Feminization laryngoplasty

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Feminization laryngoplasty
FemLar before after.png
Before and after images of a feminization laryngoplasty patient
Pronunciation /ˌlærɪŋˈɡɒplæsti/
Other namesFemLar
Specialty Laryngology
MeSH D058753

Feminization laryngoplasty (also known as FL or FemLar/Femlar) is a reconstructive surgery surgical procedure that results in the increase of the pitch of a patient, making the voice sound higher and more feminine. It is a form of Open Laryngoplasty and effectively reaches its goals via a Partial Laryngectomy of the anterior portion of the larynx, thereby diminishing the size of the larynx to cisgender female proportions. It also changes the vocal weight or resonance quality of the voice by diminishing the size of the larynx. It is a type of voice feminization surgery (VFS) and an alternative to vocal therapy. Feminization laryngoplasty is performed as a treatment for both transgender women and non-binary people as part of their gender transition, and women with androphonia. The surgery can be categorized into two main steps: Incision and vocal fold modification followed by thyrohyoid elevation. Risks and complications include granuloma, dysphonia and tracheostomy. Patients are recommended to follow perioperative management such as voice rest to hasten recovery.

Contents

Typically, the surgical procedure could shift the lower limit of the patients' vocal range upward, with little to no effect on the higher end of the vocal range, and reduce the patient's vocal weight and resonance by reducing the size of the larynx. Studies have shown a very high long-term satisfaction rate with the pitch change from this surgery, and the measured pitch change outcome is known to be typically greater than Wendler Glottoplasty, a current, separate procedure that also attempts to increase pitch by shortening the vibrating length of the vocal cords via an alternative, and less destructive, endoscopic approach. A recent study notes that the measured changes average 6 semitones for the patients' comfortable speaking pitch (20-80hz). [1] However, there have been a few outlying cases where the pitch change was too high/effective for the patient, with a maximum reported increase of 320hz in one particular case, albeit it may be possible to mitigate this by carefully choosing how much vocal cord to remove in the operating room for an individual patient. [2]

Other than pitch change, the operation could also diminish the masculine neck profile caused by "Adam's apple" after the removal of anterior cartilage, thus achieving a more feminine neck appearance. [3] This effect is more pronounced than the reduction that can be typically achieved with a tracheal shave as it explicitly goes further than a tracheal shave and removes tissue that should be avoided by the surgeon during a tracheal shave in order to feminize the voice. Thus, if a patient opts for this procedure, they will typically not need a tracheal shave.

The procedure is less popular and well-known than other forms of voice feminization surgery at the moment and is currently performed by a limited set of surgeons. This includes, but is not limited to several surgeons in the US, [4] Thailand, [5] [6] and Australia. [7] There are also other doctors using this term to describe their suite of voice and larynx feminization procedures that do not actually perform this particular procedure, but rather other procedures such as glottoplasty, cricothryoid approximation, and tracheal shaves. [8]

Background

Transgender women

Transgender women make up most of the patients of feminization laryngoplasty. During puberty, testosterone, a male sex hormone produced by the testes, causes the diameter of the larynx to increase and the vocal folds to thicken and lengthen. This change is irreversible even with the help of feminizing hormone therapy. The fundamental and resonant frequency of their voice decreases and they no longer match to the desired vocal range that suits their preferred gender identity.

Nonbinary people and cisgender women

Cisgender women with an abnormally low voice and gender nonconforming individuals may also seek feminization laryngoplasty. However, the target pitch for nonbinary people may be different from people who identify solely as women. For instance, some would hope to achieve an androgynous voice rather than a completely feminine voice. Therefore, laryngologists should work closely with patients to tailor to their personal needs to maximize satisfaction. [9]

Voice therapy

Individuals who sought vocal alterations are first recommended to undergo voice therapy to generate a desirable vocal pitch and resonance. Some individuals could substantially achieve a more feminine voice by adapting to a new habitual coordination of muscles in their vocal cords. However, results vary greatly from person to person and often require an active effort to maintain. [4] A persistent effort of using a more feminine voice could lead to straining and other pathological issues in vocal cords. [10] Surgical means of voice feminization such as feminization laryngoplasty can be an alternative to vocal therapy when effects from training alone are unsatisfactory, allowing patients to permanently modify their comfortable speaking pitch and resonance.

