The role of different types of grafts in tympanoplasty.

In 1878, Emil Berthold was the first to describe the surgical procedure of myringoplasty, using a free skin graft from the forearm,1 although Edward Ely argued in a later publication that he had been the pioneer in this procedure.2 But it was only in the 1950s that tympanoplasty-related articles reappeared in the literature. The fundamental principles of the surgical procedure were described by Wullstein3 in 1952, using a free skin graft, and Zoellner4 in 1955, using a pedicle graft. Since then, several types of materials have been used to reconstruct the tympanic membrane. Among the autologous grafts, the following can be mentioned: temporalis fascia, fascia lata, periosteum, perichondrium, cartilage with and without perichondrium, veins, fatty tissue, and skin.5,6 Several allografts are mentioned in the literature and include: dura mater, pericardium, temporalis fascia, amniotic membrane, skin, cornea, peritoneum, veins, and aortic valve.6 Recently, alloplastic grafts such as paper, absorbable gelatin sponge, and acellular dermal matrix have also been used.7 The trend toward increasingly less invasive medical procedures, with shorter hospitalization stay, has led to a demand for materials to replace autologous grafts. Theoretical advantages include the elimination of morbidity related to graft harvesting, faster healing, no visible scarring, less pain, and less risk of infection, in addition to a faster procedure and early discharge. These grafts, however, make the procedure more expensive and have shown no real advantages so far.7 The fascia temporalis is the most commonly used graft, with success rates between 93% and 97% in primary tympanoplasty, especially in well-aerated middle ears.5,8 In the last decade, however, there has been an increasing interest in using cartilage grafts as the primary alternative to its use. The stiffness and strength of cartilage confer greater stability to the graft and have a key role in the resistance against shrinkage. There is some concern, however, that