Voice Feminization Surgery
Pre-operative assessment

Audio examination

An ideal examination would include a digital recording that could be reviewed in the future against a postoperative outcome. Additionally, a standardized recording would provide comparison between techniques. The recording should be of sufficient quality that further analysis could be performed on the recording.

Speech: a 10 second recording of a standard reading passage. It can be able to capture spontaneous speech as individuals often change their pitch between stylized, reading, and spontaneous speaking.

Maximum phonation time: This is a record the maximum amount of time an individual can maintain a sound on a single breath. It is helpful to standardize this by recording it at the pitch obtained in the standard reading passage. Recording at a higher pitch will generally lead to a longer maximum phonation time. However, either recording can be useful for comparison postoperatively.

Lowest Pitch: this can be obtained stepwise by working down in pitch accompanying a piano or with a glide. This is a very important part of the recording, as it is one of the main parameters that is altered surgically. It also is a more accurate assessment of change than the comfortable speaking pitch (which can be altered with voice therapy or by an attempt to please on the part of the patient).

Highest Pitch: this can be obtained stepwise working up in pitch accompanying a piano, or with a glide. It is the goal of some patients to have this raised after surgery, but it is unknown whether any surgical procedure significantly alters this parameter.

While these are the four most important parameters, some supplemental items can be recorded that are valuable.

Loud sounds: attempts at producing a loud sound (such as “hey”) at low pitch and at high pitch offer insight into maximum volume. While it is difficult to measure, various procedures do limit maximum volume.

Soft sounds: recording singing at a soft volume, such as the first four words of the well known song “happy birthday to you” lead to insights into the alignment of the vocal cords. In particular, by singing the four words softly at low, medium and high pitch will elicit the alignment of the vocal cords at these various tensions. Various surgeries will alter the alignment of the vocal cord leading to air leak.

Video examination

Endoscopy

Flexible and/or rigid endoscopy should be performed both prior to surgery and optimally one year after surgery. While this does not address durability of the surgery, complete healing of the larynx should have occurred by one year.

Stroboscopy

Flexible and/or rigid stroboscopy should be performed both prior to surgery and optimally one year after surgery. This should be performed at low, medium and high pitch, as tensioning of the vocal cords will alter the configuration of the larynx. Vocal cords which have been altered in length or thickness may function differently at different pitches. While this exam does not address durability of the surgery, complete healing of the larynx should have occurred by one year.