Voice Feminization Surgery (VFS) and Therapy

Sounds really feminine!
Anyone who feels that they belong to the female sex would like to be perceived and, for example, be addressed accordingly on the phone. Everytime! If our voice does not match our identity, it often leads to frustration, silence or social isolation. Voice feminization is an important step in the whole transition process.

Example of a voice before and after voice feminization surgery by Prof. Markus M. Hess.

The feminisation of the voice consists (in our case) not only of the operative raising of the voice (Glottoplasty, Vocal Fold Webbing), but of a whole package of treatments. The goal is a voice that, in the overall context of speaking, has all the feminine qualities that make up a female voice. Surgeries for voice feminization focus on raising habitual speaking pitch by reducing the ability to produce a low-pitched voice. Therefor it is necessary to train you new voice by a professional voice-therapist But, how to get a feminine voice?
We designed a special voice-feminization-therapy for women who want to develop their authentic female voice and match their gender identity. The goal is a voice that has all the feminine qualities that make up a female voice.
The DEUTSCHE STIMMKLINIK is a renowned clinic that specializes in voice feminization surgery and the concept is that the most advanced surgical technique is combined with voice training and speech therapy. We take a lot of time for every single patient, listen carefully and do not give up until we understand all your worries and sensitivities.

A very experienced surgeon

Prof. Markus M. Hess, MD, specializes in voice feminization surgery to alter the voice and enhance it’s feminine qualities for clients in Hamburg, Germany. Prof. Hess routinely performs vocal feminization operations, a total of approx. 30-50 glottoplastics or other surgical methods (see infobox) per year. He gives lectures worldwide and is a leader in the research of surgical methods and therapy-accompanying measures. The Voice-Therapy, developed by Prof. Hess in collaboration with leading speech, voice and speech therapists, is tailored to the needs of transsexual patients.

Prof. Markus M. Hess about voice-feminization-surgery (Vocal Fold Webbing) and the post-operative behavior.

Preparing your surgery

The voice-feminization begins with a detailed interdisciplinary initial discussion together with the surgeon Prof. Dr. med. Markus M. Hess as well as the speech therapist (voice and speech trainer) Birte Heckmann. This interview will also analyze the potential need for preoperative vocal therapy. Our treatment package ‚voice-feminization’ comprises interdisciplinary history taking with a physician (ENT doctor) trained in voice disorders / phonosurgery and a logopedist specially trained in clinical voice disorders / vocal coaching. Diagnostics include videostroboscopy, endoscopy, electroglottography, electroacoustic voice analyses, perceptual voice assessment, voicerange profile, Acoustic Voice Quality Index, Voice Handicap Index / Transsexual Voice Questionnaire, and further tests. Subsequently a detailed briefing and discussion are offered. In case of surgery, a consent form is handed out explaining in detail all options for the following feminization laryngoplasty procedure.
Before the surgery the planning is carried out by Prof. Markus Hess. He provides you with information about treatment options and alternatives (conservative and surgical) and explains you all possible surgical procedures. After clarification of all alternatives the declaration of consent to the operation takes place.

  • Vocal Fold Webbing (nach Wendler, Gross, Kim, Anderson und vielen anderen
  • Laser Reduction Glottoplasty (nach Orloff)
  • Cricothyroidale Approximation (CTA nach Isshiki et.al.)
  • Feminization Laryngoplasty (FemLar nach Thomas)
The first two surgical methods are performed in microlaryngoscopy. The CTA and FemLar require an intervention on the outer neck. (Note: The reduction of the Adam’s apple, the so-called chondroplasty, does not lead to a change of voice, but it can be done in combination (not in one session) with any voice feminization).
The most common surgical techniques for voice feminization are described here  (in German language)

The voice feminization surgery

The voice feminization surgery (glottoplasty) is based on three pillars:
1. Shortening of the vocal cords.
2. Change the vibration dynamics of the vocal cords.
3. Reduction of the vibratory mass of the vocal cords.
Outpatient glottoplasty is painless under general anesthesia. The only a few millimeters short vocal cords are permanently connected with two hair-thin, firm seams. An additional injection of the vocal folds with a temporary implant reduces the tensile forces on the sutures during the postoperative period. Depending on the vocal fold volume, ablation is performed using the LAVA method. In addition, if necessary, the vocal folds are temporarily sedated with botulinum toxin.

