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Voice Feminization
LASER Trans-Gender Voice Surgery
Minimally-Invasive Voice Reassignment Surgery

Transgender voice changing, which is also known as feminization laryngoplasty is a complicated process that requires three factors to achieve success. A strong understanding of the process will give you the greatest chances of achieving a voice that sounds natural and is perceived as female by others.

Surgery to raise the pitch of the voice is relatively straight forward in most patients in experienced hands. Having the final voice perceived as being female, versus just a higher pitched male voice, goes well beyond pitch-raising surgery. The first step is understanding the differences between "pitch" versus "voice" versus "speech." Pitch is simply the frequency at which the vocal cords vibrate, and determines the frequency of a sound produced. Pitch is essentially ALL the voicebox (larynx) does. The pitch at which we speak is called the fundamental frequency and the array of pitches our larynx can produce is range. An untrained male voice usually has a little over an octave of range, which is 12 notes on a piano. Voice is what results as we mold that sound. Voice is shaped by the size and shape of our throats, mouth, nose and sinuses, giving it resonance, just like the size and shape of the piano which houses the strings changes it's sound. The "voice" or sound of an upright piano would sound different than that of a concert grand piano even if the same note is being played. It is important to understand that the resonators of your voice, the shape of the throat, mouth, and sinuses, can not be changed in feminization laryngoplasty. Even gender reassignment surgery and/or facial cosmetic surgery can not change these resonators. Assessing these areas pre-operatively are vital to predicting how the voice might sound, and be perceived, afterwards.

Next, voice is shaped into words and sentences. This is speech. A genetic female uses a different part of the brain to produce speech than a genetic male, and has a certain sing-song quality called prosody. This prosody is what the brain of someone listening to you will subconsciously process the voice as being perceived female versus a high-pitched male voice. (Visual cues are also very important, but for the purposes of this discussion, visual cues are assumed absent, such as telephone conversation). Prosody can not be changed with hormones or surgery. It must be learned, the way an actor would acquire the skills to take on another's personality of sorts. It requires a speech therapist very, very experienced in transgender voice changes, who can teach prosody. In most, it also requires years of practice to perfect and have it sound natural and effortless.

Perfecting prosody is 50% of the final result. This is why a genetic female with a very low speaking voice is still perceived as female, even when in the male fundamental frequency (such as many female television reporters).

The average female pitch is right around middle "C" on a piano (the normal range is within the pink arrows). The average male pitch is in a range about an octave lower than female, within the blue arrows in the picture. An octave is 12 notes on the piano (including the black keys!).  

In our practice, we can raise pitch 2/3 of an octave, or 8 notes, on average and in most cases. Some patients may get as little as 1/2 of an octave (6 notes) and others a full octave (12 notes). There are many things that predict whether you will 6, 8, or 12 notes of pitch raising, such as whether you ever smoked; have vocal fold polyps or scarring from voice abuse; limited range to begin with; or a shorter, fatter neck. In general, the lower your voice starts, the lower you will likely end up. A thorough pre-operative, in-person evaluation will help predict the degree the voice could be raised under ideal conditions.

If you look at a real piano, the higher notes have the shorter, thinner, tighter strings. This is what feminization laryngoplasty aims to achieve with your vocal cords. The vocal cords are stretched by making a small incision in a skin crease in your neck and tighten the cartilages that now allow you to go from a regular to a falsetto voice. While I am there, I can shave the Adam's Apple, a procedure termed thyroid chondroplasty. The neck incision is about 2-3 inches long and is hidden as best as possible. Notice in the before and after pictures how much thinner and more taut the vocal cords become.

Next, I move to the inside of the voicebox and use a LASER to effetely shorten the functional length of the vocal cords by creating a scar band in the front. Yellow arrow is where the scar is 3 months post-operatively.

The vocal cords only need to be shortened by about 20% to be effective. I can always go back to shorten them more if I need to, but can never lengthen them again. Although it is very unusual to go back in, it is better to be conservative in the beginning because the procedure can NOT be undone ... it is considered permanent!

A typical example:
The patient's speaking fundamental frequency was centered on D in the male range * 3 months after feminization laryngoplasty, the pitch is centered at A in the female range * which is 2/3 of an octave higher, or 8 notes, which is average.