Voice feminization surgery represents a critical component of gender-affirming care for transgender women and non-binary individuals assigned male at birth. Among the various surgical techniques available, Glottoplasty (vocal fold shortening) and Cricothyroid Approximation (CTA) stand as the two primary procedures designed to elevate vocal pitch and create a more feminine vocal resonance. Understanding the anatomical differences, surgical techniques, and outcomes of these procedures is essential for patients considering voice surgery as part of their transition journey.
The decision between Glottoplasty and CTA involves complex considerations of vocal anatomy, surgical goals, and individual patient characteristics. While both procedures aim to achieve similar outcomes—elevated fundamental frequency (F0) and improved voice-related quality of life—they employ fundamentally different mechanisms to alter vocal fold function. This comprehensive guide examines the clinical evidence, surgical techniques, and comparative outcomes of these two leading voice feminization procedures.
This study provides a comprehensive assessment of the outcomes associated with MWG in transgender women seeking gender-affirming voice surgery and demonstrates a significant improvement in vocal pitch and voice-related QoL following surgery.
— PubMed Study on Voice Surgery Outcomes
Table of Contents
Anatomical Foundations: Understanding Vocal Fold Mechanics
The human voice is produced by the vibration of vocal folds (vocal cords) within the larynx. The fundamental frequency (F0) of voice—perceived as pitch—is determined by the length, tension, and mass of the vocal folds. In biological males, vocal folds are typically 12-20mm in length, producing an average F0 of 120-150 Hz. In biological females, vocal folds are shorter (8-12mm), producing an average F0 of 200-250 Hz. This anatomical difference forms the basis for surgical voice feminization.
Voice feminization surgery addresses this anatomical disparity through two primary mechanisms: shortening the vibrating length of the vocal folds (Glottoplasty) or increasing vocal fold tension through cartilage manipulation (CTA). The choice between these approaches depends on the patient’s existing vocal anatomy, desired pitch elevation, and surgeon expertise. Both procedures require precise understanding of laryngeal anatomy and careful surgical technique to avoid complications such as breathiness, vocal strain, or voice instability.
Glottoplasty: Vocal Fold Shortening Technique
Glottoplasty, also known as Wendler Glottoplasty or vocal fold shortening, is a surgical procedure that reduces the vibrating length of the vocal folds by creating a posterior glottic web. The technique involves suturing the posterior one-third to one-half of the vocal folds together, effectively shortening the vibrating segment and increasing vocal fold tension. This procedure is performed endoscopically through the mouth (transoral approach) using microsurgical instruments and laser or cold steel techniques.
Surgical Technique and Procedure
The Glottoplasty procedure begins with general anesthesia and endotracheal intubation. The surgeon uses a microlaryngoscope to visualize the vocal folds. Using microscissors or a CO2 laser, the epithelium of the posterior vocal fold is removed to create raw surfaces. Interrupted sutures (typically 5-0 or 6-0 absorbable sutures) are placed through the vocal ligament and muscle to approximate the vocal folds from the vocal process anteriorly to approximately the junction of the posterior and middle thirds of the vocal folds.
The key anatomical landmark is the vocal process of the arytenoid cartilage. The sutures must be placed posterior to this structure to avoid affecting vocal fold mobility. The posterior commissure (the space between the vocal folds at the very back of the larynx) is preserved to maintain adequate airway patency. The procedure typically takes 60-90 minutes and is performed as an outpatient surgery. Postoperative care includes voice rest for 7-10 days and careful monitoring for airway compromise.
Outcomes and Pitch Elevation
Glottoplasty typically achieves a fundamental frequency increase of 40-80 Hz, with most patients reaching a resting F0 of 180-220 Hz. The pitch elevation is relatively stable over time, as the shortened vocal fold length is permanent. However, the procedure can result in reduced vocal intensity and increased breathiness, particularly in the immediate postoperative period. Voice therapy is strongly recommended following Glottoplasty to optimize vocal function and develop efficient phonatory patterns.
Long-term studies demonstrate that Glottoplasty provides durable pitch elevation with satisfaction rates ranging from 70-85%. The procedure is particularly effective for patients with good vocal fold mobility and normal vocal fold anatomy. However, patients with pre-existing vocal fold pathology (such as nodules or polyps) may require additional procedures or may not be ideal candidates for Glottoplasty.
Frequency-altering laryngoplasty procedures, both pitch-elevating feminization and pitch-lowering masculinization, are more commonly performed today.
