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ORIGINAL ARTICLE

Feminization of Transgender Women With Chondroplasty and Laryngoplasty

Sarah E. Hammond, MD, Erin Cohen, MD,y and David Rosow, MDy

that a piece of forbidden fruit eaten by Adam lodged in his as a Abstract: In recent years, gender affirmation surgery has broad- reminder of his disobedience.5 Accomplished linguist Alexander ened significantly from its previous focus on genital conformation Gode theorizes that the phrase originated even earlier; he speculates only to include other areas of the body as well. As society that the Latin pomum Adami is a misinterpretation of the Hebrew reconsiders its interpretations of masculinity, femininity, and gen- tappuach ha adam, which means simply ‘‘bump of man,’’ not 6 der definitions, transgender individuals have realized that they will ‘‘Adam’s apple.’’ Regardless of the etymology, the anatomical only be able to truly transition if they are recognized by the public in structure clearly has strong implications as a defining male charac- their chosen societal role. The authors review the literature and teristic and retains that qualification even in modern times. Often- times while others may view the thyroid of a transgender describe their own techniques for feminizing thyroid chondroplasty woman as a subtle prominence, the patient herself sees the feature as and laryngoplasty. conspicuous and a significant factor in her gender dysphoria.

Key Words: Chondrolaryngoplasty, facial feminization, ANATOMY feminizing laryngoplasty, gender affirmation surgery, thyroid The male enlarges significantly at , almost doubling chondroplasty, transgender in size anteroposteriorly.7 In men and women, the larynx consists of 9 cartilage subunits, 1 of which is the thyroid cartilage.7 The thyroid (J Craniofac Surg 2019;30: 1409–1413) cartilage is the longest laryngeal cartilage; 2 lateral laminae fuse in the midline over the deeper structures of the larynx, giving a shield- n the last 3 to 4 decades, gender affirmation surgery has broad- like shape and function. The male thyroid cartilage forms a 908 I ened significantly from its previous focus on genital conforma- angle with greater median projection anteriorly.8 This smaller angle tion only to include other areas of the body as well.1 As society results in longer vocal cords and a lower-pitched male .9 In reconsiders its interpretations of masculinity, femininity, and gen- contrast, the female thyroid cartilage has a more obtuse 1208 angle. der definitions, transgender individuals have realized that they will The female thyroid gland is larger, covering the thyroid cartilage only be able to truly transition in the public sphere if they are able to and creating a smoother silhouette. Overall, the effect is a more interact in every-day life in their chosen societal role. In fact, many slender and smoother neck contour that is recognized as feminine. transgender patients are satisfied with these more recognizable Originally reported by Wolfort and Parry in 1975,8 alteration of facial transitions and do not go on to seek bottom surgery. the thyroid cartilage can be done to achieve a more masculine or more The neck is an area of the body where sexual differences can be feminine contour.10 However, a thorough knowledge of the pertinent easily identified. Studies on intergender differences in neck height anatomy is crucial to maintain normal and respiration and and length by Vasavada et al2 showed that neck anthropometry to prevent complications. The extrinsic muscles of the larynx attach to parameters in females were 9% to 16% smaller than in males, with the posterolateral surfaces of the thyroid cartilage. The only a 3% to 6% gender-related decrease in head anthropometric attaches to the deep surface of the thyroid cartilage in the midline via parameters. The female third through seventh cervical vertebrae the thyroepiglottic . The intrinsic laryngeal muscles attach (C3–C7) were significantly smaller when compared with the same inferior to this ligament and function to close the or tense and male cervical vertebrae.2 Female neck muscles were also found to relax the vocal cords, allowing deglutition or inspiration and produc- be 20% weaker in extension and 32% weaker in flexion when ing phonation, respectively.7 The intrinsic muscles are innervated by compared with male counterparts.2 the recurrent laryngeal nerve with the exception of the cricothyr- A masculine neck is characterized by increased muscle volume,3 oideus which is innervated by the external branch of the superior decreased subcutaneous tissue,4 and a more prominent thyroid carti- laryngeal nerve. The external branch travels deep to the superior lage as compared with a feminine neck. In fact, the more protruding thyroid artery to enter the . Injury to this nerve can thyroid cartilage is a defining secondary sexual characteristic in occur if dissection is done too posteriorly, causing a decrease in voice males. This anatomic feature is known in popular culture as an pitch and strength. The internal branch of the superior laryngeal nerve ‘‘Adams apple,’’ or pomum Adami. The origin of this term is provides sensory innervation to the laryngeal mucosa and enters the obscure—medieval Judeo-Christian writers handed down the legend larynx through the thyrohyoid membrane. Injury to this structure can cause loss of the laryngeal cough reflex and increased risk of aspiration . Both recurrent laryngeal nerves travel in From the Division of Plastic Surgery; and yDepartment of Otorhinolaryn- the tracheoesophageal groove to the larynx, entering just posterior gology, University of Miami, Miami, FL. to the cricothyroid joint. These nerves innervate the remainder of the Received March 12, 2019 Address correspondence and reprint requests to Sarah E. Hammond, MD, intrinsic laryngeal muscles and can be injured in the course of lateral Division of Plastic Surgery, University of Miami, 1120 NW 14th Street cartilage dissection. 4th Floor, Miami, FL 33136; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD CHONDROLARYNGOPLASTY TECHNIQUE ISSN: 1049-2275 In our own practice, we have frequently performed feminization DOI: 10.1097/SCS.0000000000005569 thyroid chondroplasty in conjunction with a feminizing