Nähte bei der Glottoplastik
Nähte bei einer Glottoplastik

Surgery and aftercare

Surgery is carried out ambulatory by Prof. Hess. The surgery will take place in the Operations Center (AOZ) about 200 meters further away. There we work together with very experienced and highly qualified medical staff. After the surgery in general anesthesia, the postoperative monitoring follows in the recovery room. About 2 hours later, we conduct the follow-up examination in the DEUTSCHE STIMMKLINIK with postoperative video laryngoscopy and detailed after-care consultation and discussion of the following steps. As a general requirement in Germany, all patients receiving general anesthesia need an accompanying person for a 24 hour period.
The next day you come to the re-phoniatric check-up and the further concrete scheduling. We discuss the follow-up examinations in the following months (according to individual agreement).
Your therapeutic care includes pre- and / or postoperative speech training or speech therapy according to your personal needs. We offer you up to 10 sessions, individually planable also in double lessons, in blocks and / or in connection with the medical follow-up. Postoperatively, after the “release” of the voice by Prof. Hess, the first voice training takes place after 2-3 weeks. In exceptional cases a therapy via Skype is possible. Due to the limited personal contact or limited intervention possibilities, we prefer the on-site training in our clinic.

Medical follow-up

After about 2 hours, we conduct the follow-up examination in the DEUTSCHE STIMMKLINIK with postoperative video laryngoscopy and detailed after-care consultation and discussion of the following steps. As a general requirement in Germany, all patients receiving general anesthesia need an accompanying person for a 24 hour period.
The next day you come to the re-phoniatric check-up and the further concrete scheduling.  We individually discuss the follow-up examinations in the following months. Normally, we ask our patients after 2 and 6 weeks and after 6 and 12 months for laryngeal examinations, acoustic analysis and for new voice recording.

Trans*Voice Therapy 

You therapeutical care includes pre-and / or postoperative speech training or speech therapy according to personal needs. We offer you up to 10 sessions, individually planable also in double lessons, in blocks and / or in connection with the medical follow-up. Postoperatively, according to our rehabilitation scheme, it will soon be possible to whisper ‘loose’ again. After the “release” of the voice by Prof. Hess is started after 3-5 weeks with first vocal exercises.

The voice feminization package contains:

• Pre-operative vocal exercises • Post-operative vocal rehabilitation • Sociocultural feminization • Surgery, glottoplasty and medical follow-up • Speech therapy (articulation, speech melody and speech) • Resilience training of the new voice • Reinforcement of female pitch and resonance • Coaching and conversations to authentic female. Communication patterns. Your therapeutic care includes pre-and / or post-operative speech training or speech therapy according to personal needs. We offer you up to 10 sessions, individually planable in double lessons, in blocks and / or in connection with the medical follow-up. Postoperatively, according to our rehabilitation scheme, it will soon be possible to whisper ‘loose’ again.

Our flat rate offer includes a whole spectrum of medical and nonmedical services, where multidisciplinary pre- and postoperative voice care and consultation are obligatory and are always accepted with great appreciation.

3-5 weeks after the “release” of the voice by Prof. Hess, we start with first vocal exercises.

Modern, cosmopolitan and highly professional

The DEUTSCHE STIMMKLINIK is located in Hamburg and is easy to reach by plane and train. Hamburg is a vibrant city known for its international and safe atmosphere.
In the DEUTSCHE STIMMKLINIK the diagnostics and therapy area are physically separated from the state-of-the-art Operation Room. When you first enter the STIMMKLINIK, the bright, modern feel-good atmosphere and the interior design with its design elements convey a welcoming and cheerful ambience that does not remind you of a clinic. Here, the preliminary talks, examinations, aftercare and the voice therapies are carried out. The Ambulatory Operation Center (AOZ), about 200 meters away, is equipped with state-of-the-art equipment.

