Elsevier

Journal of Voice

Volume 25, Issue 1, January 2011, Pages 120-123
Journal of Voice

Glottoplasty for Male-to-Female Transsexualism: Voice Results

https://doi.org/10.1016/j.jvoice.2009.07.004Get rights and content

Summary

Objectives

The aim of this study was to evaluate the objective voice results of Wendler's glottoplasty in male-to-female transsexuals.

Method

We retrospectively reviewed our patients treated with Wendler's technique with minor modifications. Glottoplasty consisted in CO2-laser epithelial ablation of the anterior commissure and the two vocal folds in anterior third, suturing of the two vocal folds with two stitches of 3.0 resorbable thread, and application of fibrin sealant to strengthen the suture. Voice assessment was based mainly on fundamental frequency (F0), frequency range, jitter, maximum phonation time, phonation quotient, estimated subglottic pressure (ESGP) grade of dysphonia (G), and voice handicap index (VHI). These measures were taken before surgery and on the last follow-up visit.

Results

Our series included 15 patients with a mean age of 36 years. The mean follow-up period was 7.2 months. We did not observe any early complications related to the technique. The comparison between the preoperative and the postoperative measurements, using Wilcoxon signed rank test, showed a significant improvement of median F0 from 139 to 191 Hz (P = 0.006) with an increase in the grade of dysphonia (Gpre = 0.2, Gpost = 1, P = 0.013) and ESGP (ESGPpre = 8.1 ± 3.2, ESGPpost = 12.0 ± 3.8, P = 0.002). Other measurements, including VHI, did not show any significant differences pre- and postoperatively.

Conclusion

Wendler's glottoplasty can contribute to feminize the voice.

Introduction

Although transsexualism is a recognized disorder of gender identity in which people believe themselves to be born into the “wrong” gender body,1 it remains a very controversial topic.

The most frequent form (three out of four transsexuals) is male-to-female transsexualism (MFT).1 MFT individuals undergo many cosmetic and reconstructive surgeries, medical and hormonal therapies, and behavioral changes before reaching the feminine status.

Before performing surgical changes, they must have been evaluated by a psychiatrist. Nearly all of them have undergone genital reassignment before seeking an ear, nose, and throat specialist's opinion.2

MFT individuals are stigmatized by their deep, male-sounding voices. Even when speech therapy is capable of feminizing the voice and vocal behavior by changing breathiness, intonation, articulation, word choice, and inflection, the male voice appears in uncontrolled situations, such as yawning, coughing, and laughing.2 Their main desire is a naturally feminine voice rather than constant acting efforts to sound feminine.

Many surgical methods have been proposed for raising the pitch, using three fundamental principles: increasing the vocal folds' tension, altering the vocal folds' consistency, and decreasing the vocal folds' mass. The most frequently used method is cricothyroid approximation (CTA), first described by Isshikki et al;3 however, its main drawbacks are external incision, majoration of the thyroid notch, and inconsistent long-term results. Wendler in 19894 described an endoscopic technique that has the advantage of the absence of cervical incision and more stable long-term results.2 However, his findings have not been verified by other teams, and there are not many submissions on this topic in the English literature. Finally, peer-reviewed publications are very limited on this topic.1, 5

Our aim is to report our series of 15 consecutive patients who underwent voice feminization using a modified Wendler's technique emphasizing on objective voice results.

Section snippets

Materials and Methods

We retrospectively reviewed the records of all consecutive patients treated in our department between August 2006 and August 2008. All surgeries were performed by the senior author using Wendler's technique with minor modifications.

Results

Our series includes 15 patients with a mean age of 42.5 years. The ages ranged between 22 and 57 years.

Most of them did have speech therapy before the intervention. All of them started speech therapy after the vocal rest period of 10 days. The mean follow-up period was 7.2 months, ranging between 2 and 39 months. We did not observe any early complications related to the technique. The comparison between the preoperative and the last postoperative measurements shows a significant improvement of

Discussion

Voice change remains an important problem in transsexuals. Many options have been provided to feminize the voice. Some authors rely on voice therapy and others on surgical procedures.

Voice therapy has the advantages of being noninvasive and working on the pitch and overall vocal behavior. However, patients are often dissatisfied with speech therapy alone.

Surgeries are numerous with pros and cons for each technique. CTA first described by Isshikki et al,3 then modified by Lee et al6 followed by

Conclusion

Laryngeal surgery is only a part of voice feminization in transsexuals. Wendler's glottoplasty can contribute to feminize the voice. Special care should be taken not to deepithelize more than anterior third of the vocal folds. Further improvements in F0 will probably be seen in series including only primary transsexuals. Speech therapy must be added to modify the vocal behavior. Counseling is very important to verify that patients have realistic expectations.

Acknowledgment

The authors would like to thank Dr. Jamart for the statistical work and Mr. Rustom for the translation of the manuscript.

References (10)

  • M. Gross

    Pitch-raising surgery in male-to-female transsexuals

    J Voice

    (1999)
  • M. Landen et al.

    Prevalence, incidence and sex ratio of transsexualism

    Acta Psych Scand

    (1996)
  • N. Isshiki et al.

    Surgical alteration of vocal pitch

    J Otolaryngol

    (1983)
  • Wendler J. Vocal pitch elevation after transexualism male to female. In: Proceedings of the Union of the European...
  • L.A. Orloff et al.

    Laser-assisted voice adjustment (LAVA) in transsexuals

    Laryngoscope

    (2006)
There are more references available in the full text version of this article.

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    Citation Excerpt :

    A similar level was reported by Nolan et al10 in a previous meta-analysis, which included 7 articles and observed an increase of 72.21 Hz in the F0.10 Our meta-analysis also reported decrease in the MPT (5 studies)15,20,21,26,35 and in the frequency range (3 studies),11,12,36 and worsening of the grade of dysphonia on the GRBAS scale (3 studies).21,26,28 These changes confirm the hypothesis that, despite the effectiveness in increasing the F0, due to the creation of a two-dimensional fibrotic area without the viscoelastic properties of the VF, other acoustic parameters and the voice quality would worsen.

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Financial support and funding: the authors did not receive any financial support for the writing of this article. The manuscript is not simultaneously submitted elsewhere and has not been previously published.

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