There are several surgical techniques that attempt to feminize the voice by raising the pitch at which the vocal cords vibrate. The simplest, safest, and most commonly performed of these is crico-thyroid (C-T) approximation (or C-T fusion). In this procedure, the thyroid cartilage adam's apple) is pushed against the cricoid cartilage which lies below it, and the two are sutured together with nylon Suture or metal clips. In some cases, the cartilages are first abraded, so that they will fuse after being approximated. The approximation cause a tensing of the vocal cords, raising the pitch at which they will vibrate. The effect is exactly like what we do voluntarily when we speak at the upper end of our pitch range, without breaking into falsetto. When we do so, we are contracting the crico-thyroid muscle, which pulls the two cartilages together and thereby tenses the cords.

C-T approximation was first described by the pioneering Japanese surgeon Nobuhiko Isshiki and is currently performed by several West coast surgeons, including Toby Meltzer in Portland, Murray Morrison in Vancouver, B.C., and the infamous Toby Meyer in Beverly Hills. The operation is performed through a small horizontal incision in the neck which is placed at a natural skin fold. The resulting scar is usually well- concealed. Either local or general anesthesia can be used. A cosmetic thyroid cartilage reduction (trach shave) can be done at the same time through the same incision if desired.

Anyone considering voice surgery should also be aware that pitch is only one of the acoustic cues to masculinity or femininity in the voice.

What are the advantages of C-T approximation? It often raises the normal or baseline vocal pitch, resulting in a less masculine voice. The risk of damage to the vocal cords or nerves is slight, since the larynx is not entered. There is usually no hoarseness or roughness in the voice. The operation is theoretically reversible if the patient is dissatisfied. Since the lower range of pitches is no longer accessible to the patient, there is less worry about accidentally using a low pitch when surprised or fatigued.

What are the disadvantages of the operation? It may not be as successful as one might wish. The operation apparently only eliminates the ability to produce low tones, rather than raising the upper ones. It does not seem to result in a vocal range higher than one could voluntarily produce, using one's best effort. As one surgeon put it, "It never results in a voice I haven't heard [the patient use before". In some cases the operation may not be beneficial at all, especially if the cords are very large or thick. Isshiki uses the analogy of a violin string: a thick string cannot produce a very high note, no matter how much it is tightened. The forward rotation of the cartilages that the operation produces may increase their apparent prominence in some patients. The operation costs $1500 or more, and requires at least a week of voice rest afterwards. And if successful, it will eliminate those low tones, which one might occasionally want to use.

To my knowledge, there are no large published series of cases in the medical literature, so the foregoing assessment of risks, benefits, and complications is largely anecdotal.

Ultimately a more successful solution to raising vocal pitch may be found in procedures that reduce the mass of the vocal cords, or increase their stiffness. Laser surgery of the cords, injection of steroids to produce atrophy, and incision techniques to promote scarring and increase stiffness, have all been employed. Unfortunately, these methods carry the risk of producing hoarseness and vocal roughness, and at present I consider them investigational.

Timbre, or resonance, is also very important. Timbre is the acoustic quality that allows us to distinguish, say, a violin from a trumpet, when both are playing the same note. In the human voice, timbre results from the resonant properties of the throat, mouth, nose, and sinuses that determine how much the overtones (harmonics) of the fundamental vocal pitch will be emphasized or diminished. Women generally have smaller resonators than men, and the timbre of their voices reflects this. A man who could achieve a fundamental pitch in the female range could still have a distinctively masculine voice due to the resonant properties of his airway. Voice surgery will not effect this vocal characteristic; and this may indeed constitute the greatest limitation of surgery. Fortunately, it is possible to voluntarily alter the resonant properties of the airway to a limited extent. Research shows that subjects with experience at simulating a feminine voice make such adjustments unconsciously. Some of the techniques apparently involve shortening the airway by decreasing lip rounding, speaking with the mouth more open, and carrying the tongue relatively high and forward in the mouth.

What have I decided about surgery? Since I have a large larynx and thick cords, and since I have done reasonably well with speech therapy alone, I'm holding off for now. I'll wait for a safe and effective procedure to reduce vocal cord mass. In making your own decision, I can't over- emphasize the importance of consulting with an experienced speech therapist who will be your best advisor.