Skin Grafting in Otologic Surgery
Joseph B. Nadol, Jr.
Harold F. Schuknecht
Skin grafting performed intraoperatively or postoperatively is essential to the success of some otologic procedures (e.g., atresiaplasty, canalplasty for acquired stenosis) and enhances the success of others (e.g., tympanoplasty or mastoid tympanoplasty).
Before the current method was adopted, skin grafting had passed through two unsuccessful phases: (i) During the 1940s, free grafts of full-thickness or split-thickness skin were used by some surgeons intraoperatively to cover the bony surfaces of mastoid cavities during radical mastoidectomies and fenestration operations. The common donor sites were postauricular for full-thickness skin and the thigh or arm for split-thickness skin. The results were often disastrous because the grafts underwent areas of ulceration and granulation, subcutaneous fibrous thickening, and hyperkeratosis with collection of keratin and caused seropurulent otorrhea. (ii) During the 1940s and 1950s, full-thickness skin grafts from the postauricular area were in common use as tympanic grafts in tympanoplasty procedures. The results were often similar to full-thickness skin used in the mastoid. The subcutaneous fibrous proliferation in itself was destructive to the sound transmission qualities of the newly reconstructed middle ear system.
During the 1960s and 1970s, split-thickness skin grafts from the upper arm came into routine use as a postoperative procedure to cover unepithelialized surfaces. The grafting was performed in the office or, in the case of children, in the ambulatory surgical unit, and was done about 1 month following surgery to allow the healing process to produce a smooth, well-vascularized recipient site.
Since 1980, almost all skin grafting has been done intraoperatively with similar satisfying results. Because these thin split-thickness grafts can be introduced in an overlapping manner, it is technically easy to cover unepithelialized surfaces.
INDICATIONS
The intraoperative split-thickness skin grafting technique is used routinely in the following conditions.
Canalplasty
Chronic stenosing external otitis. In this case, meatoplasty and canalplasty are followed by skin grafting that includes the bony canal walls and the surface of the pars propria of the tympanic membrane.
Exostoses of the external auditory canal. Following meatoplasty and canalplasty and removal of exostoses, the unepithelialized surfaces of the bony canal walls are skin grafted.
Traumatic or postoperative stenosis of the external auditory canal. These cases are often complicated by a canal cholesteatoma distal to the stenotic area. Meatoplasty and canalplasty are often needed to remedy the stenosis, and skin grafting of resulting unepithelialized surfaces is necessary to prevent recurring stenosis.
Congenital aural atresia. Partial or total atresia of the external auditory canal requires an intraoperative skin grafting technique that completely covers all unepithelialized surfaces. In the case of associated microtia, the grafts must extend to the skin surface to minimize the occurrence of postoperative stenosis at the meatus of the newly created canal.
Tympanoplasty and Mastoid Tympanoplasty
In general, adjunctive split-thickness skin grafting is useful in areas of the canal or mastoid bowl that eventually become epithelialized but are not covered intraoperatively by pedicled flaps or fascial grafts.
Anterior perforations and total drum replacement. Repair of anterior perforations and total perforations nearly always require at least anterior canalplasty to obtain proper exposure of the anterior sulcus between the tympanic membrane and the anterior canal wall. Prompt epithelialization of this area is enhanced by immediate intraoperative skin grafting to prevent fibrosis and blunting of this anterior angle, which in turn may cause fixation of the malleus.
Endaural atticotomy and atticoantrotomy. This operation is usually performed in association with meatoplasty and canalplasty and is concluded by cartilage reconstruction of the lateral epitympanic wall. It provides adequate access for skin grafting of all unepithelialized surfaces.
Canal wall-up tympanomastoidectomy. The procedure usually requires canalplasty—for example, in the case of anterior or superior perforations. Prompt healing is enhanced by intraoperative split-thickness skin grafts to exposed bone of the canal.
Canal wall-down tympanomastoidectomy. Canal wall-down procedures with wide exenteration and saucerization of the mastoid cavity with meatoplasty and canalplasty may be facilitated by intraoperative split-thickness skin grafting to exposed areas of bone in the external auditory canal. In addition, in the type IV tympanoplasty a split-thickness skin graft is invaginated into the oval window directly onto the footplate of the stapes and held in place by a cotton ball to prevent postoperative fibrous obliteration of the oval window niche.
Postoperative skin grafting is used in the following situations.
Postoperative Tympanomastoid Cavity
If the surgeon does not feel comfortable with intraoperative skin grafting, the procedure can be delayed for 4 to 6 weeks. The reasons for delay may be (i) surface undulations or crypts in the walls of the recipient areas, (ii) inability to satisfactorily obliterate the mastoid, (iii) difficulty in controlling bleeding, (iv) inability to completely remove cholesteatoma matrix, or (v) complications of surgery (luxation of footplate of stapes or injury to facial nerve, lateral canal, or sigmoid sinus). Delayed skin grafting is an office procedure for adolescents and adults, whereas children require general anesthesia and therefore are done as outpatients in the ambulatory surgical unit.
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