Meet the Surgeon: Voice Feminization Surgery Explained for Patients and Therapists

The Missing Link for SLPs Podcast Full Transcript Mattie Murrey-Tegels 00:04 Hello, and welcome to this episode of the Missing Link for SLPs podcast. We are starting a very unique mini-series right now. And we're going to be talking about transgender voice from the surgeon’s perspective, from the therapist’s perspective, and also from the client’s perspective. Our first guest that we are going to be welcoming is one of the United Kingdom's top gender voice surgeons. Mr Chadwan Al Yaghchi is an innovative, experienced, and respected consultant ear, nose and throat surgeon. He specializes in adult and pediatric laryngology. He treats many voice disorders including airway stenosis, voice disorders, swallowing difficulties in adults and children, and much more. Mr Al Yaghchi also has a specialist interest in voice feminization surgery, which was developed during his time working in close proximity to the gender identity clinic in London. He went on to introduce a number of voice feminization procedures to the UK. This includes his own modification to the Wendler glottoplasty technique, which has since become the preferred method for voice feminization. Through his pioneering work in the field of gender affirmation surgery, Mr Al Yaghchi has been able to help hundreds of trans women to achieve a voice that more accurately reflects their gender identity. Outside work, Mr Al Yaghchi’s main interest is in cooking, and he used to write a food blog. He would have been a chef in a different life. I am so excited to welcome Mr Chadwan Al Yaghchi. We are with Mr Chadwan Al Yaghchi. And I am working hard to pronounce your name right, will you say it for us, please? Chadwan Al Yaghchi 01:51 I think you did really well there. So, it's Chadwan Al Yaghchi. Mattie Murrey-Tegels 01:55 Thank you. And you are a surgeon. Yet, in America, we would go by “Doctors”, and over in the United Kingdom, you go by “Mr ”. Can you explain why that is? Chadwan Al Yaghchi 02:05 Yes. There is a historical background to it. So, when you finish medical school, you get the title “Doctor” and you become a doctor. So, if you are a surgeon, once you get your membership of the Royal College of Surgeons, you become – your title is changed to “Mr ”. While if you are a physician – and all other medical specialties – remain a doctor for the rest of your career. And the historic background to that, it was back in the day it used to be a Royal College of Surgeons and Barbers. So, us and the barbers were all in the same category, and doctors – the Royal College of Physicians would not acknowledge us as equal doctors. So, we had Mr , and then – but we stuck with it, and we like it now. Mattie Murrey-Tegels 02:39 I love history. I love history. Will you share with us why you became a surgeon? Chadwan Al Yaghchi 02:44 It's something that goes back to my childhood. I come from a very scientific minded family. Both my parents were biology teachers by training. Like we had – I was fascinated by science and biology, and never read any storybooks. I always read science books, etc. And then, you'll see around you like role models, that friend’s who are like surgeons making a difference to people’s life, and you get inspiration. So, I decided, possibly around my teenage years, to get into medical school. Prior to that, I thought I was going to be either a graphic designer or computer programmer of some sort. But I changed my mind around in high school to go for medicine. And then going for surgery, I think once you finish your training, the specialty you choose is a lot related to your personality, I feel, in medicine. So, if you're the type of person who wants to get things done, you become a surgeon. Because somebody comes out – comes in with something, and comes out without it. It's – you offer them a solution on the spot. And so, it all possibly stems from there. Mattie Murrey-Tegels 03:48 So, it is. Right. Why did you choose to specialize in voice feminization surgery? Chadwan Al Yaghchi 03:53 It's something I got – again, I got exposed to that very early on in my training. So, I finished medical school. Since medical school, I wanted to be ear nose and throat. I wanted to do ENT. That was my chosen specialty since medical school. But when I started training in the UK, I worked – I did most of my training – postgraduate training in a residency, and the years before residency, at Charing Cross Hospital, where I work now as a consultant. So, this is where I ended up staying forever. So, Charing Cross Hospital, next door to us we have the first gender identity clinic in the UK. That goes back to the ‘70s – ‘60s, actually, and it was like just next door to us. And we have this historic link between