folds, or by increasing the tension of the folds. Transgender women can undergo surgery to raise their vocal pitch as measured by fundamental frequency (F0), to increase their pitch range and to remove access to lower frequency ranges in their voice. The current pitch-raising vocal surgeries include: Cricothyroid approximation (CTA) (The most common procedure) This surgery tenses and elongates the vocal folds in order to increase vocal pitch. This is done by bringing the cricoid cartilage closer to the thyroid cartilage with sutures or metal plates. The cricoid cartilage is shifted backward and upward and the thyroid cartilage is moved forward and downward. This mimics cricothyroid muscle contraction that tenses and elongates the vocal folds which causes the pitch to increase. Anterior glottal web formation or anterior commissure advancement This surgery shortens the vibrating length of the vocal folds to raise vocal pitch. The tissue of the anterior part of the vocal folds is removed, and then this tissue is sutured together to form a nonvibrating anterior web. Laser assisted voice adjustment (LAVA) In this procedure, microlaryngoscopy (a surgical procedure that looks at the vocal folds in great detail) is done in conjunction with a carbon dioxide (CO2) laser that vaporizes small portions of the vocal folds. When the vocal fold tissue is in the process of healing and scarring, the vocal folds decrease in mass and increase in stiffness. This results in a rise in vocal pitch. Laser reduction glottoplasty (LRG) This procedure involves using a carbon dioxide laser to vaporize the anterior part of the vocal folds. Then the vocal folds are tensed with sutures, causing the pitch to increase. Usually, transgender women consider vocal surgery when they feel dissatisfied with voice therapy results, or when they want a more authentic sounding feminine voice. However, it is important to note that vocal surgery alone may not produce a voice that sounds completely feminine, and voice therapy may still be needed. Although there has been evidence to show that all these surgeries can be effective in increasing vocal pitch as measured by F0, results have been mixed. However, many patients do report being satisfied with the results. Negative effects from these surgeries have been noted, including reduced voice quality, reduced vocal loudness, negative effects on swallowing and/or breathing, sore throat, infections and scarring. A positive effect of surgery can be protecting the voice from damage due to the strain