FAQ – Frequently Asked Questions

A frequently asked question is one concerning examples and statistics on pre- and post operative voice, fundamental frequencies and videos. In Germany, these kind of pre- versus postoperative comparisons are not allowed due to our competition protection laws. However, we will be happy to give you an individual recommendation when we analyze your perceptual, electroacoustic and videostroboscopic (endoscopic) recordings which always will be measured before any intervention.
 
Do glottoplasty or FemLar affect swallowing, (deep) breathing or loud screaming?
Can the result be estimated in advance based on the shape / size of the larynx / holding device? (within certain limits)
Dr. Kim supposedly works with a microscalpell instead of a laser. What are the advantages, and what is the granulate fabric for less air turbulence?
In what situations would the doctors recommend femlar vs web glottoplasty?
What are the risks of a voice feminization surgery?
Which influence on the surgical result have: – Vocal cord length – Vocal cord thickness
Is the pitch still flexible and differentiable after the surgery?
How long does it take to get an appointment for the surgery?
Which technique is better for singers: Femlar oder Wendler?
Is there a drying out of the mucous membrane after the surgery?
How long am I not allowed to speak after the operation?
What should be avoided after the surgery?
Can I just do the surgery without the speech therapy?
How long does it take for my voice to sound more feminine after surgery?
Do I have to book a hotel in Hamburg before and after the surgery?
When can I eat and drink?
When can I start doing sports?
Can I pay for my operation by credit card or check when I arrive?
What happens if I am sick at the time of the planned operation?

Do glottoplasty or FemLar affect swallowing, (deep) breathing or loud screaming?

Glottoplasty and swallowing: none of my patients that ai recall reported of swallowing problems in terms of aspiration (fluids or solid food goes into the trachea). Postoperative discomfort and rarely pain in the first days after surgery result from the laryngoscope placed into the larynx. But this is not related to the webbing and therefore not the cause.
Deep breathing: In terms of deep breathing, all patients are able to inhale and exhale the same air volume as before. In terms of rapid (maximum) flow there surely is a limitation after both procedures. Fortunately, airflow is (physiologically) mainly directed in the posterior larynx and even behind the vocal processes. However, if maximum and high effort breathing is an extremely important part of life, both surgeries should not be performed. But in the vast majority of our patients this is not the case.
Loud screaming: There is a restriction for loudest voice after glottoplasty.

Can the result be estimated in advance based on the shape / size of the larynx / holding device? (within certain limits)

Although we would be very happy to predict surgical outcome, each individual’s anatomy, physiology and voice technique and are so variable that we cannot predict the outcome. Still, our evidence comes from experience and systematic analysis. I do believe that – with time – we will come up with more reliable preoperative assessments that may predict better what will result from interventions of any kind. That’s why science is very helpful in medicine including voice therapy and vocal coaching.

Dr. Kim supposedly works with a microscalpell instead of a laser. What are the advantages, and what is the granulate fabric for less air turbulence?

James Thomas:

Dr. Kim is an outstanding surgeon. However, I don’t believe the tools make the surgeon. The surgeon should use a scalpel or a laser based on their comfort with the tool. If I were a patient, I would not make a decision based on the tool that the surgeon uses. The idea of making the web connect lower along the anterior margin so the air flows more smoothly is an interesting theory. In the individuals I have examined, I haven’t seen any difference in the subglottic area between different surgeons, including Dr. Kim’s patients.