It is estimated that about 1% of transgender women have opted for surgical procedure of voice feminization, while a larger proportion of transgender women (14%) opted for non-surgical means of voice feminization (i.e. voice therapy). [11]

History

Transgender surgery in general has gained its initial momentum in the early 1950s after the attention brought by American transgender woman Christine Jorgensen. [12] Sexual reassignment surgeries have seen an exponential increase in public awareness during that period of time. However, it was not until a few decades ago had voice feminization garnered its own recognition from public audience.

History of voice feminization

Previously, gender affirmation surgery has put great emphasis on genital conformation only. In the last few decades, as the interpretations of gender identity in society shifts, gender affirmation surgery has expanded to the territories of secondary sex characteristics, in a way that voice feminization has seen unprecedented attention. Study notes that throughout the decades, there has been an increasing trend of emphasis on social recognition (i.e. interacting with other people in the community under their own preferred gender identity) rather than sexual recognition alone. Several cosmetic surgeons have claimed that most of their patients are satisfied with alterations on secondary sexual characteristics and are not tempted to seek additional genital surgery. [10]

Traditional techniques

The first experimental study to surgically raise the speaking pitch was performed by Japanese otorhinolaryngologist Kazutomo Kitajima and his colleagues in 1979. They together discovered the inverse linear relationship between the vocal pitch and the distance between the thyroid cartilage and cricoid cartilage. [13] Based on this principle, the first surgical procedure for voice feminization, cricothyroid approximation (CTA) was developed to achieve pitch increase by reducing the separation between the two cartilages. This procedure remains the most well-known among transgender women seeking surgical voice feminization. [14] However the results are often unsatisfactory with CTA due to the unnatural falsetto quality of the voice. [15] [16] Other surgical solutions were also developed, including Wendler (Web) Glottoplasty (also known as anterior web glottal formation, newer versions of this surgery are also occasionally referred to as VFSRAC, Vocal Fold Shortening with Retrodisplacement of the Anterior Commissure), and a variant of it, laser reduction glottoplasty (LRG), as well as laser tuning, including laser assisted voice adjustment (LAVA) and vocal fold muscle reduction (VFMR). The glottoplasty and laser tuning options do not have this falsetto issue, unlike CTA. However, they generally have a longer and more complex recovery.

Modern technique

The concept of feminization laryngoplasty originated from the open laryngoplasty technique proposed by cosmetic surgeon Somyos Kunachak. [17] The first operation was then performed by James P. Thomas in 2003. [4] As opposed to previous efforts, feminization laryngoplasty results in a more significant and long-lasting pitch increase along with a more feminine voice quality. The function of cricothyroid muscle is also preserved, allowing the use of the falsetto range when needed. In addition, compared to other surgeries, feminization laryngoplasty could be undergone as one single surgery for thyroid chondroplasty to reduce the prominence of the "Adam's apple", while the other solutions had to perform chondroplasty separately. [10]

The first few surgeries were performed under local anesthesia. However, general anesthesia is now preferred over local anesthesia to prevent patients from attempting to talk during the surgery, which may lead to complications such as the tearing of sutures.

Procedure

Presurgical management

Before the operation, antibiotics such as clindamycin and ceftriaxone are administered intravenously to reduce surgical infection. Dexamethasone is also given to reduce edema. [18]

To better analyze the change in voice pitch and quality after the surgical operation, voice recordings are also taken before and after the laryngoplasty.

Incision and vocal fold modification

The horizontal cross section of thyroid cartilage before and after feminization laryngoplasty. The thyroid cartilage is cut along the red line (left), with the part in between the lines removed and the remaining parts sutured together (right). Cross section of thyroid cartilage before and after laryngoplasty at 9.11.34 PM.png
The horizontal cross section of thyroid cartilage before and after feminization laryngoplasty. The thyroid cartilage is cut along the red line (left), with the part in between the lines removed and the remaining parts sutured together (right).