The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 1409 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Hammond et al The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019

and the anterior protrusion approximately 5 to 6 mm beyond the native cartilage. Once satisfied with the appearance, they secured the graft to the patient’s existing thyroid cartilage using permanent sutures. They then closed the wound with a standard layered closure and did not leave a drain. In their report, they recommended obtaining plain films of the chest to rule out a postoperatively. They reported the patient to be well at 6 months follow-up, with free mobility of the laryngeal prominence and no resorption of the cartilage graft.14 Although this is not often requested by transgender men, it may be considered as an option for facial masculinization.

FIGURE 1. (A) Intraoperative thyroid cartilage exposure via submental incision. FEMINIZING LARYNGOPLASTY (B) Intraoperative thyroid cartilage resection specimen. Many individuals in the transgender community place just as much if not more importance on their transformation as effected by secondary sex characteristics, and rightly so. Humans both perceive laryngoplasty done by our otolaryngology colleagues. We ask our others and present themselves through largely visual and tactile transgender female patients to hold all supplements for 4 communication. However, research shows that the most accurate weeks prior to surgery. An incision directly over the thyroid and effective communication is achieved with solely one’s voice.15 cartilage should be avoided. We prefer to utilize a 2 cm submental While use can lower the voice in female-to-male trans- incision unless the patient has an obvious scar or rhytid overlying gender patients, have no significant effect on the physical the thyroid cartilage that can be used instead. In general, an incision properties of the vocal folds or the laryngeal framework, and thus 3 to 5 cm cephalad to the superior aspect of the thyroid cartilage will more extensive interventions must be performed. allow for access with sufficient downward traction of the skin. The Male-to-female (MTF) individuals commonly undergo consid- strap muscles are divided in the midline raphe and retracted erable to generate a more feminine voice. Whether laterally, exposing the underlying thyroid cartilage. The thyroid somewhat learned from societal expectations or purely biologic, a gland itself can be retracted superiorly, or divided if necessary for ‘‘feminine’’ voice is characterized by a certain cadence, intonation, adequate exposure. Care should be taken to maintain a midline articulation, inflection, breathiness, lower volume, and most impor- dissection to avoid nerve injuries more laterally and to maintain an tantly, increased pitch.16,17 As shown by Spencer in 1988 and Wolfe avascular field. After adequate, safe exposure of the thyroid carti- et al in 1990, fundamental frequency (F0) is the most important lage is achieved, the perichondrium is incised sharply. The laryn- objective vocal attribute in differentiating male and female voices. geal prominence and notch are exposed by elevating the Specifically, males typically have a F0 ranging from 85 to 150 Hz perichondrium to within 1 cm of the superior and inferior margins. 18,19 while females typically have a F0 greater than 160 Hz. Thus, the The laryngeal prominence is then assessed and the limits of resec- primary target of most vocal feminization therapies is vocal pitch. tion determined (Fig. 1). Resection of the midline cartilage is While many MTF patients are satisfied with the quality of their typically done with Rongeur instruments; however, in patients with voice following vocal therapy, it is not always possible to achieve heavier calcification, careful excision with mechanical drill burrs or the desired outcome with therapy alone. Even after extensive knives is required. Ossification of the hyaline thyroid cartilage therapy and practice, a lower voice can involuntarily be produced typically starts around age 25 with complete cartilage conversion to 11 during actions such as laughing, coughing, sneezing, or yawn- bone by age 65. Extreme caution is used to avoid laryngeal injury ing.16,17,20 Persistent conscious efforts to alter the voice can lead and disinsertion of the vocal cords. Careful technique is required to to straining and functional voice pathology including nodules, avoid penetrating the thyrohyoid membrane. Rasps and synovial , or ulcers.17,21 For patients who wish to avoid these Rongeurs are used to smooth the contour and perform finishing issues or who have limited success with therapy, voice feminization details. Once a satisfactory reduction is achieved, the strap muscles surgery represents the logical next step. are reapproximated and the skin and subcutaneous tissue closed in layers. Typically, we do not leave a drain. The patient is started the next day on subcutaneous heparin for deep venous thrombosis LARYNGEAL ANATOMY prophylaxis if they are inpatient. Complications are infrequent The first recorded surgery to create a more feminine sounding voice but can include hematoma, hypertrophic scarring, and infection. was performed in the 16th century on the Italian castrati.22 Since The most serious complications known to occur are injury to the then, surgical knowledge and technology have advanced so that vocal cords or destabilization of the epiglottis by disrupting the pitch modulation can be achieved by alteration of the vocal cords thyroepiglottic ligament. The surest way to avoid these problems is directly. Vocal fold vibration modifies pitch and generates tone, to avoid dissection of the deep and inferior surfaces of the thyroid which is then altered by oral and pharyngeal articulators to generate laminae.12 . Specifically, pitch results from contraction of the cricothyr- Although feminizing chondrolaryngoplasty is a more common oid muscle, which results in forward tipping of the thyroid cartilage procedure, masculinization of the thyroid cartilage is also possible at the cricothyroid joint. The vocal folds insert anteriorly into the and occasionally requested. Originally performed by Ousterhout on thyroid cartilage and the arytenoids fix on the cricoid lamina. Thus, cis-gender males,13 the first thyroid cartilage augmentation on a this forward tilt mechanism leads to stretching of the vocal folds and trans-gender male was reported by Deschamps-Braly et al14 in subsequent thinning of the vocal ligament. The vocalis muscle also 2017. Their technique began with a submental 1 cm incision with serves to adjust the thickness of the vocal cords.21 dissection down to the thyroid cartilage in a similar fashion as To understand the surgical methods of altering vocal pitch, it is described before. Three centimeters of costal cartilage were har- important to be familiar with1pffiffi the mathematical derivation of 2L s vested and fashioned into a masculine configuration with a scalpel. fundamental frequency Fo ¼ r where L ¼ length of vocal folds, The authors recommended shaping the cartilage into a pyramid with s ¼ longitudinal stress or tension, and r ¼ tissue density (mass per the base being 3/4 the width of the patient’s native thyroid cartilage unit length). Thus, increasing vocal pitch requires at least one of the

