Учебники / Operative Techniques in Laryngology Rosen 2008

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f)Elevate the vessel

Turn the vascular knife 90° and insert it underneath the vessel, hugging the vessel as closely as possible. The undersurface of the vascular knife is blunt and should not damage underlying tissues. The crook of the vascular knife is a right angle, and the vessel should rest in the crook of the instrument. In performing this maneuver, the point of the instrument is brought up through the epithelium on the other side of the blood vessel, allowing epithelial isolation with little or no epithelial resection (Fig. 22.5).

–With gentle downward pressure (toward the vocal fold), the vascular knife is advanced anteriorly and posteriorly under the vessel, isolating and elevating it. The principle is similar to that used when placing a right angle clamp under a jugular vein to isolate and resect it during radical neck dissection.

–Although there are no deep, penetrating vessels in normal anatomy, such vessels occur occasionally during resection of varicosities and ectasias. If possible, it is best to allow them to bleed until resection of the vessel is completed, and then to control them using a Cottonoid with topical epinephrine (ideally), further resection if the bleeding vessel is superfi-

cial, or CO2 laser cautery (1 or 2 W, 0.1 s, 30–40 mJ, slightly defocused).

–Separate the vessel. Once the vessel has been elevated beyond the limits of abnormality, it is resected and preserved for histopathologic analysis.

–Either the anterior or the posterior limit can be divided first. Simply cutting the vessel with the scissors is usually sufficient and bleeding from the normal vessel stops spontaneously. However, dividing the vessel with a brief CO2 laser burst is equally acceptable.

–The specimen is grasped gently with a microlaryngeal alligator forceps, and the second end of the vessel is resected in a similar manner (Fig. 22.6). The lesion is removed and sent for histopathologic analysis.

g)There is usually no bleeding. If there is mild hemorrhage, it can be controlled with one of the methods described in step f), above. More severe hemorrhage can also be controlled with cautery or the laser. This is not desirable near the vibratory margin, but in the lateral half of the vocal fold, this technique can be used safely when nec-

essary. CO2 lasers are not effective at controlling vessels larger than 0.6 mm in diameter.

h)If topical anesthetic was not applied to the larynx at the beginning of the case, it should be applied at the end of the case.

2.Operative CO2 laser cautery/vaporization

a)Intubation and exposure are performed as described in above

b)Instrumentation includes a CO2 laser with a microspot, suction, forceps and Cottonoid (see Chaps. 10, “Principles of Phonomicrosurgery” and 13, “Principles of Laser Microlaryngoscopy”).

c)All laser safety precautions should be implemented including wet Cottonoids or wet gauze strips over the cuff of the endotracheal tube (see Chap. 13).

d)In general, this author prefers not to use the laser for lesions on the vibratory margin or on the medial half of the vocal fold. Thermal injury in this area can cause stiffness that impairs vibration and can lead to permanent scarring. If the laser is used in the medial half of the musculomembranous vocal fold, then great care should be taken to be certain that the laser beam is tangential to the vibratory margin. When possible, an alligator or heart-shaped forceps should be used to gently retract the

Fig. 22.4  Incision immediately lateral to vascular lesion

Fig. 22.5  Dissection underneath vascular lesion

138 Surgical Management of Vocal Fold Vascular Lesions

Fig. 22.6  Excision of isolated vascular lesion

vibratory margin vessel into the glottis, so that the laser contact point is as far as possible from the vocal ligament (Fig. 22.7). For lesions on the superior surface, an alligator and small Cottonoid can be used to gently retract the mucosal laterally, so that the laser impact on the vessel is occurs not over the medial portion of the vocalis muscle, but rather lateral to the midline of the superior surface vocal fold. Lesions that occur laterally on the vocal fold (beyond the halfway point) can be treated effectively either by resection or vaporization. Chilling the vocal fold with ice, and using submucosal infusion of saline/adrenaline 1:10,000 solution, also help limit thermal injury.

e) There are two approaches to CO2 laser management of varicosities and ectasias. The classic approach is cautery using 1–2 W, 0.1 second exposure time, 30–40 mJ,

22 slightly defocused. This creates superficial cauterization of the vessel and minimizes thermal transfer to underlying tissues. The disadvantage of this technique is a fairly substantial recurrence rate (the vessel is found present a few months after surgery). Other laser surgeons (including Abitbol) use a focused beam and divide the vessel completely at several points. This may increase the risk of deeper thermal injury and stiffness, but it decreases the likelihood of recurrence.

