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Eur Arch OtorhinolaryngolDOI 10.1007/s00405-014-2890-0

OtOlOgy

Fat‑plug myringoplasty of ear lobule vs abdominal donor sites

Mustafa Acar · Demet Yazıcı · Turhan San · Nuray Bayar Muluk · Cemal Cingi

Received: 27 October 2013 / Accepted: 13 January 2014 © Springer-Verlag Berlin Heidelberg 2014

mostly below 20 dB. Fat-plug myringoplasty (FPM) is a safe, cost-effective and easy operation for selected patients. Abdominal fat graft is as effective as ear lobe fat graft on tympanic membrane healing, has cosmetic advantages and should be taken into consideration when planning fat as the graft source.

Keywords Fat-plug myringoplasty · Fat-graft tympanoplasty · tympanic membrane perforation · Fat of ear lobule · Abdominal fat

Introduction

Myringoplasty is the daily challenge of an otolaryngolo-gists practice. As the debate continues on which method is the most preferable on various patients, our job is to decide on the most compromising surgery that will lead to the maximum success.

Beginning with the seventeenth century, various grafts including skin, cartilage, vein, dura mater, perichondrium and fascia had been used for tympanoplasty with different success rates [1–4]. However, since the 1950s, autologous temporalis muscle fascia graft had been the most popu-lar graft in myringoplasty and is still the main choice of many surgeons. As the temporalis fascia has disadvantages like autolysis, infection, displacement, alternative grafting materials are yet to be on the agenda of the researchers.

Miscellaneous studies in the literature imply on the advantages of fat-plug myringoplasty (FPM) [5–10]. Besides being an active live material secreting angiogenic and growth factors promoting neovascularization and tis-sue repair, fat graft also scaffolds the gap of the perforated tympanic membrane and therefore stimulates the growth of the epithelium and mucous membrane of the de-epithelized

Abstract the purpose of this study is to compare the success rates of fat-graft myringoplasties harvesting adi-pose grafts from different donor sites (ear lobule vs abdo-men). the clinical records of 61 patients (24 males and 37 females) who underwent fat-plug myringoplasty (FPM) were reviewed retrospectively. Fat from ear lobule (FEl) and abdominal fat were used as graft materials. the impact of age, gender, systemic diseases, topography of the perfo-ration, utilization of fat graft materials of different origin on the tympanic membrane closure rate and the effect of FPM on hearing gain was analyzed. Our tympanic mem-brane (tM) closure rate was 82 %. No statistical significant difference was observed regarding age, gender, comorbidi-ties (septal deviation, hypertension and diabetes mellitus) or habits (smoking). Posterior tM perforations had signifi-cantly lower healing rate. the change in tM closure rate considering different adipose tissue donor sites was not sta-tistically significant. the hearing gain of the patients was

M. Acar ENt Department, yunus Emre State Hospital, Eskisehir, turkey

D. yazıcı (*) ENt Department, tarsus State Hospital, Ismetpasa Mh., 33440 tarsus, Mersin, turkeye-mail: demetyazici@yahoo.com

t. San ENt Department, göztepe training and Research Hospital, Istanbul Medeniyet University, Istanbul, turkey

N. B. Muluk ENt Department, Faculty of Medicine, Kırıkkale University, Kırıkkale, turkey

C. Cingi ENt Department, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, turkey

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margin [11]. In addition, the ease of harvesting fat and the simplicity of the technique make FPM a favorable outpa-tient procedure.

Fat-plug myringoplasty was first introduced by Ringer-berg [5] in 1962 where he used fat from ear lobule as the major adipose donor site. He recommended this method for the closure of small perforations with a success rate of 86.5 %. later, gross et al. [8] and Mitchell et al. [12] popu-larized FPM in children especially for residual tympanic membrane perforations after tympanic tube extrusion.

Although Ringerberg did not favor abdominal fat for grafting in his first studies, using only ear lobe as adipose donor site may have some disadvantages such as insuf-ficient grafting material and cosmetic defects. In 1964, Sterkers [13] used compressed abdominal fat for tM clo-sure and since then, various studies have been reported in the literature using both ear lobe and abdominal adipose tissue for FPM in children and in adults.

this present study is designed to compare the healing rates of FPMs when adipose tissue is harvested from differ-ent sources.

