I’m Chadwan Al Yaghchi, a voice feminisation surgeon. I work with transgender women to help them achieve a voice which more accurately reflects who they are. Ask me anything!

Does a surgery like this move someone's whole vocal range up? Is it limiting somehow? (In the sense that they'll gain less pitch than they lose, if that makes sense.)

I'm curious about the implication of this for male vocalists looking to adjust their range.

With glottoplasty generally, the whole range goes up although there are variations as some will have wider or narrower range.

While with Cricothyroid approximation the vocal range gets significantly narrower.

Neither operation is recommended for professional singers as the impact could be considerable and possibly career ending.

Is it possible to make someone's voice deeper, like in the case of a trans man?
Are there any CIS gendered individuals that seek alteration?

Yes, there are options to make the voice deeper, mainly relaxation laryngoplasty (more commonly known as type 3 thyroplasty). However, this is hardly required in trans men as the voice drops naturally once they have started on testosterone replacement.

And yes cis-gendered individuals can have pitch adjustment surgery.

How long does the surgery take? Does it involve a long stay in hospital?

No. The surgery including anaesthetic time and waking up is around 60 minutes. It is done as a day case where you go home after few hours

What's the recovery process though?

One week of complete voice rest, hydration and steaming. Avoid coughing, sneezing and throat clearing. No smoking. Reduce caffeinated and carbonated drinks.

two words at a time for a total of 10-15 words a day in week 2

Then build up vocal use gradually

Thank you for your time. Your work and results are amazing and life affirming. Two questions for you regarding your glottoplasty sutures and wound healing. These reflect some of the anxieties held by those considering surgery :)

When is the latest time into healing you have heard of a patient tearing their sutures, if at all, and what surgical intervention would be required to address this scenario?

I've heard that it's possible for the sutures to hold strong throughout the period of time required for healing yet, upon dissolving, wound separation can still occur. Have you ever encountered this in your patients and, if so, what advice can you give to other surgeons and patients in order to avoid such an outcome?

Thank you!

I had one patient a few years ago who felt a 'pop' and her voice dropped at 6 weeks after surgery. This is exceptionally rare! In the few incidences of suture breakdown I have encountered (4% in my series) it is broken down by the time of first follow up.

The dissolvable sutures I use will provide support for 6-8 weeks by the time the wound healing is strong enough to be permanent (with the one exception I mentioned)

If sutures are to break down we can repeat the glottoplasty at later date.

Thank you for your time and the work you do. Have a great weekend! :D

You too

How do you think this kind of surgery compares to traditional voice training methods? Does surgery simply make getting the desired vocal sound easier when lots of effort into voice training will likely to match these results, or do you believe that this is something voice training cannot replicate?

It varies from person to person. Some can achieve pitch elevation with therapy alone while others struggle or find the voice forced and the pitch difficult to maintain. Regardless therapy is always required for a good outcome of surgery.

Assuming recovery instructions are followed:

• Can shouting damage the structures affected with the surgery?
• Is maximum volume affected?
• Will results transfer to the higher volumes, or are they capped at normal speaking volumes?

Yes shouting in the early weeks after surgery can damage the surgery and break the sutures. Shouting, later on, can cause vocal trauma such as bleeding in the vocal cords. But that can be the case with unoperated vocal cords.

Yes vocal volume can be affected, in fact, most people will have some reduction in volume but it may not affect their day to day voice.

We know from computer modelling that the more you close of the vocal cords the more pitch increase you get and more volume loss. In real life, it is more complicated than that as there are many variables that can affect the final voice outcome. Voice therapy and breath support exercises can help restore the volume.

The results are transferred to higher volume although some people struggling with volume can get a hyper elevated pitch on shouting. Again this is very variable.

Thank you for the response. It's very informative, and the fact that you do computer modeling to model outcomes is very interesting.

I've strongly considered these surgeries, but I'm often in situations that require projecting my voice (I'm a referee so it's important for me to be heard in a crowded arena), so your response confirms my concerns.

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Shouting, later on, can cause vocal trauma such as bleeding in the vocal cords. But that can be the case with unoperated vocal cords.

This is the first I've heard about bleeding vocal cords, especially when they haven't been operated on.

The computer simulation is not my work. It is this paper

Titze IR, Palaparthi A, Mau T. Vocal Tradeoffs in Anterior Glottoplasty for Voice Feminization. Laryngoscope. 2021 May;131(5):1081-1087. doi: 10.1002/lary.28940. Epub 2020 Aug 25. PMID: 32840877.

