Comparing Voice Feminization Surgery Methods (CTA, Glottoplasty, FemLar)

Voice feminization surgeries aim to raise the habitual pitch of the voice (and sometimes alter its resonance) to a more typically feminine range. The three main surgical approaches are Cricothyroid Approximation (CTA), Wendler Glottoplasty (anterior glottic web formation), and Feminization Laryngoplasty (FemLar). Each method has distinct techniques, benefits, and drawbacks. Below is a detailed comparison, including how these procedures vary and an example of clinic-to-clinic differences (e.g. the Yeson Voice Center's technique).

Cricothyroid Approximation (CTA)

Method: CTA is an external framework surgery in which the surgeon brings the thyroid cartilage and cricoid cartilage closer together (usually with sutures or wires). This mimics the action of the cricothyroid muscle, permanently tilting the larynx to put increased tension on the vocal folds. Essentially, it "locks" the vocal folds in a somewhat stretched position to raise pitch, without directly cutting the vocal cords.

• Advantages: CTA was the first widely used pitch-raising procedure. It does not involve cutting or scarring the vocal fold tissue itself, and in principle it can be reversed (by removing or releasing the sutures) if results are unsatisfactory. The surgery can often be done in a straightforward manner via a small neck incision. Initially, CTA can achieve a moderate pitch increase (historically on the order of a few semitones), and it avoids creating a web or removing tissue from the vocal cords.

• Disadvantages: Outcomes with CTA are less reliable and often less natural-sounding than other methods. Many patients' voices acquire an unnaturally high or "falsetto" quality after CTA. Because the cartilages are braced, the voice may lack normal modulation – some describe it as monotonic or strained. Pitch gains may be modest and not long-lasting: over time the sutures can loosen or cartilage can deform, letting the voice drop partway back. (In fact, laryngologists use CTA "less and less because studies show its effects aren't as long-lasting as other types of surgery".) There is also a risk that the sutures or wires used can damage the cartilage (e.g. tearing through it), especially if under constant tension. Additionally, CTA eliminates the lower register (making it impossible to produce lower-pitched notes) but often does not adequately raise the upper range – the voice can still sound masculine if one isn't actively pitching it up, or if the person relaxes their throat. Singing ability is usually poor after CTA (hitting lower notes or a full range is typically impossible in this permanently stretched configuration). For these reasons, CTA results are often unsatisfactory, and it has largely fallen out of favor in modern voice feminization surgery.

Wendler Glottoplasty (Anterior Glottic Web Formation)

Method: Wendler glottoplasty is an endoscopic procedure (through the mouth, no external incisions) that physically shortens the vibratory length of the vocal folds. The surgeon removes or thins the epithelium (mucosal tissue) on the anterior (front) portion of both vocal folds and then stitches the front parts of the cords together, creating a small anterior web. This permanently reduces the length of the vibrating portion of the folds (similar to how a shorter guitar string produces a higher pitch). The reduced length and resulting increased tension cause a higher fundamental frequency when speaking.

• Advantages: Glottoplasty is currently the most common voice feminization surgery and is often considered the "gold standard" for pitch elevation in transfeminine patients. It is less invasive than open surgeries – done through the airway with no neck incision – and has a relatively low risk profile. Studies have shown it to be generally safe with a high success rate for raising pitch (with proper patient selection and healing). In fact, among the various procedures, anterior glottal web surgery tends to raise pitch the most on average. Many patients see their average speaking fundamental frequency (F₀) move from a male range into the female range after healing. (For example, one large meta-analysis found that vocal fold shortening procedures like glottoplasty produce the largest F₀ increases of all techniques.) Typical pitch elevation with a standard Wendler glottoplasty can be on the order of 50 Hz higher (roughly 4–5 semitones increase) for speaking voice, though individual results vary. Another benefit is that glottoplasty does not alter the resonance of the vocal tract (it leaves the throat anatomy unchanged), so the timbre remains determined by the patient's natural anatomy (this can be a pro or con depending on needs, see below). The recovery from glottoplasty, while requiring voice rest, is usually easier than an open surgery – it's an outpatient procedure with a few weeks of healing and careful voice use.

• Disadvantages: The creation of a permanent anterior web necessarily introduces some trade-offs. Because part of the vocal cords are immobilized, maximum vocal power and range are often reduced. Many patients experience a decrease in loudness or endurance – for instance, shorter maximum phonation time and slightly weaker volume. Extremely loud talking or singing (especially low notes) may be more difficult after the surgery, since the vocal folds can no longer fully vibrate along their entire length. Hoarseness or roughness in voice quality is another common side effect, at least in the early healing phase. By essentially scarring the front of the vocal folds, glottoplasty can introduce a degree of permanent raspiness or a "breathy/rough" quality, though in many cases this is mild and improves with therapy over time. Patients lose the lower part of their pitch range (which is usually desired, to prevent masculine low notes), but the upper pitch range can also be somewhat limited after web formation. The voice may have a slightly monotonic or strained character if too much tension is created. Despite these drawbacks, most patients find the trade-offs acceptable – studies using the Trans Woman Voice Questionnaire show improved satisfaction post-glottoplasty in the majority of cases, indicating that alleviating dysphoria via higher pitch outweighs the loss of some vocal versatility. It's worth noting that surgical skill and technique nuances matter: an improperly done glottoplasty (e.g. creating a web that's too long or uneven) could cause significant dysphonia. Healing must be managed carefully as well – speaking too soon can disrupt the sutures/web. In summary, Wendler glottoplasty is effective at raising pitch, but at the cost of some voice quality and range (the voice may be a bit "softer" or more fragile than an unoperated voice).