1410 # 2019 Mutaz B. Habal, MD Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 Feminization of Transgender Women following interventions: increasing vocal fold tension, reducing whereby CO2 laser is used to vaporize the mucosa down to the level vocal fold mass, or shortening the vocal fold vibrating length.17,23,24 of the vocalis muscle. This can also alter the shape of the vocal folds It is important to keep in mind that the vocal folds in cis-gendered to create a mid-glottic insufficiency which increases the ‘‘breathi- males are thicker and approximately 50% longer than those in ness’’ of the voice and thus the perceived femininity of the voice.30 25 females. Alterations to the physical properties of the vocal In 1 study of 31 patients, an average F0 increase of 27 Hz was noted. folds are not the only way to change the voice. Additional mod- More importantly, patients’ self-perception of vocal quality, loud- ifications, including changing the pharyngeal dimensions to modify ness, and vocal range were all decreased postoperatively.34 vocal resonance and teaching the patient methods of phonatory The glottoplasty technique, that is, webbing the vocal folds feedback reflex control, can be considered additional therapies anteriorly to decrease vibratory length and subsequently increase in these patients.22,23 pitch, was first proposed in 1982. Donald et al performed the procedure via an external laryngofissure approach, excising a wedge of thyroid cartilage with care to preserve the perichondrium. LARYNGOPLASTY TECHNIQUE The vocal folds were then identified posteriorly, and the medial Several open and endoscopic surgical techniques have been devel- mucosa of the anterior one-third of the vocal folds was denuded oped to target the aforementioned goal of increasing vocal pitch in prior to suturing the folds together anteriorly to form a glottal web.21 MTF individuals. Cricothyroid approximation and anterior com- Endoscopic glottoplasty is a more recent technique first pro- missure advancement have been developed to increase vocal cord posed by Wendler in 1989. The procedure begins with direct tension. Scarification, triamcinolone injection, and CO2 laser and suspension of the larynx for adequate visualiza- vaporization have been proposed to decrease vocal fold density, tion of the vocal folds and anterior commissure. CO2 laser is reduce mass, and increase rigidity. Finally, several webbing and applied to denude the anterior one-third of the vocal folds and plication strategies have been studied to decrease the vibratory anterior commissure before absorbable suture is used to create a V- length of the vocal folds.17,23,24,26 shaped anterior commissure. Fibrin sealant is applied to strengthen First proposed by Isshiki in 1974 and subsequently published in the sutures.35,36 The synechiae created serve to reduce vocal fold a larger cohort in 1983, cricothyroid approximation increases vocal mass and thus elevate pitch. There is also a resultant increase in both cord tension by tilting the laryngeal framework downward. This glottic tension and subglottic pressure, which further promotes action recapitulates the activity of the cricothyroideus, increasing vocal fold vibration.37 the tension of the thyroarytenoid muscles and the vibratory margin Several studies have been published analyzing outcomes after the of the vocal folds. Sutures are typically used to approximate the Wendler glottoplasty and proposing modifications to the technique lower thyroid to the upper cricoid,25,27 although other modifications described above.20,24 Mastronikolis et al retrospectively reviewed 31 17 28 have been described. One study by Brown et al analyzed mean MTF individuals after Wendler glottoplasty. While F0 significantly and modal F0 in 14 MTF individuals undergoing cricothyroid improved in both groups, the degree of improvement was higher in approximation. Both outcome measurements significantly patients less than 40 years old. Furthermore, estimated subglottic increased postoperatively. Interestingly, the vocal pitch