Fat Graft Myringoplasty

Considerations

• • Always review pre-op audiogram 

  • Be sure the patient's goals and expectations align with the surgical plan

  • The size and location of the perforation

    • Dr. Rasgon has experienced success with large, even sub-total, perforations 

    • Others also show that fat graft can work in medium to large perforations

    • 2014: Influence of size and site of perforation on fat graft myringoplasty

    • However, many believe that fat is best only for "small" perforations of the pars tensa

    • 2013: Fat myringoplasty outcome analysis with otoendoscopy: who is the suitable patient?

Preparation

• • Examine the post lobule fat, plan 1 cm incision

  • Infiltrate 1% Lidocaine with 1:100,000 Epinephrine 

Procedure

• • Estimate the perforation size 

  • Key: Freshen the edges well

    • Rosen or 5910 blade to postage stamp, small cups to remove

  • Excise the fat sharply, may contain dermis

    • Use the 15 blade to incise just the epidermis dermis and expose the superficial most fat

    • Turn the blade to undermine the skin in parallel with the dermis 

    • Sharply excise a block of fat without tearing or shredding  

    • Keep moist with a drop of saline 

  • Pearl: The graft must remain intact (don't shred it)

  • Key: Floxin soaked Gelfoam in middle ear to support to graft, Floxin soaked paper patch laterally to sandwich the graft

    • Cut paper patch from the small finger, short enough to stay in the canal without being pulled out accidentally 

Post-op

• • Key: Leave the paper patch totally untouched for the first 6 weeks and longer until it peels away on its own from the fat graft 

  • Medications: No Floxin initially, but start 1 drop daily POD 7 until week 6

  • Clinic 1 week 

  • Activity, for first 6 weeks:

    • Avoid nose blowing

    • When you sneeze or cough, do so with your mouth open

    • Do not fly in an airplane, swim, scuba dive, or play contact sports

    • Please do NOT allow any water into the ear canal - Use an ear plug or Vaseline coated cotton ball when showering 

  • CPT code - 69620

High-Yield

Links

• UTMB Grand Rounds - Tympanoplasty

• Iowa Protocols - Endaural Tympanoplasty