Material and method

In this retrospective study, we reviewed the clinical records of 61 patients who underwent fat-plug myringoplasty for long-standing tM perforations (>6 months) between 2009 and 2012 at Eskisehir yunus Emre State Hospital. the patients were selected according to these criteria:

1. presence of tM perforation for at least 6 months,2. perforation size being no more than 30 % of tympanic

membrane by visual assessment,3. air–bone gap 30 dB or less on the operation side, and4. absence of ossicular or mastoid pathology, normal tym-

panic cavity mucosa, no otorrhea or retraction pocket formation, no clinical evidence of cholesteatoma.

Patients who had acute inflammation or otorrhea within 3 months, had prior operation for tM perforation or hav-ing adhesive tympanic membrane remnant were excluded from the study. We also evaluated the clinical records of the patients for the presence of smoking, hypertension, sep-tal deviation, and diabetes mellitus. the perforations were classified as anterior, central and posterior.

All the operations were performed under local anesthe-sia under sedation. transcanal approach had been used to place the graft material with the aid of the operating micro-scope. A quadratic injection of 2 % lidocain with 0.125 epinephrine (Jetocain amp, Adeka, turkey) was applied to the external ear canal using a dental syringe. the rim of the perforation was freshened using a sharp pick and cup

forceps for facilitating the growth and migration of the mucosal layer and epithelium. the fat-graft for this opera-tive technique was either from ear lobule or from umbili-cus. Fat from the ear lobule was harvested from the poste-rior side of the lobule through 10–15 mm vertical incision, whereas fat from the abdomen was harvested from 1 cm below the umbilicus through 2 cm horizontal incision by local anesthesia. Fat swab at least two times bigger than the perforation was inserted through the perforation in a dumb-bell fashion by the aid of a pick and stabilized by gelfoam pieces soaked with antibiotic drops.

the patients were discharged the same day. they were advised to avoid vigorous nose blowing and straining exer-cises, and to keep their ears dry. Pure tone audiometry of the patients were performed after 3 months. Hearing gain was designated as the change in the air-bone gap after the operation. Air-bone gap was calculated as the difference of the average thresholds of air conduction and bone conduc-tion at the frequencies of 0.5, 1, 2 and 4 kHz. Follow-ups were performed by otoscopy or endoscopy at 2 weeks, 1, 3 and 6 months.

the statistical package SPSS (version 16.0) was used for statistical evaluation including independent samples t test, χ2 test and Spearman’s correlation rho efficient tests. A value of p < 0.05 was taken to indicate statistical significance.

Results

Sixty-one adult patients fulfilled the criteria for our study. the demographics, perforation topography, graft features, hearing gain, comorbidities and habits of the patients are demonstrated in table 1. We assessed the results of our study in different aspects.

there were 24 male (39 %) and 37 female (61 %) patients. the ages of the patients ranged 18–61 years with the mean age of 37.5 ± 11.6. Considering patients’ age, no significant difference between the successful and the unsuccessful graft group was detected by independent sam-ples t test (p > 0.05) (table 1).

Of the 61 fat-graft myringoplasties, 50 of them were (82 %) successful. No intraoperative or postoperative com-plications were recorded. there were 21 males and 29 females in the successful graft group, there were 3 males and 8 females in the unsuccessful graft group. the differ-ence between gender groups was not statistically signifi-cant by χ2 test (p > 0.05) (table 1).

We also assessed the effect of septal deviation, hyper-tension, diabetes mellitus and smoking on the closure rates of the tympanic membranes. there was no significant dif-ference between comorbidities (septal deviation, hyper-tension and diabetes mellitus) and habits (smoking) of the

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successful an un-successful graft groups when analyzed χ2 test (p > 0.05) (table 1).

When we classified the cases according to the locali-zation of the tympanic membrane perforation as anterior, central and posterior and analyzed its’ relationship with the closure rates, in central perforations the closure rate was 90.9 %, in anterior perforations was 88.9 % and finally in posterior perforations it was 63.2 %. this difference was analyzed by χ2 test; and there was a significant difference (p = 0.016, χ2 = 5.807) (Fig. 1).

We also evaluated the effect of graft materials on the efficiency of tM closure. In 40 patients, fat from ear lobule was used as tM graft, whereas in 21 patients, umbilical fat was used as graft material. Of the 40 ear lobule fat graft patients, 31 patients (77.5 %) had successful perforation closure, 9 of the patients (22.5 %) were unsuccessful. Of the 21 umbilical fat graft patients, 19 of them were success-ful, 2 of them were unsuccessful. In both groups, there was no significant difference between graft sources by χ2 test (p > 0.05) (Fig. 2).

