Kathy's Komments

This page will have regular comments from Kathy.

HI Kathy,

Sorry, it’s been a busy week and I’m not quite 100% yet.
The surgeon is Dr Ian Cole; he works out of St Vincents.
His full price for the procedure is $2500, he only charged $1900 (paid in advance) and says I’ll get $1100 back – I haven’t claimed this yet.
The anaesthetist was $900 and I don’t know how much I’ll get back.
I’m with Medibank private and the night in St Vincents Private was $200, the rest was covered by them.

I had a Crico Thyroid Approximation done, which also entailed a laryngeal shave at the same time.
Dr Cole’s done one Thyroid Cartilage and Vocal Cord Reduction (Kunachak) procedure.

If you want to give me as a reference, please only list my first name and give an email address

Regards, Brenda

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Here you go, sorry to hear about the problems with your computer.
I’ve been given refunds from medicare and medibank private, haven’t got the receipt back for the anaesthetist so haven’t claimed that yet.
I went back for a follow up yesterday; my FF (fundamental frequency) is sitting @ 230 Hz... I’m stoked. I also measured a peak of about 570 Hz (wow!). Age has a lot to do with a CTA, it’s most suitable for those under 40, I started off with a really good range which is why I’ve gotten good results.

Hugs Brenda

Voice Feminization Surgery: A Critical Overview

By Anne A. Lawrence, M.D., Ph.D.

Introduction: This article will briefly summarize current techniques of voice feminization surgery. The information presented here reflects my personal opinions and values, and nothing in this article should be interpreted as medical advice – always consult your personal physician.

Theory: Male and female voice differ primarily in their pitch (frequency) and in their timbre (resonance). The characteristic pitch or fundamental frequency (F0) of the male voice ranges from about 100 to 150 Hz; for the female voice, F0 ranges from 170 to 220 Hz. The lower pitch of the male voice is primarily due to the greater length and mass of the male vocal cords. The distinctive timbre or resonance of the male voice is primarily due to the greater length of the male upper airway (throat, mouth, nose, and sinuses; see Fitch & Giedd, 1999). Both fundamental frequency and resonance provide important acoustic cues to the sex of a speaker, but fundamental frequency is the more important cue (for a review see Oates & Dacakis, 1983). There is currently no practical way to surgically feminize the resonant properties of the airway (more research in this area would be desirable), but there are several operations that can surgically modify the pitch or F0 of the voice.

Fundamental frequency, F0, is inversely proportional to the length of the vocal cords, is inversely proportional to the square root of the density (mass per unit volume) of the cords, and is directly proportional to the square root of the tension of the cords (see Kunachak, Prakunhungsit, & Sujjalak, 2000). Consequently, there are really only three ways to attempt to increase F0 surgically: (a) by decreasing the vibrating length of the vocal cord (highly efficient), (b) by increasing tension of the vocal cord (less efficient, since the relationship is square root rather than linear), or (c) by decreasing the density of the vocal cord (also less efficient, since the relationship is square root).

Crico-Thyroid Approximation (CTA): The most commonly performed operation to raise F0 is crico-thyroid approximation (CTA), which is shown in the illustrations below.

In this technique, the thyroid cartilage (Adam's apple) is pushed against the cricoid cartilage that lies below it. The two cartilages are then sutured together with nylon sutures, usually placed over bolsters (Isshiki, Taira, & Tanabe, 1983; for another variation see Sataloff, Spiegel, Carrol, & Heuer, 1986). Some surgeons use metal clips to hold the cartilages together. The approximation of the thyroid and cricoid cartilages anteriorly increases the tension of the vocal cords by stretching them posteriorly. This raises the pitch at which the cords will vibrate. The operation mimics normal physiology: When we speak at the upper end of our pitch range, we do so by contracting the cricothyroid muscle, which pulls the two cartilages together and increases tension in our vocal cords.

