Voice Cosmesis: The "Voice Lift"


In the modern communication age, the voice is critical in projecting image and personality, and establishing credibility. Until very recently, it has not received enough attention from the medical profession or from the general public. In fact, most people (doctors and the general public) do not realize anything can be done to improve a voice that is unsatisfactory or even one that is adequate, but not optimal.

Historically, some techniques for voice improvement date back centuries.  Singers, actors, and public speakers have sought out "voice lessons" for centuries. However, recently techniques for voice improvement have expanded and improved; and they have become practical for a great many more people.

Vocal weakness, breathiness, instability, impaired quality and other characteristics can interfere with social and professional success.  Many problems (particularly, breathiness, softness, instability, tremor and change in habitual pitch) are associated commonly with aging. For most people, these vocal characteristics, which lead people to perceive a voice (and its owner) as "old" or "infirm," can be improved or eliminated.

The first step for anyone seeking voice improvement is a comprehensive voice evaluation. Often, voice problems that people ascribe to aging, or even to their natural genetic makeup, are caused or aggravated by medical problems. The possibilities are numerous and include such conditions as reflux, low thyroid function, diabetes, tumors, and many others. Sometimes, voice deterioration is the first symptom of a serious medical problem. So, comprehensive medical evaluation is essential before treating the voice complaints.

Once medical problems have been ruled out or treated, the next step for vocal habilitation or restoration is a program of therapy or exercise.  A multi-disciplinary team that incorporates the skills of not only a laryngologist (Ear, Nose and Throat Doctor specializing in voice), but also a speech-language pathologist (voice therapist), singing voice specialist (singing teacher working in a medical environment) and an acting voice specialist (acting voice teacher with special training.) The training involves aerobic conditioning to strengthen the power source of the voice.  In many cases, neuromuscular retraining (specific guided exercise) is sufficient to improve vocal strength and quality, eliminate effort and restore youthful vocal quality. Doing so is important not only for singers, actors, and other voice professionals (teachers, radio announcers, politicians, clergy, salespeople, receptionists etc..), but really for almost everyone. This is especially true for the elderly.  It is ironic but true that as we age, voices get softer and weaker and at the same time our spouses and friends lose their hearing.  This makes not just professional communication, but also social interaction difficult, especially in noisy surroundings such as cars and restaurants.  When people have to work to hard to communicate, they often stop; and they don't even realize that the resulting interpersonal problems are related to vocal deficiencies. Therefore, it is not surprising that when exercises and medications alone do not provide sufficient improvement, many patients elect voice surgery in an attempt to strengthen their vocal quality and endurance and to improve their quality of life. 

There are several different procedures that can be used to strengthen weak or injured voices. The selection of the operation depends upon the individual persons' vocal condition as determined by a voice team evaluation, physical examination including strobovideolaryngoscopy, and consideration of what the person wants.  Care must be taken to assure that expectations are realistic.   In most cases, surgery is directed toward bringing the vocal folds closer together so that they close more firmly. This eliminates the air leak between the vocal folds that occurs as a consequence of vocal aging (atrophy or wasting of vocal muscles or other tissues) or as a result of paresis or paralysis (partial injury to a nerve from a viral infection or other causes). In some cases, the operation is done by injecting a material through the mouth or neck into the tissues adjacent to the vocal fold, to "bulk up" the vocal tissues and bring the vocal folds closer together. This is called injection laryngoplasty and is performed usually using fat, collagen, or hydroxylapatite.  This operation is sometimes done in the operating room under general anesthesia, sometimes in the operating room under local anesthesia; and in selected people in the office with only local anesthesia. Alternatively, the problem can be corrected by performing a thyroplasty. This operation involves making a small incision in the neck. The skeleton of the voice box is entered and the laryngeal tissues are compressed slightly using Gor-Tex or silastic implants.  This procedure is generally done under local anesthesia with sedation.  All of these procedures usually are performed on an out patient basis.

Recovery usually takes days to weeks (depending on which procedure).  Any operation can be associated with complications. Rarely the voice can be made worse.  The most likely complication is that the voice improvement is not quite sufficient or that it does not hold up completely over time.  When this problem occurs, it usually can be corrected easily by "fine tuning" through additional injections or surgical adjustment of the implants. However, most of the time, satisfactory results are achieved the first time.

Voice rehabilitation through medical intervention and therapy/exercise training is appropriate for anyone unhappy with his/her vocal quality, endurance, effort, or interpersonal impact. Voice surgery to improve quality (so called "voice lift" surgery) is suitable for almost anybody who does not have major, serious medical problems such as end- stage heart disease and who is not on blood thinner medication that cannot be stopped safely for surgery, so long as that person has realistic vocal goals and expectations. However, "voice lift" surgery should really be thought of as a comprehensive program stressing medical diagnosis and physical rehabilitation, not as surgery alone.