Welcome back to our article series on gender affirming surgeries and procedures. We started with bottom surgeries in the Fall of 2022 and will end with office visit procedures such as fillers and botox in March of 2023. This installment is all about vocal surgery to raise or lower pitch. Our intro to the series also contains links to each blog.
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
Vocal Surgery
You may be well aware of voice training exercises that help people learn how to alter voice characteristics such as pitch, resonance, rhythm, tone, texture and intonation. If you’re just starting your exploration of vocal transitioning, we invite you to read some of our previous articles:
Say It Out Loud: List of Transgender Voice Training Resources
Safely Changing Pitch: Finding Your Voice
Safely Changing Pitch: Exercises to Change Your Pitch
Community and Characters: Voice Transition with Undead Voice Lab
If voice training is insufficent or inaccessible, surgery to either raise or lower vocal pitch is available.
What? Vocal Surgery to LOWER vocal pitch?
Yes! While surgery to raise vocal pitch is fairly well known, surgery to lower pitch is not. We’re stoked to be able to talk about it.
First, let’s talk anatomy of the voice box.
The larynx is a portion of the tube that connects the cavities of the nose and mouth to the lungs. In the neck it is forward of the esophagus, which is the tube that connects the nose and mouth to the stomach. At the top of the larynx is the epiglottis, which functions as a moveable lid. It covers the larynx while swallowing so that food and liquids do not enter the lungs, and uncovers the larnyx for breathing and speaking. When watching someone swallow, the up and down movement in the front of the throat is the epiglottis moving to cover and uncover the larynx.
Fun fact: the larynx in infants and toddlers is higher in the next than in older children and adults. Their epiglottis can maneuver to seal the space between the larynx and esophagus, allowing very young children to drink and breathe simultaneously. As children grow, the larynx moves downward, and the epiglottis can no longer separate the two tubes, only close or open the larynx.
You can think of the larynx as a stack of 2 big rings with a leaf on top; in between the rings are three sets of cartilage structures.
At the top: the epiglottis, which we’ve already talked about. This is the leaf.
Next is the thyroid cartilage. This is the largest ring. It is open in the back, and forms a point in the front. The thyroid glands are located in front of this cartilage in the neck, and the point is what is called the laryngeal prominence, or, in gendered non-medical speech, the adam’s apple (we’ll just use laryngeal prominence, or LP, today.) The epiglottis attaches to the front of the thyroid cartilage.
Next in the stack is the cricoid cartilage. This ring is the only full-circle ring. The bottom of the cricoid cartilage connects to the top of the trachea. The cricoid is shorter in the front and taller in the back.
On top of the back rim of the cricoid are the arytenoid cartilages. They’re shaped somewhat like pyramids. On top of the arytenoids are the corniculate cartilages. “Corni” means “horn,” and they’re shaped like wee little horns attached to the arytenoids.
Both surrounding and inside of these rings of cartilage are ligaments, muscles, and membranes. It can be super hard to explain and visualize, because there’s a lot going on there.
How Sounds Get Made: The Vocal Chords
Our ears turn sound waves into electrical signals that our brains then interpret. But how do our bodies create sound waves? It’s all air and friction, babes.
Air moves from our lungs through the trachea and into the larynx, where it is met with resistance created by the structures inside the larynx. This resistance creates vibrations which become sound waves. As these sound waves in air further progress through the mouth and nose cavities, these sounds can be altered.
When air meets more resistance, the vibrations created are faster and higher pitched. When air meets less resistance, the vibrations are slower and lower pitched. You can experiment with this by blowing raspberries and whistling. In a whistle, the lips are held more tightly together, restricting the air flow and creating more resistance compared to the loose lips of blowing a raspberry. Thus a whistle is higher-pitched than a raspberry.
What are these structures?
Inside the larynx are the vocal cords. Sometimes they are called folds. The wording can get kind of tricky and confusing here, so hang on with us.
The superior vocal cords are often called the “false” vocal cords or folds. They may also be referred to as the vestibular fold or the ventricular fold. In the larynx, they are “on top,” or closer to the epiglottis.
. The inferior vocal cords are the ones we generally think of as controlling voice sounds and are sometimes called “true” vocal cords (or folds).
“True” vocal cords are stretchy membranes that attach to the thyroid cartilage in the front and to the arytenoid cartilages in the back. The place where they attach to the thyroid cartilage is called the anterior commissure.
The false vocal cords are thin, while the true vocal folds are wide and muscular and can meet in the middle. The space where these folds meet is called the glottis.
When air from the lungs meets the flexible membranes of the “true” vocal cords, the membranes vibrate and sounds are created. Multiple muscles and ligaments move both the “true” and “false” folds into different shapes, sizes, and tensions. All of these variables play a part in the characteristics of the sounds that are created.
A view of the vocal folds from the top:
Voice coaches and vocal transition work can help you learn how to control the shape of these folds, the flow of air through these folds, and other mechanics of your respiratory system. This control allows you to change the characteristics of your voice.
Voice coach Renée Yoxon and illustrator Kay Dixon have put together an absolutely fantastic primer that goes into much greater depth about vocal anatomy and sound-making in The Transgender Voice Guide. We recommend it!
Hormonal Impact
Like other parts of the body, the larynx changes size and shape as we grow. In testosterone-dominant bodies, the larynx and its parts grow bigger than in estrogen-dominant bodies. This lengthens the vocal cords while they also become thicker. As testosterone increases the size of the larynx, the laryngeal prominence (LP) becomes, well, more prominent and is more easily seen in the front of the neck, especially in individuals with a thinner layer of fat underneath the skin.
