Voice Surgery for Professional Singers
“Voice Surgery for Professional Singers” is a highly specialized operative method aimed at reinstating the fine singing voice function of the artist.
Over a period of more than 15 years, Dr. Wohlt has developed his own special method of voice surgery and then modified the technique to be particularly gentle on the voice of the professional singer. This constitutes a surgical technique of plastic reconstruction that concerns itself with the viscoelastic properties of the delicate mucosal layers of the vocal cords, optimally minimizing trauma to healthy vocal fold tissue.
This method of voice surgery for professional singers is Dr. Wohlt's signature method, which he has performed on hundreds of artists. Judging by the years of regular follow-up examinations on the performing artists and singing professionals he has phonosurgically treated, he knows that this surgical technique produces excellent long-term vocal outcomes.
The voice of singers frequently loses its distinctive vocal quality even when minor changes occur to the vocal folds — this particularly applies to the high voice types (coloratura soprano, lyric tenor). The artist therefore tends to seek the help of a medical specialist relatively quickly, when vocal cord nodules, edema or polyps requiring surgical management are still relatively small. This can pose a particular challenge to the voice surgeon and demands a filigree surgical technique of delicate plastic reconstruction that takes into account these unique anatomical difficulties.
Typical Example: Voice Surgery on a Coloratura Soprano
The following video shows a typical example of a complex voice problem in a coloratura soprano. This female artist complained about increasing problems reaching her upper range, difficulties in vocal onset and recurrent vocal fold hemorrhages. It had been a long while since she had been able to sing her signature role of Violetta in “La Traviata”.
Vocal folds before voice surgery
This video taken before vocal cord surgery shows an elongated narrow band of vocal cord edema localized in the mid third of both vocal folds that does not allow full vocal fold closure. Additionally note the small, thickened blood vessels on the vocal fold margin.
Vocal folds after voice surgery
In the above video taken after vocal cord surgery, one can now see the smoothed vocal folds that allow improved vocal fold closure during phonation. The vascular lesions were likewise treated during the same intervention.
Gentle Vocal Cord Surgery — Only Performed Under General Anesthesia
Dr. Wohlt performs vocal cord surgery exclusively on patients under general anesthesia. The safest and most effective way for the surgeon to undertake the delicate microsurgical intervention calmly is on the anesthetized patient. This prevents any serious injuries to the vocal folds that might be caused by a patient's spontaneous, uncontrolled movements during the procedure.
Anesthesiological monitoring of the patient by a chief anesthesiologist is ensured throughout the entire surgery.
Caution: No Vocal Cord Surgery on the Conscious Patient
Dr. Wohlt categorically rejects the method of indirect vocal cord surgery, especially for treating voice professionals.
The indirect method involves the conscious patient sitting in the examination chair facing the surgeon who employs a long, bent instrument (grasping forceps) that is advanced through the oral cavity down to the patient’s larynx. Not rarely, this undertaking triggers a strong gag reflex that causes the patient to make erratic defensive movements.
Here, the surgeon can only operate with one hand because he is holding an optical instrument in the other. Essentially, single-handed surgery merely consists of a blunt plucking or, even worse, a tearing off of the tissue lesions on the vocal fold surface. Since it can never be predicted with certainty how the mucous membrane boundary along the vocal fold margin will tear, this version may excise much larger portions of healthy tissues than desired or intended.
The result may invariably be irreversible vocal damage.
Proponents of the single-handed, conscious-patient method will argue that it allows stroboscopic verification at all times to determine how much tissue has been removed. As true as that may sound, it still glosses over the fact that any vocal fold tissue — once lost — cannot be reinstated, no matter how frequently the stroboscope is inserted. The outcome is often permanent injury to the voice.
The egregious disadvantages associated with indirect microlaryngoscopy are why Dr. Wohlt performs all phonosurgical interventions exclusively under general anesthesia.
Gentle Vocal Cord Surgery Using Only the Finest Stainless Steel Microinstruments
For vocal cord surgery, Dr. Wohlt exclusively uses ultrafine microinstruments hand fabricated of stainless steel in France. These precision instruments in the hands of a skilled voice surgeon are the optimal choice for performing delicate and gentle surgery on the free margins of vocal fold in professional singers.