distribution pressure was also significantly higher postoperatively, which is was also altered postoperatively, with a tendency toward unimodal important for vibratory mechanisms as noted earlier.16 distribution as opposed to the bimodal pitch distribution more Glottoplasty techniques without the use of CO2 laser have also commonly seen in transgender individuals.28 A study by Yang been proposed. Meister et al analyzed 21 patients who underwent a 29 et al also showed similar improvement in F0 after cricothyroid Wendler glottoplasty modification in which the anterior one-third approximation. In several patients, however, this increase in fre- of the vocal folds are de-epithelialized, sutured, and then injected quency seemed to decline over time.29 with botulinum toxin to facilitate postoperative voice rest. In this Cricothyroid approximation does not put the vocal folds directly study, postoperative F0 was noted to be elevated into the female at risk and can be done under local anesthesia with sedation. range without significant reduction in vocal range for the majority However, one unfavorable outcome is that manipulation of the of patients.23 Using a similar technique with finer suture, Yilmaz cricoid and thyroid can accentuate the laryngeal promi- et al extended the region of de-epithelialization to half of the vocal nence, which is a particularly undesirable outcome in this patient fold area. Postoperatively, 85% of patients’ voices were rated as 30 population. Furthermore, several studies have noted a decline in feminine, F0 was significantly increased, and Voice Handicap Index pitch after approximately 1 year and ultimate failure in roughly one- was significantly decreased. Interestingly, 7 patients underwent a third of patients. To analyze the etiology of this failure, Tschan second surgery with laser reduction of vocal fold mass despite et al31 assessed cricothyroid joint anatomical variations. They found favorable outcomes overall.30 that postoperative success correlated to cricothyroid joint anatomy Several authors have noted that the absorbable suture used in a and recommended surgery only in individuals with a well-defined Wendler glottoplasty or its modifications has the potential to joint and obvious protuberance.31 dehisce. In a study by Anderson,25 the was denuded First proposed by Lejeune et al32 in 1983, anterior commissure and carboxymethylcellulose gel injected into the thyroarytenoid advancement is an alternative method to increase tension and muscles to medialize the anterior aspect of the vocal fold edges, subsequently raise vocal pitch. An inferiorly based flap is raised promoting webbing without the use of suture. Significant increase on the anterior thyroid cartilage and then advanced superiorly in an in F0, good patient satisfaction, and adequate web formation as seen attempt to tighten the vocal ligament. Care is taken to avoid with a fiberoptic laryngeal examination were noted postopera- detachment of Broyles ligament.32 Wagner et al evaluated 14 tively.25 Kim et al retrospectively reviewed 362 patients who patients who underwent either cricothyroid approximation or ante- underwent vocal fold shortening and retrodisplacement of the rior commissure advancement and found similar success rates anterior commissure. The anterior vocal fold was denuded and between the 2 techniques. However, less than one-third of patients then nonabsorbable nylon sutures were placed in the lateral thyr- had postoperative F0 in the female range or were able to be oarytenoid and vocalis muscles. A significantly higher pitch perceived as female on tape, demonstrating the difficulty in quali- increase was noted in younger patients and in patients without fying what constitutes a feminine voice.33 concomitant thyroid chondroplasty. Postoperative analysis revealed Laser-assisted voice adjustment creates a controlled scar, target- retained regularity of mucosal wave, as well as comparative acous- ing the vocal cord mass only. Orloff et al described this technique, tic and aerodynamic outcomes.22

