Cricothyroid approximation (type 4 thyroplasty)
The original pitch-raising operation, and the one most often described in outdated sources as the standard. It is not the standard any more, and the reason why is worth understanding before you accept a quote for it.
How it works
Cricothyroid approximation — CTA, or Isshiki type 4 thyroplasty — raises vocal pitch by increasing the tension in the vocal folds rather than shortening them. The surgeon exposes the larynx through a horizontal neck incision and draws the cricoid cartilage upward towards the thyroid cartilage with permanent sutures, mimicking the action of the cricothyroid muscle you use naturally when you raise your pitch. The larynx is held in that stretched position, so a higher pitch becomes the resting state.
It is elegant in principle: it reproduces a physiological mechanism rather than removing tissue. In practice it has one structural weakness, and that weakness is why glottoplasty overtook it.
Why it fell out of favour
The pitch gain depends on the sutures holding the two cartilages in a stretched relationship indefinitely. Cartilage is not an ideal material for holding tension: sutures can loosen, cut through, or settle over months as tissue remodels. When that happens the larynx relaxes back towards its original position and the pitch falls with it.
Published series report meaningful rates of this pitch relapse, typically appearing between six and eighteen months after surgery, and it is the most-cited reason the operation is now used selectively rather than as a first choice. Reported initial gains of +3 to +6 semitones are real; the question is how much of it is still there at two years.
Two further drawbacks: it requires an open neck incision and therefore a 4 to 5 cm scar, which glottoplasty does not, and the tension it creates can reduce vocal range and make the voice feel effortful.
Cricothyroid approximation vs glottoplasty
| Cricothyroid approximation | Wendler glottoplasty | |
|---|---|---|
| Mechanism | Increases fold tension | Shortens vibrating length |
| Access | Open neck incision | Through the mouth |
| Scar | 4–5 cm | None |
| Initial pitch gain | +3 to +6 st | +3 to +7 st |
| Durability | Relapse reported in a meaningful minority | Stable once the web has healed |
| Reversibility | Sutures can in principle be released | Web can be divided but quality is not reliably restored |
| Combines with tracheal shave | Same surgical field | Needs a separate incision |
| Current role | Selective | Default worldwide |
When it is still the right operation
It has not been abandoned, and there are situations where a surgeon will reasonably prefer it:
- Where endoscopic access is poor. Some patients cannot be adequately exposed for a transoral procedure — anatomy, neck mobility, dentition, or previous surgery. An open approach sidesteps that entirely.
- Where a tracheal shave is being done anyway. The surgeon is already in the field, so the marginal cost of an open approach is lower.
- Combined with glottoplasty in patients needing a larger elevation than either delivers alone. This combination is used by some surgeons and is a legitimate reason for an open procedure.
- Where scarring at the anterior commissure from previous surgery makes a reliable web unlikely.
- Theoretical reversibility. Releasing sutures is more plausible than undoing a healed web — though "theoretically reversible" is a weak reason to choose a procedure with a higher relapse rate.
The question to ask if it is offered to you
If a provider proposes cricothyroid approximation as their standard pitch-raising operation rather than for one of the reasons above, ask directly why they are not recommending glottoplasty. There are good answers — access, combination, their own outcome data — and there is a poor one, which is that it is the technique they learned and glottoplasty is not in their repertoire. You are entitled to know which it is, and to seek a second opinion either way.
Frequently asked
What is cricothyroid approximation?
Cricothyroid approximation, also called type 4 thyroplasty, raises vocal pitch by suturing the cricoid cartilage upward toward the thyroid cartilage so the vocal folds are held under increased tension. It reproduces the action you use naturally to raise pitch, but holds the larynx there permanently.
Why is glottoplasty preferred over cricothyroid approximation?
Three reasons. Glottoplasty is done through the mouth and leaves no scar, whereas cricothyroid approximation needs a 4 to 5 cm neck incision. Glottoplasty is stable once the web has healed, whereas cricothyroid approximation has a meaningful reported rate of pitch relapse as sutures settle over six to eighteen months. And glottoplasty delivers comparable initial pitch gains.
Is cricothyroid approximation reversible?
More plausibly than glottoplasty, since sutures can in principle be released, but this should not be treated as a real advantage. Tissue remodels around the fixation and releasing it does not reliably restore the original voice.
When would a surgeon still recommend it?