Charing Cross Hospital and the gender identity clinic. So, we provided all the surgical treatment with all different specialties – us, urology, facial plastic, plastic surgery. So, since early days, I’ve been exposed to a very niche area, where we used to perform gender affirming voice feminization surgery. And I'm now the third generation of surgeons who took that work. So, it started with Mr Anthony Cheeseman, who introduced cricothyroid approximation to the UK, then my colleague, Professor Guri Sandhu. And then, I took it over now and pushed it a bit further with the introduction of glottoplasty. Mattie Murrey-Tegels 05:13 Yes, I have heard that. I teach anatomy and physiology. I teach voice disorders. I've worked over in London – in the UK, Nottingham, as a specialist voice therapist. So, I'm so excited to hear the work that you've done and where that drive is coming from. Where does that drive come from, then, for you leading the gender affirming voice surgeries in the United Kingdom? Chadwan Al Yaghchi 05:44 Yeah, as I said, I got the privilege of being exposed to gender affirming surgery since like just finishing medical school and starting early years of residency. And I saw firsthand how much of a difference it makes to people’s lives. The patient’s access to treatment, like 15 years ago, is a bit different to now. Social acceptance is a bit different. So, it used to be – well, it’s still a major life hurdle transgender people need to jump through to get a voice that matches their identity. But early on, like 15 years ago, when I was first starting after medical school, it was very niche, but it made a huge impact to the lives of transgender clients, patients we see. And then, I took an interest – a research interest in the beginning, collecting data, and all of that stuff you do as a first year resident. And that interest stayed with me ‘till this day. Mattie Murrey-Tegels 06:39 So, shifting away a little bit from what drives you, I would like to have the conversation change a little bit more on the clients that you have that come and work with you. Is there anything you wish that you knew those clients knew before they first consulted with you about voice feminization surgeries? Chadwan Al Yaghchi 06:57 I wish they knew about it a lot more than they do, because there are very little resources out there, unfortunately . It’s still an area that is not really covered in material that is accessible to everyone, that's widely available. The resources are not there. There is a lot in literature, medical literature, but there isn't a lot that is easily accessible to people. So, to know about the surgery – to these days, you would imagine without – with the information and the availability of data that we all have, this should be second nature. Everyone should know that this thing exists. And I have has a lot of clients that come to me, and it was like, “I've never knew there is such a thing” Mattie Murrey-Tegels 07:38 Right. Chadwan Al Yaghchi And that's very common, to come. So, that's one thing. The other thing, I wish there is good reliable resources people read – forums, internet forums and support networks are essential. But I think having information coming from medical resources in an accessible language is also essential so people can have a well-rounded understanding of what to expect. Hear it from both patients who went through the process, but also clinicians who delivered the service as well. Mattie Murrey-Tegels 08:09 So, you are going to be the voice from the surgeon’s perspective on what to expect. Can you give us an overview of what to expect in the surgeries? Chadwan Al Yaghchi 08:17 So, in general, there are three approaches – three general approaches you can take to feminize the voice. So, it's like the strings of a musical instrument. So, you either need to increase the tension, have a shorter string, or have a thinner string. And the same – it's a very crude way to describe it, but this is roughly how vocal cords work. So, the general three approaches: If you want to get more tension, you go with a cricothyroid approximation, which stretches the vocal cords and holds them in place. And that's becoming old fashioned. I think there is a lot of downside to cricothyroid approximation. It's hardly ever practiced these days. There is a lot – so much better alternatives, on all accounts. So, it's very, very rarely I will do cricothyroid approximation, and for very exceptional circumstances. The other two approaches are either get a [inaudible 09:07], and we can do a vocal folds muscle reduction with a Co2 laser or any alternative laser, and that will thin the muscle in the vocal fold, leading to increased pitch. Mattie Murrey-Tegels 09:17 Mhm. Chadwan Al Yaghchi 09:17 Or, by far the most reliable, and most