When the disease process is under control, the tympanic membrane remnant is prepared for grafting. A rim of tissue is removed from the perforation edge to remove diseased tissue or mucosal thickening and encourage migration of healthy epithelium and the mucosal layer. For those patients where an over-under tympanoplasty is to be employed, the malleus is clearly visualized by elevating the tympanic membrane. The periosteum of the malleus is incised with a fine sharp needle (Fig. 5-2). This periosteal cuff is then used to elevate the tympanic membrane off the short process of the malleus, neck of the malleus, and then the long process of the malleus to the fibrous umbo area (Fig. 5-3). At this point either a microalligator-type scissors or the laser
is used to totally remove the remnant from the malleus.
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