What is involved in a right fat graft myringoplasty procedure?

Right Fat Graft Myringoplasty Procedure

A right fat graft myringoplasty is a minimally invasive surgical procedure that uses autologous fat to repair a tympanic membrane perforation, typically performed under local anesthesia in an outpatient setting with high success rates of 80-90% for small perforations. 1, 2

Procedure Overview

Patient Selection

• Ideal candidates:
  • Small tympanic membrane perforations (less than 30% of the pars tensa) 3
  • Patients without previous ear surgery have higher success rates 2
  • Can be used for both primary repairs and revision cases after failed conventional myringoplasty 4

Anesthesia

• Typically performed under local anesthesia 2, 4
• Can be done as an outpatient procedure

Fat Harvesting Options

1. Ear lobe fat (most common) 4, 3
2. Abdominal fat 4
3. Umbilical fat (alternative with reported 100% success rate in pediatric cases) 1

Surgical Technique

1. Preparation of the perforation site:

   • Freshening the edges of the perforation to stimulate healing
   • Removing any epithelial ingrowth at the perforation margins

2. Fat harvesting:

   • Small incision at the chosen donor site (typically ear lobe)
   • Extraction of an appropriate amount of fat (slightly larger than the perforation)

3. Fat graft placement:

   • The harvested fat is trimmed to appropriate size
   • The graft is placed through the perforation using an hourglass technique:
     • Part of the fat remains in the middle ear
     • Part remains in the ear canal
     • The constricted portion sits within the perforation

4. Stabilization:

   • The graft is typically held in place without sutures
   • May be supported with absorbable gelatin sponge if needed

Advantages and Outcomes

Benefits

• High success rates (82-87% overall) 2, 4
• Minimally invasive compared to traditional tympanoplasty
• Short procedure time (average 16 minutes) 5
• No hospitalization required
• Angiogenic properties of fat help overcome poor vascular supply near perforation 4

Hearing Outcomes

• Typically preserves or slightly improves hearing
• Mean improvement of 9.3 dB in air conduction thresholds reported in some studies 3
• No worsening of bone conduction thresholds 5

Prognostic Factors

Factors Affecting Success

• Perforation size: Success rates significantly decrease when perforation exceeds 30% of the pars tensa 3
• Location: Anterior perforations have lower success rates 3
• Previous surgery: Primary cases have better outcomes than revision cases 2
• Myringosclerosis: Does not appear to negatively affect outcomes 3

Post-Procedure Care

• Typically outpatient follow-up
• Patients should avoid water exposure to the ear
• Avoid activities that create pressure changes (flying, diving)
• Follow-up visits to monitor healing and graft take

Modifications and Variations

Some surgeons combine fat grafting with hyaluronic acid (HAFGM) to potentially improve outcomes, with comparable success rates to traditional underlay and overlay techniques but with shorter operative times 5.

Pitfalls to Avoid

• Using too small a fat graft (should be slightly larger than perforation)
• Inadequate freshening of perforation edges
• Attempting to repair perforations larger than 30% of the tympanic membrane with this technique
• Not considering anatomical factors like anterior perforations that may reduce success rates

Fat graft myringoplasty represents a cost-effective, minimally invasive alternative to traditional tympanoplasty techniques for appropriately selected patients with small tympanic membrane perforations.