The procedure is done under general anesthesia, and the key steps are as follows. After complete preparation and draping, the postauricular region and the meatus is injected with 1% Xylocaine with epinephrine, with a 1:10,000 concentration of epinephrine. It is wise to alert the attending anesthesiologist that this high concentration of epinephrine is being used. A postauricular incision is made without performing any transcanal dissection first. Before the incision is made, an imaginary line is drawn through the roof of the ear canal and brought back postauricularly; this is a landmark for the insertion of the temporalis muscle whose overlying fascia is harvested easily. The upper part of the incision is gently carried down so the fascia is visualized, and then a rake is inserted. With a small scissors, a plane is created between the subcutaneous tissue and the fascia. Finger dissection is very useful at this point. A large piece of fascia is harvested and the area lightly cauterized. The rake is removed and then the lower part of the incision is carried down to the mastoid bone, identifying the spine of Henle. At this time, a retractor is introduced and the posterior canal skin is partially elevated. Using a No. 69 blade, a transverse incision is made in the canal skin and then the anterior "jaw" of the retractor is now placed in the upper flap while the posterior part of the retractor is placed in the inferior flap. The microscope is then brought into place, the
incision enlarged, and the ear canal and eardrum are now completely visualized.
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