Eiman Abu Bandora, Michal Icht, Noa Diamant, Micalle Carl, Yotam Lior, Narin Nard Carmel Neiderman, Roni Vass, Hen Chaushu, Yuval Nachalon, Yael Oestreicher-Kedem
9 min
Laryngochondroplasty (LCP), often referred to as a tracheal shave, is a gender-affirming procedure used to reduce the prominence of the thyroid cartilage. While hormone therapy affects many secondary sex characteristics, it does not alter the post-pubertal laryngeal cartilage, making surgery the primary option for achieving a more feminine neck contour. A newer, less invasive technique known as direct transvestibular laryngochondroplasty (DTVLCP) allows surgeons to reduce the cartilage via an oral approach, avoiding external neck incisions.
Given the central role of voice as a gender cue for transgender women, researchers sought to evaluate whether DTVLCP impacts vocal quality. Previous literature on LCP often relied on subjective reports or heterogeneous surgical cohorts, leaving a gap in objective, technique-specific data. This retrospective cohort study analyzed 28 transgender women who underwent DTVLCP, comparing preoperative and postoperative voice recordings. Researchers utilized standardized acoustic parameters, including fundamental frequency (F0), formant frequencies (F1, F2), jitter, shimmer, and maximum phonation time (MPT), to assess any changes in vocal function.
Analysis revealed that DTVLCP had no statistically significant impact on the measured acoustic parameters. Although some patients reported subjective changes in their voice, clinical examination via flexible fiberoptic laryngoscopy confirmed that vocal fold mobility remained intact in all participants. Subgroup comparisons—such as those comparing patients who had isolated DTVLCP versus those who had it combined with facial feminization—revealed no significant differences in acoustic outcomes, supporting the overall safety of the procedure regarding phonatory function.
These findings provide much-needed, objective evidence that DTVLCP is a safe and reliable option for gender-affirming neck surgery. By demonstrating that the procedure does not negatively affect vocal acoustics, clinicians can better counsel patients about the risks and outcomes of the surgery, helping to alleviate concerns regarding potential voice loss or alteration.
PURPOSE: To evaluate objective technique-specific voice outcomes following direct transvestibular laryngochondroplasty (DTVLCP) in transgender women. METHODS: A retrospective cohort study conducted at a tertiary referral Center. Included were all transgender women who underwent DTVLCP from December 2019 to July 2025. Their pre- and postoperative voice recordings were analyzed using standardized acoustic parameters, including fundamental frequency (F0), formant frequencies (F1, F2), jitter, shimmer and maximum phonation time (MPT). Subgroup analyses compared patients with and without subjective voice changes and those undergoing isolated versus combined procedures. RESULTS: Voice recordings of 28 transgender women (mean age 27.8 years) were available for acoustic analysis. Postoperative vocal fold movement was preserved in all patients. Seven patients reported subjective voice change. A comparison of pre- and postoperative acoustic analysis of the cohort's voice recordings revealed no statistically significant changes in the measured acoustic parameters (mean F0, F1, F2, jitter, shimmer, and maximum phonation time). No significant acoustic changes were found between the subgroup of patients who reported subjective postoperative voice changes (n = 7) and that of patients who did not (n = 21), and between patients who underwent isolated DTVLCP (n = 9) and those who had the procedure combined with lower facial feminization surgery (n = 19). CONCLUSION: DTVLCP was not associated with significant objective changes in the measured acoustic voice parameters. These findings support the safety of DTVLCP with respect to voice and provide technique-specific evidence in a field where existing data are largely derived from subjective reports and heterogeneous surgical approaches.
Sam: Had previous studies already shown that voice was preserved, or was the evidence too mixed to answer this particular question?
Alex: Most previous reports relied on subjective assessments. Objective acoustic studies were scarce, and some combined different surgical approaches. One mixed cohort included only a handful of patients having this direct approach, so the evidence specific to it was limited.
Sam: Then the contribution is not a new voice test. It is applying objective tests consistently to patients having the same named technique.
Alex: That is the key design choice. The researchers reviewed consecutive adult patients undergoing this operation and compared each person’s preoperative and postoperative recordings. Five patients were excluded because follow-up or baseline recordings were missing.
