The microflap technique was introduced in 1982, and was published and illustrated in 1986. The original concept was to preserve epithelium as a biological dressing and buffer against traumatic contact from the contralateral vocal fold, to minimize fibroblast proliferation and scar.

Although it improved outcomes in comparison with vocal fold “stripping” and other earlier techniques, surgical results in some cases were unsatisfactory. This was probably due to disruption of basement membrane and extracellular matrix protein beyond the limits of the pathology. In some patients, this resulted in stiffness in an area greater than that of the original lesion, and slow recovery. For that reason, the microflap technique was abandoned by this author in 1991, and replaced by the mini-microflap, first published in 1995. Microflap surgery still has a place in the management of selected pre-malignant and malignant lesions, selected papillomata and a few other abnormalities. Laryngologists should be familiar with the technique but should avoid it for vibratory margin cysts, polyps and other similar lesions. For these lesions, mini-microflap technique should be utilized, and surgery should be limited strictly to tissue already deranged by pathology.

Careful evaluation in the office with stroboscopy is strongly recommended to assess the anatomy of both vocal folds prior to surgery.

Sometimes operative findings are different from findings on office stroboscopy, making the consent process critical in case the intraoperative plan needs to change to accommodate appropriate treatment of pathology.

Aligning the microscope so that the view is straight down the laryngoscope will permit optimal visualization.

Positioning the larynx so that both vocal folds are viewed equally and so that the entire anterior commissure is viewed will mimic optimal exposure conditions in the operating room.

A chair with arm rests will allow support of the elbows so that muscular strain in the shoulder girdle is limited; this support will prevent hand tremor and increase the precision of manipulation of the distal end of the microinstruments.

Stabilization of the proximal end of each microinstrument in the lateral margin of the proximal end of the laryngoscope is recommended. This positioning also allows the microinstruments to be out of the way of the center of the laryngoscope where the surgeon′s view is critical.

The use of both hands for phonomicrosurgery is required and takes practice.

Operating for too long a period of time will induce muscular fatigue and risks a poor outcome from lack of precision. Stopping intermittently for thirty seconds is one strategy to limit this fatigue effect.

Although intuitively it might seem that the instrument that is “operating” (removing a polyp or cyst) is more likely to do damage and requires all of the focus of the surgeon, this is often not true. A more likely unfavorable event is for the surgeon to forget about the instrument that is retracting the mini-microflap, to over-retract and to partially or totally tear the mini-microflap. This event is problematic because it will remove some lamina propria and mandate healing in the surgical site by secondary intention, prolonging healing and likely inducing more scar formation.