3. Pulsed dye laser/pulsed-KTP laser

The pulse dye and pulsed KTP laser are relatively new instruments, currently being evaluated for safety and efficacy in the treatment of various vocal fold lesions. They have an affinity for vascular structures. Preliminary experience suggests that these lasers may be an excellent tool for management of varicosities and ecta-

 

Fig. 22.7  Vascular lesion along free edge of the vocal fold; the mucosa/varix is manipulated laterally with the alligator forceps by lateral traction

sias. They are utilized in an outpatient setting through a flexible endoscope with a working channel or passed peroral during simultaneous flexible laryngoscopy. As additional research is completed and clinical experience is acquired, laryngologists should consider this technology as a possible adjunct to, or replacement for, the options detailed above.

22.6Postoperative Care and Complications

(See also Chap. 11, “Perioperative Care for Phonomicrosurgery”)

If the lesion is on the vibratory margin, then voice rest for up to approximately 1 week is recommended. If the surgery has been limited to the superior surface of the vocal fold, voice rest generally is limited to 2–3 days, to be followed by gentle voice use. In some cases, voice rest is not prescribed at all (particularly if the cut ends of the offending vessel are in the anterior and posterior thirds of the vocal folds, where the shearing forces are much less likely to disrupt a blood clot than they are in the middle third of the vocal fold).

For patients placed on voice rest, a session with a speech– language pathologist is arranged to bring the patient off voice rest at the appropriate time. After voice rest has been completed, gentle voice use is employed for at least 3–6 weeks from the time of surgery, to permit firm healing of the blood vessels before they are subjected to the phonatory forces of loud phonation or singing.

 

Postoperative care includes anti-reflux medications that were started prior to surgery and are continued after surgery. Pain medications that do not alter coagulation are prescribed. Drugs that do affect clotting are discontinued prior to surgery (the patient is provided with a list), and not resumed until at least 1 week after surgery, unless there is compelling medical necessity to start medications sooner (such as Coumadin). Antibiotics and steroids are not used routinely.

Complications can include:

■Dental injury

■Pain, anesthesia/hypoesthesia of the tongue

■Dysgeusia

■Recanalization or recurrence of the vessel (particularly after laser cauterization)

■Vocal fold stiffness, scarring, and consequent dysphonia

Postoperative pain and neurologic dysfunction usually resolves spontaneously. Most commonly, recovery occurs within 2–3 weeks, but recovery may take 3 months.

All patients receive preoperative and postoperative voice therapy.

Vocal fold scarring is extremely rare with excision of vascular lesions. It occurs more commonly after laser treatment of vascular lesions. Scarring may produce disruption of the mucosal wave and substantial dysphonia when it occurs near the vibratory margin. However, scarring that occurs laterally also may impair voice function and be troublesome, especially to high-performance voice users. Adhesion of the mucosa to underlying tissues along the superior surface prevents the normal excursion and reflexion of the mucosal wave. Care should be exercised to minimize operative trauma at any point along the vocal fold, using cold or laser techniques, especially in singers.

Key Points

■Vocal fold vascular lesions may occur at any location on the vocal fold and are categorized as:

■Varix

■Papillary ectasia

■Spider telangiectasia

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■Only vascular lesions that have caused bleeding or other symptoms should be treated surgically in most cases.

■Some vascular lesions respond to hormonal manipulation or are asymptomatic and do not require surgical intervention.

■Resection of vascular lesions with minimal disturbance of surrounding tissues provides the best chance to avoid scarring and recurrence.

■The CO2 laser can be used for varicosities, particularly those not in the medial half of the vocal fold, but it adds an additional risk of thermal injury.

Precautions must be used to minimize these risks if CO2 laser treatment is utilized.

■Office-based treatment using pulsed dye laser/ pulsed KTP laser treatment is possible and should be considered in appropriate clinical settings.

■Postoperative dysphonia is not common, particularly after resection with cold instruments but may occur, and patients should be counseled accordingly.