Sam: What did a patient actually do for those recordings? A voice can sound different in conversation than when holding a single note.
Alex: They sustained vowels, counted aloud, and read from a standardized Hebrew passage. The researchers measured fundamental frequency, the vocal fold vibration rate closely related to pitch. Measuring it across different tasks helped distinguish a vowel-specific finding from a broader speech change.
Sam: Pitch alone would miss other changes. What else did they extract?
Alex: They measured formants, resonant frequencies shaped by the vocal tract. They also measured jitter and shimmer: small variations in vibration timing and amplitude. Finally, they measured maximum phonation time, how long a patient could sustain a vowel.
Sam: So the battery covered pitch, resonance, vibration regularity, and sustained voice production. What happened when they compared before with after?
Alex: Across thirteen acoustic outcomes, none showed a statistically significant change after correction for multiple comparisons. Vocal fold movement was also preserved in every patient, as assessed through flexible scope examinations.
Sam: Why emphasize the correction? Was there a result that looked different before they applied it?
Alex: Pitch increased during the sustained “ah” vowel before correction. But that result did not remain significant after controlling the false discovery rate, which addresses false positives across multiple tests. Pitch during the other vowel, counting, and reading did not show significant changes.
Sam: An isolated vowel result is not persuasive evidence that the operation raises someone’s everyday speaking pitch.
Alex: The authors also urge caution because the pattern was inconsistent across tasks. They discuss possible mechanisms, including scarring and behavioral adaptation, but explicitly call them speculative. The study does not establish a pitch-raising effect.
Sam: Let’s return to the patients who noticed something. What did they report that these acoustic tests did not distinguish?
Alex: Seven patients reported voice changes. The reports included reduced vocal range, fatigue, and a voice described as more feminine, more masculine, or more throaty. Follow-up scope examinations found no laryngeal anatomical abnormalities in that group.
Sam: Were their acoustic changes different from those of patients who reported no change? That comparison seems more informative than the overall average alone.
Alex: The subgroup comparison found no statistically significant differences. The authors interpret this as a reminder that these acoustic measures may not fully capture subjective voice experiences. It does not mean those experiences were absent or unimportant.
Sam: A reduced range or increased fatigue could matter to someone even if the measured pitch and vibration regularity stay similar.
Alex: Those complaints are why the authors emphasize individualized counseling and managing expectations. They also compared isolated surgery with surgery combined with lower facial feminization procedures. That comparison found no significant differences in acoustic change either.
Sam: We have several negative comparisons in a small sample. How far should we trust them as evidence of safety?
Alex: I would call them useful reassurance, not proof that the procedure cannot affect voice. The paired recordings and consistent surgical approach are strengths. But a small retrospective cohort cannot rule out uncommon harm or establish that smaller differences are absent.
Sam: Timing matters too. If most recordings were early, they might miss changes that emerge later.
Alex: The median postoperative recording was just under two months after surgery. Follow-up ranged from weeks to years, so these were not measurements at a common recovery stage. The authors explicitly acknowledge that short follow-up for some patients may miss long-term outcomes.
Sam: Did the recordings taken later suggest that timing changed the picture?
Alex: Longer follow-up correlated with greater increases in a resonance measure during “ah.” That association survived multiple-comparison correction, but few patients had long follow-up. The authors treat it cautiously and cannot determine its mechanism.
Sam: So neither the main result nor that timing association supports a universal claim. This is evidence about measured outcomes, in this cohort, after this particular operation.
Alex: And at a single institution. The findings should not automatically transfer to other cartilage-reduction techniques. The authors call for larger cohorts, consistent recording times, and longer follow-up.
Sam: Who should read the full document, and where should they start?
Alex: Surgeons providing gender-affirming neck contouring and researchers studying voice outcomes should read it. Start with the operative description in the Introduction, then the paired acoustic results. Read those alongside the subjective symptoms and follow-up discussion, rather than relying on the conclusion alone.
Sam: And for researchers outside that clinical area, what is the line to remember?
Alex: This technique showed no significant change in measured voice features, but that is not a guarantee of an unchanged voice.
Sam: Keep both the recordings and the patient’s experience in view.