Table 1 Patient demographics, perforation topography, graft features, hearing gain, comorbidities and habits

*p value shows the results of independent samples t test

**p value shows the results of χ2 test representing the significance of difference between successful and unsuccessful cases

Fat graft success rate P*

Successful (n = 50) Un-successful (n = 11) total (n = 61)

Mean ± SD Min−Max Mean ± SD Min−Max Mean ± SD Min−Max

Age 37.52 ± 11.74 18.00−61.00 37.72 ± 11.73 19.00−55.00 37.55 ± 11.64 18.00−61.00 p = 0.958 t = −0.053

n % n % n % P**

gender

Male 21 875 3 12.5 24 100.0 p = 0.572 χ2 = 0.319

Female 29 78.4 8 21.6 37 100.0

Perforation localization

Central 30 90.9 3 9.1 33 100.0 p = 0.016 χ2 = 5.807

Anterior 8 88.9 1 11.1 9 100.0

Posterior 12 63.2 7 36.8 19 100.0

graft source

Fat of ear lobulus (FEl)

31 77.5 9 22.5 40 100.0 p = 0.214 χ2 = 1.543

Abdominal fat (AF) 19 90.5 2 9.5 21 100.0

Hearing gain

None 1 11.1 8 88.9 9 100.0 P < 0.0001 χ2 = 27.664

<10 dB 18 85.7 3 14.3 21 100.0

10–20 dB 29 100.0 0 0.0 29 100.0

>20 dB 2 100.0 0 0.0 2 100.0

Comorbidities

Septal deviation

Present 9 81.8 2 18.2 11 100.0 p = 0.989 χ2 = 0.000

Absent 41 82.0 9 18.0 50 100.0

Hypertension

Present 4 66.7 2 33.3 6 100.0 p = 0.309 χ2 = 1.037

Absent 46 83.6 9 16.4 55 100.0

Diabetes Mellitus

Present 7 100.0 0 0.0 7 100.0 p = 0.191 χ2 = 1.711

Absent 43 79.6 11 20.4 54 100.0

Habits

Smoking

Present 13 86.7 2 13.3 15 100.0 p = 0.589 χ2 = 0.292

Absent 37 80.4 9 19.6 46 100.0

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And finally, we analyzed the difference in hearing gain of successful and unsuccessful patients by χ2 test. In suc-cessful group, hearing gains were higher as expected than the unsuccessful group (p < 0.0001, χ2 = 27.664) and most of the hearing gain was between <10 and 10–20 dB (table 1). When we compared the hearing gain of the ear lobule group with abdominal fat group for successful patients with Fisher’s exact test, we could not find a statis-tically significant difference (p = 0.43). Also we detected that the hearing gain was lower in older, hypertensive patients and at the patients who had posterior tM perfora-tion by Spearman’s correlation test (p < 0.05).

Discussion

the idea of myringoplasty first emerged in the seventeenth century by the attempts of Banzer [1], who tried to repair

the tympanic membrane perforation by the aid of a small ivory tube in 1640. However, it was Berthold [2] who in 1878 successfully achieved first successful tympanic clo-sure by a full thickness skin graft. As the repair of tM by Berthold’s method caused recurrent perforations and cho-lesteatoma, different graft materials were tested by various surgeons to overcome the obstacles of this method. First by Hagerman in 1958 and later by Ortegen in 1959, the autol-ogous temporalis muscle fascia had been introduced as the ultimate graft material for tympanoplasty, and since then, this graft is the most popular grafting material in otological surgery [3, 4].

In 1962, Ringerberg [5] published his article on the use ear lobule fat graft in tympanic membrane perforations and introduced this method as a simple, reliable and cost-effective procedure for small tM perforations. However, his operational technique was very different from the one that is used nowadays. He elevated the tympanomeatal flap,

Fig. 1 Fat graft success rates related to the topography of the perforation

Fig. 2 Fat graft success rates related to the graft sources (fat of ear lobulus vs abdominal fat)

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explored the middle ear and placed the graft lateral to the perforation, but not through the perforation in the dumb-bell fashion as introduced by Althaus [6] as we mostly use today and also used in our study.

In this study, we assessed our results in different aspects. We evaluated the impact of age, gender, systemic diseases, topography of the perforation, utilization of fat graft mate-rials of different origin on the tympanic membrane closure rate. We also analyzed the effect of FPM on hearing gain of the patients.