Selected Bibliography

1Hirano S, Yamashita M, Kitamura M, Takagita S (2006) Photocoagulation of microvascular and hemorrhagic lesions of the vocal fold with the KTP laser. Ann Otol Rhinol Laryngol 115:253–259

2Hochman I, Sataloff RT, Hillman RE, Zeitels SM (1998) Ectasias and varices of the vocal folds: clearing the striking zone. Ann Otol Rhinol Laryngol 108:10–16

3Hsiung MW, Kang BH, Su WF, Pai L, Wang HW (2003) Clearing microvascular lesions of the true vocal fold with the KTP/523 laser. Ann Otol Rhinol Laryngol 112:534–539

4Postma GN, Courey MS, Ossoff RH (1998) Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol 107:472–476

5Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, Anderson RR (2006) Pulsed angiolytic laser treatment of ecstasies and varices in singers. Ann Otol Rhinol Laryngol 115:571–580

Chapter 23
Vocal Fold Scar	23
and Sulcus Vocalis

23.1Fundamental and Related Chapters

Please see Chaps. 4, 7, 8, 10, 32, and 48 for further information.

23.2Disease Characteristics and Differential Diagnosis

Vocal fold scar (Fig. 23.1) and sulcus vocalis (Fig. 23.2) are two similar pathologic processes that involve derangement and abnormalities of the lamina propria resulting in dysphonia, glottic insufficiency, and severe abnormality in the pliability of the vocal fold. The primary difference between vocal fold scar and sulcus vocalis is the type of alteration that occurs within the lamina propria. Sulcus vocalis is characterized by an absorption or loss of the lamina propria resulting in a deep, linear furrow along the free edge of the vocal fold. Vocal fold scar is characterized by a deposition of abnormal tissue within the lamina propria, typically thick, fibrous tissue.

The symptoms of patients with vocal fold scar and sulcus vocalis include dysphonia, decreased volume, effortful phonation, diplophonia, increased pitch, and a breathy, severe, harsh voice quality. The etiology of sulcus vocalis is usually associated with an acquired condition due to excessive voice use or trauma to the vocal folds. There are also reports of a congenital deformation of the vocal fold resulting in sulcus vocalis; however, this is a much rarer condition. Vocal fold scar is an acquired condition from some type of traumatic activity of the vocal folds. This can occur from repeated vocal fold hemorrhage, external laryngeal trauma, intubation injury, and excessive laser or cold-steel phonomicrosurgery. The most common cause of vocal fold scar, and most likely sulcus vocalis, is phonotraumatic behavior characterized by misuse, overuse, or inappropriate use of the voice. This typically occurs over a prolonged period, resulting in either absorption of the lamina propria (sulcus vocalis) or deposition of abnormal tissue within the lamina propria (vocal fold scar).

A variety of associated lesions can occur with sulcus vocalis and vocal fold scar, most notably, vocal fold cyst and fibrous mass. These two lesions can occur in a subepithelial or ligamentous area (see Chap. 4, “Pathological Conditions of the Vocal Fold”). Unique to sulcus vocalis is the formation of a mucosal bridge. A mucosal bridge is a thin band of mucosa that runs parallel to the vocal fold. It is connected anteriorly and posteriorly but not attached to the free edge of the vocal fold

(Fig. 23.3). Frequently, this mucosal bridge causes diplophonia and severe dysphonia because of its separate vibratory characteristics from the main vocal fold.

Fig. 23.1  Sulcus vocalis

Fig. 23.2  Vocal fold scar

142	Vocal Fold Scar and Sulcus Vocalis

Fig. 23.3  Mucosal bridge associated with sulcus vocalis

Differential diagnosis of vocal fold scar and sulcus vocalis include:

■Fibrous mass

■Polyp

■Vocal fold cyst

■Rheumatologic lesions of the vocal folds

Vocal fold atrophy due to muscle loss and a thinned lamina propria can have a similar appearance on laryngeal exam to sulcus vocalis, given that in both entities the vocal fold will have a “bowed” appearance. The difference between vocal fold atrophy and sulcus vocalis is the lamina propria stiffness that occurs in sulcus vocalis but is not present in vocal fold atrophy.

23.3Surgical Indications and Contraindications

The medical and surgical approaches to patients with vocal fold scar and sulcus vocalis are very similar. As in the approach to most voice disorders, maximum nonsurgical approach should

23 be utilized for the treatment of voice disorders for patients with sulcus vocalis and vocal fold scar. This typically includes treatment of medical conditions such as LPR and allergic disease, as well as optimizing speaking and singing techniques with voice therapy and singing voice therapy (see Chap. 7, “Nonsurgical Treatment of Voice Disorders”). After maximum nonsurgical therapeutic applications, a careful evaluation of the functional limitations associated with the patient’s voice disorder should be undertaken, especially by using a multidisciplinary approach with a medical and a speech–language pathology evaluation. Surgery is indicated if the significant functional limitations remain after nonsurgical treatment (see Chap. 8, “Timing, Planning, and Decision Making in Phonosurgery”).

