Placement of Graft

The parchment-like fascia graft is now removed from the Teflon block and trimmed to the appropriate

FIGURE 5—4 Graft placed on top of malleus (lateral).

FIGURE 5—5 Same view with graft visible through a tympanic defect.

size. Generally for near-total perforations, the fascia is trimmed to a tongue shape with the anterior edge about 10 mm in diameter; the graft is then made about 15 mm in length. This allows the graft to be tucked under the anterior, inferior, and superior bony annulus, over the malleus and then onto the posterior bony canal wall (Fig. 5-4). The remnant of tympanic membrane is then placed onto the lateral surface of the graft and the remainder of the ear canal skin flaps are replaced into their normal position (Fig. 5-5). A disk of EpiFilm (Medtronic Xomed, Inc., Jacksonville, FL), a bioactive lamina composed of an ester of hyaluronic acid, is placed onto the lateral surface of the tympanic membrane. A Gelfoam 8-mm disk is placed lateral to the EpiFilm, and then antibiotic ointment is applied through a 14-gauge soft catheter on a 5-cc syringe placed onto the Gelfoam, filling the anterior sulcus of the ear canal.

The self-retaining retractors are removed, hemos-tasis is secured, and then the T incision is closed with an absorbable suture. The postauricular incision is sutured with an absorbable suture in a subcuticular manner. No skin sutures are necessary.

The ear canal is then visualized under the operating microscope and evacuated from blood, making sure not to suction onto the graft, but placing the vascular strip skin onto the fascia graft. This is held

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