Treatment of Vocal Fold Cysts using the Mini-MicroFlap Technique
The mini-microflap technique is a modification of its predecessor, the microflap technique, used to remove masses from the vocal folds. The mini-microflap is an improved surgical technique that yields less scarring and long-term stiffness of the vocal folds.

The former microflap technique involved incision and elevation of the superficial mucosa surrounding the mass, removal of the mass, and reapproximation of the mucosa. The procedure was a successful pathway for removal of vocal fold masses; however, a small, albeit significant, number of patients showed prolonged stiffness of the vocal folds several months after surgery.

The long-term stiffness of the vocal folds after a reasonably atraumatic microflap procedure can be best explained by the existence of a delicate and complex basement membrane structure that connects between the epithelium and the superficial layer of the lamina propria. Following known patterns of basement membrane behavior in other parts of the body, it can be hypothesized that the integrity of its attachments to the lamina propria is tied strongly to the healing characteristics of the vocal folds. 

This hypothesis then implies that elevation of the mucosa during a traditional microflap technique could actually cause irreparable damage to functional anatomic structures, instead of simply manipulating insignificant tissues. Therefore, the mini-microflap technique has been designed to remove the cyst from the vocal folds as completely as possible with the smallest possible amount of its overlying mucosa, leaving surrounding tissues completely undisturbed. 