In our study, the closure rate of tM perforation was 82 % and our finding was consistent with the literature where the rates ranged between 76 and 100 % [7–9]. there was no statistical difference between males and females as confirmed in other fat-graft myringoplasty studies [8–10].

When we evaluated the impact of age on the tM clo-sure rate, we could not observe a statistically significant difference. generally, young age (smaller than 7 years) is considered as a risk factor for myringoplasty surgery using temporalis muscle fascia or tragal perichondrium as grafts [14–16]. However, in fat-plug myringoplasty studies, no statistically different results were detected in young-aged patients [8, 17, 18]. Our study did not compromise pediat-ric patients. Our youngest patient was 18 and oldest patient was 61 years old, and although we concluded that age did not affect tM closure rate, it did have an effect on the hear-ing gain of the patients, and older the patient, lesser the hearing gain after the operation.

We also assessed the effect of perforation localization on the tM closure rate. We classified the perforations as anterior, central and posterior and observed that posterior perforations’ closure rate was lower than the others sig-nificantly. there were various aspects on this issue in the literature. generally speaking, because of poor vascular supply and difficulty in visualization of the anterior limits, the anterior perforations are thought as a bad prognostic factor for tympanoplasty [19, 20]. However, as Dedden’s et al. [17] and gross et al. [8] mainly used this method in children who had perforations after eardrum tubes were extracted, their perforation site was mainly anteroinferior and did not detect that this was a bad prognostic factor for fat-plug myringoplasty. Ayache et al. [10] easily performed FPM by otoendoscopy and favored this method in anterior perforations. these findings were also confirmed by the study of Koc et al. [21] and Fiorino et al. [11] where they had mainly patients with previous otologic surgery and by the study of Kim et al. [22] where they had mostly primary myringoplasty patients. However, in contrast to these, Kon-stantinidis et al. [23] asserted in their research that anteri-orly located perforations have significantly lower healing rate despite the use of the otoendoscope and linked their results to the bulging of the anterior wall which is often observed in the greek population. In our clinical study

posterior tM perforations had significantly lower success rate and this finding was consistent with the study of Singh et al. [24] where they compared different graft materials for myringoplasty.

the main objective of our study was to evaluate the effect of fat graft materials from different donor sites on tympanic membrane closure rate. Although Ayache et al. [10] and Fiorino et al. [11] used both ear-lobe and abdomen as fat graft donor site, they did not compare the success rate of different fat graft sources. to our knowledge, our study is the first in the literature querying this difference. Ringen-berg [5] recommended and favored ear lobe fat for FPM by demonstrating ear lobe adipocytes being more compact and having more fibrous supporting tissue than buttocks or abdominal fat, and by stating that this is an advantage for myringoplasty. However, Kwong et al. [9] asserted that this feature of ear lobe fat may complicate angiogenesis and tis-sue repair contrary to Ringerberg’s observations and they manifested a clinical success of 100 % using umbilical fat in their study. Our results were harmonious with Kwong et al.’s findings and we did not observe a statistically sig-nificant difference between different graft materials.

And finally, we assessed the hearing gain results of the patients after FPM. there were conflicting outcomes of various studies in the literature. In the studies of Singh et al. [24] and Dursun et al.[25], hearing improvement less than 10 dB was gained after FPM. But these studies used this technique only for small perforations (≤3 mm). Kon-standinidis et al. [23] could not detect statistically signifi-cant hearing improvement after FPM. In the study of Koc et al. [21], the average air–bone gap decreased significantly after the operations and hearing gain was more prominent at larger perforations. In contrast, Kim et al.’s [22] study showed less hearing improvement with bigger perforations. We found out that hearing improvement was significantly better after successful operation and hearing gain was mostly below 20 dB. When we compared we also deter-mined that the hearing gain was lower in older, hyperten-sive patients and at the patients who had posterior tM per-foration as posterior perforations had the higher rejection rate.

Conclusion

the ease and safety of the procedure makes this myringo-plasty technique an excellent outdoor procedure. In this study, adipose tissue both from ear lobule and umbilicus was found to be feasible for fat-plug myringoplasty. to our knowledge, ours is the first study in literature analyzing the tM closure rates between different adipose graft donor sites. While previous studies had demonstrated the fat graft obtainability from ear lobe, umbilicus and buttocks, none

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of them analyzed and compared the difference between them considering tM closure rate. As our study group is relatively small, more research is needed on how different adipose tissue donor sites affect tympanic membrane clo-sure rate when FPM technique is performed.

Conflict of interest We have no conflict of interest that we should disclose.

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