# 2019 Mutaz B. Habal, MD 1411 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Hammond et al The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019

voice include validated perceptual instruments such as the Voice Handicap Index and Voice-Related Quality of Life scales. Some studies use third-party blinded opinions of voice recordings for intervention assessment.20 Laryngeal stroboscopy can also provide crucial information regarding the perceived length, pliability, and thickness of the vocal folds, allowing clinicians to subjectively determine the success of an intervention.38 However, some studies rely on nonvalidated perceptual measures (eg, ‘‘Patient was satis- FIGURE 2. (A) Visualization of vocal cords before glottoplasty. (B) Mucosal fied with her voice’’) that do not allow for easy comparison.30,38 approximation in modified glottoplasty technique. The lack of conformity among outcome measurements in the literature thus only adds to the difficulty in comparing techniques in this cohort. The feminization laryngoplasty is a more recently developed In our experience, patients seeking significant voice feminiza- surgical technique described by Kunachak et al in 2000. The tion through endoscopic means are best served with a glottoplasty, procedure involves resection of a vertical anterior segment of since laser-assisted voice adjustment has been found to generate thyroid cartilage, together with the anterior aspects of the true only modest increases in F0. One benefit of cricothyroid approxi- and false vocal folds. The remaining vocal folds are sutured mation and feminization laryngoplasty is that they can be performed together under tension to move the anterior commissure more at the same time as a thyroid chondroplasty, but cricothyroid posteriorly. This action also shortens the vocal folds and decreases approximation is associated with gradual loss of efficacy over time. the size of the vibratory glottis. A significant increase in average Thus, further studies are warranted to analyze optimal patient- pitch from 174 to 315 Hz was noted, as well as a reduction in the centered strategies for raising vocal pitch. thyroid notch.26 Thomas and Macmillan performed feminization laryngoplasty in 94 patients while incorporating additional thyrohyoid approxi- CONCLUSION mation. They resected 10 mm of superior thyroid alar cartilage, then Transgender patients and their healthcare providers would argue approximated this to the hyoid bone with sutures. This served to that the transformational power of facial and vocal feminization or shorten the vertical height of the pharynx, creating a more feminine masculinization is actually stronger than that of the genital transi- resonance cavity. In their postoperative review, average speaking tion.1 To modify a patient’s appearance as well as the voice with pitch and lowest attainable pitch were increased. Despite seemingly which they communicate enables them to move through the world favorable outcomes, one-third of patients ultimately underwent as their desired gender. This leads to substantial effects on 38 revision due to uneven and/or inadequate tension. their psychological health.1 Only when a patient can be seen and At our institution, we perform a modified glottoplasty technique heard as their intended gender can they finally be comfortable with often in conjunction with a procedure to address the laryngeal themselves. prominence. The operation is performed under general anesthesia utilizing a small (5.5 mm) endotracheal tube to facilitate visualiza- tion. An appropriately sized laryngoscope is used to adequately ACKNOWLEDGMENT visualize the entirety of the anterior commissure during suspension The authors thank Christopher J. Salgado, MD for his support and microlaryngoscopy (Fig. 2A). Additional anterior counter pressure contribution to this work. is applied as needed to the larynx for improved exposure. Micro- laryngeal forceps are used to carefully retract the mucosa of the REFERENCES anterior one-third of the vocal folds, and a thin layer of the medial mucosa from this region is stripped toward the anterior commissure 1. Plemons E. Formations of femininity: science and aesthetics in facial feminization surgery. Med Anthropol 2017;36:629–641 and excised. The same steps are repeated on the contralateral side. 2. Vasavada AN, Danaraj J, Siegmund GP. Head and neck anthropometry, Hemostasis is achieved with a potassium titanyl phosphate laser set vertebral geometry and neck strength in height-matched men and to 525 millijoules of pulsed energy. Saline is subsequently injected women. J Biomech 2008;41:114–121 into each vocal fold with a laryngeal needle for improved visuali- 3. Zheng L, Siegmunc G, Ozyigit G, et al. Sex-specific prediction of neck zation. 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1412 # 2019 Mutaz B. Habal, MD Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 Feminization of Transgender Women

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# 2019 Mutaz B. Habal, MD 1413 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.