Voice Thickening

Voice thickening is the process of transforming the voice into a thicker, richer tone that matches age, gender, physical appearance, or professional position. The group that most frequently seeks voice thickening treatments at clinics consists of middle-aged and older male patients who want to have a deeper and more resonant voice. These patients are often men in professions such as executives, businessmen, or politicians who need a charismatic voice to succeed in their careers.

Here, two situations arise. First, thickening the voice changes the individual’s self-perception. Many people who have undergone voice thickening surgery report increased self-confidence after the operation, leading to greater success in both their social and professional lives. The second situation is that a thick and rich voice correlates with the perception of authority in society. For a CEO, soldier, or lawyer, a thin, weak voice does not align with the leadership role they represent, whereas a deep, commanding voice conveys an image of a persuasive and inspiring leader.

Aside from aesthetic concerns, voice thickening most often appears in a functional disorder known as mutational falsetto. This condition affects adult men whose physical appearance and larynx are normal for their age, but whose voice remains thin and childlike. Typically, several sessions of voice therapy can provide sufficient thickening without the need for surgery.

Various surgical methods are used to achieve the desired voice depth. In all surgical techniques, the main goal is to reduce vocal cord tension, lowering the fundamental frequency of the produced sound and thus thickening the voice.

Reducing Vocal Cord Tension (Relaxation)

This surgical method aims to reduce the tension of the vocal cords to lower the fundamental frequency, resulting in voice thickening. Indications include mutational falsetto not improved by therapy, female-to-male transgender patients, persistent high pitch despite adequate hormone therapy, some congenital voice disorders, vocal cord atrophy, vocal sulcus, and vocal scars. Additionally, it is applied to individuals without any pathological condition who simply want a deeper or thicker voice.

Relaxation thyroplasty was first described by Isshiki, with several modifications published since. Although the surgery can be performed under general or local anesthesia, local anesthesia is preferred to monitor the patient’s voice during the operation. A horizontal incision is made at the mid-level of the anterior border of the thyroid cartilage. Skin flaps are elevated, and the strap muscles are separated at the midline. The outer perichondrium is incised vertically along the midline and elevated bilaterally. After this, the surgical steps vary according to the chosen modification.

Lateral Approach – Original Isshiki Technique: Vertical cartilage incisions 5 mm posterior to the midline from the upper to the lower edge of the thyroid cartilage are made, removing 4-5 mm wide cartilage strips without damaging the inner perichondrium. The remaining cartilage edges are either sutured together or overlapped and sutured. Rarely, the procedure may be unilateral.

Medial Approach – European Laryngology Society Modification: Full-thickness vertical cartilage incisions 5 mm posterior to the midline from upper to lower thyroid cartilage edges are made using a scalpel or a fine drill if calcified. The inner perichondrium remains intact. It is elevated posteriorly about 1 cm with a fine elevator. The anterior cartilage strip is pushed inward and overlapped by lateral cartilage pieces. Patient’s voice and endoscopic view are checked during surgery. Once a satisfactory voice is achieved, the lateral cartilage edges are approximated and fixed with non-absorbable sutures. Experimental studies with excised canine larynges show combined type IIIb thyroplasty with type I thyroplasty reduces fundamental frequency more while increasing vocal fold tension and normalizing vibratory pattern.

Koçak Technique (Window Relaxation Thyroplasty – Diamond Thyroplasty): A diamond-shaped thyroid cartilage island is prepared with at least 3 mm of intact tissue at upper and lower edges. The horizontal corners extend laterally at least 10 mm parallel to the glottic plane. Cartilage incisions are made with a scalpel or a fine drill if calcified without damaging inner perichondrium. The island is circumferentially elevated. Absolute symmetry at the glottic level is achieved, with additional resections if needed. The island naturally shifts posteriorly 4-5 mm, resulting in desired pitch lowering. It can be pushed further posteriorly or stabilized with Gore-Tex if required. Endoscopic visualization during surgery is useful. If breathiness or diplophonia occurs, medialization or vertical reorientation of the cartilage island may be necessary.

After all techniques, following hemostasis, the outer perichondrium is sutured at midline, strap muscles are approximated, usually a drain is placed, and skin is closed to complete the operation.

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