widely practiced nowadays, is anterior web glottoplasty, which aims to shorten the vocal cords. So, if you use either, you need to [inaudible 09:28], and remove the lining of the front half of the vocal cords, and then stitch them together. And that will shorten the vibrating segment of the vocal cord. It’s like if you’re playing a guitar, when you press your finger note goes up, and that’s pretty much the same principle applies here. Mattie Murrey-Tegels 09:44 And you were instrumental in making some of those changes, or adding to the glottoplasty procedures? Chadwan Al Yaghchi 09:52 Yes. So, the glottoplasty was first described in the late ‘80s, early 1990s – so, it was Professor Wendler, the operation is named after. So, it's the Wendler glottoplasty. So, he used to work in Charité Hospital in Berlin, and he noted that people who come with iatrogenic web – so, somebody who had surgery on the larynx, damaged the anterior commissure of the vocal cord, and ended up with a web anteriorly, they have a higher fundamental frequency, a higher pitched voice. So, when he had his first transgender clients coming to his clinic asking for a voice feminization, he thought, why don't we create a web and see if that works, and it did. And nowadays, that’s become the standard procedure, practice across the world. And each of us surgeons will practice these – and we are still a very small pool, unfortunately – each one of us have their own modification – how you put the sutures, what instrument you use, what do you combine with it, etc. So, it's all a modification of the original technique described by Professor Wendler. Mattie Murrey-Tegels 10:55 Wonderful. Can you give us some of the factors that you as the surgeon consider in considering a patient for voice feminization surgery? And do you take every patient that comes your way? Chadwan Al Yaghchi 11:08 Yes, I almost take every patient. So, I don't want to say I will take every patient, but I think it is an essential part of the gender transition. It’s a gender affirming surgery. It’s not a cosmetic procedure. And it makes a huge difference to a person's life. I wake up in the morning, I open my mouth and speak. All I need to worry about is what I say. Imagine if every time you talk, you need to worry about how do I how sound, how am I being perceived, what do I want to say? How is –. It's very difficult. It's draining to do this every single day in every situation – social, professional, it’s really life limiting. So, I will take – yes, most patients, and then you will tailor the approach to the individual person. So, there are – some people will do better with therapy first, some people will do better with surgery than therapy. I think the jury's out on which approach is better, and I think you need to individualize that. And then other factors that are essential, that patient’s have realistic expectations, patient’s are well understanding of the procedure, and an understanding of the limitation. Because there are vocal tradeoffs that they're going to go through. If I can give them a higher pitch, I will take some of the quality of their voice or the ability to use their voice in a certain setting. So, you will have that discussion with the patient, make sure the patient has the right support network around then, and then, I will tailor my approach to an individual person Mattie Murrey-Tegels 12:38 Wonderful. You mentioned that sometimes it works – where do most of your – it works well if they have therapy, or they've had some – maybe voice training beforehand, or some therapy beforehand. Are there factors that would not qualify a patient for your services? Chadwan Al Yaghchi 13:56 Possibly one. So, there is the technical side of things. That is the patient's suitability for the surgery, the general anesthetic, anatomy, do they have – can I have access, do I need an alternative approach, etc. Patient’s, as I say, sometimes if I have a patient with a realistic expectation, or if I have doubt on the patient's understanding of the procedure, I will seek a second opinion. I sometimes will ask an opinion from gender psychologists, or a gender psychiatrist, to have other discussions and have the patient think about other aspects to it. A patient comes in, and “I want my voice to be this”. But there is a bigger picture, and it needs to fit with the bigger picture. It needs to fit around their life, their work, etc. And if there is – if I'm not sure that the patient will have the right support structure around them, I will make sure that is there before we proceed with surgery because it's a life changing event, and people need to be prepared for it properly. Mattie Murrey-Tegels 13:59 They absolutely do. Some of the clients that I have worked with, they can get so far with the voice – gender