General anesthesia would be administered beforehand. A 5 cm long horizontal incision would then be made at a skin crease above the thyroid notch, allowing the postoperative scar to be hidden under the crease. After flaps have been created under the platysma, the strap muscles would be separated along the midline to expose the thyroid cartilage. This allows a strip of the anterior thyroid cartilage to be removed using electrocautery to effectively reduce the contour of the Adam's apple and the diameter of the laryngeal opening. [18] [19]

A quarter of the anterior false folds would also be removed to further reduce the diameter of the upper larynx and to provide a better view of the true vocal folds. Subsequently, up to 50% of the anterior vocal folds is removed and the length of pharynx is shortened to raise the speaking pitch. The overall size of glottal region is also reduced, which diminishes the thyroid notch. [10] [19]

Thyrohyoid elevation

By elevating the thyrohyoid muscle, the distance between the thyroid cartilage and the hyoid bone can be decreased. This may be further facilitated by removing upper thyroid alae in the operating room to provide additional room to elevate the larynx. [20]

At last, eight holes are drilled on the thyroid cartilage and hyoid bone for the placement of sutures and screws, securing and suspending the structure of the larynx higher in the neck, but still allowing it to move up and down to facilitate functions such as swallowing. The strap muscles are then reattached and the skin is closed with sutures. [19]

Postsurgical management

Following surgery completion, patients are prescribed acetaminophen with narcotic pain medication for pain relief and cefpodoxime or levofloxacin for 7 days to minimize infection. [18]

Risks and complications

Granuloma of the vocal cord Vocal cord granuloma.jpg
Granuloma of the vocal cord

After feminization laryngoplasty, most patients would experience a drop in voice volume and some may experience a decreased vocal pitch. Continuity of range might also be negatively affected. Therefore, the surgery might be less suited for vocal performance professionals. [3] Instead, an alternative procedure, Vocal Fold Shortening and Retrodisplacement of the Anterior Commissure (VFSRAC), a type of modified Wendler Glottoplasty, is generally recommended as it preserves the ability to sing. [21] Vocal Fold Muscle Reduction, a standalone laser tuning procedure, can also be considered for professional voice users as well. [22]

Granuloma in the vocal cords is also a possible complication, which may cause a soft and whispery voice. The granuloma should eventually be coughed out, or in some case be removed manually. [18] Dysphonia is another common symptom in the first two months of recovery, but the issue gradually resolves in most patients. Further treatment or revision surgery might be needed for some patients with serious unresolved sound hoarseness after extended periods of recovery. [16] If the vocal cords heal with asymmetrical tension, laser treatment is generally required to correct the defect.

In some rare cases, severe swelling could lead to difficulty in breathing, which may require tracheostomy to bypass the area of obstruction. [20]

Post-operative care

Following feminization laryngoplasty, patients are usually discharged without the need for overnight stay. Exceptions would be made when complications have occurred, during which the patient would have to stay in a hospital for up to a week.

Complete voice rest after the surgery is also necessary for fast healing as the vocal cords are only supported by a few sutures. Those who have undergone the procedure are advised to have vocal rest for at least 2 weeks, no aerobic activity for 3 weeks and no weight lifting for a month to give time for scar tissue to develop and support the larynx. [3] It is also advised to refrain from having surgery requiring intubation for at least 3 months. [20]

To maximize the effects of the surgery and to adapt to the new feminine voice, patients are also highly recommended to undergo vocal therapy, during which patients could learn to feminize their voice intonation, volume, resonance and non-verbal communication such as gesture and articulation. [11]

For patients who are still unsatisfied with the pitch increase after the surgery, revision surgery or laser tuning could be considered to improve results. However, a revision is generally not recommended to patient with medical records of voice surgery prior to feminization laryngoplasty.

