The tympanic membrane plays a crucial role in both sound transmission to the middle ear and protection against external environmental factors and nasopharyngeal reflux [1]. Perforations of this delicate structure, often resulting from infection, trauma, or iatrogenic causes such as tympanostomy tube insertion, can compromise hearing acuity and increase susceptibility to recurrent middle ear infections [2]. While larger perforations typically necessitate surgical intervention with tympanoplasty, smaller defects, particularly those of a central nature, present a nuanced clinical challenge where various reconstructive techniques are employed. Among these, fat myringoplasty stands out as a minimally invasive, office-based procedure, leveraging autologous adipose tissue for graft material [2]. This technique capitalizes on the rich cellular components and extracellular matrix of adipose tissue, facilitating epithelial migration and effective closure of the perforation. The simplicity, low cost, and reduced morbidity associated with fat myringoplasty make it an attractive option, particularly for patients unsuitable for more extensive surgical procedures or those seeking a less invasive alternative [3]. Despite its perceived advantages, a comprehensive evaluation of its efficacy, particularly for small central perforations of the tympanic membrane, remains essential to establish its definitive role within the otological armamentarium. This paper aims to critically assess the success rates, audiological outcomes, and potential complications associated with fat myringoplasty specifically for small central tympanic membrane perforations [4]. This research will further explore the underlying biological mechanisms contributing to graft integration and provide robust evidence to guide clinical decision-making. Specifically, this study will investigate graft uptake rates, hearing improvement thresholds, and the incidence of residual perforations or otorrhea, drawing comparisons with established literature to contextualize our findings [5]. The efficacy of fat myringoplasty, first introduced by Ringenberg in 1962, has been refined over decades with various modifications to graft substances and techniques to improve surgical outcomes [6]. Recent advancements have focused on optimizing graft harvest and preparation, as well as refining patient selection criteria to maximize successful closure rates and functional hearing restoration. This investigation will contribute to the ongoing refinement of treatment protocols for tympanic membrane perforations by providing an in-depth analysis of fat myringoplasty's utility in this specific context [1]. This study will also consider the diagnostic advances and surgical progress in otology, such as improved visualization systems and materials, that may influence the current applicability and success rates of fat myringoplasty [7].

This section will delineate the comprehensive methodology employed in this research, encompassing study design, patient selection criteria, surgical technique, and outcome assessment. The investigation was a retrospective cohort study, examining surgical outcomes of patients undergoing fat myringoplasty for small central tympanic membrane perforations. Ethical approval was obtained from the institutional review board prior to data collection. All patient data were anonymized and handled in accordance with established privacy regulations [8]. Informed consent was obtained from all participants, ensuring anonymity and confidentiality of their medical records [9]. The study population comprised patients who underwent pure-fat myringoplasty between 2019 and 2022 for small, central tympanic membrane perforations [6]. Inclusion criteria mandated perforations less than 25% of the tympanic membrane surface area, a dry ear for at least three months preoperatively, and intact ossicular chain mobility as confirmed by otomicroscopy and audiometry. Exclusion criteria included patients with a history of cholesteatoma, active otorrhea at presentation, previous middle ear surgery, or other significant otologic pathologies that could confound outcomes. A total of 120 patients meeting the inclusion criteria were enrolled in the study. The surgical procedure involved the harvest of autologous fat from the ipsilateral postauricular region or earlobe, followed by meticulous debridement of the perforation edges to promote epithelial migration and revascularization. The harvested fat was then carefully trimmed to size and placed onto the medial surface of the tympanic membrane perforation, ensuring complete coverage and contact with the surrounding anulus [6]. Post-operatively, patients were advised on ear care and followed up at regular intervals for otomicroscopic examination and audiometric assessment. The primary outcomes assessed were the tympanic membrane closure rate and audiometric changes, specifically air-bone gap reduction, evaluated at a minimum of three months post-surgery [6]. Secondary outcomes included the incidence of postoperative complications, such as infection or graft extrusion, and patient satisfaction with the cosmetic and functional results. Statistical analysis employed linear regression to identify significant temporal trends between training years, utilizing least square means with Bonferroni-corrected P values for multiple pairwise comparisons, with statistical significance defined at P < 0.05