affirming voice work that we do, but they need that surgery to get them to that final [crosstalk]. Chadwan Al Yaghchi 14:15 Yeah. Mattie Murrey-Tegels 14:17 And I understand the moment they open their mouth they're misgendered, and how painful that is, and it just cuts down on who they can authentically be. Chadwan Al Yaghchi 14:25 Yeah. Mattie Murrey-Tegels 14:25 So, I love that you are taking in the whole approach of the whole entire person that you are working with. Chadwan Al Yaghchi 14:33 Exactly. Mattie Murrey-Tegels 14:35 So, who are some other members on your team that you work with then? You mentioned a psychologist? Chadwan Al Yaghchi 14:42 Yeah. So, we – I work very closely with speech and language therapy. So, I work with Christella Antoni, who is one of the leading speech and language pathologists in gender affirming voice therapy in the UK. So, again, I’ve known Christella since I was – earlier years residency, because she used to work in our clinic and other gender identity clinics back in the day. So, I work very closely with Christella and her team of therapists. She has like three or four therapists in her practice. And we have open dialogue, always, and then we share patients and we take each other’s opinion. So, it's a true partnership between us. I work with other therapists around because my patients come from a wider geography as well. And then the rest of it is our surgical team, nursing team, etc. So, I think the core people are going to be the voice surgeon, a speech and language therapist, with easy access to psychologists and psychiatric support. Mattie Murrey-Tegels 15:40 Do you take in your intakes? Do you take any – and this may be somebody else on the team – do you take any pre-operation measurements, spectrums, or habitual pitches, or anything like that? Chadwan Al Yaghchi 15:52 Yes, we do. So, I do that, and also Cristella will do that. So, I do it in my clinic when I see them first, but then when they go for their pre-op therapy, they will have a comprehensive assessment. So, in general, I will do free speech, fundamental frequency, the rainbow passage, reading the rainbow passage, fundamental frequency, maximum formation time. I do a vocal range profile – possibly not every single patient. And I do VHI-10, and a transforming voice questionnaire as patient reported outcome measures. So, this is my standard set of measurements – acoustic and voice patient reported measures. Mattie Murrey-Tegels 16:34 Many of the same measurements we do here. Chadwan Al Yaghchi 16:37 Yeah. Mattie Murrey-Tegels 16:38 What is your optimal range? How young? How old? Chadwan Al Yaghchi 16:44 I – well, how young is 18. I can't operate on children from a regulatory point of view because I don't have pediatric practice in my National Health Service. So, I do not operate on children. So, it needs to be 18 as my minimum age because of that. And I do not have an upper limit. I know there is variation in the literature on ideal age, and I think there is some evidence and literature that the operation works better in the younger population under 40. Anecdotally, from my own figures, I do not see that correlation. However, I do see that patients under 40, or under 30, they will do generally better. But I think that pitch is one thing, but the whole resonance, their ability to work with a therapist, their speech pattern that they have picked – when you have early years transition, you picked a lot of speech pattern already. So, you're already – your speech pattern is already feminized when you come in. And all of these factors play a role of the overall success of the surgery. I think the figure of fundamental frequency. I don't think age makes a difference. Mattie Murrey-Tegels 17:57 Okay. If you have a client – when you have a client that is looking for a surgeon such as yourself to perform this surgery, what do you recommend that that client or patient looks for in a voice affirming surgeon? Chadwan Al Yaghchi 18:12 Above all, go to an ear, nose and throat surgeon because – and in particular, somebody who is a laryngologist with a sub specialist interest in the laryngology, somebody who operate on the vocal cords all the time, somebody who understands the physiology of voice, and the anatomy of voice, and the anatomy of the vocal cords. And so, that's as a default. So, you need that person with that background knowledge. And in terms of a voice feminization surgeon, because, again, not every laryngologist does this work, try to go for a person who has good experience, who has good results, and who do this operation often enough. Mattie Murrey-Tegels 18:52 Yes. Chadwan Al Yaghchi 18:53 I think, like a lot of things, if you do an operation once or twice a year, maybe you shouldn't be doing it. Maybe you should ask