 

Often the first surgical step is a diagnostic microlaryngoscopy. This is important for planning purposes and to determine the severity of the vocal fold pathology and the severity of the condition as well as to remove associated lesions such as fibrous mass, cysts, and/or mucosal bridge. One of the key aspects of the indications for surgery and the surgical approach for the treatment of patients with vocal fold scar/sulcus vocalis is to ascertain the degree of glottal insufficiency associated with the vocal fold scar and sulcus vocalis as well as the symptoms of vocal fatigue and decreased volume. For patients with a significant amount of glottal insufficiency and the primary symptoms of vocal fatigue and decreased volume, a vocal fold augmentation procedure or medialization procedure is often the appropriate first step for patients with vocal fold scar and sulcus vocalis (see Chaps. 31, “Vocal Fold Augmentation via Direct Laryngoscopy”; 33, “Peroral Vocal Fold Augmentation in the Clinic Setting”; 34, “Percutaneous Vocal Fold Augmentation in the Clinic Setting”; 38, “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”; and 39, “GORE-TEX® Medialization Laryngoplasty”).

After the patient’s glottal insufficiency has been addressed by vocal fold augmentation or medialization if needed, often a direct approach to the lamina propria deficit associated with vocal fold scar and sulcus vocalis is indicated. This can be achieved with the following different approaches:

1.Excision of associated lesion (Chaps. 10, “Principles of Phonomicrosurgery” and 17, “Vocal Fold Cyst and Vocal Fold Fibrous Mass”)

2.Excision of sulcus vocalis/vocal fold scar and mucosal reapproximation (see below)

3.Vocal fold fat graft reconstruction (see below)

4.Superficial vocal fold injection of collagen based materials (Chap. 32, “Superficial Vocal Fold Augmentation via Microlaryngoscopy”)

5.Gray minithyrotomy (Chap. 48, “Gray Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis”)

Contraindications comprise:

■Unreasonable expectations regarding voice quality improvement (i. e., complete resumption of normal voice)

■Persistent phonotraumatic behavior

■Untreated LPR

■Active rheumatologic disease (rheumatoid arthritis, Wegener’s granulomatosis, etc.)

■Anatomic factors resulting in poor laryngoscope visualization (relative)

In summary, a comprehensive approach to patients with sulcus vocalis and vocal fold scar involves the following:

1.Detailed, multidisciplinary evaluation (may include diagnostic microlaryngoscopy)

2.Maximum nonsurgical rehabilitation

3.Proper assessment of functional voice limitations and establishment of reasonable goals with surgical therapy

4.Excision of associated lesions

5.Augmentation or medialization of the vocal folds if warranted

 

6.Direct reconstruction of lamina propria using:

a)Superficial vocal fold injection (Chap. 32, “Superficial Vocal Fold Augmentation via Microlaryngoscopy”)

b)Fat graft reconstruction via microlaryngoscopy (see below)

c)Gray minithyrotomy (Chap. 48, “Gray Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis”)

23.4Surgical Equipment

Surgical equipment includes the following:

■Standard phonomicrosurgery set (Table 10.1)

■Knot pusher

■Regular insulin (100-U bottle)

■Lactated ringers (l liter)

■5.0, 6.0, and 7.0 absorbable suture with a variety of small microsurgical needles (often found in ophthalmology operating room supplies)

■Microlaryngoscopy needle holder

23.5Surgical Procedure

1.Excision with reapproximation via microlaryngoscopy

The goal of this procedure is to remove invaginated epithelial tissue associated with sulcus vocalis and reapproximate adjacent normal mucosa with sutures. This approach can also be used with vocal fold scar, using a microflap approach, excising abnormal vocal fold scar in the subepithelial plane and then reapproximating adjacent normal mucosa with microsutures. A concern regarding this approach should be the eventual “rounding” of the vocal fold morphology, especially along the free edge of the vocal fold. Thus, this approach is indicated when there is only small epithelial defects or when there has been no mucosal excision required as part of the approach. The advantage to this approach is that it will result in a straight, smooth vocal fold edge, which is often a preparatory step for later reconstruction using fat graft reconstruction or Gray’s minithyrotomy or superficial vocal fold injection with collagen based material.