Caution: No Vocal Cord Surgery Using Lasers
In this context, Dr. Wohlt also warns singers against vocal fold operations using lasers. In contrast to the conventionally used microinstruments made of stainless steel (cold instruments), the laser emits thermal energy. If the laser is designed to work like a "hot knife”, the heat generated can seriously impair the mucosal layers and leave burn injuries. Furthermore, the effects of the laser can activate certain cells resident in the deeper mucosal layers. These cells are called fibroblasts and, when activated, produce fibrotic, i.e. hardened, portions of tissue. The consequence can be irreversible, scarring lesions to the vocal fold tissue. Since scar tissue is not capable of vibratory motion, this laser treatment sometimes ends in serious voice disorders.
Due to its special propensity for treating vascular changes on the vocal folds, the use of the KTP laser—also called the green light laser—has been increasing over the past years. However, it is very risky when used to treat professional singers. The case of a famous opera singer, who underwent laser surgery for vocal cord polyps and was still voiceless almost a year later, illustrates the risks associated with this method. Although marketed as “modern”, phonosurgery with lasers can be harmful, especially for professional singers.
The significant risks and potential harms of laser surgery are the reasons that Dr. Wohlt performs all voice surgeries with ultrafine microinstruments made of stainless steel.
An Interview with Gerrit Wohlt, M.D.: Voice Surgery for Professional Singers
In its May/June 2016 issue, ORPHEUS, the international opera magazine in publication for over 40 years, printed an article titled: "Gerrit Wohlt, M.D. — Voice Doctor to the Stars, Episode 1: Voice Surgery for Professional Singers". In an extensive interview with Dr. Wohlt. Clauspeter Koscielny asked the “Voice Doctor to the Stars” about the special form of voice surgery he developed.
Voice Surgery for Professional Singers
Dr. Wohlt ranks internationally as one of the most authoritative specialists in diseases of the singing voice and enjoys distinction as a voice surgeon for operatic luminaries and pop stars worldwide. He lives and works as a laryngologist and phoniatrician at his own centers for voice medicine | voice surgery in Berlin and Vienna, is a trained singer with stage experience and works as a singing coach to several famous singers. In a number of interviews for ORPHEUS, he spoke with Clauspeter Koscielny about his extensive experience in the medical and surgical management of the singing voice.
Dr. Wohlt, as the personal laryngologist to prominent singers your experience with performing artists has certainly been interesting and unique. In our first conversation, I would like to concentrate on your surgical work. Let’s launch right in: What skills should a professional singer look for in a voice surgeon whom he can trust?
To begin with, I would place the bar exceptionally high in terms of this medical practitioner’s qualifications and experience. He or she must not only be a skilled surgeon, but must be able to offer a holistic concept for the therapeutic management of singers as well. In addition to many years of phonosurgical experience as a laryngologist and phoniatrician, their special surgical focus should be on so-called voice-improving operations, in other words, phonosurgery. These are the initial minimum qualifications. What is of even greater importance is a profound understanding of the singing voice and extensive practical experience with the profile of requirements for singing professions. Optimally, voice surgeons should have their own singing experience and possess enough musical talent to be able to accompany the singer on the piano and fall back on their own comprehensive expertise in vocal pedagogy.
How do you judge the care provided to singers by hospital staff?
I reject the concept of divided competence, particularly when it comes to the medical care of singers. To me, it is inconceivable that a voice surgeon would rely on the experience of non-medical staff or in-house speech therapists and singing teachers when an artist's voice quality is at stake. How does a singer rely on a team? Who bears which responsibilities? In my opinion, the attending voice doctor must be highly competent in the fields of vocal arts medicine, phonosurgery as well as vocal pedagogy. In the end, you can only give what you have inside. If this only applies to the very few – then that's just the way it is!
Dr. Wohlt, you have ranked among the most distinguished and authoritative voice surgeons for a long time. How did that come about? What's your recipe for success?
That success lies presumably in a combination of technical skills and my personal affinity to singing. Perhaps, on top of that comes a unique enthusiasm, my great passion and my burning emotion for the human singing voice, which is what lends my work—especially my surgical work—that added substance. This is reflected in the enjoyment and confidence I radiate. And that is what the singers sense. For the last 15 years now, I have been developing a special surgical technique for performing voice surgery and modified it to the needs of the professional singer’s voice. It constitutes delicate plastic reconstruction work to reinstate the fine vibrations of the vocal cords. The outcome later becomes the decisive criterion for achieving a soft, nuanced voice. I would say, this method of voice surgery is my signature method: I have meanwhile performed it on hundreds of singers. Based on the years of regular follow-up examinations on my patients, I know that this surgical technique produces excellent long-term vocal outcomes. Moreover, for years, I have likewise been developing a special form of post-phonosurgical voice therapy: it's called vocal rehabilitation for professional singers after surgical interventions. This rehabilitative method, in principle, follows a graduated regimen of adapted vocal training exercises specifically designed to accommodate for the postoperative needs of the singing voice. However, it is not a “method” that can be applied to every singer in the same way. Rather, it is a treatment modality that is individually modified to the particular needs of each singer.