 

Markus Hess

In our daily phonosurgical practice patients very often ask for ‘laser’ surgery, as if the laser was ‘magic’. The laser is an instrument and only as good as the hands controlling it. Although lasers are very important for phonosurgery, I must say that the patient should rather ask for the best technique and equiment that is on the market for a specific task and then ask if the surgeon has experience with this best technique – including the question if the surgeon has the specific tools. In highly specialised centers these tools will be available. So, in essence, surgeons think different to achieve best results: they choose from a spectrum of different instruments within their armamentarium, and if lasers work better for them than ‘cold steel instruments’, then its fine – and probably the best choice for their patient as well.
The concept and hope, that less turbulence due to ramping the air flow at the anterior subglottic site would result in clearer voice outcome, is compelling. If this concept were adequate and correct, it would make sense to put a lot of effort into this surgical step of the glottoplasty procedure. From our own experiences and from subglottic laryngoscopies in postoperative patients who had glottoplasties performed from other surgeons we could not see big differences, if any, from their subglottic anatomy that would prove that this funnel effect is actually achieved, and this also includes patients that I saw who were operated by Dr. Kim. At any rate, aerodynamics of phonation are very complex and there is at this stage of scientific research no method that can prove of disprove this concept.

 

In what situations would the doctors recommend femlar vs web glottoplasty?

When comparing these two surgical approaches, one must bare in mind that all individuals have – more or less – different voice boxes (laryx anatomy varies a lot interindividually). The angulation of the thyroid cartilages and the lengths of vocal folds as well as their thick are very different. It is like the shape and consistency of our faces, noses, ears etc.. Therefore, a technically exactly similar performed surgery can turn into a great result in one female and in others there might be only favourable results.

 

If one wants to start with a less invasive surgery, it seems clear that surgery only addressing the length and shape of vocal folds is less invasive and risky than doing an open neck surgery. Most females decide to have a glottoplasty and preserving the laryngeal framework anatomy and supplement with phonatory and voice therapy as well as vocal coaching for improvement of voice feminization.

However, a comparison of these two methods is not ‘fair’ in terms of what these technique aim for: FemLar attempts resonance changes as well as fundamental frequency (F0) changes and adds the Adam’s apple reduction, whereas glottoplasty and vocal fold shortening and retrodisplacement of the anterior commissure (VFSRAC) does not.

 

What are the risks of a voice feminization surgery?

This question is one of the most important and encompasses every point that is changing after surgery. Because voice is such a complex entity, we always have to find out what the individual’s expectations are – ranging from easily measurable F0 to personal favorable timbres and self perception. The expectations are not easily reduced to items in a questionnaire – that is why we thouroughly have to go through the individual’s history and (voicing) capabilities. That having said, we always try to find out if realistic expectations can be found. Otherwise, the indication for surgery should be thought over, or surgery should be cancelled.

Glottoplasty is one of the safest methods to raise the pitch, if the vocal folds can be accessed via direct microlaryngoscopy (which is frequently possible). However, the way of webbing and suturing can always lead to postoperative hoarseness and therefore this point has to be pointed out in the preoperative informed consent.

 

If the vocal folds have already been pretreated, then they can no longer vibrate symmetrically after a second intervention. That’s why good (first) surgery is so important. Improper surgery can cause hoarseness. However, there could be temporary complications such as pitch instability, foreign body sensation in the throat, rough voice – but these symptoms are all temporary.

Which influence on the surgical result have: – Vocal cord length – Vocal cord thickness

Pitch is determined by the combination of length, mass and tension. You may look up the physics formula online. To whatever extent as surgery can change these parameters, the comfortable speaking pitch will be changed.

  • Shorter cords lead to a higher pitch.
  • Tighter cords lead to a higher pitch.
  • Thinner vocal cords lead to a higher pitch.

It is the same as a string on a guitar.

 

Is the pitch still flexible and differentiable after the surgery?

After glotoplasty, the modulatory ability is preserved because the vocal fold tensioner (the so-called CT muscle) is not touched.

How long does it take to get an appointment for the surgery?

The witing time depends on the availability of our logopedist and surgery, because we always combine both interventions. Within the last months we receive many requests, so that we allot more time and space. The waiting time is roughly 6-8 weeks.

Which technique is better for singers: Femlar oder Wendler?