a) Complete exposure of vocal folds with a large laryngoscope (see Chap. 10)

b) Endoscopic visualization with angled endoscopes and vocal fold palpation with high-powered microlaryngoscopy assessing the severity and nature of the vocal fold pathology

c) Subepithelial infusion of 1:10,000 epinephrine in attempt to hydrodissect and clearly delineate the area of the sulcus vocalis/vocal fold scar

d) Mucosal cordotomy at the junction of normal vocal fold epithelium and the sulcus vocalis deformity at both the upper and lower aspect of the deformity

e) Submucosal excision of the sulcus vocalis

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f)Subepithelial dissection of a superiorly based flap (back elevation) and subepithelial elevation of an inferiorly based mucosal flap in preparation for reapproximation

g)Suture reapproximation of cut edges of the mucosa resulting in approximation of the mucosal cut surfaces (see part 4., below)

2.Vocal fold slicing technique via microlaryngoscopy (as described by Paulo Pontes)

The objective of the vocal fold slicing technique is to reduce the glottal gap and to increase vocal fold vibration in order to improve phonation in cases presenting with severe sulcus vocalis and vocal fold scar.

Contraindications

a)Lack of patient understanding of the procedure

b)Lack of acceptance of aphonia for 4 months

c)Limitations for receiving postoperative voice therapy Surgical procedure: methods and techniques

The main principle of this technique is to “break” the tension caused by the ligamental alteration in order to obtain vibration and to reduce the glottal gap, which is achieved by the resultant displacement of a more flexible and bulky tissue from the free edge of the vocal fold.

a)General anesthesia and orotracheal intubation

b)Endolaryngeal exposure with suspension microlaryngoscopy

c)Incision on the superior surface of the vocal fold (ante- rior–posterior), parallel to the free edge of the vocal fold The cordotomy should be made 3–4 mm lateral to the free edge of the vocal fold (Fig. 23.4).

Fig. 23.4  Sulcus vocalis with proposed incision lines (dashed) for the slicing technique of Pontes

144

Vocal Fold Scar and Sulcus Vocalis

Fig. 23.5  Raising deep flap with flap elevator

Fig. 23.6  Slicing of deep flap

	d) Deep dissection to create a mucosal flap
		The vocal ligament is included inside this flap and, if it
		remains thin, a portion of the muscle may be also in-
		cluded to preserve arterial supply (Fig. 23.5).
	e) The dissection should extend inferiorly to approximately
		3 mm beneath the inferior border of the sulcus.
	f)	Place small incisions, caudally oriented, in the superior
		margin of the flap to create three or four smaller flaps
		(inferiorly based) (Fig. 23.6). Gradually deepen the inci-
		sions to avoid retraction of the initial flap (Fig. 23.7).
	g) The central microflaps should be of different lengths and
		should pass over the ligament in the inferior lip. Differ-
		ent lengths are useful to maintain ligament fragments
		in different heights, which must be intraoperatively ob-
23
		served as soon as the microflaps retract themselves.
	h) The technique should be done bilaterally when there is bi-
		lateral disease not dependent on the sulcus asymmetry.
	i)	Care is taken to preserve intact mucosa on both sides
		around the anterior commissure.
	j)	Glue or sutures are not useful or needed.
	Postoperative care
	a) Prophylactic oral antibiotics
	b) Voice rest for 3 days
	c)	Vocal exercise, speech therapy
		i. Vocal exercises should begin around the seventh
		postoperative day, initially with vibration exercises to
	Fig. 23.7  Asymmetric superior-inferior incisions through the vocal	make tissues flexible and to help remove fibrin, thus
	fold microflap	avoiding adherences.

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Fig. 23.8  Placement for incision and area of proposed elevation of overlying microflap for vocal fold fat graft reconstruction

ii.Voice quality will remain poor for 3–4 months. When healing has completed (~4 months), the vocal fold surfaces appear more regular compared to the preoperative pattern. The vocal folds exhibit greater

flexibility and vibration in spite of the reduction or absence of the mucosal wave. The glottic gap disappears or is dramatically reduced.