somebody else who does it day in and day out. It’s just there is a build up of experience, you get exposed to it, you will be – you would have seen a variety of patients. You can deal with the different situations, more than when you do this occasional treatment. So, go to somebody who has a good track record. Mattie Murrey-Tegels 19:14 And a comprehensive team, like you have. Chadwan Al Yaghchi 19:17 Exactly, exactly. It's not a solo practice. It's a team sport, and you need to have that right team around you. Mattie Murrey-Tegels 19:26 Right. What would you say to the patient who is questioning whether to go ahead or not? Any words of advice? Chadwan Al Yaghchi 19:34 Don't rush into it. If you are asking yes or no, and if you are considering if it's the right thing or not, maybe you should start with therapy first. Therapy is noninvasive. It has no downside in terms of voice, apart from the investment of money and time, of course. But in terms of voice, in terms – it's noninvasive, it's reversible. It has no lifelong changes. Start there, possibly. Have an opinion from the therapist. Work with a therapist that you trust, that has the right experience. See if you can achieve your goals by therapy alone. And then don't rush into surgery. It's a – again, it's a life changing operation. So, make sure you're doing it for the right reasons, with the right person, at the right time for you, Mattie Murrey-Tegels 20:20 As a therapist who does treat gender affirming voice work, we also do things with language patterns, speech patterns, prosody patterns, gestures, all the things that add to that feminization. Chadwan Al Yaghchi 20:31 Of course. Like, I can change a single parameter. I can change fundamental frequency. That's all I can do. So, my part of the overall picture of voice feminization is really minimal. Mattie Murrey-Tegels 20:42 Oh - Chadwan Al Yaghchi 20:43 But it's all the other aspects to it – the intonation, language content, the resonance, all of that is essential to have a good natural sounding voice and a natural outcome. Mattie Murrey-Tegels 20:55 Absolutely. Absolutely. I so believe in the work that you do. Chadwan Al Yaghchi 21:00 Yes. Mattie Murrey-Tegels 21:00 Next question. When a person does go through a surgery, tell us about the recovery time. Chadwan Al Yaghchi 21:09 The recovery times – it varies a lot between surgeons because there isn't any evidence base, really. So, each of us thinks what they think is right. I think we all take a cautious approach in terms of vocal rest. So, I ask my patients to have a complete voice rest for one week. And maybe a word or two, 10 to 15 words a day in the second week. So, it's very minimal. So, it’s just trying to get the right balance between protecting the sutures – when you put the stitches, you don't want to stress the stitches and lead to break down. But early mobilization is essential for the healing of the vocal cords. So, we all know you shouldn't leave – when you do any other voice surgery, you shouldn't leave a patient on a prolonged voice use, you need to get – voice rest, sorry. So, you need to get that right, the balance right. And I think it's possibly one week complete voice rest, second week very, very minimal. It works good, in my hands. I know other surgeons will keep patients quiet for a whole month, some will do one week, some will do two weeks. It’s variable. Mattie Murrey-Tegels 22:14 How many follow up visits? Chadwan Al Yaghchi 22:17 I do a minimum of two. So, we communicate with the patient early on a lot. The recovery, etc., I like to do the first visit, ideally around three to four weeks, because at that time a lot of the healing would have happened. So, it's a good indicator of how the healing is going to go, and it's a good indicator of where the voice is going to be. It's very early days, and the voice pitch, especially in the early week or two, the pitch goes up and down quite significantly. There is a lot of hoarseness, a lot of strain. Vocally, the voice is going to be very weak. So, around three to four weeks things settle down. So, as long as the recovery is going well, and we're communicating with a patient via email, etc., everything is looking good as it’s on track, so we'll do the first visit around three to four weeks, and that will be around the time when they start their first session of therapy postoperatively. And then we do another visit around three months after that. Mattie Murrey-Tegels 23:12 So, I should have asked this question beforehand: when a patient begins to consider having the surgery and they first meet with you, what is the timeframe for first meeting with you and the surgery? Chadwan Al Yaghchi 23:27 It's – because I have a bit of a waiting list. So, we – normally, it takes three months between the first time