Introduction: Cholesteatoma surgery aims to eliminate disease, restore function, and avoid complications. Open cavity surgery is commonly complicated by ongoing problems that may result from failure to achieve one or several of these aims, e.g. poor disease clearance, failed epithelial migration, or ischemia-related infection.

The aim of wall reconstruction is to reverse these problems as far as is practicable. The essentials to achieve this are a well-fitted, durable, biocompatible wall support layer, healthy skin and a restored vascular supply.

Method: Recreating the support layer requires a suitably tensile and biocompatible material that can be readialy shaped and curved, remaining durable in the long term. Where possible, full skin coverage is desirable to facilitate EAC healing. Long term stability requires a well-designed vascular supply to nourish the skin; the middle temporal flap has the best theoretical and demonstrable vasculature for this role.

Wall assembly by conventional tympanoplasty methods druing reconstruction is difficult, due to space constraints. An alternative “front-to-back” skin-flap-support layer sequence is optimal, preceded by the appropriate drum/chain repair.

Outcomes: The results of previous techniques exhibted difficulties related to the design of each. The use of titanium sheeting appears to have overcome the problems of biocompatibility, shaping and stability. The middle temporal flap has succeeded in restoring vascular supply and canal skin health.Recreation of the EAC lumen dimensions to a more normal diameter without obstructing protrusions largely restores epithelial migration. Restoration of hearing depends on the middle ear pathology and Eustachian function, as in routine tympanoplasty. This pathology is severe in many of these cases.