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Table of Contents
ORGINAL ARTICLE
Year : 2013  |  Volume : 15  |  Issue : 2  |  Page : 27-31

Fat graft myringoplasty: Simple, fast and reliable technique


1 Department of ORL & Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Otolaryngology& Head and Neck Surgery, La Timone University Hospital Center, Marseille, Fance

Date of Web Publication21-Jul-2020

Correspondence Address:
M.D Badi Aldosari
24 BD Mireille Lauze 13010 Marseille
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.290345

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  Abstract 


Objective: The aim of this study was to present our results of fat graft myringoplasty. Due to its simplicity and reliability, this technique seems to be as efficient as other classical graft techniques.
Patients and Methods: We analyzed data from 131 patients operated in our hospital for a tympanic perforation between 2002 and 2010 using an endoscope-guided techniques with adipose graft. Patients were evaluated postoperatively at seven days, one month, three months and one and two years. Criteria of success were the complete closure of the tympanic membrane, absence of lateralization of the tympanic membrane and no audiometric impairment.
Results: Treatment was successful in 92 % of adult patients and 94 % of pediatric patients with at least two years follow-up. The failures occurred in patients with contraindications such as myringosclerosis, myringitis and perforation size greater than 50% of the tympanic surface.
Conclusions: Endoscopic-guided myringoplasty using an adipose tissue graft is a rapid, safe, reliable and efficient procedure that should be performed in first intention for selected indications .

Keywords: Tympanic perforation, fat, otoendoscopic procedure.


How to cite this article:
Aldosari B, Thormassin J M. Fat graft myringoplasty: Simple, fast and reliable technique. Saudi J Otorhinolaryngol Head Neck Surg 2013;15:27-31

How to cite this URL:
Aldosari B, Thormassin J M. Fat graft myringoplasty: Simple, fast and reliable technique. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2013 [cited 2022 Nov 28];15:27-31. Available from: https://www.sjohns.org/text.asp?2013/15/2/27/290345




  Introduction Top


Myringoplasty is a surgical procedure specifically designed to close tympanic membrane defects. The major objective of myringoplasty is to restore the vibration properties of the tympanic membrane and to achieve a good anatomical result under the preservation of the anterior tympanomeatal angle . In the history of otologic surgery a number of procedures have been applied for tympanic membrane repair [1].

During the fifties, Wullstien and Zollner advised the use of thin skin grafts [2]. Other authors like Sooy followed in 1956 , then House and Plester in 1958 who advocated a skin flap either fashioned according to the auditory canal or used as a free graft [3]. In the sixties, Hermann described a myringoplasty procedure by use of temporalis fascia graft,which became gradually accepted and,even to date, is the most widely used material[4].ln parallel , Rigcnbcrg in 1962 and Sterkers in 1964 confirmed the effectiveness of fat graft myringoplasty in tympanic membrane repair in the case of small-sized perforations[5]. Adipose tissue is formed by the accumulation of adipocytes grouped in lobules that arc separated by connectivc tissue trabeculae of mesenchymal origin. Function of adipose tissue include nutrition,lipogenesis and protection. In myringoplasty, and contrary to other graft materials, fat acts as an autologous graft capable of stimulating the reconstruction of the Fibrous layer after scar tissue debridement[5].

The purpose of this analysis was to evaluate the results of this technique of myringoplasty performed using an endoscope, with the advantage of not only the absence of detachment tympani-metal but also complete control of the anterior angle, even in case of unfavorable conformation of the ear canal (bulging of the anterior wall, exostosis).

Judging by the rate of recurrences, failures or even complication, it becomcs, in our opinion, evident that endoscopic-guided fat graft myringoplasty has the inherent potential of significantly improving the surgical outcome of the minimally invasive procedure which is conducted on an outpatient basis, and in most cases under local anesthesia


  Materials and Methods Top


This retrospective study was conducted in the Department of Otolaryngology at the La Timone University Hospital between December 2002 and December 2010. Clinical data on 131 patients (131 tympanic membrane perforation) were analyzed, 99 cases in the adult population and 32 eases in children [Table 1]. These patients all operated by the same operator a senior under endoscopic guidance myringoplasty, under local or general anesthesia, with insertion graft taken from adipocyte in the periumbilical area of the abdominal region. Patients were evaluated postoperatively at seven days, one month, three months and one and two years.
Table 1: Localization and distribution of tymopanic membrane perforation

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Criteria of success were the complete closure of the tympanic membrane . absence of lateralization of the tympanic membrane and no audiomctric impairment.