Longer, bigger, thicker, or more relaxed vocal cords produce a lower voice. Shorter, smaller, thinner, or tighter vocal cords produce a higher voice. The interior size and shape of the larynx also affect pitch: larger larynxes have more volume, while smaller ones have less.
This is why taking testosterone can lower a voice, but taking estradiol doesn’t raise voice pitch: the larynx and interior structures grow with testosterone, but they don’t get smaller with estrogen.
Now, finally, the surgeries.
A term to know:
F0 – fundamental frequency: this is the lowest soundwave in a range. For voices that are often interpreted as masculine, the fundamental frequency is between 85 to 150 Hz (Hertz.) Voices with a fundamental frequency above 160 Hz are often interpreted to be feminine. (Jordan Jakomin discusses voice pitch in this blog.)
There are many qualities that affect how our brains interpret a voice. Voice therapy can help a person learn how to manipulate many of them, but may not be sufficient for a person to achieve their desired fundamental frequency or frequency range. This is where voice surgery (also known as phonosurgery) comes into play.
Note: voice surgery can be risky because the larynx and its surrounding structures are both complex and relatively small in overall shape.
Surgeries To Raise Fundamental Frequency
Cricothyroid approximation: increases vocal cord tension
Anterior Commissure Advancement: also increases vocal cord tension
Glottoplasty: techniques to change the shape of the vocal folds (Check out our later article Getting Nerdy About Glottoplasty Surgeries!)
Endoscopic Shortening: reduces the length and shape of the larnyx
Cricothyroid Approximation (CA):
In CA, the thyroid cartilage is physically moved downward. Because the “true” vocal cords attach to the thyroid cartilage in the front, this pulls them and increases their tension. Greater tension in these membranes increases voice pitch.
PROS to CA: can be done under local anesthesia and does not risk the vocal cords themselves
CONS to CA: may increase laryngeal prominence. This can be distressing for some individuals.
Anterior Commissure Advancement (ACA):
The anterior commissure is where the “true” vocal folds attach to the thyroid cartilage. In ACA surgery, one of the vocal flaps is moved. This pulls on ligaments and creates more tension, thus raising pitch.
PROS to ACA: doesn’t mess with the structure of the vocal folds
CONS to ACA: appears to be less successful in significantly raising fundamental frequency.
Glottoplasty:
There are several different types of surgery in this bucket. A simple definition of “glottoplasty” is “webbing the vocal folds in the front of the larynx to decrease length and increase tension, and thus, pitch.”
Lasers!
Lasers can be used to remove some of the tissue of the vocal folds. The targeted vocal folds are then joined together, reducing the length of the folds and increasing tension.
Laser can also be used to remove tissue bulk on vocal folds and make them thinner, or to change the shape of the “true” vocal folds where they meet, thus changing the character of the voice.
Manipulation may also be done by suturing folds together without laser reduction.
Endoscopic Shortening
In a shortening surgery, a section (or sections) of the thyroid cartilage and vocal folds in the front of the neck are removed. The structures are then re-joined in a way as to move the anterior commisure forward. This surgery creates a smaller space inside the larynx and increases the tension of the vocal folds, thus raising pitch. This type of surgery may be called “laryngeal framework surgery.”
PROS: appears to be the surgery most likely to significantly raise fundamental frequency
CONS: most potentially damaging surgical option to the vocal cords
Surgery to Decrease Vocal Pitch
Another type of laryngeal framework surgery is the flipside of endoscopic shortening: surgery used to decrease the tension of the vocal cords. Just as increasing tension raises pitch, decreasing tension lowers voice pitch. This surgery may be referred to as “Isshiki thyroplasty type III (IT3.)”
During surgery the front section of thyroid cartilage is altered.
Vertical approach with cartilage removal:
Slender vertical strips of cartilage are removed on both sides of the center of the thyroid cartilage. This “frees up” the center of the thyroid where the folds attach and allows it to move in towards the back of the neck, decreasing tension on the vocal cords.
Window approach with no cartilage removed:
A notch is cut into the center of the thyroid at the same level where the vocal cords attach. This relaxes the cartilage and moves the attachment point closer to the back of the neck, which reduces vocal cord tension.
PROS: very effective; can be done under local anesthesia or sedation. If done under local anesthesia, voice changes can be monitored in real time, as the patient is awake and able to use their voice.
CONS: while the vocal cords themselves are not touched, the structure of the larynx is changed. The vertical approach may decrease the laryngeal prominence, which can cause distress in some patients.
Prep and Recovery:
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Hyung-Tae Kim (2020) Vocal Feminization for Transgender Women: Current
Strategies and Patient Perspectives, International Journal of General Medicine, , 43-52, DOI:
10.2147/IJGM.S205102
Hammond, S. E., Cohen, E., & Rosow, D. (2019). Feminization of Transgender Women With Thyroid Chondroplasty and Laryngoplasty. The Journal of Craniofacial Surgery, 30(5), 1409–. https://doi.org/10.1097/SCS.0000000000005569
Nolan IT, Morrison SD, Arowojolu O, Crowe CS, Massie JP, Adler RK, Chaiet SR, Francis DO. The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization. J Craniofac Surg. 2019 Jul;30(5):1368-1375. doi: 10.1097/SCS.0000000000005132. PMID: 31299724.
Haben CM. Masculinization Laryngoplasty. Otolaryngol Clin North Am. 2022 Aug;55(4):757-765. doi: 10.1016/j.otc.2022.04.011. Epub 2022 Jun 23. PMID: 35752489.
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