Voice Feminisation Surgery (VFS), or Gender-Affirming Laryngeal Surgery (GALS)

How it works, the risks and benefits, and how to get the best results from surgery.

Voice feminisation surgery (VFS) will change the structure of your larynx (voice box) permanently. For many people, VFS is a very effective way of altering the sound of the voice to attain gender congruence. Research tells us that these surgeries can be very effective in helping individuals to achieve their voice goals, and enhancing quality of life1. Some studies have measured people’s voice satisfaction after surgery to be as high as 85%2. However, VFS surgeries come with risks as well3. It’s very important to know about the risks as well as the benefits of VFS before undergoing any procedure. This guide is designed to help you to make the best choice for you and your voice, in conjunction with your surgeon, and to know what to expect during VFS and afterwards.

Types of Surgery: what will happen to my voice?

These are the four most common types of VFS, along with a simple description of what your surgeon will be doing during the procedure. In general, VFS aims to change the vocal cords in the following ways, which all raise pitch: increasing tension, decreasing thickness, and decreasing length (shortening)6.

Cricothyroid Approximation (CTA)4,6

The cricothyroid muscle is responsible for raising your pitch. When it contracts, it tilts the larynx forwards, which stretches the vocal cords. When the vocal cords are stretched, they vibrate at a higher pitch. CTA surgery shortens and sutures the cricothyroid muscle and cartilages, effectively putting them into a permanent position of contraction. When successful, this means the vocal cords will be permanently stretched. This limits to voice to a higher range and relieves the effort of having to always keep the voice up.

Risks: some research indicates only 50% of people are satisfied with their voice long term after CTA4. Not recommended for those under 30 (higher risk of postoperative deformity; cartilages aren’t hard enough yet in young people). As this muscle is responsible for pitch and register, CTA can reduce pitch range significantly and sometimes induce an unnatural sounding falsetto 4.

Wendler’s Glottoplasty (WG)4, 5,6

This surgery shortens the vibrating length of the vocal cords. Your surgeon will remove the tissue at the front of your vocal cords (about one third of the vocal cords) and then stitch this portion together to create a “web”. Only the remaining section of the vocal cords will vibrate to make sound, which will create a higher pitch. This surgery is often done in combination with CTA (shortening and tightening)

Feminisation Laryngoplasty (FemLar)4,6

This is a complex multifactorial surgery that shortens the vocal cords, and raises the position of the larynx in the neck. This creates a higher pitch, and a shorter vocal tract for brighter resonance. Your surgeon will likely remove parts of the thyroid cartilage (the one you can feel; ‘adam’s apple’), create a glottal web (explained above), and lift the entire voice box up in the neck by attaching the thyroid cartilage closer to the hyoid bone (this part is called Thyrohyoid elevation).

Laser Reduction Glottoplasty (LRG)6

This surgery is carried out by using a strong laser to evaporate some of the thickness of the vocal cords. This decreases the mass (thickness) of the cords, and also increases stiffness of the vocal cords by creating scar tissue. These both function to raise pitch.

Something to note: Just as everyone’s voice is unique, not all these surgery techniques will be appropriate for everyone, and they will have varying results. For example, in some people, there is plenty of space between the larynx and the hyoid bone, and thyrohyoid elevation will result in a significant change in the sound of their voice. In others, these two structures are already close together, and the same surgical intervention won’t noticeably change the sound of their voice.

It will be essential to discuss which options (or combination of options) are most suitable for you, your voice, your specific goals, and your physical anatomy with your surgeon. Like any medical treatment, you must carefully evaluate whether the procedure aligns with your goals and overall health, considering the benefits as well as the risks. These surgeries don’t work for everyone; there are a range of results reported in research, and these surgeries carry significant risks. The outcomes often depend on individual factors too, such as lifestyle, vocal health management, and overall health management. Often, your surgical options might also be limited to your surgeon’s specialities (not all surgeons offer all procedures).

Further reading: I recommend reading the following page written by a specialist voice surgeon: https://www.voicedoctor.net/surgery/pitch/feminization-laryngoplasty

Weighing your options: benefits and risks

A 2024 systematic research6 review including 656 patients found that after Wendler Glottoplasty, fundamental frequency (pitch) was significantly increased by an average of 67.27Hz. An average speaking pitch of 166Hz (about an E3) was recorded across patients after surgery. Quality of life scores were also significantly improved6. These positive findings have been echoed in other high quality studies8. Most studies show that Vocal Feminisation Surgery is an effective voice feminisation method associated with high success and satisfaction6,8. Generally, these surgeries have a low risk of postoperative complications.