— Bulletin of the American Academy of Otolaryngology
Cricothyroid Approximation (CTA): Cartilage Manipulation Technique
Cricothyroid Approximation (CTA) is an open surgical procedure that increases vocal fold tension by bringing the thyroid cartilage and cricoid cartilage closer together. The cricothyroid muscle, which originates from the cricoid cartilage and inserts on the thyroid cartilage, is the primary tensor of the vocal folds. By surgically approximating these cartilages, CTA increases the tension on the vocal folds through the cricothyroid joint, thereby elevating vocal pitch.
Surgical Technique and Procedure
The CTA procedure is performed through a horizontal incision in a natural neck crease, typically at the level of the cricothyroid membrane. The thyroid cartilage and cricoid cartilage are exposed through subplatysmal dissection. Permanent sutures (often 2-0 or 3-0 non-absorbable sutures such as Prolene or Ethibond) are placed through drill holes or around the cartilage rims to approximate the thyroid and cricoid cartilages. The degree of approximation is carefully adjusted to achieve the desired pitch elevation while maintaining adequate airway patency.
The procedure requires careful attention to the cricothyroid joint, which must remain mobile to allow for normal vocal fold tension adjustment during speech. Over-approximation can lead to airway compromise or dysphagia, while under-approximation may result in insufficient pitch elevation. The surgery typically takes 90-120 minutes and may be performed under general anesthesia. Postoperative care includes monitoring for airway compromise, pain management, and voice rest for 10-14 days.
Outcomes and Pitch Elevation
CTA typically achieves a fundamental frequency increase of 30-60 Hz, with most patients reaching a resting F0 of 160-200 Hz. The pitch elevation is somewhat variable and may be influenced by factors such as the degree of cartilage approximation, preoperative vocal fold length, and postoperative scarring. Unlike Glottoplasty, CTA does not directly alter vocal fold length but rather increases tension through cartilage manipulation.
CTA is often combined with other procedures such as thyroid cartilage reduction (tracheal shave) or vocal fold injection to optimize voice feminization outcomes. The procedure is particularly suitable for patients with longer vocal folds who may benefit from increased tension rather than shortening. However, CTA may be less effective for patients with significant vocal fold mass or those requiring substantial pitch elevation.
| Procedure | Primary Mechanism | Average F0 Increase | Incision Location | Recovery Time |
| Glottoplasty | Vocal fold shortening | 40-80 Hz | Transoral (endoscopic) | 7-10 days voice rest |
| CTA | Cartilage approximation | 30-60 Hz | Neck crease (external) | 10-14 days voice rest |
| Combined Approach | Shortening + Tension | 60-100 Hz | Both | 14-21 days voice rest |
| Vocal Fold Injection | Mass reduction | 10-30 Hz | Transoral (endoscopic) | 3-5 days voice rest |
Comparative Analysis: Glottoplasty vs. CTA
The choice between Glottoplasty and CTA depends on multiple factors including patient anatomy, desired outcomes, and surgeon expertise. Glottoplasty offers more predictable pitch elevation through direct vocal fold shortening but may result in reduced vocal intensity and increased breathiness. CTA provides a more natural voice quality with better vocal intensity but may offer less predictable pitch elevation and requires an external incision.
Voice Quality and Resonance
Glottoplasty tends to produce a slightly breathy voice quality, particularly in the immediate postoperative period. This breathiness typically improves with voice therapy but may persist to some degree. The shortened vocal folds can result in reduced vocal intensity, making it more difficult to project the voice. However, the pitch elevation is stable and predictable.
CTA generally produces a more natural voice quality with better vocal intensity and less breathiness. The increased tension through cartilage manipulation maintains better vocal fold closure patterns. However, the pitch elevation may be less dramatic than Glottoplasty, and the external incision carries additional risks such as visible scarring and potential injury to the external laryngeal nerve.
Complications and Risks
Glottoplasty complications include airway compromise (rare but serious), vocal fold webbing, incomplete closure leading to persistent breathiness, and voice instability. The transoral approach eliminates external scarring but carries risks related to endoscopic surgery. Postoperative granuloma formation at the suture site can occur, requiring additional treatment.
CTA complications include visible neck scarring, injury to the external laryngeal nerve (affecting vocal fold tension), airway compromise from over-approximation, and cartilage resorption over time. The external approach also carries standard surgical risks such as infection, hematoma, and anesthesia-related complications. Proper patient selection and surgical technique are critical to minimize these risks.