See also

Related Research Articles

<span class="mw-page-title-main">Vocal cords</span> Folds of throat tissues that help to create sounds through vocalization

In humans, the vocal cords, also known as vocal folds, are folds of throat tissues that are key in creating sounds through vocalization. The length of the vocal cords affects the pitch of voice, similar to a violin string. Open when breathing and vibrating for speech or singing, the folds are controlled via the recurrent laryngeal branch of the vagus nerve. They are composed of twin infoldings of mucous membrane stretched horizontally, from back to front, across the larynx. They vibrate, modulating the flow of air being expelled from the lungs during phonation.

<span class="mw-page-title-main">Larynx</span> Voice box, an organ in the neck of amphibians, reptiles, and mammals

The larynx, commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about 4–5 centimeters in diameter. The larynx houses the vocal cords, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word 'larynx' comes from the Ancient Greek word lárunx ʻlarynx, gullet, throatʼ.

<span class="mw-page-title-main">Reinke's edema</span> Medical condition

Reinke's edema is the swelling of the vocal cords due to fluid (Edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.

<span class="mw-page-title-main">Adam's apple</span> Feature of the neck

The Adam's apple is the protrusion in the neck formed by the angle of the thyroid cartilage surrounding the larynx, typically visible in men, less frequently in women. The prominence of the Adam's apple increases in some men as a secondary male sex characteristic during puberty.

Feminizing Gender-affirming surgery for transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.

<span class="mw-page-title-main">Recurrent laryngeal nerve</span> Nerve in the human body

The recurrent laryngeal nerve (RLN) is a branch of the vagus nerve that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. There are two recurrent laryngeal nerves, right and left. The right and left nerves are not symmetrical, with the left nerve looping under the aortic arch, and the right nerve looping under the right subclavian artery, then traveling upwards. They both travel alongside the trachea. Additionally, the nerves are among the few nerves that follow a recurrent course, moving in the opposite direction to the nerve they branch from, a fact from which they gain their name.

<span class="mw-page-title-main">Posterior cricoarytenoid muscle</span> Muscle of the larynx

The posterior cricoarytenoid muscle is a intrinsic muscle of the larynx. It arises from the cricoid cartilage; it inserts onto the arytenoid cartilage of the same side. It is innervated by the recurrent laryngeal nerve. Each acts to open the vocal folds by pulling the vocal fold of the same side laterally. It participates in the production of sounds.

<span class="mw-page-title-main">Cricoid cartilage</span> Complete ring of cartilage around the trachea

The cricoid cartilage, or simply cricoid or cricoid ring, is the only complete ring of cartilage around the trachea. It forms the back part of the voice box and functions as an attachment site for muscles, cartilages, and ligaments involved in opening and closing the airway and in producing speech.

Chondrolaryngoplasty is a surgical procedure in which the thyroid cartilage is reduced in size by shaving down the cartilage through an incision in the throat, generally to aid those who are uncomfortable with the girth of their Adam's apple.

<span class="mw-page-title-main">Cricothyroid ligament</span> Ligament of the larynx

The cricothyroid ligament is a ligament in the neck. It connects the cricoid cartilage to the thyroid cartilage. It prevents these cartilages from moving too far apart. It is cut during an emergency cricothyrotomy to treat upper airway obstruction.

<span class="mw-page-title-main">Cricothyroid muscle</span> Muscle of the larynx

The cricothyroid muscle is the only tensor muscle of the larynx aiding with phonation. It is innervated by the superior laryngeal nerve. Its action tilts the thyroid forward to help tense the vocal cords, thus increasing the pitch of the voice.

<span class="mw-page-title-main">Superior laryngeal nerve</span> Branch of the vagus nerve

The superior laryngeal nerve is a branch of the vagus nerve. It arises from the middle of the inferior ganglion of the vagus nerve and additionally receives a sympathetic branch from the superior cervical ganglion.

"Voice therapy" or "voice training" refers to any non-surgical technique used to improve or modify the human voice. Because voice is a social cue to a person's sex and gender, transgender people may frequently undertake voice training or therapy as a part of gender transitioning in order to make their voices sound more typical of their gender, and therefore increase their likelihood of being perceived as that gender. Having voice and speech characteristics align with one's gender identity is often important to transgender individuals, whether their goal be feminization, neutralization or masculinization. Voice therapy can be seen as an act of gender- and identity-affirming care, in order to reduce gender dysphoria and gender incongruence, improve the self-reported wellbeing and health of transgender people, and alleviate concerns over an individual being recognized as transgender.