Where endoscopic access is poor because of anatomy, neck mobility or previous surgery; where an open procedure such as a tracheal shave is being done anyway; combined with glottoplasty when a larger elevation is needed than either gives alone; or where scarring at the anterior commissure makes a reliable web unlikely.
Full pathway, technique comparison, recovery and costs: voice feminization surgery in Turkey. The pitch-lowering equivalent is type 3 thyroplasty.
Related treatments in Istanbul
Sources
Figures on this page that come from published research are listed here with the study they come from, so you can check them yourself.
- Isshiki N, Morita H, Okamura H, Hiramoto M. Thyroplasty as a new phonosurgical technique. Acta Oto-Laryngologica, 1974;78(5–6):451–457. The paper that introduced laryngeal framework surgery.
- Impact of Wendler glottoplasty on acoustic measures and quality of voice in transgender women: a systematic review and meta-analysis. European Archives of Oto-Rhino-Laryngology, 2024. Meta-analysis of 20 studies, 656 patients.
- Coleman E, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 — Voice and Communication chapter. International Journal of Transgender Health, 2022;23(sup1):S1–S259.
Why cricothyroid approximation lost ground to glottoplasty
Through the 1990s and 2000s, cricothyroid approximation was the default pitch-raising operation. It has been steadily displaced by Wendler glottoplasty, and the reason is durability. CTA works by suturing the cricoid and thyroid cartilages closer together, permanently imitating what the cricothyroid muscle does when you reach for a high note: it stretches the vocal folds. Stretch raises pitch immediately, and early post-operative gains of several semitones are common in published series. The problem is what happens over the following year. Sutures cut slowly through cartilage, cartilage remodels under constant load, and the artificially held tension relaxes. A meaningful share of patients lose part of the initial rise by the twelve-month mark, which is why longer follow-up studies report smaller average gains than early ones.
Glottoplasty attacks a different variable. Instead of tensioning the folds, it shortens the vibrating length by joining the front portion of the two folds. Shorter strings vibrate faster whatever the tension, so the result does not depend on a mechanical hold staying tight. That is the core reason most high-volume voice surgeons now offer glottoplasty first and reserve CTA for specific situations: revision cases, patients who cannot accept any temporary airway risk, or as a secondary tightening procedure.
CTA or Wendler glottoplasty: how the choice is actually made
| Question | Cricothyroid approximation | Wendler glottoplasty |
|---|---|---|
| How it raises pitch | Stretches the folds by fixing two cartilages together | Shortens the vibrating length of the folds |
| Approach | External, through a neck incision | Endoscopic, through the mouth, no skin incision |
| Typical reported gain | Several semitones early; partial loss over 6–12 months is common | 3–7 semitones, more stable at one year |
| Effect on loudness | Projection often reduced while tension holds | Loudness usually recovers with therapy |
| Reversibility | Partially reversible early, by releasing the sutures | Not reversible |
| Visible scar | Yes, low neck crease | No |
Notice what is not in the table: price. The two procedures cost broadly the same in Istanbul, so cost should not drive the decision. Anatomy, revision status and your tolerance for a neck scar should.
If the pitch falls again
Loss of the early gain is the characteristic CTA disappointment, and it is worth knowing the options before surgery rather than after. Re-tightening the sutures is possible but faces the same cartilage-fatigue problem. The more common revision today is to convert: perform a glottoplasty on top of the previous CTA, taking pitch stability from fold shortening rather than tension. Your surgeon should discuss this pathway at the first consultation; a surgeon who presents CTA as a one-and-done certainty is describing the 1995 literature, not the current one.
Is cricothyroid approximation reversible?
Partially, and only early. Releasing the sutures within the first months lets the cartilages drift back toward their old position, and pitch usually falls with them. After a year or more of healing and remodelling the cartilages may have fused along the new geometry, and release no longer restores the original voice. Treat it as effectively permanent when you decide.
Will CTA change my singing range?
Yes, and more predictably at the top than glottoplasty. Because the folds are held near their stretched position, the room you previously used to reach high notes is partly spent at rest. Most patients keep a usable but narrower range shifted upward. Professional singers should model this trade-off with their surgeon and a singing teacher before committing.
Can CTA be combined with a tracheal shave?
Frequently, and the combination is anatomically convenient because both procedures use the same region of the neck. The caution is the opposite combination order: performing a tracheal shave after a CTA requires care not to disturb the suture fixation. If you want both, say so at assessment so they can be planned as one operation.
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