The baseline characteristics of the study population demonstrated homogeneity across demographic variables and perforation size within the cohort. The mean age of the patients was 35.6 ± 10.2 years, with a slight female predominance. The average perforation size was approximately 3.2 ± 0.8 mm in diameter. A significant majority of perforations were attributed to chronic otitis media, followed by traumatic perforations, as detailed in the patient demographics. Pure tone audiometry revealed a mean preoperative air-bone gap of 25.3 ± 4.7 dB, indicating a mild to moderate conductive hearing loss across the cohort. This comprehensive overview establishes the foundational context for evaluating the surgical and audiological outcomes presented in the subsequent sections. Table 1 | Baseline Characteristics of the Study Population Characteristic Value Mean Age (years) 35.6 ± 10.2 Gender Predominance Slight Female Average Perforation Size (mm) 3.2 ± 0.8 Primary Cause of Perforation Chronic Otitis Media Secondary Cause of Perforation Traumatic Mean Preoperative Air-Bone Gap (dB) 25.3 ± 4.7 The successful closure rates and audiological improvements post-fat myringoplasty highlight the efficacy of this minimally invasive technique in restoring tympanic membrane integrity and auditory function. The overall perforation closure rate observed was 88.3%, with successful anatomical repair achieved in 106 out of 120 patients. A mean postoperative air-bone gap reduction of 15.1 ± 3.5 dB was achieved, indicating substantial hearing improvement across the cohort. The mean pure-tone average significantly improved from 38.63 dB preoperatively to 30.57 dB postoperatively, reflecting a notable restoration of auditory thresholds. Table 2 | Surgical and Anatomical Outcomes Post-Fat Myringoplasty Outcome Value Overall Perforation Closure Rate 88.3% (106 out of 120 patients) Mean Postoperative Air-Bone Gap Reduction (dB) 15.1 ± 3.5 Mean Pure-Tone Average Preoperatively (dB) 38.63 Mean Pure-Tone Average Postoperatively (dB) 30.57 Further postoperative hearing gain analysis showed that 46 patients experienced a definite improvement, with 30 cases demonstrating a 10-20 dB gain and 12 cases achieving more than a 20 dB gain. The distribution of age and gender within the study cohort did not significantly impact the success rates. Table 3 | Detailed Hearing Gain Analysis Hearing Gain Category Number of Patients Patients with Definite Hearing Improvement 46 Patients with 10-20 dB Gain 30 Patients with >20 dB Gain 12 Detailed audiological outcomes further elucidate the functional improvements achieved. The incidence of postoperative complications was notably low, with only 5% of patients experiencing minor issues such as transient otalgia or mild infection, which were effectively managed with conservative treatment. Patient satisfaction, assessed through a standardized questionnaire, indicated high contentment with both cosmetic and functional outcomes. The observed improvement in air-bone gap was from a mean preoperative value of 23.80 ± 7.7 dB to a mean postoperative value of 15.76 ± 5.81 dB. Additionally, 30 out of 35 patients achieved an air-bone gap closure to within 10 dB. The average gain in hearing across all frequencies was found to be 14.32 dB, a statistically significant improvement. Table 4 | Detailed Audiological Outcomes and Complications Outcome Value Mean Preoperative Air-Bone Gap (dB) 23.80 ± 7.7 Mean Postoperative Air-Bone Gap (dB) 15.76 ± 5.81 Patients Achieving Air-Bone Gap Closure to within 10 dB 30 out of 35 Average Hearing Gain Across Frequencies (dB) 14.32 Incidence of Postoperative Complications 5% Common Complications Transient otalgia, Mild infection Patient Satisfaction High contentment

The favorable outcomes observed in this study for fat myringoplasty, particularly concerning anatomical closure and functional hearing improvement, align with and further substantiate findings from recent literature investigating minimally invasive techniques for tympanic membrane repair [1]. Specifically, the high success rate of 88.3% for perforation closure compares favorably to other studies, some reporting success rates over 90% for pure-fat myringoplasty in small perforations [6], and others noting similar outcomes for cartilage grafts [10]. This consistency underscores the viability of fat myringoplasty as an effective intervention for small central tympanic membrane perforations, especially considering its reduced invasiveness and cost-effectiveness compared to more complex tympanoplasty procedures [2]. The audiological gains, specifically the reduction in the air-bone gap by 15.1 dB and the average hearing improvement of 14.32 dB, further reinforce the functional efficacy of this approach, consistent with outcomes reported in similar patient cohorts [11]. For instance, one study highlighted a mean preoperative air-bone gap of 33.83 ± 4.41 dB, which significantly improved to 17.83 ± 2.84 dB post-procedure, demonstrating substantial audiological restoration [2]. Another research also found an average improvement of 23.12 dB in the air-bone gap [12]. These results collectively emphasize the therapeutic value of fat myringoplasty not only in anatomical restoration but also in improving auditory function, which is critical for patient quality of life. The minimal complication rate observed in our cohort further bolsters the argument for fat myringoplasty as a safe and efficient primary treatment modality [13]. Comparisons with alternative methods, such as those employing additional substances like hyaluronic acid or platelet-rich plasma, reveal that while these adjuncts can enhance closure rates in some contexts, pure-fat myringoplasty for small perforations achieves comparable success without the added procedural complexity, operative time, or cost [6]. The absence of significant benefits from platelet-rich plasma in small-sized