What relevance, how much importance do you attribute to voice surgery for professional singers?
To me, operating on a singer is an artistic act. Surgeries, as I like to say, are my concerts that I prepare for with scrupulous stagecraft and "sing” at with great energy and inner enthusiasm. After a successful finale to my operation, I take my bows in appreciation. Each time, I regard this as a great gift—to perform a wonderful piece of work and be permitted to give ill singers their voices back. When I, as a voice surgeon, operate on a singer, my intervention is aimed at giving shape and sound—in the intrinsic sense—to his or her instrument. This creative work must be guided by a high sense of responsibility and a profound understanding for the human singing voice with all its multiple facets. This understanding can only be acquired—at least in my opinion—through long years of personal singing experience and cannot be substituted by a large number of surgical cases or innumerable scientific publications.
Medical textbooks often describe laryngeal operations as “routine procedures”. Is that how you would describe an operation on a singer?
Surgery on a singer is never a routine procedure. That description inappropriately trivializes—for my sensibilities—a truly career-defining decision in a singer’s life. Therefore, a preliminary consultation must discuss and address the realistic chances associated with the surgery alongside its risks, but also the fears felt by the singer. In and of itself, vocal cord surgery on a performing artist is like an artistic project—if I may say so—a work of art itself. You see, the voice surgeon works on creatively shaping and forming the instrument to design, if you will, the sound quality it produces. And the surgeon must also be aware of the importance of this. The doctor calling this routine has not grasped the true nature of this especially creative type of surgery.
Above, you spoke of surgery case numbers. Do you believe that the quantity of procedures should be a decision-making criterion in selecting a voice surgeon? And, if you would allow the question … how many singers have you operated on?
Overall, I would count a good 1000 singers in 20 years of surgical work. That is a relatively high number given that vocal cord surgeries are not that common in singers, but results from my specialization in vocal surgery of the singing voice. Fundamentally, I am less concerned with case numbers because: We are talking about quality, indeed, about quality of inestimable value. And, this is not subject to exponential multiplication. Of course, the voice surgeon must understand his craft, as every craftsman must do: he takes his apprenticeship, gets a diploma and then is conferred his master craftsman title. Albeit, surgery on a singer requires much much more than that. It must be an artist who operates on an artist. What I am referring to is the voice surgeon’s exceptional gift to enter into, to create with each singer an aura of “artistic resonance” before, after, and even during the operation. That may sound a little lofty, but I am firmly convinced of this. Indeed, that conviction is the basis of my daily work.
How ought we interpret what you mean by “artistic resonance”?
The affinity, the sensitivity to understand, empathize and sense. Before every surgery —beyond the scope of detailed medical facts and bodies of evidence and also beyond the disease-related limitation of a patient's singing ability—to sense the way in which the singer identifies with his individual instrument as an artist. Sometimes very fine, delicate vocal qualities are at play. Qualities which one, in my belief, as a physician can only truly grasp when one has gathered singing experience of their own. And these fine vocal qualities, which the disease usually prevents the singer from accessing and which are what the surgeon aims to restore, must be given special consideration during the procedure. For example, before every vocal cord operation, I activate what I call my inner sense of sound. This not only involves getting mentally “attuned” to the individual singer's personality, but rather constitutes a build-up of an inner “resonance” to the unique quality of his or her singing voice. What I mean is a sort of internalized retracing, empathizing with and generating a mental feeling for a certain phonation. Then, I ask myself before every single step how will this step impact the singer’s voice quality and his or her own individual voice. I hereby openly acknowledge that my inner voice always has been and continues to be my best counsel and adviser.
Dr. Wohlt, may I ask you to summarize today’s conversation?
Let me say this in closing, there is one very special trait that is required for these operations—above and beyond all the talent, all the giftedness and all the experience one may have—in a matter which is so crucial for the further career, life planning and fortunes of a singer: It's humility. Ultimately, success is dictated by a superordinate choreography that is not in our hands. In that respect, we should be modest.