Total Tympanic Membrane Reconstruction (TTMR): A Published Technique for the Most Difficult Eardrums
Total tympanic membrane reconstruction (TTMR) is an operation that rebuilds the entire eardrum when no usable part of it is left. It was developed for patients whose eardrum has been completely destroyed, including after one or more failed repairs. The published closure rate is 92% overall, and 97% when the patient's own temporalis fascia is used.
This article addresses a specific surgical problem and a specific surgical solution. The problem is the patient whose tympanic membrane — the eardrum — is essentially gone. There is no useful remnant to graft onto. The patient may have had multiple previous failed repairs. The ear may discharge chronically. The hearing may be severely affected. By the time these patients reach a specialist, they have often been told that nothing more can be done, or that further surgery is unlikely to succeed.
The solution is a technique I developed and published specifically for this problem: total tympanic membrane reconstruction, or TTMR. The technique was described in the peer-reviewed paper Total tympanic membrane reconstruction: AlloDerm versus temporalis fascia, published in Otolaryngology–Head and Neck Surgery in 2005 (volume 132, page 906) and subsequently selected for the Mosby Yearbook of Otolaryngology, Head and Neck Surgery 2006 as a featured contribution to the field. This article explains what the technique is, why it works, and why it produces the closure rates that older techniques cannot match in this patient group.
Why standard techniques fail in complete tympanic membrane loss
Traditional tympanoplasty techniques — both underlay and overlay — work well when there is residual eardrum to graft onto. The graft is positioned against the remaining drum, the patient's own tissue grows over the graft, and the eardrum heals. This works in the great majority of standard perforations, and the individual techniques are described separately.
The problem arises when there is no useful residual eardrum. In these patients — those who have had complete or near-complete loss of the drum from previous surgery, from chronic disease, or from extensive cholesteatoma resection — the standard techniques have nothing to grip onto. The published failure rates in this group with traditional techniques have historically been substantial: 15–48% failure even in experienced centers, with the most common failure modes being complete non-take of the graft, mucosalization (the inner ear lining growing across the graft and re-perforating it), incomplete healing of the edges, and anterior blunting (a deformity where the front of the eardrum balls up into a thick scar). Revision surgery in this group has historically failed in nearly half of cases.
What TTMR does differently
The TTMR technique was designed specifically to overcome the failure modes of standard reconstruction in patients with complete eardrum loss. The key technical elements:
An extreme lateral anterior free graft harvest incision. The graft is harvested through an incision designed to provide the wide surgical exposure needed to work with no eardrum remnant to use as a landmark.
Complete removal of the annular ligament. The annular ligament is the band of tissue that normally anchors the eardrum to the bony rim of the ear canal. In patients who have failed previous repairs, this ligament is typically scarred, thickened, or partially destroyed. Standard techniques work around it. TTMR removes it completely and reconstructs from a clean foundation.
Removal of any unusable tympanic membrane remnants. Patches of scarred, thickened, or partially detached residual drum that compromise healing are removed, leaving a clean surgical bed for the new graft.
Silicone stenting of the middle ear and ear canal. A thin silicone sheet supports the graft during healing and prevents the inner ear lining from contacting the graft before it has had time to heal properly.
Split-thickness skin grafting in the ear canal where the lateral graft meets the canal skin, ensuring that the entire reconstructed surface heals as a single continuous epithelial layer.
The choice of graft material. Temporalis fascia from the patient's own body (the autologous option) or AlloDerm dermal allograft (the allograft option). The published study showed that both materials are highly effective, with the autologous fascia preferred when available in primary cases and AlloDerm particularly useful in revision cases where the fascia has been used previously or when delayed healing is anticipated.
