8Temporalis Fascia and Perichondrium Grafts

FWhy a soft-tissue graft, and which one

Almost every ossiculoplasty rests on an intact, mobile tympanic membrane. The prosthesis or remodelled chain drives the oval window only if the drum lateral to it can vibrate and the cleft behind it stays aerated — Wullstein’s original definition of a successful tympanoplasty [1956]. When the drum is perforated, thinned or destroyed, the surgeon must rebuild it, and for most ears the rebuilding material is a thin sheet of the patient’s own connective tissue. The two soft-tissue workhorses are temporalis fascia and perichondrium (usually harvested from the tragus or concha, with or without a thin sliver of attached cartilage).

Both are popular for the same reasons. They are autologous, so they will not be rejected; they are avascular, so they tolerate the slow ingrowth of new blood supply across a graft bed; and above all they are thin, pliable and acoustically near-transparent, healing into a supple membrane that vibrates much like the native drum. Temporalis fascia became the standard graft after Sheehy and Glasscock popularised it in the 1960s, though the technique had in fact been introduced a few years earlier in Lund and Essen [1967, 2022]. Perichondrium offers the same supple healing surface and, when a disc of cartilage is left attached, the option of added stiffness for ears that need it. The clinical question is rarely “which is better in the abstract?” but “which does thisear need?” — a theme this module returns to repeatedly.

FHarvesting fascia and perichondrium

A great practical advantage of these grafts is that the donor sites lie inside the operative field. Temporalis fascia is the loose areolar fascia overlying the temporalis muscle, just above the root of the zygoma. Through a postauricular or endaural incision the surgeon extends the dissection superiorly, incises the fascia, and peels a sheet free; the muscle itself is left undisturbed and the cosmetic result is hidden in the hairline. The harvested sheet is cleaned of fat and muscle, then commonly pressed or air-dried flat on a block so it becomes thin, stiff enough to handle, and easy to slide into position before it rehydrates and softens in the middle ear.

Tragal perichondrium is taken through a small incision on the medial surface of the tragus, cosmetically inconspicuous; the perichondrium is lifted off, alone or with a thin tragal cartilage disc. Conchal cartilage and perichondrium are reached through the same postauricular incision and provide a naturally curved, slightly larger graft well suited to shield and palisade designs. Each donor tissue has a characteristic feel: fascia is the thinnest and most compliant, bare perichondrium is similar but a touch sturdier, and any attached cartilage trades acoustic transparency for retraction-resistant stiffness. The explorer below maps the three sites and their handling.

THow a graft takes: healing and histology

“Take” is the engraftment of the avascular sheet onto the drum bed and its incorporation into a durable membrane. It depends not on the graft sprouting its own vessels but on the surrounding tissue colonising it. After placement, the squamous epithelium of the canal and drum remnant migrates across the lateral surface of the graft, while mucosacreeps over its medial surface; fibroblasts and new capillaries invade the connective-tissue scaffold from the graft bed. A close, immobile, well-vascularised contact at the perforation margin — and freedom from infection and from a heaping of squamous debris — is what allows this ingrowth to succeed.

Importantly, the graft does notregenerate a normal trilaminar drum. Human temporal-bone histopathology of successfully healed fascia grafts shows that the fascia persists essentially unchanged — it does not significantly remodel, alter its thickness, or rebuild the organised radial-and-circular fibrous lamina of the native pars tensa [2018]. The healed neomembrane is therefore a serviceable fibrous sheet re-epithelialised on both sides, supple enough to vibrate but mechanically simpler than the original drum. This is the histological reason a soft-tissue graft is excellent at closing a perforation and giving a vibrating surface, yet a stiffer cartilage-based reconstruction is preferred where the membrane must instead resist retraction or carry a load.