<span class="mw-page-title-main">Toby Meltzer</span> American surgeon

Toby R. Meltzer is an American plastic and reconstructive surgeon. Meltzer specializes in sex reassignment surgery male-to-female, sex reassignment surgery female-to-male, and facial feminization surgery. In the 1990s, Meltzer pioneered the neovaginal construction technique that increased the ability of the neoclitoris to feel sensations. According to his website, Meltzer performs 2-4 vaginoplasties a week, and that he has performed over 3000 male and female sexual reassignment (SRS) surgeries. Joan Roughgarden called Meltzer one of the leading surgeons in this specialized field. He practices in Scottsdale, Arizona.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Puberphonia is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a 'falsetto' voice. The voice may also be heard as breathy, rough, and lacking in power. The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. This disorder usually occurs in the absence of other communication disorders.

Endoscopic laser cordectomy, also known as Kashima operation, is an endoscopic laser surgical procedure performed for treating the respiratory difficulty caused as a result of bilateral abductor vocal fold paralysis. Bilateral vocal fold paralysis is basically a result of abnormal nerve input to the laryngeal muscles, resulting in weak or total loss of movement of the laryngeal muscles. Most commonly associated nerve is the vagus nerve or in some cases its distal branch, the recurrent laryngeal nerve. Paralysis of the vocal fold may also result from mechanical breakdown of the cricoarytenoid joint. It was first described in by Kashima in 1989.

Thyroplasty is a phonosurgical technique designed to improve the voice by altering the thyroid cartilage of the larynx, which houses the vocal cords in order to change the position or the length of the vocal cords.

Arytenoid adduction is a surgical procedure used to treat vocal cord paralysis. A suture is used to emulate the action of the lateral cricoarytenoid muscle and position the paralyzed vocal cord closer to the midline. This allows the two vocal cords to meet and can improve speaking and swallowing ability for affected patients. Arytenoid adduction is often performed in conjunction with medialization thyroplasty.

Laryngotracheal reconstruction is a surgical procedure that involves expanding or removing parts of the airway to widen a narrowing within it, called laryngotracheal stenosis or subglottic stenosis.

