10.2147/IJGM.S205102. PMC 7024865. PMID 32104050.
  21. ↑ Titze, Ingo R.; Palaparthi, Anil; Mau, Ted (May 2021). "Vocal Tradeoffs in Anterior Glottoplasty for Voice Feminization". The Laryngoscope. 131 (5): 1081–1087. doi:10.1002/lary.28940. ISSN 0023-852X. PMC 9285120. PMID 32840877.
  22. ↑ Kim, Hyung-Tae (February 2020). "Vocal Feminization for Transgender Women: Current Strategies and Patient Perspectives". International Journal of General Medicine. 13: 43–52. doi:10.2147/IJGM.S205102. ISSN 1178-7074. PMC 7024865. PMID 32104050.
  23. ↑ Kunachak, S; Prakunhungsit, S; Sujjalak, K (November 2020). "Thyroid cartilage and vocal fold reduction: a new phonosurgical method for male-to-female transsexuals". Annals of Otology, Rhinology & Laryngology. 109 (11): 1082–6. doi:10.1177/000348940010901116. PMID 11090002. S2CID 22558188.
  24. 1 2 3 4 Nuyen, BA; Qian, ZJ; Campbell, RD; Erickson-DiRenzo, E; Thomas, JP; Sung, CK (August 17, 2021). "Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique". Otolaryngology–Head and Neck Surgery. 167 (1): 112–117. doi:10.1177/01945998211036870. PMID 34399638. S2CID 237149860.
  25. ↑ Thomas, James P.; MacMillan, Cody (September 2013). "Feminization laryngoplasty: assessment of surgical pitch elevation". European Archives of Oto-Rhino-Laryngology. 270 (10): 2695–2700. doi:10.1007/s00405-013-2511-3. ISSN 0937-4477. PMID 23632870.
  26. 1 2 3 Thomas, JP. "Technical Information | Feminization laryngoplasty". Archived from the original on October 15, 2021. Retrieved March 23, 2022.
  27. 1 2 3 Thomas, JP. "Patient Information | Feminization laryngoplasty". Archived from the original on September 18, 2021. Retrieved March 2, 2022.
  28. ↑ "Voice Feminisation Surgery". London Voice & Swallowing Clinic. Retrieved 1 September 2023.
  29. ↑ Aires, Mateus Morais; Alencar Araripe Nunes, André; Campos e Santos, Érica Cristina; Carneiro, Christiano de Giacomo; Catani, Guilherme Simas do Amaral; Hachiya, Adriana; Haguette, Erik Frota; Neves, Luciano Rodrigues; Sant' Anna, Geraldo Druck; Sarvat, Marcos André de (May 2026). "Glottoplasty for vocal feminization in transgender women: position paper of the Brazilian Academy of Laryngology and Voice (ABLV)". Brazilian Journal of Otorhinolaryngology. 92 (3) 101777. doi:10.1016/j.bjorl.2026.101777. PMC 12994021. PMID 41806533.
  30. ↑ Thomas, James Phillip (August 2022). "Feminization Laryngoplasty - A Comprehensive Approach to Reducing the Size of the Larynx and Pharynx". Otolaryngologic Clinics of North America. 55 (4): 739–748. doi:10.1016/j.otc.2022.05.002. PMID 35750518.
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