**2.2 Wound creation**

Early treatments for benign vocal fold lesions consisted of stripping (de-epithelialization) of the entire vocal fold (Sataloff, Spiegel et al. 1995). The healing process after this method of treatment often resulted in significant vocal fold scar formation which causes a change in the stiffness and viscoelastic layered structure of the lamina propria. This inhibits normal vibration of the vocal fold, and can cause significant dysphonia and possible glottic incompetence. However with the discovery by Hirano of the layered structure of the vocal fold and its implications on healing, treatment is now focused on preserving as much of the normal vocal fold structures as possible (Hochman and Zeitels 2000; Fleming, McGuff et al. 2001; Thekdi and Rosen 2002; Burns, Hillman et al. 2009). Avoiding injury to the deeper structures is important during voice microsurgery to minimize vocal fold scarring and persistent post-operative hoarseness.

Current methods in voice microsurgery are divided into two main categories based on the surgical instruments used – either laser surgery or cold surgery. In laser surgery, a CO2 laser is used to ablate tissue and for coagulation of the target region (Yan, Olszewski et al. 2010). Together with a micro-manipulator for precise cutting, the reduced blood loss during laser surgery enables a relatively clear view of the surgical field. Although studies have found no significant difference in surgical outcomes between laser and cold surgery (Zeitels 1996; Hormann, Baker-Schreyer et al. 1999; Benninger 2000), risk of thermal damage to surrounding tissues is still dependent on familiarity with the equipment and surgical technique. This coupled with the increased cost of equipments, maintenance, additional personnel and their training (Yan, Olszewski et al. 2010), has driven the continued use of traditional "cold" voice microsurgery techniques.

Access to the vocal folds for microsurgery typically utilizes suspension laryngoscopy (Zeitels, Burns et al. 2004), where a rigid laryngoscope inserted via the patient's oral cavity provides a direct view of the vocal folds. The laryngoscope is suspended over the patient's chest, freeing the surgeon's hands for operating. A binocular operating microscope is used to provide magnification. Due to the prohibitive space constraints of laryngoscopes, microlaryngeal instruments are thin and long to access the lesion while maximizing of the surgical field. A significant level of dexterity is needed to handle the microlaryngeal tools, especially considering the fragile structure of the vocal fold. However cold surgery allows for tactile feedback and is better utilized in techniques like the micro-flap excision of benign vocal fold lesions (Zeitels 1996), which we will focus on for the course of this chapter.
