Surgery exclusively by Dr. Robert Vincent
La Causse Ear Clinic de Béziers It is one of the most influential centers of modern otology, and the Dr. Robert Vincent It is an international reference in middle ear surgery and advanced ossicular reconstruction. This procedure is available. exclusively on the app SurgSchoolDr. Vincent meticulously demonstrates his microsurgical approach to a complex scenario: a severely atrophic tympanic membrane, transposed and eroded anviland the need to place a hammer replacement prosthesis (MRP) next to a TORP on a extremely fragile plate.
Initial assessment: atrophic tympanic membrane and ossicular chain alteration
The case begins with the examination of a left ear with a completely atrophic tympanic membraneThis is accompanied by an exostosis that obstructs the view of the anterior angle. The malleus handle is present, but malpositioned and at high risk of perforation if mobilization is attempted. This situation necessitates a reassessment of traditional ossicular reconstruction.
During the initial dissection, the surgeon identifies a transposition of the anvil previously performedThe footplate was poorly positioned and lacked adequate contact with the footplate, which explains a previous reconstructive failure. Dr. Vincent decided to remove it completely to properly expose the stapes footplate.
Stage exposure and review findings
After removing the anvil transposition, a movable but extremely thin platenwith signs of erosion or microfracture attributable to previous surgery. This fragility necessitates protecting the plate before any prosthetic reconstruction to prevent perilymphatic fistulas or TORP instability.
Venous interposition over the footplate
In a classic gesture of otology examination, Dr. Vincent obtains a vein graftidentifying its inner surface and firmly securing it to the plate. This maneuver allows:
- Sealing of pre-existing microcracks.
- Mechanical reinforcement of the plate.
- Stable surface for TORP support.
The technique is especially relevant in surgeries with thermal trauma or residual erosions of previous interventions.
Tympanic reinforcement and malleus handling
Due to the degree of tympanic atrophy, the surgeon decides:
- Cut the malleus tendon, which generated unwanted traction.
- Place perichondrium under the handle of the hammer to reinforce the entire previous area.
- Do not use the native hammer due to the risk of iatrogenic perforation, opting instead for a MRP (Malleus Replacement Prosthesis) anchored to the bone wall of the canal by means of two perforations made with a 0,6 mm diamond bur.
This is a key educational aspect: MRP allows the hammer function to be reconstructed without depending on a non-viable native structure.
TORP placement and length adjustment
Following a meticulous protocol, Dr. Vincent measures the distance between the MRP and the reinforced plate:
- Estimated length: 7 mm.
- Strategy: initially insert the TORP into 6 mm for later retract it to 7 mm exact using the adjustment technique.
Final stability is verified by observing the correct alignment between the hammer prosthesis and the TORP.
Final protection with cartilage
Before closing, the surgeon shapes a thin sheet of tragal cartilage to cover:
- The head of the TORP
- The MRP hooks
- The tympanic reinforcement perichondrium
This stabilizes the prosthetic construct and protects against resorption or extrusion.
Closing and final result
After completely repositioning the panomeatal flap, the stable alignment of the MRP–TORP complex and the absence of tension on the reconstructed tympanic membrane. The closure is completed with Merocel.
The video constitutes a Masterclass in revision surgery of the middle ear, showing:
- How to manage atrophic structures
- How to address failed anvil transpositions
- When to use an MRP
- How to reinforce an unstable plate
- How to ensure a durable prosthetic assembly