TPlacement: underlay versus overlay

Where the graft sits relative to the drum remnant defines the two classic techniques. In the underlay(medial graft) technique the fascia is laid beneath the fibrous remnant and the malleus handle and is supported from below on absorbable gelatin sponge. It is technically simpler, heals quickly, and avoids the two characteristic complications of lateral grafting. In the overlay (lateral graft) technique the squamous epithelium is meticulously removed and the graft is placed lateral to the fibrous remnant; it gives superb exposure of anterior and total perforations but demands more skill and time.

Overlay’s two signature pitfalls are lateralisation (the graft heals too far laterally, away from the malleus, losing ossicular contact and hearing) and anterior blunting(a fibrous wedge fills the anterior sulcus, dulling the drum). Rizer’s large prospective comparison of overlay and underlay grafting made the pragmatic point clearly: both techniques achieve reliable take and hearing, so the decisive factor is careful, precise technique rather than which side of the annulus the graft lies on[1997]. In modern practice the underlay is the everyday default for most perforations, with overlay reserved for selected anterior or subtotal perforations where its exposure earns its extra risk. In either case the anterior edge of the graft must be deliberately supported, as a medially slumping anterior margin is a common cause of residual perforation and blunting.

CTake rates and the choice of material

How reliably do these grafts close a perforation? For a straightforward primary ear the answer is “very reliably.” Temporalis fascia gives anatomical closure in roughly the high-80s to mid-90s percent in most series; in a direct comparison of adult underlay tympanoplasty, fascia achieved about 84% take with 76% hearing improvement and tragal perichondrium a closely comparable result, the authors slightly favouring cartilage-perichondrium for its durability and easy harvest [2012]. In children, where Eustachian-tube immaturity makes take harder, fascia and tragal perichondrium again performed similarly, each with about 83% anatomical success and no significant difference in hearing [2019]. The chart below places these figures side by side.

The pattern that emerges from the larger evidence base is a trade-off, not a winner. A meta-analysis of 44 studies and over 4,500 patients found that cartilage achieves a significantly higher take rate than temporalis fascia, while fascia gives a marginally smaller postoperative air-bone gap; overall hearing gains are comparable [2025]. In plain terms: soft tissue is the most acoustically transparent option and is ideal where the ear is favourable, whereas cartilage-reinforced perichondrium buys reliability and retraction resistance at a small acoustic premium that is hard to detect in practice. The honest summary for the clinic is that fascia and bare perichondrium are excellent default grafts for the well-behaved ear, and the addition of cartilage is reserved for the ear that needs the extra security.

CSupporting the reconstructed chain

Within an ossiculoplasty the soft-tissue graft is not just a patch over a hole — it is the lateral face of the reconstructed transformer, and the surface the prosthesis or remodelled chain ultimately works against. Three roles matter. First, it must re-establish a sealed, aerated middle ear: a perforation leaks the very pressure difference the transformer concentrates, so closing it restores the impedance match and protects the round window from direct sound [1956]. Second, it must support the lateral end of the prosthesis— in primary cases the fascia is laid to drape over the prosthesis head or, better, over an interposed cartilage shield, so that the construct is held and the head plate does not sit against bare drum.

Third, the graft choice must match the mechanical demand. A thin fascia or bare perichondrium is perfect over an intact chain or a simple perforation in a dry, well-aerated ear. But where a rigid alloplastic head plate must couple directlybeneath the drum — or where the ear is atelectatic, revision or poorly aerated — fascia alone tends to retract onto the promontory and the head plate erodes through it and extrudes. There the standard solution is to back the soft tissue with cartilage: a perichondrium-cartilage island or shield spreads the load, resists retraction, and markedly lowers extrusion[2012, 2025]. The practical rule is therefore to use the thinnest, most transparent graft the ear can safely tolerate: fascia or bare perichondrium when the drum has only to vibrate, and a cartilage-reinforced graft when it must also bear a load or hold against retraction. Chosen this way, the soft-tissue graft does quietly what the whole reconstruction depends on — it restores the supple, supported, vibrating membrane that turns a tidy ossicular repair into a hearing result.