BACKGROUND: With the development of new ENT techniques, many male transsexuals who wish to become women usually request a surgical procedure to raise the fundamental frequency of the voice (feminization). The ENT specialist and the voice-therapist have to use an interdisciplinary approach to this growing social demand. The aim of this study was to show the results in a group of transsexual patients after Wendler\'s anterior synechiae, with additional voice-therapy treatment.
METHODS: Ten male transexulas who wish to become women patients who had Wendler glottoplasty and voice-therapy were assessed. The surgical procedure consisted of a de-epithelialization of the anterior third of both vocal folds; this area was sutured and the surface of both vocal folds was vaporised with laser diode. Pre- and postsurgery voice assessment consisted of measuring fundamental frequency (Fo) and maximum phonation time, administering the transgender self-assessment questionnaire (TSEQ) and obtaining perceptual voice assessment by inter-rater agreement.
RESULTS: All the male transsexuals who wish to become women patients significantly increased their Fo (106 Hz on average) after the treatment. Furthermore, significant improvements were shown in self-reported satisfaction and in the degree of voice feminization. No improvements in the maximum phonation time were observed.
CONCLUSIONS: Wendler glottoplasty is a surgical procedure to contribute to feminising the voice, with good medium-term results and without noteworthy medical complications. The increase in vocal tone was observed using several pre- and post-surgery control measures and voice therapy.

The inverted peno-scrotal flap is considered the standard technique for vaginoplasty in male-to-female transsexuals. Nowadays, great importance is also given by patients to the reconstruction of the clitoro-labial complex; this is also reconstructed with tissue coming from glans penis, penile skin envelop and scrotal skin. Since the first sex reassignment surgery for biological males performed in Thailand in 1975, Dr Preecha and his team developed the surgical technique for vaginoplasty; many refinements have been introduced during the past 40 years, with nearly 3000 patients operated on. The scope of this paper is to present the surgical technique currently in use for vaginoplasty and clitoro-labioplasty and the refinements introduced at the Chulalongkorn University and at the Preecha Aesthetic Institute, Bangkok, Thailand. These refinements consist of cavity dissection with blunt technique, the use of skin graft in addition to the penile flap, shaping of the clitoris complex from penis glans and clitoral hood, and the use of the urethral mucosa to line the anterior fourchette of the neo-vagina. With the refinements introduced, it has been possible to achieve a result that is very close to the biological female genitalia.