A novel graft material for endoscopic tympanoplasty using the pre-tragal SMAS layer
Reviewed by Aileen Lambert

The traditional biological graft materials for providing a scaffold for tympanic membrane reconstruction include temporalis fascia as well as conchal and tragal perichondrium/cartilage. This group from Taiwan present a novel graft option using the superficial musculo-aponeurotic system (SMAS) layer. They describe in this paper the methods used for harvest (with a linked video) as well as outcomes from 30 patients undergoing an endoscopic type 1 tympanoplasty for a dry perforation, with a six-month follow-up period, with a single surgeon. The retrospective design used a cohort of 30 matched patients who had traditional temporalis fascia graft reconstruction with the same surgeon and approach. The temporalis fascia was approached via a 2cm supra-auricular incision. The reason for seeking a novel graft cited by the authors is the move, in some centres, towards a transcanal approach to tympanoplasty, particularly with endoscopic ear surgery (EES) gaining momentum. They highlight that the tragal cartilage most commonly used in EES is a limited resource, particularly in revision surgery, and it serves an important function as the anterior wall of the EAM. The access described to harvest the SMAS graft is via a similar incision to that used for tragal cartilage graft, and the SMAS layer is identified between the tragal perichondrium and skin. Once the harvested SMAS graft is cleaned of muscle and fat, it is compressed/dried in a similar manner to a temporalis fascia graft. The outcomes measured were perforation closure rate, mean hearing gain and length of surgery, which revealed no statistically significant differences between the two groups. There were no significant complications in either group. The results of a postoperative donor-site scar patient satisfaction survey favoured the SMAS graft incision. This paper demonstrates the clinical feasibility (in a relatively small cohort of patients with admittedly short follow-up) of this novel SMAS graft, which would be of benefit in revision cases where there is no further usable tragal cartilage and perichondrium.

The Pretragal Superficial Musculoaponeurotic System Fascia: A New Graft Material for Transcanal Tympanoplasty.
Lin MY, Chang TS, Liao JB.
OTOLOGY AND NEUROTOLOGY
2020;41(5):644-53.