Vocal cord bleeding is small bleed within the vocal cord. A bruise efefctivly.

Thank you for the reference. I've found the article, so I will look into it. (link for anyone else)

This has been one of the best AMAs I've seen in a long time. I really appreciate the in-depth answers you've given, not only for myself but for others

Pleasure

Growing up, was this the profession you were passionate about?

Thank you for my first question! Yes, I wanted to be a surgeon since I was a teenager. Then towards the end of Medical School, I decided to be an Ear Nose and Throat Surgeon. I couldn't be happier with my choices!

What is the referral process for someone seeking voice feminisation surgery?

You can self refer to my clinic by contacting us directly. I am also to receive referrals from GP, Speech and Language therapists, psychiatrists or other ENT colleagues.

Different countries have different referral pathways.

Excellent! Thank you so much for your time to answer these.

Pleasure

What is it like seeing the difference you are making every day in people's lives?

It is truly humbling to do my small part to improve people's quality of life. It is the small things in life that we take for granted that have the biggest impact.

I'll throw in another question. :) This one is to do with the contribution to science and how to make the lives of transgender women a little easier with supporting literature.

When can we expect to see publications from you on your work with glottoplasty?

Literature of that sort may help the NHS consider funding the operation for those in difficult situations!

As always, thanks again for your time. I hope you get the recognition you deserve for your wonderful work.

The publication will hopefully be within the next 12-18 months. I will be looking to add significant knowledge by showing a large series and exploring factors of success and variation. I also have a keen interest on patient-reported outcome measures (PROMs) which has been sadly neglected in publications around voice feminisation.

I submitted an abstract of my work to The Fall Voice Conference later in the year. Hopefully if accepted it will put my results out there in the scientific domain.

Watch this space!

What are the risks with having the surgery? Is there a chance you could end up mute?

No you will not end up mute.

There are general surgical risks such as bleeding pain and infection, there is a small risk of teeth damage, extremely small risk of laser injury. All these are small risks.

Some people will have an excess inflammation of the cords that will require treatment and might lead to prolonged hoarsiness.

Finally there are possible voice long term risks including:

- possible reduction of voical volume which might impact the ability to shout and project the voice
- long term hoarseness and strain which can be managed by speech therapy

Are there procedure in place to reduce these risks or address them when they come up?

Yes of course, good surgical practice, maintaining the highest levels of standards before during and after surgery, adhering to surgical safety procedures and good surgical techniques all play a role in reducing risks. complications can often be treated with medications such steroids and antibiotics.

Having said that there is no surgery without risks. Like everything in life my patients and myself need to balance the risks vs benefits when we make shared treatment decisions.

How much impact will grottoplasty have on involuntary sounds such as coughs and laughter. And what about when you are poorly? These are all cases when my voice training completely fail me.

In general, the pitch of cough and laughter will go up. If you are poorly, especially laryngitis, then the pitch might go down like everyone else but it recovers.

Ok, but the effects of the surgery will still be of benefit for these scenarios?

Also if you don’t mind, how long before you can talk again after surgery?

Yes there is a positive impact in all these scenarios.

After surgery you will need complete voice rest for one week then very gradual build up over 4-6 weeks.

How about reversals? Do you have people come back who change their mind and want to go back to the original self? Is it possible to reverse or just change it again to a different tone?

Glottoplasty should be considered permanent. It can be reversed technically but it might leave scarred vocal cords and a permanently hoarse voice.

I hope you see this, but have you ever had experience with a patient with Tourette Syndrome? I would love to one day undergo a surgery like this, but I'm afraid my vocal tics would prevent me from recovering properly.

No I have not. I understand the concern. I don't have an easy answer but it possibly needs multidisciplinary work to see if tics can be reduced with medical treatment.

Can I ask about costs? I appreciate this may vary in certain circumstances, but on average perhaps for a trans woman seeking surgery with yourself in the UK?

In the range of £5000-6000 depending on the procedure.

How much control can you have about how a patient sounds afterwards?

There is a variation of the results among patients even if they have identical surgery. Glottoplasty only adjust the length of the vocal cords (with a slight adjustment of tension if combined with LAVA) but the bulk remains unchanged.

Having said all of that, the majority will get results around the middle of the range (55-60Hz increase)

Hi also can having a trachea shave prior to surgery impact the results of this surgery in anyway? Thank you

If done properly with no complications it should not have an impact on the results of the glottoplasty. If however there was excessive removal of the cartilage resulting in damage to the front of the vocal cords (anterior commissure) then that is very difficult to fix as the vocal cords lose tension.