References

  1. ↑ Nuyen, Brian A; Qian, Z Jason; Campbell, Ross D; Erickson-DiRenzo, Elizabeth; Thomas, James; Sung, C Kwang (2022). "Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique". Otolaryngology–Head and Neck Surgery. 167 (1): 112–117. doi:10.1177/01945998211036870. PMID   34399638. S2CID   237149860 . Retrieved 1 September 2023.
  2. ↑ Kim, Hyung-Tae (2020). "Vocal Feminization for Transgender Women: Current Strategies and Patient Perspectives". International Journal of General Medicine. 13: 43–52. doi: 10.2147/IJGM.S205102 . PMC   7024865 . PMID   32104050.
  3. 1 2 3 Thomas, JP; MacMillan, C (April 30, 2013). "Feminization laryngoplasty: assessment of surgical pitch elevation". European Archives of Oto-Rhino-Laryngology. 270 (10): 2695–700. doi:10.1007/s00405-013-2511-3. PMID   23632870. S2CID   23507643 . Retrieved March 2, 2022.
  4. 1 2 3 Thomas, JP. "Feminization laryngoplasty" . Retrieved March 2, 2022.
  5. ↑ "Voice Feminization / VFS". Kamol Cosmetic Hospital. Retrieved 20 August 2023.
  6. ↑ "Voice Change Surgery". Voice Change Surgery - Dr. Ornouma. Retrieved 20 August 2023.
  7. ↑ "Larynx Reconstruction". Queensland Voice Centre - Larynx Reconstruction. 8 April 2016. Retrieved 20 August 2023.
  8. ↑ "Voice Feminization". Center for Care of the Professional Voice.
  9. ↑ Davies, S; Papp, VG; Antoni, C (November 16, 2015). "Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside". International Journal of Transgenderism. 16 (3): 117–159. doi:10.1080/15532739.2015.1075931. S2CID   21705607 . Retrieved March 24, 2022.
  10. 1 2 3 4 Sarah, EH; Erin, C; David, R (Jul 2019). "Feminization of Transgender Women With Thyroid Chondroplasty and Laryngoplasty". The Journal of Craniofacial Surgery. 30 (5): 1409–1413. doi:10.1097/SCS.0000000000005569. PMID   31299733. S2CID   139104457 . Retrieved March 22, 2022.
  11. 1 2 "Voice Feminization Surgery: Transgender Voice Change Surgery". Cleveland Clinic. Retrieved March 2, 2022.
  12. ↑ Meyerowitz, J (2006). "Transforming Sex: Christine Jorgensen in the Postwar U.S.". OAH Magazine of History . 20 (2): 16–20. doi:10.1093/maghis/20.2.16. JSTOR   25162028.
  13. ↑ Kitaijima, K; Tanabe, M; Isshiki, N (Jan 1979). "Cricothyroid distance and vocal pitch. Experimental surgical study to elevate the vocal pitch". Annals of Otology, Rhinology & Laryngology. 88 (1): 52–5. doi:10.1177/000348947908800109. PMID   426446. S2CID   36049428 . Retrieved March 22, 2022.
  14. ↑ Ornouma, S; Suthee, R; Egoy-Salvan, L (2013). "Expertise of Voice Feminization Surgery to 270 Diverse International Patients". Atlas of Operative Otorhinolaryngology and Head and Neck Surgery: Voice and Laryngotracheal Surgery (Volume 4). Jaypee Medical Publisher. p. 1252. doi:10.5005/jp/books/11961_30. ISBN   9789350904824. Archived from the original on January 19, 2022. Retrieved March 22, 2022.
  15. ↑ Yang, CY; Palmer, AD; Murray, KD; Meltzer, TB; Cohen, JI (June 2020). "Cricothyroid approximation to elevate vocal pitch in male-to-female transsexuals: results of surgery". Annals of Otology, Rhinology & Laryngology. 111 (6): 477–85. doi:10.1177/000348940211100602. PMID   12090702. S2CID   8966461 . Retrieved March 23, 2022.
  16. 1 2 Kim, HT (February 12, 2020). "Vocal Feminization for Transgender Women: Current Strategies and Patient Perspectives". International Journal of General Medicine. 13: 43–52. doi: 10.2147/IJGM.S205102 . PMC   7024865 . PMID   32104050.
  17. ↑ Kunachak, S; Prakunhungsit, S; Sujjalak, K (November 2020). "Thyroid cartilage and vocal fold reduction: a new phonosurgical method for male-to-female transsexuals". Annals of Otology, Rhinology & Laryngology. 109 (11): 1082–6. doi:10.1177/000348940010901116. PMID   11090002. S2CID   22558188 . Retrieved March 2, 2022.
  18. 1 2 3 4 Nuyen, BA; Qian, ZJ; Campbell, RD; Erickson-DiRenzo, E; Thomas, JP; Sung, CK (August 17, 2021). "Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique". Otolaryngology–Head and Neck Surgery. 167 (1): 112–117. doi:10.1177/01945998211036870. PMID   34399638. S2CID   237149860 . Retrieved March 2, 2022.
  19. 1 2 3 Thomas, JP. "Technical Information | Feminization laryngoplasty". Archived from the original on October 15, 2021. Retrieved March 23, 2022.
  20. 1 2 3 Thomas, JP. "Patient Information | Feminization laryngoplasty". Archived from the original on September 18, 2021. Retrieved March 2, 2022.
  21. ↑ Kim, HT (June 21, 2016). "A New Conceptual Approach for Voice Feminization: 12 Years of Experience". International Journal of General Medicine. 127 (5): 1102–8. doi:10.1002/lary.26127. PMID   27328327. S2CID   5405815 . Retrieved March 20, 2022.
  22. ↑ "Voice Feminisation Surgery". London Voice & Swallowing Clinic. Retrieved 1 September 2023.
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