Toynbee Memorial Lecture 1994: mastoid surgery and the Hong Kong Flap

Critical evaluation of the outcome of surgery for cholesteatoma has favoured open cavity techniques. These methods have however been plagued by an inability to consistently produce healthy well healed cavities. The strength and stability of the normal tympanic membrane depends upon the separation of squamous epithelium from the middle ear mucosa by a fibrous tissue layer. Traditional methods of dealing with the cavity fail to reproduce a similar anatomically stable arrangement. In order to achieve the highest percentage of dry, stable disease-free ears after employing basic surgical principles of wide access to facilitate meticulous removal of all cholesteatoma, we have utilized a vascularized deep temporalis fascia flap for complete coverage of the cavity eliminating all raw areas. This fibrous layer provides the optimal substrate for epithelial resurfacing. Excellent healing even under unfavourable circumstances is ensured by the rich blood supply to the pedicled temporalis fascia flap. Considering patient preferences and cost effectiveness, the optimal treatment for cholesteatoma must be one operation, provided it achieves a dry safe ear. Based upon rational concepts, the 'Hong Kong Flap' technique of reconstructing the mastoid cavity involves a straightforward procedure requiring no special technical skill that consistently achieves this ideal.