All About Laser-Assisted Voice Adjustment Surgery (LAVA) For Voice Feminization Surgery Revisions

Laser-assisted voice adjustment (LAVA) is an endoscopic (no neck scar) laser surgery used as a revision technique after other voice feminization surgeries. It does not replace more effective surgeries, such as (Wendler's) Endoscopic Glottoplasty or VFSRAC. LAVA may play a helpful role when small pitch or symmetry adjustments are needed. Because the surgery relies on how one heals and induces vocal fold scarring, its outcomes are variable (2,4,5).

Below I've written an overview of what LAVA is, how it works, expected outcomes, and why its use is generally limited to revision surgeries.

Content warning: contains photographs of vocal fold anatomy

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How does laser-assisted voice adjustment surgery work?

LAVA is done as an outpatient procedure under general anesthesia and typically lasts less than an hour. Using a C02 laser, the surgeon removes a portion of the true vocal fold mucosal membrane. A small trough is made parallel to the medial margin of the vocal folds, but inset 1-2mms. Preserving the vibratory margin aims to reduce the impact on vocal quality (2,4,5). While the entire membranous cover may be removed in the trough, the muscle is not impacted (including the muscle is a different surgery, laser reduction glottoplasty (LRG) (3,6).

Pre- and post-surgical photos after laser-assisted voice adjustment (LAVA) from Orloff et al., 2006

Pre- and post-surgical photos after LAVA from Nuyen & Orloff 2023

LAVA's goals:

• Reduce vocal fold mass

• Induce stiffness through scar formation, though scarring differs by person, surgical technique, and healing conditions

• Which in turn aims to raise the fundamental frequency (pitch) (4,5)

• "LAVA does not shorten the vocal folds, nor does it thin the folds to lighten vocal weight" (Dr. Yung, ASHA conference, 2024)

What does recovery look like?

• Vocal rest: 7 days

• Healing: By around 12 weeks, the vaporized area has scarred, allowing the final results to be heard

• Durability: Voice changes are permanent (4,5)

What are the potential outcomes from LAVA surgery?

While the majority of patients experience a small pitch increase, others may see little change, or even a decrease in pitch. A 2006 study by Orloff et al. reported that 78% of patients experienced an average increase of 37 Hz, but the range spanned from –34 Hz (decrease) to +58 Hz (increase), reflecting the variability. This pitch increase is lower than Wendler's glottoplasty or VFSRAC, and is also less consistent. 

It is conspicuous that in the ONLY study we have that looks in depth at LAVA use for voice feminization, Orloff et al (2006), outcomes were inconsistent:

• 22% of patient's FO decreased or did not change

• 40% had blinded listeners rate their voices as Mr. or mixed

• only 40% were satisfied with their results

Notably, people who previously had a chondrolaryngoplasty (tracheal shave) are likely to see a more limited pitch increase due to changes in the muscles surrounding the anterior commissure (4,5).

What are the potential side effects from LAVA surgery?

"Inducing scar tissue within the delicate and important vibratory aspects of the true vocal folds, especially the lamina propria and medial aspect of the thyroarytenoid muscle, cause great concern" (2). These vocal concerns may manifest in the following side effects:

• Voice quality changes (hoarseness, vocal strain, strangulated vocal quality)

• Pitch related issues (pitch instability, unsatisfactory low pitch, unnaturally high pitch, diplophonia: two pitches, reduced vocal range)

• Reduced vocal clarity and projection (decreased speech clarity, decreased loudness)

These types of voice quality complications are more likely in people with a history of smoking, alcohol use, pre-existing voice disorders, prior voice surgery, uncontrolled gastroesophageal reflux disease (GERD), or poor vocal hygiene (4,5).

An additional study by Casado-Morente et al. (2024) investigated combining VFSRAC with LAVA. They found that there was minimal additional pitch increase compared to VFSRAC alone. There were also more vocal side effects in the patients who had both procedures (1).

What are the contraindications for LAVA surgery?

Prior laryngeal trauma, head or neck cancer, laryngeal surgery, or damage to the anterior commissure during chondrolaryngoplasty (tracheal shave) are all medical contraindications (4).

People with heavy occupational voice use and singers are less likely to be satisfied with the surgery (4,5).

When may LAVA be helpful?

Although LAVA is not recommended as a first choice for most people for voice feminization surgery, there are specific times where it can be useful:

• For transfeminine people who've completed voice feminization therapy, LAVA could provide the small additional pitch elevation needed for the voice to be gendered correctly in daily life.

• If someone's pitch is in the upper end of the gender ambiguous range, the greater pitch increase from glottoplasty could result in an unnaturally high voice. LAVA could raise the pitch a more limited amount.

• Between 0% and 12.5% of transgender women studied who have received anterior glottic webs, such as Wendler's glottoplasty or VFSRAC, have required minor revision surgeries. LAVA allows surgeons to selectively thin small areas of mucosa endoscopically, aiming to correct concerns such as asymmetry, or slightly increase pitch (4).

In summary, Laser-assisted voice adjustment is less predictable than glottoplasty, offers a smaller potential pitch increase, and carries higher risk. It may be a useful tool for small postoperative revisions, but has limited use as a first-choice pitch raising surgery.

Ready to find your voice? Reach out to us at harmonicspeech.com to set up your free phone consultation.

Tallulah Breslin, MS, CCC/SLP

References

1. Casado-Morente, J. C., Benjumea-Flores, F. L., Romero-Gomez, B., Angulo-Serrano, M. S., O’Connor-Reina, C., Casado-Alba, C., Galeas-Lopez, A. J., & Carricondo, F. (2024). Comparison between two surgical techniques for increasing vocal pitch by endoscopic shortening of the vocal folds. Journal of Voice, 38(6), 1513–1520.

2. Dwyer, C. D., Schneider, S. L., Gutierrez, D., & Rosen, C. A. (2023). Gender-Affirming Voice Surgery: Considerations for Surgical Intervention. Seminars in Speech and Language, 44(2), 76–89. https://doi.org/10.1055/s-0043-1761948

3. Lanham, K., Melnick, B. A., O'Connor, M. J., Bartler, A., Fuentes, R. J. C., Ho, K. C., & Galiano, R. D. (2025) Efficacy and patient satisfaction in voice feminization procedures: a systematic review and meta analysis. Otolaryngology- Head and Neck Surgery, Vol. 172(5), 1521-1538.

4. Nuyen, B., & Orloff, L.A. (2023). Laser-Assisted Voice Adjustment (LAVA). In: Courey, M.S., Rapoport, S.K., Goldberg, & L., Brown, S.K. (eds) Voice and Communication in Transgender and Gender Diverse Individuals. Springer, Cham. https://doi.org/10.1007/978-3-031-24632-6_14

   • This is a book chapter that describes Orloff et al (2006)'s findings and places it in the context of more modern understanding of how the voice works.

5. Orloff L. A., Mann A. P., Damrose J. F., & Goldman S. N. (2006). Laser-assisted voice adjustment (LAVA) in transsexuals. Laryngoscope, 116:655–660.

6. Yılmaz T. (2023). Sequential Wendler Glottoplasty and Laser Reduction Glottoplasty for Voice Feminization. The Laryngoscope, 10.1002/lary.30958. Advance online publication. https://doi.org/10.1002/lary.30958