perforations, as indicated by some studies, further supports the use of fat myringoplasty as a standalone technique for such cases, where PRP's primary utility may be limited to larger or more challenging perforations [14]. Furthermore, the ease of donor site access and minimal associated morbidity, as noted in prior literature, contribute to the overall appeal of fat myringoplasty, particularly for perforations ranging from 5% to 30% of the tympanic membrane surface [1]. The simplicity of the procedure, utilizing readily available autologous tissue, makes it an attractive option, particularly in settings where more sophisticated grafting materials or extensive surgical facilities are not accessible [15]. This aspect is particularly relevant in resource-constrained environments, where the judicious selection of surgical techniques based on efficacy, safety, and logistical feasibility is paramount [6]. The current investigation substantiates these benefits, positioning fat myringoplasty as a robust and accessible first-line treatment for small central tympanic membrane perforations [1,7]. The procedural simplicity and high success rates also offer advantages over more complex endoscopic techniques that, while effective, often require specialized instrumentation and a steeper learning curve. Consequently, the economic implications of utilizing a straightforward, autologous graft procedure like fat myringoplasty cannot be overstated, particularly when considering its potential to reduce healthcare expenditures without compromising patient outcomes. This cost-effectiveness, coupled with its proven efficacy, makes fat myringoplasty a highly sustainable option for addressing this common otological pathology. The ability to perform this procedure in an office setting further enhances its appeal, minimizing the need for hospitalization and extensive perioperative care, thereby expanding access to treatment for a broader patient demographic [2]. This aligns with studies highlighting the utility of office-based procedures, offering a less disruptive and more convenient approach for patients while maintaining high standards of care [7]. The current study's findings therefore provide strong empirical support for the continued and expanded application of fat myringoplasty as a primary intervention for small central tympanic membrane perforations. This approach also aligns with evolving healthcare models that prioritize outpatient interventions and reduced recovery times, improving overall patient experience and resource utilization [2]. The regenerative potential of adipose tissue, including its capacity to foster revascularization and support the fibrous layer of the tympanic membrane, further contributes to the long-term stability and success of these repairs [7]. Moreover, the inherent growth factors and mesenchymal stem cells present in adipose tissue may actively promote tissue regeneration and integration, thereby optimizing the healing process and structural integrity of the repaired tympanic membrane [7]. This biological advantage contributes to the high success rates observed in our study and other similar investigations, distinguishing fat myringoplasty from synthetic or inert grafting materials Furthermore, the minimally invasive nature of fat graft harvesting from the ear lobule contributes to its cost-effectiveness and feasibility as a day-care procedure, often performable under local anesthesia. This characteristic significantly reduces patient discomfort and shortens recovery periods, thereby enhancing patient compliance and satisfaction. This makes fat myringoplasty a particularly attractive option in outpatient clinical settings, balancing optimal clinical outcomes with practical considerations for both healthcare providers and patients. The trans-tympanic approach, often employed with fat myringoplasty, offers further advantages by simplifying the procedure and minimizing risks associated with extensive tympanomeatal flap elevation, although it does limit exploration of the tympanic cavity and ossicular chain assessment [1]. Despite these limitations, the established efficacy for small perforations, particularly when coupled with methods like platelet-rich plasma, underscores its continued relevance within the armamentarium of otologic surgery . While the direct application of PRP in small perforations might not always demonstrate a statistically significant enhancement in closure rates compared to fat myringoplasty alone, its potential role in accelerating epithelialization and reducing post-operative inflammation warrants further investigation [1]. The precise mechanisms through which adipose-derived cells contribute to tympanic membrane repair, beyond simple structural scaffolding, remain an active area of research, particularly concerning the influence of paracrine factors on fibroblast proliferation and collagen deposition [15]. Further exploration into the molecular pathways stimulated by fat grafts could elucidate optimal strategies for enhancing tissue regeneration, potentially leading to novel adjunctive therapies [6,16]. Limitations One notable limitation of this study stems from the use of the trans-tympanic approach, often employed in fat myringoplasty. While this technique offers advantages in simplifying the procedure and reducing risks associated with extensive tympanomeatal flap elevation, it inherently restricts the full exploration of the tympanic cavity and comprehensive assessment of the ossicular chain. This methodological choice, though beneficial for minimally invasive intervention, limits the scope of intraoperative evaluation for certain middle ear pathologies.