Complications

a)Thin adherences can occur and should be cut in 2–3 weeks.

b)Granulomas can occur but can be left intact because spontaneous remission typically occurs, avoiding the creation of depressions. They should only be resected if too large and/or fibrotic.

3.Vocal fold fat graft reconstruction via microlaryngoscopy

This procedure is aimed at developing a pocket in the pathologic lamina propria with or without excision of the associated vocal fold scar and laying small grafts of autologous fat into the pocket for “reconstruction” of the lamina propria and improved lamina propria function postoperatively. This entire procedure is done via microlaryngoscopy with simultaneous fat graft harvest. The fat graft harvest technique is discussed separately (see below).

a)Place largest possible laryngoscope for allowing full visualization of the vocal fold. (Note: This procedure is difficult to perform via a small laryngoscope because of the complexity of the dissection and the need for placement of sutures within the vocal fold.)

b)Angled visualization of the vocal fold pathology via telescopes (see Chap. 10, “Principles of Phonomicro­ surgery”)

Fig. 23.9  Elevation of pocket in preparation for fat graft implantation

c)Vocal fold palpation to assess vocal fold scar and sulcus vocalis pathology and severity (during the palpation and angled visualization steps, potential surgical incisions on the vocal folds should be considered)

d)An incision is then made with a microknife (sickle) through the mucosa immediately lateral to the area of the vocal fold scar/sulcus vocalis. The placement of the incision should be carefully done to allow enough mucosa medial and lateral to the incision for microsuture placement. It is wise to make this incision longer in the anterior–posterior dimension than typically required to have complete exposure of the area of vocal fold scar/sulcus vocalis (Fig. 23.8).

e)Carefully elevate the mucosa off the ligament and underlying vocal fold scar. This should be done in a slow, careful fashion, making great effort to avoid fenestration of the overlyingmucosa.Thiswillsignificantlyhamperthesuccess or ability to perform fat graft reconstruction (Fig. 23.9).

f)Remove any associated lesion or scar once the microflap elevation is performed.

g)Verify that there is a wide pocket in the area of the vocal fold scar/sulcus vocalis, in both the anterior–posterior dimension as well as the superior–inferior dimension.

h)Place suture through the cut mucosal edges both medial and lateral but not tying or throwing any knots with this suture now (Fig. 23.10). Each free end of the suture can be secured outside the laryngoscope with a small bulldog clamp (see below section on placement of sutures in vocal fold.)

i)Directly implant fat grafts into the pocket. The pocket should be filled with the maximum amount of fat graft

146

Vocal Fold Scar and Sulcus Vocalis

Fig. 23.10  Pocket in area of vocal fold scar elevated and sutures placed through mucosal edges

possible, allowing complete or close approximation of the mucosal edges at the incision location (fat harvest techniques as described below) (Fig. 23.11).

j)Tie three knots of the previously thrown suture through the mucosal cut edges (see below) (Fig. 23.12).

k)Palpate free edge of vocal fold to ensure the fat graft implants are stable in the pocket and do not easily come out of the mucosal incision with a moderate amount of pressure along the free edge of the vocal fold.

Fig. 23.11  Placement of fat grafts into pocket of previously elevated vocal fold scar

4.Placement of sutures in the vocal fold

Placement of sutures in the vocal fold is intended to assist the reapproximation of mucosal flaps in the vocal fold. This is most commonly used for fat graft reconstruction but can also be used for a variety of microflaps associated with glottic web surgery. Placement of sutures should be carefully planned to allow adequate mucosal closure of the vocal fold without distortion of the shape of the vocal fold. If too “aggressive” placement of a suture on either side of the mucosal

23

Fig. 23.12  Postoperative result after fat graft reconstruction	Fig. 23.13  Placement of needle through mucosa during suturing of
	the vocal fold mucosa

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incision is done, a “pinching” of the vocal fold will occur at the suture site and this will be counter productive to the surgical procedure at hand.