CTA is performed through a small horizontal incision in the neck, which is placed at a natural skin fold; the resulting scar is usually invisible or easily concealed. Either local or general anesthesia can be used. Because F0 varies with the square root of vocal cord tension, CTA is a relatively inefficient way to increase F0.

The few follow-up studies of CTA in the published literature have reported inconsistent outcomes. Neumann, Welzel, and Berghaus (2002) reported results in 67 patients; nearly all achieved an increase in fundamental frequency, with a mean increase of 5 semitones. However, the modal increase was only 2-3 semitones, and only 28% of patients achieved a F0 in the female range (defined by the authors as 174 Hz or greater), although this percentage increased to 38% at 6-month follow-up. Only 2 patients were made worse by the procedure. De Jong (2003) described outcomes in a series of 30 patients, 26 of whom were available for follow-up. Most patients (85%) were satisfied with their results; mean FO increased from 122 Hz to 181 Hz. Wagner, Fugain, Monneron-Girard, Cordier, and Chabolle (2003) reported results in 14 patients who underwent CTA (9 patients), anterior commissure advancement (2 patients), or both (3 patients). Over three quarters achieved subjectively satisfying results, but the median increase in F0 was only 11 Hz. Of the 9 patients who underwent CTA alone, only 4 achieved postoperative F0s of 160 Hz or greater. Brown, Perry, Cheesman, and Pring (2000) described outcomes in 14 patients; their patients had a relatively high mean F0 of 152 Hz before surgery. Mean F0 did not increase significantly after CTA, but modal frequency did, to a mean of 175 Hz. Results were highly variable, with 2 patients showing very large increases in modal F0, and 2 patients showing no increase.

Advantages: No surgery on the vocal cords themselves; theoretically reversible if the patient is dissatisfied.
Disadvantages: Requires neck incision; prolonged healing process; long-term results have sometimes been favorable, but are inconsistent and sometimes unsatisfactory.
Assessment: Cautiously endorsed in selected cases.

Advantages: Performed endoscopically, no neck incision.
Disadvantages: Minimal pitch elevation; potential for hoarseness or breathiness; no published series in transsexual women.
Assessment: Not recommended.

Advantages: Performed endoscopically, no neck incision.
Disadvantages: Minimal pitch elevation; prolonged recovery period; potential for hoarseness.
Assessment: Not recommended.

More recently, Gross (1999) described a similar procedure performed endoscopically, without any cartilage resection. In his series of 10 transsexual patients, the mean postoperative F0 achieved was 201 Hz (range 154 to 240 Hz). The mean increase in F0 was 81 Hz (range 49 to 125 Hz). Duration of follow-up ranged from 35 to 45 months. All but two patients suffered transient decreases in vocal intensity, some very minor; these reportedly improved with speech therapy.

Advantages: Can be performed endoscopically, without neck incision; small published case series demonstrates long-term effectiveness.
Disadvantages: Potential for breathiness or voice weakness.
Assessment: One of the better procedures. Arguably the procedure of choice for patients who insist on undergoing pitch-elevation surgery.

Thyroid Cartilage and Vocal Cord Reduction: Recently a team of Thai surgeons (Kunachak, Prakunhungsit, & Sujjalak, 2000) reported a new, very aggressive, and highly effective (perhaps too effective) surgical technique for pitch elevation. Their procedure involved the open resection of a central strip of the thyroid cartilage, about 8 mm wide, along with resection of the anterior one-third of the vocal cords and reconstruction of the anterior commissure (where the vocal cord meet anteriorly). Their technique is shown in the illustration below.

The authors reported the results of their procedure in six Thai patients, the oldest of whom was 27 years old. F0 increased from a preoperative mean of 147 Hz (range 100 to 172 Hz) to a postoperative mean of 315 Hz (range 264 to 420 Hz). A mean postoperative F0 of 315 is fairly high even by female standards; when such a high F0 is combined with the resonant characteristics of a male airway, the subjective impression might be very unusual, and might perhaps result in unwanted attention to the voice. Interestingly, four patients in the study had preoperative F0s of 160 or higher; such F0s would typically allow them to be judged female without surgery, at least by Western standards (see Spenser, 1988, and Wolfe, Ratusnik, Smith, & Northrop, 1990). Two patients developed granulomas of the anterior commissure, which were easily treated with CO2 laser vaporization. Follow-up times ranged from 5 to 72 months.