Published outcomes
The original 2005 publication reported an overall perforation closure rate of 92% in a series of 50 patients with complete tympanic membrane perforations operated between 1999 and 2004. Within that series, the subset of patients reconstructed with autologous temporalis fascia — natural tissue from the patient's own body — achieved a closure rate of 97%, with AlloDerm achieving similar overall efficacy and a statistically significantly shorter healing time. These results — for a patient population in which traditional techniques had historical success rates in the 50–60% range — represented a substantial improvement in what was achievable for this group.
The practical implication for patients today is that when complete tympanic membrane loss is reconstructed with TTMR using the patient's own natural tissue, the published closure rate is 97%. This is a level of success that, in patients with no usable eardrum remnant, was not previously thought to be achievable and is, to this day, substantially higher than what traditional techniques produce in this most difficult patient group.
Who is a candidate for TTMR
The TTMR technique is specifically designed for patients with:
Complete or near-complete loss of the tympanic membrane from any cause
Failed previous tympanoplasty with significant residual perforation
Multiple failed previous repairs
Chronic perforations with extensive scarring and minimal usable drum remnant
Cholesteatoma resection requiring complete tympanic membrane reconstruction
Other complex tympanic membrane defects unsuitable for standard tympanoplasty
For patients with standard perforations and adequate residual drum, traditional tympanoplasty techniques work very well and are typically the preferred approach. TTMR is reserved for the more difficult cases.
Why this matters for patients considering a second opinion
If you have had one or more failed eardrum repairs, and you have been told that further surgery is unlikely to succeed or that nothing more can be done, the most important question is whether you have been evaluated by a surgeon who has access to and experience with the techniques designed for difficult cases. The TTMR technique was developed precisely for patients in your situation. The published outcomes — in patients exactly like you — show that the historical pessimism about revision tympanoplasty success is no longer warranted when the right technique is applied by an experienced surgeon. When a second opinion before ear surgery makes sense is set out separately.
A consultation costs you a visit. The potential gain is a dry, safe, healed ear after years of recurrent problems.
Frequently asked questions
What is TTMR?
Total tympanic membrane reconstruction is an operation that rebuilds the entire eardrum when no usable remnant is left. It differs from standard tympanoplasty in that the annular ligament and any unusable remnants are removed first, the middle ear is stented with silicone during healing, and the reconstruction is built from a clean foundation rather than onto existing drum.
Can an eardrum be rebuilt if it is completely destroyed?
Yes, in suitable patients. Complete loss of the eardrum is the exact situation TTMR was developed for. In the published series of 50 such patients, the overall closure rate was 92%, and 97% in the subset reconstructed with the patient's own temporalis fascia.
I have had several failed ear operations. Is it worth trying again?
Often, yes. Repeated failure usually reflects the technique used rather than the ear being beyond repair. TTMR was designed for exactly this group, and what matters is whether the surgeon has the technique and instrumentation for difficult cases.
Fascia or AlloDerm — which is used?
Both are effective. Temporalis fascia from the patient's own body is preferred in primary cases when it is available. AlloDerm is particularly useful in revision cases where the fascia has already been used, or where delayed healing is expected, and it heals significantly faster.
What makes TTMR different from a normal tympanoplasty?
A standard tympanoplasty grafts onto what is left of the eardrum. TTMR assumes there is nothing left to graft onto, so it removes the scarred annular ligament and unusable remnants, stents the middle ear, and rebuilds the whole drum as one continuous surface.
How much does the operation cost in Belgrade?
The fee depends on the complexity of the case, so the clinic quotes it once your records and imaging have been reviewed. Call AF Medico Belgrade on +381 60 140 67 57 or send your records through the contact form.
Book a consultation at AF Medico Belgrade
Bring your operative reports, audiogram and any CT imaging. Prof. Dr. Fishman will review what was done before, what the ear looks like now, and whether TTMR is the right reconstruction for it.
Consultations: +381 60 140 67 57
AF Medico Belgrade, Vodice 35, 11090 Belgrade, Serbia
This article is for information only and is not a substitute for individual medical examination, diagnosis or treatment.