Apologies if you've already answered this elsewhere, and apologies if this question is one you get too often, but I'm curious as to what inspired you to start using your professional skills as an ear, nose, and throat surgeon to offer trans-specific healthcare?

What did your job look like before you began this chapter of your career?

I have a physical disability (cerebral palsy) and most doctors I see are specialists in the parts of the body impacted most by my condition, but of course, they only set out to have specific knowledge of those parts of the body. Being able to help me is incidental to that.

It sounds like you chose, specifically, to become very involved in trans healthcare after you familiarized yourself with the concept. I think that's beautiful and I wanted to know why you made that choice.

No need for apologies at all. I love to help and make a positive impact on someone's quality of life. I, and the whole team, genuinely love working with trans gender people. It has been the most rewarding and humbling professional experience.

I still have a busy NHS and private practice in addition to voice feminisation.

I am super extra specialist in my other roles and almost treat one condition but I like to think that I can see the whole person not just the airway or the vocal cords.

Are the results permanent? How likely are they to change over time?

In general, there are two surgeries for voice feminisation:

1. Cricothyroid approximation was the main surgery we performed up to few years ago. The pitch increase tends to drop in time over the years.
2. Cricothyroid approximation was the main surgery we performed up to a few years ago. The pitch increase tends to drop in time over the years.e. The results are permanent once all healed.

Edit: Glottoplasty is my current preferred technique. The results are permanent once all healed.

Thank you!!!

Apologies, I am not sure why but it happened few times now which I managed to spot.

Glottoplasty is my preferred method. The results are permanent once the healing is complete

Hi what would you say the difference is between your method of voice feminization and yesons method is?

I don't have exact knowledge of the finer details of the Yeson technique. Happy to explain my method.

How come people detransitioning from male back into female have permanent deeper vocal effects? Is it the same for the reverse?

This question isn't strictly related to glottoplasty but it's because when people assigned female at birth take hormone therapy to transition to male, it alters the physiology of the larynx permanently, it is for all intents and purposes the same as a male puberty.

When people assigned male at birth transition to female, hormone replacement therapy doesn't reverse puberty, hence why the surgical intervention is required.

Exactly that. The effects of testosterone on the larynx are irreversible.

What are your recommendations for voice training before/after surgery. Is there a minimum number of sessions required before you will perform VFS? Do you have any recommendations for who to go to for training and will different types affect the outcome of surgery differently?

There are two general approaches:

Full course of voice therapy and surgery if therapy doesn't give the desired effect then move to surgery. Normally 10-20 sessions.

Otherwise surgery first then therapy, in this case, you need one session before surgery then a few sessions of voice rehabilitation after surgery, then voice feminisation therapy as required.

What's the youngest patient you've had and what's the youngest you'd take?

Over 18 years old.

Hi there...

How would you characterize the differences, advantages and disadvantages between Wendell glottoplasty as you perform it and as it is performed in Yeson, Korea?

How about Wendler glottoplasty in general and Dr. James Thomas' feminization laryngoplasty?

Each surgeon including Yeson has their own variation on glottoplasty hence we call it Modified Wndlers Glottoplasty. The way we place the sutures, the material, the use of laser, the depth of the suture to include muscle or ligament or just lining can play a factor.

Dr Thomas operation works in a completely different way as it aims to rebuild the larynx to new shape and dimention.

Glottoplasty is less invasive compared to Fem Lar and recovery is quicker.

I also don't use Botox after surgery allowing early voice use.

Having said that both Dr Kim and Dr Thomas are excellent colleagues with vast experience and their results are fantastic.

Thank you.

So, to paraphrase, the variations of the Wendler procedure mainly differ in the use of sutures, material, laser, and other factors, but the results as a rule are similarly good.

And while Dr. Thomas' method is completely different, the same can be said of his results, the main difference being the degree of invasiveness and recovery time.

٩(๑❛ᴗ❛๑)۶

You put it much better!

How much does it cost?

It depends on the type of surgery. Generally in the region of £5000-6000

Would it have any impact on someone who lets say does a half hour cardio a day? Also thank you for answering me

Extremely unlikely. No one ever reported to me limitation in exercise once healing is complete.

I’ve heard before that subsequent surgery and intubation can damage the vocal chords and/or drop the pitch back to previous levels - do you have any experience of this either way?

Not first-hand experience in my patient cohort.

To minimise the risk I advise against elective surgery under general anaesthesia for 3 months after glottoplasty.

After that anaesthesia should be ideally done with a laryngeal mask airway (LMA) with no tube going between the vocal cords. However, that is not always suitable. So if intubation is required I advise using a size #6 endotracheal tube.