  Results Top


121 patients ha\e successfully tympanic membrane closure with at least two years follow-up, 91 adults and 30 children [Table 2] . The failures occurred in patients with contraindications such as myringosclerosis, myringitis and perforation size greater than 50 % of the tympanic surface.
Table 2: Successful tympanic membrane closure (2 years follow-up)

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  Discussion Top


Surgical technique

Endoscopes

It is best to ha\e 3t least two endoscopies at 0 and 30 degrees. 2.7 mm diameter, autoclavablc. Endoscopes are powered by a light cold halogen light source 150 and 300watts. The advantage of a camera with a zoom is indisputable, to obtain a magnified image full screen. The w hole of this de\ ice can be connected to a digital recording console for archh ing

Interventions

Anesthesia

Anesthesia is affected b> application of a solution of cocaine (Bonain) on the tympanic membrane. It is generally not necessary to perform infiltration of the skin of the external auditory canal , especially as cold iidocaine through the perforation can be responsible for a particularly \ertiginous symptoms unpleasant for the patient. In the ease of infiltration of the ear canal, we use concentrated Iidocaine 2°”o with the addition of adrenaline in the absence of contraindication. If the anticipated patient compliance is poor or if the patient explicitly requests it. one may sw itch to general anesthesia. In children, the operation done under general anesthesia. Several sites can be selected for the grafl: ear lobe, a abdomen, thigh. The periumbilical abdominal site is preferred. The skin is less sensitive, less bleeding and the amount of adipose tissue is efficient quality. A five-millimeter incision is performed under local anesthesia in the periphery of the umbilicus. The collcction consists of a pack of about five cubic millimeters in one piece not crushed. The graft is carefully placcd in an isotonic solution. The sampling site is closed by slowly absorbable suture [Figure 1]. It is also possible to make the incision in the umbilicus. Similarly, in the lateral periphery, so as to conceal the scar.
Figure 1: Periumbilical incision for adipose graft Myringoplasty

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We used the optical zero-degree or 30 degree angle by the site of the perforation and the habit of the operator. The lens is inserted automatically in the external auditory meatus. Any bleeding is a source of additional difficulty. Progression of the endoscope is done under control of the monitor.

Freshening of the edges:

This is crucial and determines the success of the graft. The freshening of the edges of the perforation can be carried out by means of a point or by means of a fiber laser [Figure 2]. The absence of all shreds of epidermis persistent in the periphery of the perforation, or to the inner face of the eardrum should be veryfied. This situation is at risk of iatrogenic cholesteatoma after impaction of graft. The use of the optical angle of 30 degrees to facilitate the verification of the inner face of the eardrum is recommended.
Figure 2: A: freshing the edges of perforation by the point B: freshing the edges of perforation by the fiber laser

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Establishment of the graft:

The size of the pack fat must be greater than that of the perforation so as to ensure spontaneous graft constriction. The fat is deposited at the perforation under endoscopic control. It is then introduced through the perforation by placing half of the graft within the tympanic cavity [Figure 3]. An additional maintenance is optionally performed by means of a biological adhesive. A piece of dry correspond “ftis placed above the graft. A few drops of biological glue maintain it.
Figure 3: Deposition of fat graft inside the perforation

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Postoperative care:

The external auditory meatus is closed with a hydrophilic cotton. Before his departure, the patient is then monitored for a period of 2 hours to ensure there is no audio-vcstibular symptoms secondary to the procedure. The first postoperative visit is carried out after seven days for the removal of the cotton. Non ototoxic ear drops are prescribed for a period of four to six days. The second visit takes place after the first month. Finally it is the of the third month that we can judge the final results [Figure 4].
Figure 4: A- the perforation before the operation B-3 months post operation C-2 Years post operation

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Indications

This technique is, whether in first or second-line, on a residual eardrum perforation after conventional myringoplasty. Restitution must result in a vibrating membrane anatomical location w ith a good conservation tympanomeatal angle. We obtained 92% closure of the tympanic membrane, which is comparable to the main series related to the exclusive use of the endoscope surgery [8],[9],[10], The previous situation of perforation is not a poor prognostic factor. However, the analysis of our failures can list a number of conlra-indications that the preoperative examination will allow: the existence of localized atrophy of tympanic membrane, myringosclerose plate or htaline infiltration, localized or dilTuse myringitis, and a retractable fibrous scarring of the eardrum. Similarly the perforation will allow assessment of the middle ear mucosa for any inflammation. If olorrhoea is present it will be preferable to postpone the operation.

