Before being able to undergo any surgical procedure, the person concerned must:

• identify a specialized clinical center for the feminization of the voice (Infotrans.it offers a list of structures, present on the national territory, able to provide this type of services in the "Map of services" section)
• schedule a medical examination with the speech specialist, otolaryngologist and with the speech therapist for:
  • careful phoniatric/ ear, nose, and throat (ENT)  and speech therapy evaluation
  • laryngoscopic and laryngostroboscopic examinations (endoscopic instrumental examinations that allow to visualize the state of the vocal cords and the vibration of the mucosa)
  • electroacoustic examinations of the voice (procedures that allow to record the voice and analyze the characteristics of the voice signal)
  • evaluation of the modality of use of the voice in basal conditions.

Elsewhere and at other times, the following procedures will be carried out:

• interview with a psychologist in order to assess the motivation and conviction of the person who intends to undergo the intervention (not all locations have a dedicated psychologist in the facility for which an external evaluation will be required)
• pre-operative anesthesia evaluation (verification of the possibility of undergoing general anesthesia)

The evaluation of the speech specialist will allow us to understand if it is necessary to undertake a rehabilitative speech therapy process before undergoing the intervention and if there are indications for the intervention itself. Generally, an assigned male at birth trans person uses a falsetto register (stretching the vocal cords when speaking), that should be abandoned before performing the intervention to change the voice pitch.
In general, if taking any prescription drug, one should discuss it with the speech specialist and anesthesiologist. It may be necessary to stop taking it several days before the surgery. Pharmacological treatment can be resumed at the doctor's discretion. On the contrary, it is not necessary to interrupt any hormone therapy that may be taken.

Cricothyroid approximation
The most widely used surgery to raise the pitch of the voice is the cricothyroid approximation (type IV tyroplasty) which can also include a remodeling of the Adam's apple (a protuberance that is observed mainly in males in the area of the neck). The cricothyroid approximation raises the voice pitch by increasing the tension of the vocal cords. The surgery begins with an incision on the skin of the neck of about 3-4 cm. Subsequently, we proceed with the approximation (approximation) of the thyroid and cricoid cartilages. The thyroid cartilage is the cartilage structure that forms the aforementioned Adam's apple on the outside of the neck and which contains the vocal cords inside. The cricoid cartilage is shaped like a ring and forms the lower part of the larynx. Anteriorly, the two cartilages are joined through the cricothyroid membrane. Through the application of some stitches, the two cartilages are brought closer to each other, thus causing a stretching of the vocal cords and an increase in the tone of the voice. The skin is then sutured with an aesthetic stitch (type of suture that generally guarantees less visible scars). If necessary, a small drain is applied (thin tube that allows liquids to escape into a small bag connected to it) which will be removed in the days following the surgery. Finally, some patches are placed on the suture. The surgery is performed under general anesthesia. The duration of the surgery varies according to the surgical difficulties
Glottoplasty
Another intervention used to raise the pitch of the voice is glottoplasty which acts on the length of the vocal cords by reducing their vibrating part. The operation is carried out with an endoscopic approach in microlaryngoscopy (i.e. without external cuts), by inserting a rigid metal tube (laryngoscope) into the mouth which, with the use of the operating microscope, allows you to view the interior of the larynx and therefore the cords vowels. The mucous membrane of the anterior part of the vocal cords is removed, by using micro scissors and peeler or the CO2 laser, and then the previously "decorticated" anterior portion of the vocal cords is sutured; in this way the length of their vibrating part is reduced. Glottoplasty is performed under general anesthesia. The duration of the surgery varies according to the surgical difficulties.

Hospitalization is 1-2 nights (it can vary based on the clinical course and needs).

After cricothyroid approximation surgery (type IV thyroplasty), the person will have to observe a period of absolute silence of 7-10 days. Such silence is of crucial importance and its non-observance can strongly compromise the final result. In the postoperative period after glottoplasty surgery, the person must speak with a whispered voice and avoid coughing, to consolidate the suture of the vocal cords and prevent premature rupture of the sutures, which are reabsorbed in about three weeks.
The first phoniatric/speech therapy check-up is scheduled 7-10 days after the operation while, approximately 3 weeks after the operation, the person will have to undertake a speech therapy rehabilitation process to optimize the surgical result and harmonize the "new voice" in the social context, work and family. A quarterly check is also recommended at least for the first year after the intervention.

Like all medical and surgical acts, even if conducted with competence and experience, in accordance with current standards of science and regulations in force, even cricothyroid approximation surgery can involve risks of complications, albeit infrequent.
Among these we remember:

• neck pain in the early post-surgical period
• mild difficulty while swallowing
• generally modest bleeding of the vocal cords
• possible formation of keloid (hypertrophic scar) or retracting and permanent scars

Among the complications related to the voice it is possible to have:

• a transient alteration of the voice signal
• a functional failure (failure to reach the desired frequency and voice quality)

As for the glottoplasty operation, the most important possible complication is the rupture of the suture between the anterior part of the vocal cords, which can occur especially if the person does not comply with the prescribed behavioral rules and post-operative therapies. It follows that the elevation of the pitch of the voice does not reach the expected result and dysphonia appears due to the reduced vibration of the anterior part of the vocal cords which had been "decorticated" and the anterior glottic commissure no longer has an acute angle. In these rare cases, glottoplasty revision surgery is performed.

Pre- and post-surgical visits and instrumental examinations are carried out with regular payment of a health ticket, taking into account any exemptions. The surgery is not the responsibility of the person, when it is carried out under the agreement, while when it is carried out in a self-employed regime, it provides for an economic contribution. In some locations, speech therapy rehabilitation (pre and post surgery) is the responsibility of the person.