What are your opinions on botox after this surgery? Thank you

I don't use botox but other very good colleagues do. The jury is out on this one. It is related to the debate of early vs late mobilisation of the vocal cords. We don't have enough research to answer this question in glottoplasty specifically. In other voice surgeries, we know that 72 hours of voice rest is ideal. I tend to go with early mobilisation and I feel one week of total voice rest gives the right balance.

I want to be a better singer, can you adjust my chords? 😁

No unfortunately not! :-)

Do you know any surgeons in Switzerland that can perform these procedures?

I don't know anyone in Switzerland but there are a few colleagues in Germany, Spain and Lichtenstein or you are very welcome to come see me here in the UK. I get clients from all over Europe, Canad and the US

Is there a way to similarly help trans men?

Yes, there are options to make the voice deeper, mainly relaxation laryngoplasty (more commonly known as type 3 thyroplasty). However, this is hardly required in trans men as the voice drops naturally once they have started on testosterone replacement.

Do you have an age limit on surgery?

18+, no upper limit.

Have you ever performed this surgery on a woman assigned female at birth?

Yes I have. The same principles apply

do neck strengthening exercises work for making your voice deeper?

I need to look into that as I don't know the answer.

First off, kudos on your work.

I am not trans, nor have many or really any trans friends. I'm a professional vocalist and have been my entire professional life and had a few questions that I think could potentially overlap.

1. With the technique, is it something that could somehow be used to raise vocal pitch in regards to singing? I've found myself in the last 7-8 years lose about 1 step of pitch. I know that some of it can be down to age, was just curious if the procedure could ever be performed electively for something like that? A large amount of my colleagues have had multiple surgeries for nodes, polyps etc. I guess simple version of the question is 1. Can you raise sung vocal pitch? 2. Why does it lower with age/use for some (me), but others don't seem to diminish much well into their 70s (McCartney , Wonder etc)

2. Completely unrelated to the throat aspect of your practice, but figured maybe you'd come across something in your practice about tinnitus. Mine is absolutely caused over exposure over the years, I've started being much more proactive to protect my hearing now. Too little too late. Are there any rumblings about some type of 'cure' for tinnitus? Also, Ive had the ringing for so long I'm beginning to question whether people do hear true 'silence' if left alone in a quiet room?

Anyways, thanks for reading and thanks for helping those women find their voice. I can't even imagine what it must be to speak and not hear who you are.

Glottoplasty is not recommended in singers as the results can significantly impact your ability to sing and can be career ending.

People's voices change with age due to loss of muscle bulk in the vocal cords and reduced tension (these effects act in different ways). The rate of muscle loss can vary between people.

I am not aware of any upcoming treatment for tinnitus but that is really not my area of expertise.

Are there any disadvantages of a trans having smaller vocal folds after surgery? As in not getting as much oxegyn as needed or will ot be the same amount prior to surgery?. I know vocal fold length varies alot

No not really unless the person is a short distance elite runner.

For everyone else, there is no real long term impact on breathing or oxygen as most of the airflow through the glottis (the space between the vocal cords) is in the posterior (back) part of the cords. This area remains unchanged with glottoplasty as we place our sutures in the front part of the cords.

Whats the best surgical option to correct hormonal voice change?

The same principles apply. the options are voice therapy then surgery if therapy failed or surgery then therapy.

The best operation will be glottoplasty.

If the pitch increase required is small (15-25 Hz) the Laser Assisted Voice Adjustment (LAVA) done as a sole procedure is an option.

Currently in the US therapy/surgical procedures related to gender affirming voice are considered elective and not typically covered by health insurance. Are the perceptions similar in the UK with a different healthcare structure? Do you anticipate a trend towards these interventions being more accessible for those making gender transitions?

Not currently covered by insurance companies but there is a move to get it funded. Hopefully in the near future.

What's your policy on minors?

18+ only

I think what you do is fantastic as is taking the time to put up with us internet strangers.

So, I'll ask something that will hopefully give some chuckles.

Have you watched/heard of Dr. Glaucomflecken on YouTube?

As a doctor, you might enjoy his bits. I hope you have an excellent day

Thank you.

Yes I love his work. The video on ear nose and throat doctors and cotton buds gave me endless laughs. Very accurate caricature of us.

How does it make you feel when you watch some states try to pass legislation restricting access to care for their transgender kids?

Makes me feel sad.

Me as well. Thanks for doing something positive that improves the quality of life for people who suffer from so much discrimination.

It is an honour and a pleasure.