you met me and you decide to go ahead with surgery, until I have time in my schedule to list the patient. So, it's around – well, roughly around three months. And it's – you need some cooling down period as well. It's not good to have a consultation and go for surgery the following day. I think I would say a minimum of a couple of weeks’ time for reflection, maybe a bit longer. Get you to read the material we provide. Come back with questions. We have a lot of that. People, once they've gone and read the material, they have a consultation, a lot more questions start to come to mind. They come back to me and we answer these questions. They have time to meet my therapy colleagues, as well. So, the three month lead time is a bit longer than I would like. I would like to make it a little bit shorter, but not too short. I think maybe six to eight weeks is around a good time between first visit and the actual surgery time. Mattie Murrey-Tegels 24:28 I like that processing time – very important. Chadwan Al Yaghchi 24:31 Yes. Mattie Murrey-Tegels 24:31 It’s a big – Chadwan Al Yaghchi 24:32 [crosstalk] important. In this day and age, people go on YouTube, they see results, they like the results, they come to you, and they’re like, “I want this voice”. Mattie Murrey-Tegels 24:43 Yes! Chadwan Al Yaghchi 24:44 You're not going to get that voice. Mattie Murrey-Tegels 24:45 No! Chadwan Al Yaghchi 24:46 You’re going to get your own in a higher pitch. And so, this instant gratification, instant results. I cannot – I can't provide that. So, patients need to be aware of the process and then take their time to understand the process and come to the right conclusion and the right decision, hopefully. Mattie Murrey-Tegels 25:09 What are some of the top questions patients do have for you? Chadwan Al Yaghchi 25:15 A lot. We talk about – people ask, “How am I going to sound post op”? And “What are the results? Am I guaranteed that I’m going to get this result?” And, unfortunately, it's not. There is – with all voice feminization surgery, including with a glottoplasty, there is a degree of variability between people. It's because, again, we're changing a single parameter that controls fundamental frequency. So, when I look into my results – I presented recently in the Fall Voice Conference in San Francisco, so I presented my first 110, and it's a naturally distributed result. So, the majority of people will get around the center, around the average, which is around a 62 hertz increase. But some people will get on the lower center, some will get on the higher center. So, there is a variation of the results. So, that's one thing I get asked. I don't get asked that question a lot, but something I made sure that I raise is some tradeoffs that people are going to go through. Voice projection will be affected. It's a fact of life. When I shorten the vocal cords, some projection will be lost. Projection, ability to raise your voice, project over a large room or crowded room will be limited. So, that's something I make sure that people understand the impact on their social life, but, more importantly, work. Mattie Murrey-Tegels 26:39 Is range sometimes limited as well? Chadwan Al Yaghchi 26:43 Range is variable. I think if you look into what's published in literature, it's almost a toss of a coin. It’s 50/50. Some people will get a wider range. Some people will get a narrower range. With cricothyroid approximation, the range will be a lot smaller. So, the range will go up, but it will be very narrow. It varies, but it narrows the range significantly. I think with glottoplasty, the bottom of the range will go up, the fundamental frequency will go up, the top of the range often does not go up anymore. So, it's a net effect, that it narrows the range, but in the right direction. Mattie Murrey-Tegels 27:18 [crosstalk] Chadwan Al Yaghchi 27:18] But some people will get a wider range. Some people can go upwards with singing. Mattie Murrey-Tegels 27:24 Sometimes surgeries don't always produce the results people want. What is your view on that? What happens then? Chadwan Al Yaghchi 27:32 Yes. So, there is a degree of failure associated with the surgery. Again, glottoplasty is a lot better than cricothyroid approximation, which works in like 70% of cases. I think with glottoplasty there is sutural breakdown, which can happen. I think in my practice it’s around 3%, 3.5% that the sutures do not hold, or they do break down after surgery, and it’s something we can go back and correct. But there is also a group of patients, possibly around 5%, who will have excellent results, as in surgically. It looks beautiful. It’s healed. It's healed fine, no problems. But the voice has increased very little or has not increased at all. And that, unfortunately, is disappointing but