Feminization Laryngoplasty (FemLar)

Method: Feminization laryngoplasty is a more extensive surgical approach that physically reconstructs the larynx (voice box) to a smaller, more female size. Pioneered by surgeons like Dr. James Thomas, it is an open-neck surgery combined with endoscopic work on the vocal folds. In a FemLar procedure, the surgeon typically performs a partial frontal laryngectomy – removing or reshaping the anterior part of the thyroid cartilage (the "Adam's apple" area) and also shortening the vocal folds themselves by excising a section of the vibrating tissue. The vocal cords are then reattached in a more posterior (back) position within the larynx, effectively tensioning and shortening them to raise pitch. In addition, most FemLar surgeries include a thyrohyoid approximation (laryngeal elevation): the thyroid cartilage (larynx) is sutured a bit higher toward the hyoid bone. This elevation does not directly increase F₀, but it shortens the vocal tract and shifts resonance upward (producing a brighter, more feminine timbre). In essence, FemLar tackles all aspects of a deep voice: it reduces the size of the vocal folds (length and mass), increases their tension, and shrinks the overall laryngeal framework to alter resonance.

• Advantages: When done by an expert, FemLar provides a comprehensive feminization of the voice. Because it addresses pitch and resonance, the resulting voice often sounds more naturally feminine (not just higher-pitched but also lighter in timbre). The average pitch increase is significant – studies have found a comfortable speaking pitch rise of about 6 semitones (e.g. from ~139 Hz to ~196 Hz on average) after FemLar. This corresponds to roughly a 20–80 Hz upward shift, which is often greater than what Wendler glottoplasty alone achieves. In other words, FemLar tends to yield a higher overall pitch outcome than the smaller endoscopic procedures. It also reliably eliminates the lowest vocal tones (one study noted the lowest attainable pitch was raised by 7 semitones), preventing inadvertent "masculine" slips into a low register. Importantly, by reducing the size of the larynx, FemLar also provides a cosmetic benefit: it dramatically reduces the Adam's apple bulge and can obviate the need for a separate tracheal shave. In fact, the anterior cartilage removal in FemLar feminizes the neck profile more than a standard tracheal shave would (since a shave only trims excess cartilage without risking the voice, whereas FemLar actually removes part of the voice box itself). Patients who undergo feminization laryngoplasty typically report high long-term satisfaction with their pitch and voice changes. The voice after healing can be stable and clear in the female range for everyday speaking, without the need for constant conscious effort to stay high. Because the procedure was developed specifically for transfeminine patients, its multi-faceted approach (pitch + resonance change) often yields a voice that is both high-pitched and distinctly feminine in quality.

• Disadvantages: FemLar is the most invasive option and thus carries greater risks and recovery demands. It requires an open incision in the neck and removal of part of the laryngeal cartilage (essentially a controlled partial laryngectomy), which inherently is a more delicate procedure. Potential complications include scarring or webbing in undesired places, granuloma formation (benign inflammatory growths at the surgery site), or even temporary breathing difficulties – in rare cases a tracheostomy (breathing tube) may be needed if swelling obstructs the airway. The healing period is longer and may involve more extensive voice therapy and precautions. By significantly altering the larynx, FemLar also irreversibly changes the voice – if too much tissue is removed, the voice could end up too high or thin. (There have been outlier cases where pitch was raised to an extreme degree – one patient's voice increased by 320 Hz, far beyond the typical female range. This kind of overshoot is rare but illustrates that over-correction is possible if the surgeon misjudges how much to shorten the folds.) In general, FemLar will permanently eliminate low pitches and can also slightly reduce the top of the range – one study noted the highest reachable pitch decreased by ~2 semitones post-op. Thus, singing voice is affected: patients may lose both their lowest notes and a bit of their highest, leaving a narrower range (some sources report singing is only partially possible after FemLar, especially for classical techniques). The voice can sound "operated" if healing isn't optimal – e.g. an unnatural or strained quality if scar tissue is excessive. Another consideration is availability: very few surgeons worldwide perform true feminization laryngoplasty. It is a specialized operation currently offered by a limited number of centers (some in the U.S., Thailand, Australia, etc.). Some other surgeons may advertise "laryngoplasty" but are actually doing smaller adjustments (like a glottoplasty or CTA plus a shave). Because of its complexity, FemLar tends to be more expensive and often a last resort if other methods or voice therapy did not achieve the desired results. In summary, feminization laryngoplasty offers the largest and most holistic voice change (pitch + resonance), but at the cost of a more involved surgery with higher risk and limited accessibility.

