Dear Reader
I note the various reports on FEMLAR and the work executed by Dr Thomas in developing the FEMLAR treatment. As reported by Dr Thomas, the results from FEMLAR can sometimes be satisfactory, and in other cases rather disappointing. In an objective manner, I would like to add some comments below.
The FEMLAR procedure requires opening up a front portion of cartillage in a given person's neck, reshaping the cut cartillage, stretching the vocal folds and then reattaching the vocal folds to a region whereat the cut cartillage is rejoined. This is a very difficult procedure to perform, and it is credit to Dr Thomas that he has had several successes when attempting this procedure. However, it worth addressing some pertinent issues below.
In reattaching the vocal folds, if there is differening tension, diaphony can results as the two vocal folds should be ideally substantially matched in their tension/resonant-frequency characteristics over the operating frequency range of the voice. Such matching of tension is difficult to ensure during FEMLAR surgery, although, in theory, could be correctable by laser adjustment.
Perhaps more significant is that vocal folds need to have lateral symmetry as well as axially symmetry, at least in respect of their vibrating mass. If there is axial asymmetry, the edges of the vocal folds do not meet in phase when articulating post-FEMLAR treatment, resulting in a poor-quality voice, largely devoid of higher frequency harmonic contemt. There is a YouTube video of a Spanish transgender girl where this is clearly a severe problem. Axial asymmetry can arise, for example, on account of vascular disruption occurring as the vocal folds are cut at one end and then stretched, resulting in thinning of both vocal folds at one end (i.e. axial asymmetry). If the vocal folds after FEMLAR are quite thick, then correction using laser may be appropriate. However, if considerable thinning occurs due to vascular deficiency or other genetic factors, the only sensible approch to employ is vocal fold augmentation, for example using Restylane (temporary filler), Radiesse (more permanent) or autologous fat transfer. Such augmentation is also difficult as it requires to take into account a need to ensure lateral symmetry of the vocal folds if diaphony is to be avoided. Moreover, autolous fat augmentation is subject to some of the injected fat being absorbed; if this occurs differentially between the vocal folds, diaphony can result (i.e. vocal folds vibrating at slightly different frequencies). I is very difficult for the surgeon to estimate the amount of augmentation material required when the degree of likely reabsorption is not known, anmely can vary from individual to individual.
A conclusion is that a good voice requires many parameters to be adjusted absolutely correctly. If a FEMLAR procedure is implemented which leaves some of these parameters mal-adjusted, a degraded voice will result, which has been found in the case of several FEMLAR candidates (see aforementioned reference to YouTube film). This has been generally reported in the literature as being a problem of FEMLAR.
There is a strong argument that FEMLAR is a sub-optimal treatment. It is safer to have a cricothyroid shave ("Adam's Apple removal"), and then use laser ablation to increase vocal fold tension to a femanine region, as axial symmetry is preserved (by avoiding cutting at one end of the vocal folds) as vascular disuption is not caused, and lateral symmetry is also maintained. Laser ablation can cause scar tissue to form which has different mechanical properties to heathy vocal fold tissue, so the laser work has to be implemented with great skill. Injections of Restylane are known to soften scar tissue permanently, and can (in theory) be used to ameliorate problems due to excess laser use resulting in the formation of scar tissue in vocal folds.
Before agreeing to FEMLAR, it is essential that you understand the process, its risks, its biological consequences, and the costs involved in trying to address problems in case the FEMLAR treatment does not result in a workable achieved set of vocal fold parameters at first attempt. When FEMLAR goes wrong, it can go badly wrong, and hence there is a risk element. Thus, FEMLAR is not a routine well-characterized process, but one that carries considerable risks of a poor outcome occurring. This is reality. I would imagine that Dr Thomas, if he is honest to himself, would endorse my comments above.
Kind reards
Timara
