Surgical Procedures
(1) Anesthesia: all patients were subjected to both general anesthesia and local infiltration anesthesia. . (2) Preparation of graft: an arc incision was made on the tragus 3 mm from the free margin. The subcutaneous tissue was dissected to cut a piece of tragus cartilage-perichondrium complex of suitable size. (3) Preparation of graft bed: annulus fibrocartilagineus in the vicinity of the perforation was removed using a cachet hook. (4) Elevation of tympanomeatal flap: an arc-shaped incision (3/4 circle of the EAC) was made from 6 o’clock to 2 o’clock position clockwise on the right ear (or 10 o’clock to 6 o’clock position clockwise on the left ear) at the junction of the skin and mucosa, and then tympanomeatal flap was dissected and elevated up to the annulus. (5) Exploration: the ossicular chain was confirmed to be intact and mobile, and the orifice of the eustachian tube was unobstructed. (6) Placement of grafts: perichondrium on the parotid side was harvested for later use (Step 7). The cartilage-perichondrium complex was trimmed to an appropriate size, with the perichondrium slightly wider than the cartilage, and a wedge-shaped notch to accommodate the malleus handle. The graft was then placed on the inner side of the residual tympanic membrane. The tympanomeatal flap was repositioned back once the graft tightly fit the tympanic membrane. (7) Extra patching: if the graft did not tightly fit the residual tympanic membrane or if the marginal perforation had no tympanic remnant to support the graft, an extra perichondrium patch was used to strengthen the anterior-inferior tympanic membrane. We trimmed the perichondrium (prepared in Step 6) into a wide and long strip, laid it at the fissure with a crochet hook and folded it inward to make it in good contact with both the residual tympanic membrane /annulus and the graft. After that, we confirmed that the extra patch was firmly stabilized and tucked (Figure 1 and 2 for the extra patch). (8) Filling of the external auditory canal with gelatin sponge. (9) Suture of the tragus incision.