there’s not a lot I can change in that. Because, again, it's a single parameter that we’re trying to change. There are all the other aspects around that. However, what I tell my patients when they don't have that increase in fundamental frequency, I always say give therapy a second chance. Now the tool you have to use has been adjusted, the instrument is the right size, it might be a lot easier to do the things that you couldn't do with therapy previously. So, give therapy a second chance. And if that still doesn't work, then we look into what alternative surgical approaches we can offer, including mainly the muscle reduction, or in rare cases cricothyroid approximation. Mattie Murrey-Tegels 28:58 Mhm. From a therapist’s view, I love that. I have had patients come back following their surgeries, and we have, through the therapy, achieved the voice that they were looking for in addition to the surgeries. We've also had them come back and not be happy, and they go after more surgeries and more surgeries and more surgeries, to the point where their voice is almost nonfunctional, so. Chadwan Al Yaghchi 29:18 Yeah. And then that's on both patient and surgeon to – Mattie Murrey-Tegels 29:23 Right. Chadwan Al Yaghchi 29:24 - to say, enough is enough. That we're not doing the right thing. We all – we love to help. We love to help. And I would like to think that the motivation in the majority of surgeons is their keenness to help, and they want to try to do right for their patient. But at some point, you need to take a step back and think, am I doing the right thing? And then take the patient with you on this journey. Explain your reasoning. Mattie Murrey-Tegels 29:49 Absolutely, absolutely. What are some factors that a patient can do to increase the success rate of their gender from invoice surgery? Chadwan Al Yaghchi 29:59 I think following post operative instruction is very important. Maybe we overdo it a bit on worrying the patient about don’t cough and don’t talk – but I think there is a place for that. So, follow the instruction. Vocal rest, etc. Keep yourself well hydrated, all of that. Voice hygiene postoperatively. Look after your vocal cords as the healing happens. Don't rush into going back to work. I've seen patients that 10 days later, they're back in the office on Zoom calls, and then they ended up with muscle tension dysphonia, and it takes so long to unpick, and then try to get them to relax their larynx and then restart the process. So, take your time. Don't rush into vocal use. And work with a therapist. Don't say, “I've done my surgery, I’ve had like one session. I sound good. I'm out of here”. Post operative therapy is essential. Mattie Murrey-Tegels 31:01 And it’s not a checkbox. You're correct. “I’m done. The surgery is done. I've done this. My time is …” Click, click, click – Chadwan Al Yaghchi 31:06 Yes. Mattie Murrey-Tegels 31:06 – check, check. It's a very dynamic and sensitive process that is individual for each person. Chadwan Al Yaghchi 31:12 Exactly. It's a process, and then that process varies from person to person. It's – I have patients that they will go see a therapist because I make them go to see a therapist, but that's not that's not the right thing! Genuinely, if you want the best outcome from the surgery, therapy is as essential as the surgeon. Mattie Murrey-Tegels 31:34 So, stepping outside of the box just a little bit. My specialty is dysphasia. I'm presenting at a national conference next week. Is there a correlation between gender affirming voice surgery and dysphasia? Which I also know is a specialty of yours. Chadwan Al Yaghchi 31:50 I haven't seen myself, and I'm not aware that there is evidence in literature. There might be something outside that I'm not aware of. I'm not aware of any. Mattie Murrey-Tegels 31:59 [crosstalk] Chadwan Al Yaghchi 31:59 Yeah. I have patients that they report a change of swallowing in the early days, but it settles down very quickly. I don't think – it’s the scope, it’s the jet ventilation, it’s the dryness, it’s the mucus, it’s the change of sensation. But they settle down to normal very quickly. I don't think there is a correlation, not what I’ve seen. Mattie Murrey-Tegels 32:20 I didn't think so either, but I thought you would be the one to ask. Chadwan Al Yaghchi 32:23 Yeah, thank you. No, I have not seen a link. Mattie Murrey-Tegels 32:26 So, final words of advice for the individual who is considering voice – gender affirming voice surgery. Chadwan Al Yaghchi 32:34 Take your time. Do your research. See the right surgeon. See more than one surgeon if you're not – there is nothing wrong with taking a second opinion. I frequently will ask people, please go and seek a second opinion, have that wider different point of view. And work with a therapist. Surgery