Recently Portland ENT surgeon James Thomas web-published his results in a single case using a similar procedure, which he calls "feminization laryngoplasty."

Advantages: Small published case series suggests long-term effectiveness; thyroid cartilage resection offers cosmetic benefits.
Disadvantages: Highly invasive and irreversible; requires neck incision; high potential for over-correction.
Assessment: One of the better procedures, albeit quite aggressive.

Many if not most transsexual women are capable of achieving an F0 in the lower part of the female range through voice training alone, without voice surgery. The problem is not physiologic incapacity; the problem is finding the motivation to undertake the hard work of learning the necessary vocal skills and of practicing them consistently until they become second nature. Nevertheless, in my opinion, most transsexual women should concentrate primarily on voice training, and consider voice feminization surgery only as a last resort.

References:

Abitol, J. (1995). Atlas of Laser Voice Surgery. San Diego, CA: Singular Publishing.

Brown, M., Perry, A., Cheesman, A. D., and Pring, T. (2000). Pitch change in male-to-female transsexuals: Has phonosurgery a role to play? International Journal of Language and Communication Disorders, 35, 129-136.

de Jong, F. (2003, September). Surgical raise of vocal pitch in male to female transsexuals. Paper presented at the XVIII Biennial Symposium of the Harry Benjamin International Gender Dysphoria Association, Gent, Belgium.

Donald, P. J. (1982). Voice change surgery in the transsexual. Head and Neck Surgery, 13, 246-250.

Fitch, W. T., & Giedd, J. (1999). Morphology and development of the human vocal tract: A study using magnetic resonance imaging. Journal of the Acoustical Society of America, 106, 1511-1522.

Gross, M. (1999). Pitch-raising surgery in male-to-female transsexuals. Journal of Voice, 4, 433-437.

Isshiki, N., Taira, T., Tanabe, M. (1983). Surgical alteration of the vocal pitch. Journal of Otolaryngology, 12, 335-340.

Kunachak, S., Prakunhungsit, S., & Sujjala, K. (2000) Thyroid cartilage and vocal fold reduction: a new phonosurgical method for male-to-female transsexuals. Annals of Otology, Rhinology, and Laryngology, 109, 1082-1085.

Kerstin Neumann, K., Welzel, C., & Berghaus, A. (2002). Cricothyroidopexy in Male-to-female-Transsexuals – Modification of Thyroplasty Type IV. International Journal of Transgenderism, 6(3). Retrieved December 30, 2003 from http://www.symposion.com/ijt/ijtvo06no03_03.htm

Oates, J., & Dacakis, G. (1983). Speech pathology considerations in the management of transsexualism: A review. British Journal of Disorders of Communication, 18, 139-151.

Pincus, S. J. (1997, June). Voice surgery. Paper presented at the Second International Congress on Sex and Gender Issues, Philadelphia.

Sataloff, R. T., Spiegel, J. R., Carrol, L. M., & Heuer, R. J. (1992). Male soprano voice: A rare complication of thyroidectomy. Laryngoscope, 102, 90-93.

Spenser, L. (1988). Speech characteristics of male-to-female transsexuals: A perceptual and acoustic study. Folia Phoniatrica, 40, 31-42.

Wagner, I., Fugain, C., Monneron-Girard, L., Cordier, B., and Chabolle, F. (2003). Pitch-raising surgery in fourteen male-to-female transsexuals. Laryngoscope, 113, 1157-1165.

Wolfe, V., Ratusnik, D., Smith, F., & Northrop, G. (1990). Intonation and fundamental frequency in male-to-female transsexuals. Journal of Speech and Hearing Disorders, 55, 43-50.