The direction of passing from right to left or left to right depends on which vocal fold is being sutured and the handedness of the surgeon. In general, it is difficult to backhand the suture via a microlaryngoscopy approach and thus, a right-handed surgeon will typically pass the suture through the cut edges of the mucosa right to left (vice versa for a lefthanded surgeon). The needle should be placed within 1–1.5 mm of each mucosal edge.

a)Typically, the microsuture is placed through each mucosal edge in a separate pass of the needle and thus, the surgeon should plan not to pass the needle through both cut edges in one movement of the needle. This allows for more control of the placement of the needle through the mucosal edge, which is essential. Furthermore, the mucosal free edge does usually not need to be held with another instrument while the needle is placed, given that with the proper angle preparation of the microsurgical needle, it will pass quite easily through the mucosal flap. The needle is typically held and passed through the mucosal flap using a microlaryngoscopy needle holder. Another option is using a straight alligator, however, the microlaryngoscopy suture holder has somewhat broader jaws, which will hold the needle in a more stable fashion and allow better control of the needle as it passes through the mucosal flap. After the first part of the needle has penetrated and passed completely through the mucosal surface, the suture holder is released and either the suture holder or a curved alligator is used to complete the passing of the needle through the mucosal edge. As the needle is drawn through the mucosal edge, the curve of the needle should be continued in a careful and gentle fashion to avoid applying undue stress or trauma to the vocal fold, which may tear the mucosal flap (Fig. 23.13).

b)After the needle is passed through each side of the free edge of the mucosa, both ends of the suture are brought out through the proximal portion of the laryngoscope.

c)A moderate amount of tension should be placed on the suture during high-powered microlaryngoscopy visualization to ensure that the suture has been placed through the free edges of the mucosa in the appropriate fashion. If the surgeon is dissatisfied with the suture location, then the suture should be removed and the process repeated.

d)Using the two ends of the suture outside the laryngoscope, a simple knot can be tied using a straight alligator and a free hand (Fig. 23.14a).

e)After a single knot has been tied, one end of the suture is held with the surgeon’s nondominant hand outside the laryngoscope, and the other end can be loosely held by an assistant.

f)The knot pusher is then placed around the knot outside of the laryngoscope and slowly used to pass the knot down the laryngoscope towards the vocal fold. As the knot pusher moves the knot down the laryngoscope, the assistant and the surgeon’s other hand can be used

to maintain a “relaxed” tension on the suture arms, thus allowing the knot to be slipped down into position at the vocal fold (Fig. 23.14b).

g)Once the knot is close to the vocal fold, the free ends of the suture are released by the surgeon and the assistant.

h)The two strands of the suture coming off the knot near the knot are then grasped with a straight and/or curved alligator under visualization with high-powered microlaryngoscopy.

i)The knot is then slowly tightened with the alligators, with great care taken to not overtighten the knot. If the knot is too tight, then the vocal fold morphology will be significantly distorted and will then result in a poor vocal outcome (Fig. 23.14c).

j)The knot should be tightened enough to allow close approximation of the mucosal edges, but not strangulation of the associated tissue and deformation of the morphology of the vocal fold. An approximately 1-mm gap should be preserved between the mucosal surface of the vocal fold and the tied knot (Fig. 23.12).

k)Scissors can be used to cut the ends of the suture, approximately 2–3 mm away from the knot, after two more additional knots have been thrown in the exact same

fashion.

Alternate method of suture placement/knot tying

a)Both ends of the suture are grasped with mosquito hemostats, and an additional hemostat is placed between sutures distal, close to the opening of the laryngoscope (Fig. 23.15a).

b)The left (white suture in Fig. 23.15a) suture is looped around the right suture a total of three times clockwise. The free end of the left (white) suture is advanced toward the initial (distal) crossing of the two strands of suture (Fig. 23.15b).

c)The free ends of the left (white) suture are used to create a slipknot around the open loop adjacent to the distal stationary hemostat. Microlaryngeal alligator forceps are used to grasp the left (white) suture at its final “crossing”; this step prevents the knot from forming prematurely and subsequently breaking. The end of the suture is marked with a pen for easier identification under the microscope during knot tying (Fig. 23.15c).

d)The loose knot assembly is advanced down the laryngoscope by pushing distally with microalligator forceps while pulling back on the other (black) suture. When the level of the vocal folds is reached, the knot assembly is released, taking care not to allow the loose knot assembly to untie (Fig. 23.15d).

e)The microscope is then brought into the field and the free end of the left (white) suture is grasped with microalligator forceps and advanced distally, while providing counter-tension with the opposite (black) suture. A secure knot will form at the level of the vocal folds, as depicted (Fig. 23.15e).

5.Fat graft harvest and preparation

A small amount of fat of various sizes is required for fat graft vocal fold reconstruction. The harvest locations can be the ear lobe, axilla, umbilicus, or prior scar location. The fat