is one aspect. Pitch is one aspect of voice that is perceived as feminine. You need to address the overall picture, and it’s essential that therapy and surgery go hand in hand for a good outcome. Mattie Murrey-Tegels 33:09 Mhm. Any words of advice for the speech therapist working with a client recovering from – Chadwan Al Yaghchi 33:18 Know your surgeon. Communicate with your surgeon. Go and see the surgery, how the surgery is done. And then, there are two sides to this. There is the standard, just go into your toolbox. Look into postoperative. It’s somebody who had surgery on their vocal cords. They are very hoarse, a very weak voice postoperatively. And work on your standard approach to voice therapy postoperatively. So, all therapists have that in their toolbox. Just go back into your toolbox. Use the tools that you have, and then work on the therapy, on the feminization therapy as well. Mattie Murrey-Tegels 33:55 It's funny, you mentioned to go watch a surgery. Because when I was practicing in England, I was invited into to watch surgeries, and I've never watched surgeries here. How does the speech therapist approach an ENT to say, “Can I sit in?” How do we build those relationships? Chadwan Al Yaghchi 34:11 In ENT, we’re a really friendly bunch, in general. Like we're one of the easy, easygoing, approachable specialties in terms of between [crosstalk]. Mattie Murrey-Tegels 33:55 [crosstalk] Chadwan Al Yaghchi 34:20 Yeah. So. And then we work closely with speech and language therapists within our hospital. So, just raise interest. Get in touch. Speak to your surgeon and say. Everyone will welcome you in their operating theater. I know very few surgeons that would not. I can't think of a surgeon that will turn it down flat out. There is – Mattie Murrey-Tegels 34:43 Right. Chadwan Al Yaghchi 34:44 There is also some logistics that you need to jump through. But I will really welcome any speech and language therapy. In fact, in our National Health Service, when we have a new therapist joining our team – because, again, I work in airway stenosis, mostly, in my National Health Service, so we have quite a large team – so, when we have a new therapist joining us, it’s part of their induction to come to our theater and see how the operation is done. See – just understand how the operation, what’s the impact, how much trauma is there to the larynx, etc. So, your surgeon is – will be very welcoming, just approach them. Mattie Murrey-Tegels 35:19 Wonderful. Well, thank you for your time today. And thank you for opening – you reached out to me and said, “Let's have this interview. Let me share with you what I do”. And I am so excited about this. We're going to be pulling on some gender affirming voice patients who – and we're going to meet with them. We're also going to be working with some therapists that work with this population. And I'm just so excited to be having these conversations. So, thank you very, very much for your time. Chadwan Al Yaghchi 35:45 No, thank you very much for having me. It's an absolute pleasure. Thank you. Mattie Murrey-Tegels 35:53 I hope you enjoyed that as much as I did. One of the things that struck me most about that conversation was Mr Al Yaghchi was just as humble and as authentic as could be. This podcast is all about finding guests, finding listeners, finding people who share this purpose, this drive that we all are looking for, and creating a space where we can come together and support one on one another. I so enjoyed that conversation. You may have noticed, about a third of the way in, I got a little nervous, and I think I asked him the same question twice but just in a different angle. And then I got out of my head and I got back into the conversation. So, it's okay to get nervous a little bit with some of the people that we talk to, and some of the areas that we're branching into. It's okay to not know everything and to not be perfect, and to also really show up as our genuine authentic selves, which is what I think this conversation was all about. So, I am really glad you listened all the way through to the end of this. If you're watching this on YouTube, I'm really glad that you watched all the way to the end of this, and thanks for coming aboard. Please like, share, follow, subscribe – all of those things to help build this podcast up, The Missing Link for Fresh SLPs – nope, the Missing Link for SLPs. Go to our website freshslp.com. Find us on Instagram @FreshSLP. Find me on LinkedIn. Reach out to me. Tell me what you want, what you need, and we will keep these conversations going. And we may just invite Mr Al Yaghchi back again, because I would love to hear more about his food blog, and some of the other work that he's doing. So, take care and looking forward to having you listen again!