In general, singing styles differ significantly (classic to non-classic, hobby to high professional). And even for a surgically untreated larynx professionality in singing is still in most cases an enormous challenge. The more the singing is relying on a perfect, clear voicing and soprano-like easy onset in highest pitches, one might not go for any feminization surgery risk. One of the challenges is that the vocal fold mass, tension, length and tissue characteristics not only change with surgery, but also change with hormones and voice use. Too many variables to reliably predict outcome yet. But many researchers are working on this, including us.

If singing is the main priority or income in life, then avoiding any surgery may be the optimum option.

Is there a drying out of the mucous membrane after the surgery?

A dehydration of the laryngeal mucous membranes by the narrowed glottis does not occur. The exhaled air has 100% humidity. Much more, normal nasal breathing plays a role with its three functions of dirt filtration, heating and humidification.

How long am I not allowed to speak after the operation?

In the DEUTSCHE STIMMKLINIK we recommend an adequate mechanical stimulation of the vocal folds in the early healing phase, since, according to recent research, this leads to better functional results. In other words – direct postoperative whispering is allowed. The voiceless whispering is trained before surgery. The women need to communicate, otherwise they stay in isolation.
By definition, whispering is a kind of unvoiced speech in which the speech sounds are not formed with the vocal folds. It’s a noise, not a sound.
Absolute vocal silence we consider only limited and maximum for three to five days. As a rule, our patients are allowed to whisper in a low voice.
The recommendation to be silent for several weeks or month after a voice feminization surgery and not to whisper is widespread. Many colleagues feel safe with this recommendation, because the total vocal rest is difficult to verify. Thus, possible, unsatisfactory results, always be justified by a non-observed speech prohibition.

What should be avoided after the surgery?

Clearly: coughing, to clear one’s throat, sneezing and loud screaming. The techniques, to avoid these are trained by our speech therapist before the surgery.

Can I just do the surgery without the speech therapy?

No, we reject this in the DEUTSCHE STIMMKLINIK. A sole voice feminization surgery in very few cases leads to a completely satisfactory result.
The Trans*Voice speech therapy can be done but without feminization surgery. It is important to know that working on the voice can be very hard. You must practice out of your comfort zone and consistently. There can be setbacks in the process that can cause frustration and disappointment. THAT IS NORMAL. However, if you are ready and motivated to hold on to strenuous vocal exercises, then the first step is already done.
With a voice feminization operation, we can significantly facilitate and shorten individual areas in the therapy process. First successes are likely to come faster, but even here, setbacks are possible and you will not be spared continuous training.

How long does it take for my voice to sound more feminine after surgery?

Only after a healing phase, which can last at least 14 days, if not a few weeks, a voice feminization is achieved.
Experience has shown that there is a slight, temporary swelling of the tissue immediately after the operation, so that the voice that can be heard directly after the operation will not already be the permanent state. In general it takes 6 – 12 month to achieve a truly feminine voice.

Do I have to book a hotel in Hamburg before and after the surgery?

Yes, that’s the best. The day before and the day after the surgery, please come again for a  follow-up examination and further concrete scheduling. We discuss the follow-up examinations in the following months (according to individual agreement).

When can I eat and drink?

After a glottoplasty everything can be eaten and drunk. Avoid the consumption of very spicy foods; Dairy products, nuts and red wine promote the formation of slime. In addition, there is a risk of reflux in case of wrong nutrition. Observe yourself what is (not) good for you, everyone reacts differently.
Drink sufficient, preferably (still) water, which ensures well-moistened mucous membranes.

When can I start doing sports?

After a glottoplasty you should do without sports for about 6 weeks. Caution with weight training:
To stabilize, the body uses the vocal fold closure. Pressing exercises (for example strength training, heavy lifting but also intercepting movements, for example in balance exercises) can endanger wound.

Can I pay for my operation by credit card or check when I arrive?

No, unfortunately you can not. We only accept bank transfers or cash payments.

What happens if I am sick at the time of the planned operation?

If you can present a medical certificate certifying that you can not be operated on due to a physical condition, the operation will be postponed for free.

If you have further questions, please let us know (send to kontakt@stimmklinik.de). We will publish the answer here.
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