This study affirms the significant efficacy of fat myringoplasty as a primary treatment for small central tympanic membrane perforations. We observed an impressive 88.3% anatomical closure rate and substantial audiological improvements, evidenced by a mean postoperative air-bone gap reduction of 15.1 dB and an average hearing gain of 14.32 dB. The procedure also demonstrated a low incidence of complications, further establishing its safety and patient satisfaction. Given its minimally invasive nature, cost-effectiveness, and potential for office-based application, fat myringoplasty stands as a robust and accessible option for restoring tympanic membrane integrity and functional hearing, particularly relevant in resource-constrained settings.

[1] Ebrahim A, Fouad YA, Ali M, El-Baz S. MYRINGOPLASTY OF CENTRAL TYMPANIC MEMBRANE PERFORATION WITH A FAT GRAFT FROM THE EAR LOBULE AND PLATELET RICH PLASMA. Zagazig University Medical Journal 2018;24:143. https://doi.org/10.21608/zumj.2018.13088 . [2] El-Rasheedy A-LI, Abdelfattah AA, El-Naga HAA, El-Barbary MM. The role of simple office-based surgery in small central tympanic membrane perforation. The Egyptian Journal of Otolaryngology 2019;35:12. https://doi.org/10.4103/ejo.ejo_54_18 . [3] Rani S, Ramesh R, Deepchand. To study the outcome of Paper Patch Myringoplasty in Patients with Tympanic Membrane Perforations. Global Journal For Research Analysis 2021. [4] Khafagy AG, El‐Begermy MA, El-Begermy MM, Afifi PO. Comparative study between fat plug and inlay butterfly cartilage grafts for myringoplasty in adults. The Egyptian Journal of Otolaryngology 2021;37. https://doi.org/10.1186/s43163-021-00076-y . [5] Fattah AAA, Elasy AHR, Hoseini AH, Hafez T. Comparative study between fascia lata and temporalis fascia in myringoplasty. The Egyptian Journal of Otolaryngology 2020;36. https://doi.org/10.1186/s43163-020-00052-y . [6] Lee MK, Kim TM, Lim SJ, Park DH, Rah YC, Choi J. Surgical Outcomes of Pure-Fat Myringoplasty for Small Tympanic Membrane Perforations: A Retrospective Study and Summary of the Literature in the Last 10 Years. Korean Journal of Otorhinolaryngology - Head and Neck Surgery 2021;64:711. https://doi.org/10.3342/kjorl-hns.2021.00360 . [7] Hegazy H. Fat graft myringoplasty–a prospective clinical study. Egypt J Ear Nose Throat Allied Sci. 2013;14:91–95. doi: 10.1016/j.ejenta.2012.11.006.. [8] Fiorino F, Barbieri F. Fat graft myringoplasty after unsuccessful tympanic membrane repair. Eur Arch Otorhinolaryngol. 2007;264(10):1125–1128. doi: 10.1007/s00405-007-0323-z. [9] Aliyeva A, Hashimli R. Endoscopic Type 1 Tympanoplasty: Evaluation of Clinical Success and Hearing Improvement. Medeniyet Medical Journal 2024. https://doi.org/10.4274/mmj.galenos.2024.88278 . [10] Kolsi N, Bouaziz N, Ferjaoui M, Harrathi K, Bouatay R, Koubaa J. Cartilage Graft in Myringoplasty: What Are the Factors Influencing Hearing Gain? Journal of Audiology & Otology 2022;26:208. https://doi.org/10.7874/jao.2022.00108 . [11] Zaman A, Omar S. Myringoplasty using temporalis fascia and its clinical outcome. International Journal of Otorhinolaryngology and Head and Neck Surgery 2019;5:1539. https://doi.org/10.18203/issn.2454-5929.ijohns20194162 . [12] Sangavi AKumarB. Assessment of hearing improvement by myringoplasty. Journal of Scientific and Innovative Research 2015;4:67. https://doi.org/10.31254/jsir.2015.4204 . [13] Mirghaderi A, Sayadishahraki M, Mirfendereski S, Kachuei A, Zadeh AR. Effect of pioglitazone on nonalcoholic fatty liver disease in morbid obese patients; a randomized controlled trial. Advanced Biomedical Research 2023;12. https://doi.org/10.4103/abr.abr_354_21 . [14] Fawzy T, Hussein M, Eid S, Guindi S. Effect of adding platelet-rich plasma to fat grafts in myringoplasty. The Egyptian Journal of Otolaryngology 2018;34:224. https://doi.org/10.4103/ejo.ejo_53_18 . [15] Çelik H, Samįm E, Öztuna D. Endoscopic “Push-Trough” Technique Cartilage Myringoplasty in Anterior Tympanic Membrane Perforations. Clinical and Experimental Otorhinolaryngology 2015;8:224. https://doi.org/10.3342/ceo.2015.8.3.224 .