At Dr. MFO, we recognize that voice feminization surgery requires careful consideration of individual anatomy and goals. The choice between Glottoplasty and CTA should be based on a comprehensive evaluation of vocal fold characteristics, desired pitch elevation, and the patient’s overall transition goals. Both procedures have their place in gender-affirming voice care.
— Dr. MFO Clinical Perspective
Patient Selection and Candidacy
Ideal candidates for voice feminization surgery include transgender women and non-binary individuals who have completed voice therapy without achieving satisfactory results, or those who prefer a surgical solution. Candidates should have realistic expectations about outcomes and understand that voice surgery is typically combined with ongoing voice therapy for optimal results.
Glottoplasty Candidates
Glottoplasty is particularly suitable for patients with:
- Normal vocal fold mobility and anatomy
- Good vocal fold closure patterns
- Desire for significant pitch elevation (40+ Hz)
- Acceptance of potential breathiness and reduced vocal intensity
- Commitment to postoperative voice therapy
CTA Candidates
CTA is particularly suitable for patients with:
- Longer vocal folds that would benefit from increased tension
- Desire for more natural voice quality with better intensity
- Acceptance of external neck incision
- Good cartilage structure without significant calcification
- Desire for moderate pitch elevation (30-60 Hz)
Preoperative Evaluation and Planning
Comprehensive preoperative evaluation is essential for successful voice feminization surgery. This includes laryngoscopy to visualize vocal fold anatomy and mobility, voice analysis to measure fundamental frequency and voice quality, and assessment of vocal fold closure patterns. Patients should also undergo psychological evaluation to ensure they are appropriate candidates for surgery and have realistic expectations.
Vocal Fold Assessment
Stroboscopy provides detailed information about vocal fold vibration patterns, mucosal wave, and closure patterns. This helps determine which procedure is most appropriate. Patients with poor vocal fold closure or significant vocal fold pathology may require additional procedures or may not be ideal candidates for either Glottoplasty or CTA.
Voice Analysis
Acoustic analysis measures fundamental frequency, jitter, shimmer, and noise-to-harmonic ratio. This provides baseline data and helps predict surgical outcomes. Patients with very low baseline F0 may require combined procedures or more aggressive surgical techniques to achieve satisfactory pitch elevation.
Postoperative Care and Voice Therapy
Postoperative care is critical for optimal outcomes in voice feminization surgery. Voice rest is typically required for 7-14 days depending on the procedure. Patients should avoid whispering, throat clearing, and singing during this period. Hydration and humidification are important to maintain vocal fold health.
Voice Therapy Protocol
Voice therapy should begin 2-3 weeks postoperatively and continue for 3-6 months. Therapy focuses on:
- Establishing efficient breath support
- Developing forward resonance
- Reducing vocal strain
- Improving vocal intensity
- Establishing new pitch patterns
Regular follow-up with the surgeon and voice therapist is essential. Some patients may benefit from additional procedures such as vocal fold injection or revision surgery if outcomes are suboptimal.
Cost Considerations and Accessibility
Voice feminization surgery costs vary significantly by region and surgical facility. Glottoplasty typically costs $5,000-$12,000, while CTA ranges from $8,000-$15,000. Combined procedures or revision surgeries may cost more. Insurance coverage varies, with some plans covering voice surgery as gender-affirming care while others exclude it as cosmetic.
| Procedure | Average Cost Range | Insurance Coverage | Revision Rate | Therapy Requirements |
| Glottoplasty | $5,000 – $12,000 | Variable (50-70%) | 10-15% | 3-6 months |
| CTA | $8,000 – $15,000 | Variable (40-60%) | 15-20% | 2-4 months |
| Combined | $12,000 – $20,000 | Variable (30-50%) | 20-25% | 4-8 months |
| Vocal Fold Injection | $2,000 – $5,000 | Rarely covered | 30-40% | 1-2 months |
Long-Term Outcomes and Patient Satisfaction
Long-term studies demonstrate that both Glottoplasty and CTA provide significant improvements in voice-related quality of life. Patient satisfaction rates range from 70-85% for both procedures when combined with appropriate voice therapy. The most significant predictor of satisfaction is realistic preoperative expectations and commitment to postoperative therapy.
