Editorials

Has your voice turned a bit raspy over the years? If so, it's likely that your vocal cords have gone the way of your chin: slack and draggy. But now that injecting botulism into your neck have spruced things up in the face department, why not give the vocal cords a little firming up? 

At the Manhattan offices of Dr. Peak Woo, a potion made from the ground-up skin of human cadavers does just that. 

The painless neck injection will leave your voice silky-smooth. If evidence suggesting that your body will eventually incorporate the dead tissue, making it into your own, creeps you out, just think: What could be more horrifying than to be a 50-year-old with the face of Britney Spears and the voice of Charlotte Rae? 

While these kinds of surgeries—call it throatox—have been taking place in hospitals to reverse birth defects and restore voices to people who have suffered trauma to their necks for ages, that kind of work used to require invasive surgery—and a hospital stay. Now that Dr. Woo has found that injecting cadaver skin into the neck does the same thing, the Mt. Sinai Medical Center otolaryngologist is offering throatox to the masses. 

The substance behind this quasi-Frankensteinian form of cosmetic surgery is called Cymetra, and Dr. Woo thinks it will do for vocal cords what Botox did for facial wrinkles. 

“If you can have a Botox injection to correct wrinkles, why would you go for a face-lift?” he said. “Similarly, in this case, it’s a complicated surgical procedure versus an in-office injection.” 

Dr. Woo, a trim 50-year-old with medium-length, spiky black hair, has an office on Park Avenue, where in the four years that he has been using Cymetra, he said, he has only come across a handful of people who felt squeamish about Cymetra’s source. 

Cliff Marks, on whom Dr. Woo performed the Cymetra procedure last year, had no reservations about using the dead skin. 

“I was happy to have anything that would help me speak better,” said Mr. Marks, a 42-year-old advertising executive who has been hoarse all his life. “When you have vocal issues and you can’t use your vocal cords like you’d hope, any hope that the doctor gives you to make it better is a solution.” 

Mr. Marks first came to Dr. Woo to have a polyp removed from one of his vocal cords. During the surgery, Dr. Woo noticed that Mr. Marks had been born missing a small piece of one cord. 

“I had never realized that,” Mr. Marks said. “I just thought, ‘Hell, I’m hoarse, what can I do?’” 

Dr. Woo recommended the Cymetra injection to correct the deficiency. 

“He gave me a basic understanding that it came from donated tissue,” said Mr. Marks. “I didn’t have any problems with it at all … nor did I seek approval from any [friends or family].” 

To perform the new procedure, which he generally does in his office, Dr. Woo first numbs the patient’s neck with Novocain. Through the nose he will then pass a fiber-optic laryngoscope, which displays a picture of the patient’s throat on a monitor. He will then take the needle and thread it through the neck, near the Adam’s apple, and make the injection in the vocal fold itself. The improvement to the vocal cord should take two to four weeks. After 10 minutes of observation, the patient goes home. 

Cymetra is made solely by a New Jersey.–based biotech company called LifeCell, which first rolled out the product in late 2000. Donated skin has been available for uses like skin grafts on burn patients since 1985, but its emergence in injectable form was unique to LifeCell’s efforts. According to the company’s chief financial officer, Steven Sobieski, the company makes Cymetra by taking donated human tissue, stripping it of all its blood, and its top, epidermal layer, until all that remains is several layers of collagen and proteins. The skin is then freeze-dried with liquid nitrogen, minced into tiny particles and put into syringes for packaging. Doctors on the receiving end turn the powder into an injectable paste by drawing up saline solution into the syringe. 

“All the things we’re trying to do in surgery is getting the [folds] back together again so they can vibrate,” said Dr. Steven Schaefer, chairman of the department of otolaryngology at New York Eye and Ear Infirmary. 

LifeCell had originally envisioned Cymetra to be used as a way to erase scars, but when Dr. Woo heard about the new substance, he was the first one to suggest its use in vocal-fold augmentation, or “voice-lift” surgery. And after some initial success in animal subjects, Dr. Woo won approval to begin using it on humans. In 2002, he published the first peer-reviewed study on its use in otolaryngology. 

There are now only a handful of doctors across the country who use Cymetra. Dr. Jonathon Aviv, director, division of laryngology, at Columbia University Medical Center and a colleague and friend of Dr. Woo’s, wants to wait to make sure there are no long-term adverse effects before he starts offering Cymetra to patients. 

Dr. Woo, for his part, has yet to find any adverse reactions, but he said that in about 20 percent of his patients the Cymetra will be partially absorbed by the body, necessitating another injection. Many of the patients who got one of his Cymetra injections four years ago, however, never needed another visit. In fact, one of the main reasons Dr. Woo has become such a true believer in Cymetra is that, unlike other injectable substances like collagen or fat, Cymetra appears to mesh perfectly with the vocal cords, causing no allergic reactions or swelling. Indeed, LifeCell claims that in animal studies the material will actually bond with the body’s living tissue and allow blood supplies to grow through the Cymetra. Although Dr. Woo has not been able to confirm that claim, he does say that that might account for a peculiar phenomenon he has witnessed in Cymetra patients. 

“We have seen that some people, a year after you do their injection, their voice keeps getting better,” he said. “You first put it in as soft-tissue filler, but then that tissue becomes more robust.” 

Although Cymetra has been around since early 2000, its use in vocal-fold augmentation has only recently begun to increase in popularity. Dr. Woo, director of the Grabscheid Voice Center at Mt. Sinai Medical Center, now performs about one per week. 

Done right, the injection will plump up the limp vocal cord, making it stronger, and hence less gaspy and better able to regulate pitch. 

“If you can hand people back their whole voice strength and their pitch, you have turned back the clock a little bit,” said Dr. Stephen Rothstein, associate professor of otolaryngology at New York University Medical Center, who has done three Cymetra injections in the past six months. 

Of course, one must consider the source—cadaveric tissue. 

“There are some patients who say, ‘No, I don’t want skin from another person,’” said Dr. Woo, “But that’s not a reasonable concern,” because the skin has been completely sanitized and stripped of all identifiable elements, he said. 

The vocal folds, like any other muscle, atrophy with age, and can lose some of their bulk. When that happens, air rushes out in breathy, gaspy bursts, and the pitch of the voice starts to change. 

“You’ll have a guy in his seventies, and he complains that when he answers the phone, the person on the other side thinks the guy is his wife—because the pitch in his voice has gone up,” said Dr. Rothstein, who also has a private practice at NYU “[Conversely,] you’ll have a female in her seventies and the perception is that it’s a guy on the phone.” 

“If you’re older and you’re a C.E.O. of a company and you’re not speaking effectively, is that vanity or is that functional?” Dr. Andrew Blitzer, director of the New York Center of Voice and Swallowing Disorders at Roosevelt–St. Luke’s Hospital Center. “What you’re doing for a living is being diminished as a result of your communicative inability. That is a functional impairment.” 

But Dr. Aviv, of Columbia, says interest is spreading to the vain malingerers of Manhattan's Upper East Side. 

“Do people come in saying ‘I want my voice to sound like I was when I was 45’?” said Dr. Jonathan Aviv, “Sure, we hear that all the time.” 

Of course, as long as there are novel plastic surgeries, there will be people with obscure maladies—are deformed vocal folds the new deviated septums?—who need them medically. 

And, for what it’s worth, according to Dr. Blitzer, you can only turn back the laryngeal clock so far. 

“I don’t think if you take someone who is older and they have a raspy voice, that you can do this operation and make people think they’re 30 years old,” he said. 

But there is, he said, only one way to find out.›