Technique Variations and Clinic Differences

It's important to note that not all surgeries are equal – there is significant variation in technique between different surgeons and clinics, even for the "same" procedure. Surgical skill and specific methods can influence outcomes greatly:

• Wendler Glottoplasty Variations: Some surgeons perform glottoplasties with a laser (so-called laser reduction glottoplasty, LRG), vaporizing the front vocal fold mucosa to create the web, whereas others use cold instruments (microscissors) to dissect the tissue. Some will secure the anterior web with sutures, others with fibrin glue, or a combination, which can affect healing. The length of vocal folds that is webbed can also vary (surgeons must judge how much to shorten – too little won't raise pitch enough, too much can cause an overly high, thin voice). These nuances mean that outcomes differ: for example, a small retrospective study compared standard Wendler glottoplasty to an augmented technique and found the average pitch increase was ~48 Hz for a basic glottoplasty versus ~70 Hz when using an advanced method that included additional laser tuning. In practice, well-executed glottoplasties generally raise speaking pitch into the female range, but centers with more experience or refined techniques often report higher pitch gains and better voice quality.

• Yeson Voice Center's VFSRAC: A notable example of technique variation is the Yeson Voice Center in South Korea, which is highly regarded for its voice feminization surgeries. Yeson's proprietary method, called Vocal Fold Shortening and Retrodisplacement of the Anterior Commissure (VFSRAC), is essentially an advanced form of endoscopic glottoplasty. In VFSRAC, the anterior commissure (where the vocal cords meet at the front) is surgically released and moved backward, and the front of the vocal folds (including some of the underlying muscle) is sutured together in a shortened position. This effectively decreases the length and mass of the vibrating portion while also adding some tension – addressing all three factors (length, tension, mass) that affect pitch. Yeson surgeons also use laser techniques (LAVA) to fine-tune the edges of the folds. The result is a consistently strong pitch elevation with, reportedly, a more natural timbre than older methods. Published data and Yeson's own 12-year study show an average fundamental frequency increase of ~73–74 Hz in their transgender clients (e.g. from ~135 Hz pre-op to ~208 Hz six months post-op). This aligns with independent studies – one comparison found VFSRAC produced significantly greater F₀ increases and better patient voice scores than traditional Wendler glottoplasty. Patients of Yeson often praise that their voice remains clear and feminine without an "operated" quality. The center emphasizes that the technique yields a "natural voice" (as opposed to the falsetto-like quality of CTA or the roughness of a web). It's worth noting that Yeson's favorable outcomes also rely on rigorous postoperative care (they require strict voice rest and daily exercises, plus have speech pathologists guide recovery). In summary, Yeson's reputation reflects both an advanced surgical method and extensive experience (they have performed thousands of cases), resulting in high pitch gains and patient satisfaction.

• Other Clinics and Approaches: Aside from Yeson, there are other experienced surgeons with their own refinements. For example, some surgeons in Europe and North America also perform modified glottoplasties or combined approaches. A few have attempted to improve CTA by using miniplates or anchors instead of sutures to hold the cartilages (to avoid the sutures cutting into cartilage), but CTA's drawbacks largely remain. Some practitioners offer laser-only vocal fold tuning for minor pitch increases (without creating a web), which may be useful for small adjustments but generally yields a smaller pitch change than web formation. And as noted, feminization laryngoplasty itself can vary – not all surgeons include the thyrohyoid elevation or the same extent of cartilage reduction. Surgeon experience is critical: voice surgery is as much an art as a science, and outcomes improve with surgeons who specialize in it. Patients researching options should ensure they know which procedure is actually being offered. Terms like "voice feminization surgery" can mean different things; some clinics marketing "laryngoplasty" may actually be doing an endoscopic web (glottoplasty) or a CTA plus a tracheal shave. Always look for published results or patient testimonials from a given surgeon.

In conclusion, each method has its niche. CTA is less favored today due to modest, sometimes unnatural results and stability issues. Wendler glottoplasty is a widely used, relatively safe technique that produces a significant pitch raise, though with some reduction in vocal power and potential hoarseness. Feminization laryngoplasty offers the most dramatic and holistic voice transformation (addressing both pitch and resonance with high success rates), but it is invasive and only performed by a few specialists. Finally, differences in surgical technique (such as those employed by renowned centers like Yeson) mean that even the "same" procedure can yield different outcomes. Prospective patients should weigh the advantages and disadvantages of each approach – and consider starting with voice therapy – to choose the option that best fits their vocal goals, tolerance for surgery, and access to experienced surgeons.

Sources:

• Cleveland Clinic – Voice Feminization Surgery Overview
• Thomas, J.P. et al. (2013) – Feminization laryngoplasty outcomes
• Wikipedia – Feminization Laryngoplasty (summary of procedure and results)
• Casado-Morente et al. (2024) – Comparative study of Wendler glottoplasty vs. VFSRAC
• Yeson Voice Center – Description of VFSRAC technique and outcomes
• Wikipedia – History of Voice Feminization (CTA vs glottoplasty) (CTA falsetto issue)