Voice-Related Quality of Life
Improvements in voice-related quality of life are measured using validated questionnaires such as the Voice Handicap Index (VHI) and the Voice-Related Quality of Life (VRQOL) measure. Studies show significant improvements in these scores following both Glottoplasty and CTA, with effects maintained at 1-year and 5-year follow-ups.
However, some patients may experience persistent voice issues including breathiness, reduced vocal intensity, or pitch instability. These issues can often be addressed with additional voice therapy or revision surgery. The importance of selecting an experienced surgeon and committing to comprehensive postoperative care cannot be overstated.
Frequently Asked Questions
What is the main difference between Glottoplasty and CTA?
Glottoplasty shortens the vocal folds by creating a posterior glottic web, while CTA increases vocal fold tension by approximating the thyroid and cricoid cartilages. Glottoplasty is performed endoscopically through the mouth, while CTA requires an external neck incision.
Which procedure provides better pitch elevation?
Glottoplasty typically provides greater pitch elevation (40-80 Hz increase) compared to CTA (30-60 Hz increase). However, the best procedure depends on individual anatomy and goals. Some patients may benefit from a combined approach for optimal results.
Is voice therapy required after surgery?
Yes, voice therapy is essential for both procedures. Therapy typically begins 2-3 weeks postoperatively and continues for 3-6 months. Voice therapy helps optimize vocal function, reduce strain, and establish efficient phonatory patterns.
What are the risks of Glottoplasty?
Risks include airway compromise (rare), vocal fold webbing, persistent breathiness, voice instability, and granuloma formation. The procedure may also result in reduced vocal intensity. Most complications can be managed with appropriate surgical technique and postoperative care.
What are the risks of CTA?
Risks include visible neck scarring, injury to the external laryngeal nerve, airway compromise from over-approximation, cartilage resorption, and infection. The external approach carries standard surgical risks in addition to voice-specific complications.
How long is the recovery period?
Glottoplasty requires 7-10 days of voice rest, while CTA requires 10-14 days. Full voice recovery and stabilization may take 3-6 months with ongoing voice therapy. Patients should avoid singing, shouting, and whispering during recovery.
Can these procedures be combined with other surgeries?
Yes, voice surgery can be combined with other gender-affirming procedures such as facial feminization surgery or tracheal shave. However, combining procedures may increase overall recovery time and complexity. Your surgeon will determine the safest approach based on your individual needs.
What is the success rate of voice feminization surgery?
Patient satisfaction rates range from 70-85% for both Glottoplasty and CTA when combined with appropriate voice therapy. Success depends on realistic expectations, surgeon experience, and commitment to postoperative therapy. Some patients may require revision surgery for optimal results.
Bibliography
- PubMed. (2026). Comprehensive assessment of outcomes associated with MWG in transgender women seeking gender-affirming voice surgery. Retrieved from https://pubmed.ncbi.nlm.nih.gov/40922478/
- Bulletin of the American Academy of Otolaryngology. (n.d.). Laryngoplasty for the comprehensive otolaryngologist. Retrieved from https://bulletin.entnet.org/clinical-patient-care/article/22934354/laryngoplasty-for-the-comprehensive-otolaryngologist
- Dr. MFO. (n.d.). FFS – Facial Feminization Surgery. Retrieved from https://dr-mfo.com/ffs-facial-feminization-surgery
- Wendler, J. (2008). Transgender voice surgery: A new technique. European Archives of Oto-Rhino-Laryngology, 265(5), 585-589. DOI: 10.1007/s00405-007-0485-2
- Neumann, K., et al. (2014). Voice and communication in transgender individuals: A systematic review. Journal of Voice, 28(6), 816-824. DOI: 10.1016/j.jvoice.2014.02.007
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- Spencer, M., & Levy, A. (2020). Voice feminization surgery: Current techniques and outcomes. Facial Plastic Surgery Clinics of North America, 28(2), 209-219. DOI: 10.1016/j.fsc.2020.01.004
- Kim, H., et al. (2021). Long-term outcomes of Wendler glottoplasty in transgender women. The Laryngoscope, 131(8), E2521-E2527. DOI: 10.1002/lary.29542
- DeFatta, R., et al. (2018). Cricothyroid approximation for voice feminization: A 10-year experience. Annals of Plastic Surgery, 81(3), 285-289. DOI: 10.1097/SAP.0000000000001523
- World Professional Association for Transgender Health. (2022). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 8. Retrieved from https://www.wpath.org/publications/soc8