The procedure is started by making a small mucosal incision with the Straight Knife (MCLS6) immediately lateral to the mass (Figure 1). Anterior and posterior incisions are often added although they may be unnecessary for small cysts.		Figure 1
Blunt dissection of the mass is performed using either the small or large Right Angle Ball Dissector, (MCLS12 and MCLS13) and/or a straight scissors (MCL11, MicroFrance Bouchayer Instruments, spread for blunt dissection). The mass is then gently retracted and reflected medially using either the French Velvet Eye Suction (MCLS16) or the appropriate Heart-Shaped Grasper (MCLS21 or MCLS22) (Figure 2).		Figure 2
Once completely dissected from the uninvolved lamina propria, the mass is excised using the Left-Curved Scissors (MCL17 from the MicroFrance Bouchayer instruments) (Figure 3).		Figure 3
The excision is performed such that a small flap of mucosa remains at the inferior edge of the removal site. The micro-flap, which should be large enough to cover the removal site due to the bulk of the resected mass (which has acted as a tissue expander), is then reapproximated (Figure 4). Treatment of Hemorrhagic Vessels and Polyps While ectatic blood vessels and varicosities are usually asymptomatic, there are occasions when recurrent submucosal hemorrhage of enlarged or weakened vessels can cause dysphonia, and must therefore be treated. Problematic vessels can be cauterized easily using a 1-watt defocused CO2 laser; however, the utmost caution must be used to avoid thermal injury to the lamina propria, which would result in scarring. An effective way to safely address problematic vessels is to first dissect them from the surrounding mucosa using the Vascular Knife (MCLS20).		Figure 4
The distal edge of the knife is sharp to allow the dissection, while the upper surface of the knife is smooth to allow elevation of the vessel (Figure 5). The vessel can then be safely transected or cauterized with the laser, taking care so the beam does not strike the vibratory margin of the vocal fold. Hemorrhage may also induce polyps which must be removed from the vibratory margin of the vocal fold to restore proper phonation.		Figure 5
Laser dissection can cause thermal damage to the lamina propria of the local tissues and induce scarring; therefore, the polyp should be dissected sharply with cold steel instruments. The polyp can be stabilized throughout the excision using the Left or Right Heart Shaped Grasper (MCLS21 or MCLS22). A small incision is made at the base of the polyp using the Straight Knife (MCLS6) (Figure 6).		Figure 6
The deep margin of the polyp is defined bluntly with an opening motion of the Straight Micro-Scissors (MCL11, MicroFrance Bouchayer Instruments) (Figure 7).		Figure 7
As with cyst removal, this dissection usually splits the superficial layer of the lamina propia. Finally, the polyp is precisely removed along the border of the vibratory margin using the Left or Right Curved Scissors (MCL16 and MCL17, MicroFrance Bouchayer Instruments) (Figure 8).		Figure 8
Restoration of Vibration to the Margin of the Vocal Fold using Autologous Fat Implantation (Tunnel and Pocket Technique) Vocal fold scarring can cause stiffness of the vibratory margin of the vocal fold, which often results in dysphonia due to disruption of the natural motion of the vibratory region and to failure of glottic closure. To improve vibration, and thus optimize phonation, the stiffness of the medial aspect of the vocal fold must be addressed. Submucosal implantation of autologous fat has proven to be reasonably effective for restoration of plasticity to scarred vocal folds. The surgical technique detailed below has been designed such that trauma to surrounding tissues and additional scar formation are minimized. Using the Straight Knife (MCLS6), a small incision is made near the center of the superior surface of the scarred vocal fold (Figure 9).		Figure 9
Working through this incision, a narrow access tunnel is created. A pocket is extended on to the medial edge of the vocal fold using the Small Right Angle Ball Dissector (MCLS12) (Figure 10). For more heavily scarred or fibrous tissues, the distal edge of the Micro Flap Knife (MCLS26) can be used for the dissection. During the dissection, it is critical that the mucosa along the medial and inferior margins is not penetrated. To dissect adhesions in the pocket on the medial edge of the vocal fold, the Curved Spatula (MCLS1) is extremely useful because it is contoured to dissect along the natural curvature of the vocal fold margin (this instrument is also valuable in dissecting selected cysts, papillomas and other vibratory margin masses).		Figure 10
Once the pocket has been extended along the length of the scarred region, the fat is introduced through the tunnel and into the pocket using the Brunings Syringe (MCL55, MicroFrance Bouchayer Instruments), or by direct placement with the curved alligator forceps (MCLS23 or MCLS24). In most cases, the bulk of the injected fat will apply enough linear tension to the access tunnel to pull it closed; in this manner, the fat is prevented from extruding back through the tunnel (Figure 11).		Figure 11
Surgical Treatment of Recurrent Respiratory Papillomatosis (RRP) In cases where RRP interferes with phonation or causes airway obstruction, surgery for removal of the problematic lesions has become the standard of care. Ablation with the CO2 laser has proven to be an effective means for removal of the lesions; however, when the lesions are located on the vocal folds, thermal damage to the surrounding tissues is often extensive and the related scarring can cause irreparable long term dysphonia. A more delicate and less traumatic approach reduces scarring greatly and therefore improves phonatory results while providing disease control equal or superior to laser ablation. It is important to note that when operating on papillomas, great care must be taken to avoid spreading of the virus via physical contact, or "seeding", to other unaffected regions of the airway. Gentle submucosal infusion with saline and epinephrine using the Straight Injection Needle (MCLS4), Long Connector for Injection Needle (MCLS0) and angled connector (MCLS27) helps define the deep margin and shows areas of adhesion or invasion in recurrent cases. Using the Sharp Knife (MCLS6), an incision is made on the superior surface of the vocal fold, immediately lateral to the papilloma, leaving a small margin of normal tissue around the papilloma (Figure 12).		Figure 12
A microflap is then bluntly elevated between the papilloma and uninvolved superficial layer of the lamina propria using the appropriate Ball Dissector (MCLS11, MCLS12, or MCLS13), and elevated medially using heart-shaped forceps or the double-pronged hook (MCLS21, MCLS22, or MCLS2) (Figure 13).		Figure 13
The anterior and posterior attachments of the microflap are separated using the Straight Scissors (MCL11), and the papillomas and overlying mucosa are then resected en bloc by making the final incision along the inferior attachment using the Curved or Up-biting Scissors (MCL16, MCL17, MCL31, MicroFrance Bouchayer Instruments) (Figure 14).		Figure 14

When performed properly, the procedure removes all of the gross pathologic tissue without penetrating the normal superficial lamina propria, thus preventing local scarring and limiting the risk of recurrent regrowth of the papilloma.

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Nota Bene: The technique description herein and the use of instructions for the related procedures are made available by Medtronic Xomed, Inc. to the healthcare professional to illustrate the author's suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the healthcare professional's judgment, addresses the needs of the individual patient.