The use of the endoscope

The use of the endoscope is helpful when the perforation is also associated with a strong convexity of the anterior bony part of the external auditory canal. The use of endoscopy applied to otologic surgery has demonstrated its worth, particularly in the surgery of cholesteatoma or tumors of the tympanic cavity, but also in the surgery for ty mpanic perforations [10],[11],[12],[13],[14], The use of the optical or zero degree telescope or even a 30 degree telescope, allows for inspection of all relevant anatomical structures and provides a panoramic v iew of the anterior angle and the perforation margins with the aid of this technique . bone drilling of the external auditory canal can be avoided. The use of a cuned wullstein needle facilitates dcepitheliallization of the anterior margin of the perforation. The use of this technique didn’t eliminate the need for drilling the external auditory canal, which often causes noise- induced acoustic trauma. It also saves a considerable amount of time which, in turn, provides the option of using local anesthesia in the adult patient.


  Conclusion Top


Endoscopic-guided fat graft myringoplasty is an innovative surgical procedure, simple to perform, fast and reliable even in the hands of less experienced surgeons.

Harvesting the fat graft from an abdominal donor site is preferable because the skin is less sensitive, there is less bleeding and the amount of adipose tissue is sufficient and of good quality.

In most adults, the procedure is performed on an outpatient basis under local anesthesia. In children, following preoperative preparation, it is possible to use mask anesthesia, avoiding endotracheal intubation. This minimally invasive procedure may be indicated for first or second intention healing of a persistent perforation. A good outcome is achieved with more than 92 % of tympanic closure with six months postoperatively.

For a complete success of this procedure, it is necessary, however, that certain pre-conditions be considered: the size of perforation must less than 50% of the size of the tympanic membrane, the anterior site of the perforation may have no contact with annulus, a non-inflammatory state of the mucous membrane of the tympanic cavity, no myringsclerotic plaques may be in contact with the perforation, no localized myringitis may be present adjacent to the perforation, no atrophic areas of the tympanic membrane and pellucid zones.

Disclosure: The authors declare no conflict of interest or financial disclosure.



 
  References Top

1.
Wullstein H. Theory and practice of tympanoplasty. Laryngoscope. 1956; 66:1076-93.  Back to cited text no. 1
    
2.
Sterkers JM. Greffe adipocytaircultramincc pour tvmpanoplastic. Ann Otolaryngol ChirCervico fac. 1964: 81:265-70.  Back to cited text no. 2
    
3.
Ringenberg JC. Fat graft tympanoplasty. Laryngoscope. 1962; 72:188-92.  Back to cited text no. 3
    
4.
Guerrc-Millo M. Adipose tissue hormones. J Endocrinol lnvcst.2002; 25:855-61.  Back to cited text no. 4
    
5.
Miner JL. The adipocyte as an endocrine cell. J AnimSci. 2004; 82:935-41.  Back to cited text no. 5
    
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Kim S. Moustaid-Moussa N. Secretory, endocrine and autocrine paracrine function of the adipocyte. J Nutr. 2000; 130:3110S-5S.  Back to cited text no. 6
    
7.
Ayachc S. Braccini F, Facon F, Thomassin JM. Adipose graft: an original option in myringoplasty. OtolNeurotoI. 2003:24:158-64.  Back to cited text no. 7
    
8.
Karhukcto TS. llomaki JH, Puhakka I I.I. Tvmpanoscope. ORL J Otorhinolaryngol Relat Spec. 2001:63: 353-7  Back to cited text no. 8
    
9.
El-Guindy A. Endoscopic transcanal myringoplasty. J LaryngolOtol. 1992;106:493-5.  Back to cited text no. 9
    
10.
Usami S. lijima N. Fujita S.Takunii Y. Endoscopic-assistcd myringoplasty. ORLJ OtorhinolaryngolRelat Spec. 2001:63:287-90.  Back to cited text no. 10
    
11.
Tarabichi M. Endoscopic middle car surgery. Ann OtolRhinolLarvngol. 1999; 108:39-46.  Back to cited text no. 11
    
12.
Thomassin JM, Korchia D, Doris JM. Endoscopic-guided otosurgcry in the prev ention of residual cholesteatoma Laryngoscope. 1993; 103:939-43.  Back to cited text no. 12
    
13.
Thomassin JM. Candela FA, Decat M, ct al. Surgery under otoendoscopic control. Rev LaryngolOtolRhinol. 1996:117:409-15.  Back to cited text no. 13
    
14.
Thomassin JM. Otoendoscopically Guided Surgery. Springer-Verlag* 1994 : pp 87  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Materials and Me...
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