However, it's important to know that there are risks, and it’s possible that these surgeries don’t deliver the anticipated results. In some unfortunate cases, they can create permanent damage. Below is a summary of the risks and drawbacks that you might face, which is important to consider.

• Permanent decrease in pitch range6,8 (how high and low you can go)

• Decrease in maximum phonation time (how long you can sustain a single note)6,8

These two factors are a side effect found in most research papers. It has not been found to significantly impact spoken voice production in most people, though in professional voice users (singers, public speakers, etc), this could certainly have a bigger impact, and surgery should be approached with particular caution6,8.

• A higher pitch does not always guarantee being perceived as female, even if your pitch falls within the ‘female range’6. More on this later.

• Post-operative complications; most of these are temporary or can be corrected during reoperation without long-term consequences8. The following table outlines possible complications, as well as the frequency with which they have occurred in various studies6.

The most common risk will be in the early healing process; the newly stitched portion of the vocal cords (WG surgery) can’t adhere tightly together until they are fully healed. This area of the vocal cords is particularly susceptible to the formation of scar tissue, because the contact area is fast-moving and also experiences the greatest vocal fold contact forces4. If scar tissue forms, incomplete vocal cord closure, leading to breathiness and vocal weakness, is inevitable4. Poor vocal health (smoking, drinking, voice abuse), and voice use in the early healing state, will expose the voice to a much higher chance of the above risks and poor long-term outcomes4,5,6,7.

Getting the best results from voice surgery

As you already know from the previous section, to get the best results and reduce the chances of post-surgical complications, it will be critical that you take the best care of your voice that you possibly can. This means:

1. Following your surgeon’s advice post-operatively.

This will include a period of complete vocal rest (silence!) while your stitches heal, and can range anywhere from 10 days to several weeks6. It might also include short-term antibiotic and/or anti-inflammatory medications to assist with healing and reduce the chances of infection6.

1. Observe a terrific vocal health regimen. This also means staying generally healthy in diet and lifestyle, too. You will need to stay well-hydrated (2L daily), avoid inhaled irritants (smoke), avoid phonotraumatic behaviours (shouting/excessive loud talking), get good quality sleep, get lots of vocal rest, avoid alcohol and any other substances that cause dehydration, irritation, and drying of the vocal cords (i.e., caffeine, spicy foods, citrus, chocolate). Limit your voice use in the early days after your complete vocal rest period; avoid activities that cause vocal strain (i.e., long phone calls, screaming, talking over noise, coughing and throat clearing).

2. Voice therapy. Surgery alone only changes the fundamental frequency (pitch) of the voice. It doesn’t change other important gender markers, like articulation patterns, formant frequencies (resonance), and intonation patterns 6-8. Resonance (which contributes to the brightness of the voice) is determined by other things that surgery cannot change: tongue height, shape and size of the oral cavity, lip rounding, etc 6-8. Also, surgery will change vocal fold resistance (and pressures needed to make sound), necessitating a period of adjustment in the way you use your voice from a trained voice therapist. Research shows that the best results are achieved with a combination of surgery and voice therapy4,6,7,8. Studies that have measured changes in listeners’ perceptions of gender have found that changes are significantly greater in people that have combined voice therapy with surgery, as compared to people that had surgery without voice therapy4.

   
   

In summary: voice therapy is considered the first line of treatment, as it is non-invasive and affects not only pitch, but other gender cues, such as intonation, resonance, speech rate, intonation, etc. However, surgery is a beneficial option for individuals that are concerned with the pitch of their voice in situations that do not always remain under conscious control (laughing, sneezing), or those individuals whose pitch resides low in the masculine range, making it more challenging to sustain use of higher pitches without vocal fatigue and strain. Surgeries are generally safe, but it’s important to be aware of the risks, and the commitment that will be necessary to your vocal health and ongoing voice therapy during healing!

If you want to start voice training (any good surgeon will tell you to start therapy before surgery) please book here for a free 15 minute consult.

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Written by Anna Stephens, Speech Pathologist, Gender Voice Centre