Many patients who want a higher pitched voice as part of their gender affirming care undergo pitch modification surgery known as modified Wendler glottoplasty. This involves lasering away the vibratory surface of the anterior aspect of the vocal cords and then sewing the vocal cords together to form a web. This results in a shorter vibratory surface and a higher pitched voice. To sound more feminine, intensive work with a specialized speech language pathologist is crucial.https://www.mountsinai.org/locations/grabscheid-voice-swallowing-center/our-services/transgender-voice-feminization
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Mark S. Courey, MD Matthew C. Mori, MD Diana N. Kirke, MD Zachary G. Schwam, MD
The Mount Sinai Oto Laryngology Surgical Video Series presents Wendler gloop plasty or voice feminization surgery. This procedure is performed by our department, laryngologist. For those patients desiring a higher fundamental frequency in pitch, we will resect the anterior one third of the vocal fold, thereby creating an anterior glottic web and shortening the functional vibratory length if done with attention to symmetry. This procedure reliably increases vocal pitch without significantly changing vocal roughness or breaths. This is a schematic diagram of a Coronal cross section through the vocal folds. The important structures are labeled zooming in an incision is made through the epithelium on the upper lip region. The vocal ligament incised along the medial surface and dissected off the underlying thyro retinoid or T A muscle. This is also known as the vocalis muscle. The T A muscle fash is left intact. If possible, we create an inferiorly base flap of mucosa at the inferior arcuate line to decrease the likelihood of co-opting the mucosa and lessening the risk of granulation tissue formation under suspension microlaryngoscopy. A co two laser with a pattern generator is used to measure the distance from the vocal process to the anterior comma the goal is to respect 45% of this length. We start with an incision in the upper lip that is less than 40% as it will expand during surgery as the tension is released. After the initial mucosal incision, the laser line is shortened to 1.5 to 1.8 millimeters for the dissection. An instrument is used to attract the incise portion immediately to gain countertraction. The amount of vocal fold to be removed is the anterior one third, a similar procedure is performed on the right vocal fold to a similar depth. Transverse posterior cuts are made first on the right and then on the left retracting the tissue immediately gives one enough traction to be able to dissect between the T A muscle and the vocal ligament first on one side and then on the other. Once the muscle is exposed, we create the flap at the inferior arcuate line anteriorly, the tissue is removed on block, pulling it off the anterior macula flavum. This is a 70 degree endoscopic view showing the extent of resection. The endoscope is looking anteriorly towards the anterior comma. The tissue has been removed down to the level of the vocal or T A muscle. Next four vir sutures are placed to reapproximate the raw surfaces and to create an anterior glottic web. This diagram shows the entry points of the four sutures. It is critical to have anterior and posterior symmetry as well as lateral symmetry. The four color coded labels standing for left anterior, left posterior, right, anterior and right posterior will correspond to a later diagram. This schematic will show one of the two sets of su placement. The needle is brought through the height of the entire right vocal fold with the sutures then brought back up through the Lagos. The same is done on the left side and the loose suture ends are tied together to form a knot. This nod is then pushed down inferior to the vocal folds, bringing the two sides together toward the midline. The sutra needles are then cut and the free ends are used to tie another knot. This knot is then pushed down tightly and the free edges of each vocal fold are brought in close proximity. Now, let's see it. In practice, the left anterior suture is placed and left to hang on the Larios cope to be tied later. Then the right anterior suture is placed and again left to hang on the Lagos cope. The left posterior suture is then placed and then the right posterior. At the end of suit placement, there is a web of sutures hanging off the larios cope, they should be well organized. However, so that one can keep track of what goes where the colors and text labels correspond to the earlier diagram. The arrows represent the direction that the sutras are coming in. All sutures are passed superior to inferior through the vocal fold. And then are pulled out through the larynx. The end marks the end with the needle on it. The matching symbols are the ends that will get tied together. The stars and circles represent the two inferior knots below the vocal folds. These are tied first. The hexagons and rectangles are the superior sutures and will be cinched down last. This shows the tying of the anterior inferior knot or the green start to the pink star. From the prior diagram, the needles have been cut off. A two handed surgeon's knot is thrown onto an assistant's finger followed by two subsequent single throws. It is important that all knots are square. The sutures are cut and this knot is passed down below the vocal folds. The same procedure is done with the posterior inferior knot and is not shown here. Next, tying of one of the superior surface knots is shown again. A two handed square surgeon's knot is thrown, it is then pushed down with an endoscopic knot pusher and subsequently forceps. It is tied down tightly. The same thing is done for the posterior superior knott. Generally speaking, it is important not to leave any exposed muscle as it makes patients prone to forming granulation tissue. As shown here in a different patient aligning the upper and lower masses is very important as shown here. This is an early postoperative stroboscopic exam from our patient showing the expected appearance. An anterior web has formed without granulation tissue this is a three month stroboscopic exam showing a well formed mature anterior glottic web speech therapy with a specialized speech language pathologist will be key to achieving the desired outcomes.
