Influence of size and site of perforation on fat graft myringoplasty

The impact of adding platelet-rich plasma during fat graft myringoplasty for managing medium-sized tympanic membrane perforations: A prospective randomized case-control study

PURPOSE

This study aimed to evaluate the effect of adding platelet-rich plasma (PRP) during FGM to close medium-sized TM perforations.

METHODS

This prospective randomized case-control study was conducted from February 2017 to March 2022. We included 320 patients with a medium-sized TM perforation with inactive mucosal otitis media. Transcanal FGM managed all patients under general or local anesthesia according to the patient preference. According to PRP, patients were divided into two groups: the first with PRP (170 patients) and the other without PRP (150 patients). We evaluated the closure rate of both groups one month, six months, and one year after the surgery. Also, we assessed the audiological performance before and one year after the operation for the patients with a successful closure.

RESULTS

The closure rate was 87.6 % in the first group and 72.7 % in the second group, with a statistically significant difference between both groups as the P-value, was 0.001. Successful closure of the ABG to <10 dB occurred in 95.3 % of group A and 90.8 % of group B without a statistically significant difference between both groups (P-value = 0.163).

CONCLUSIONS

This prospective comparative study on a relatively large number of patients revealed that FGM effectively closed medium-sized TM perforations. It also significantly improved postoperative audiological performance in both groups. Adding PRP during the FGM enhanced the closure success and the healing process without recorded complications. We recommend using the PRP in the routine FGM for closing medium-sized TM perforations.

Factors influencing successful reconstruction of tympanic membrane perforations: a systematic review and meta-analysis

PURPOSE

Based on a systematic review and meta-analysis, our study aimed to provide information about the factors that influence the success of tympanic membrane reconstruction.

METHODS

Our systematic search was conducted on November 24, 2021, using the CENTRAL, Embase, and MEDLINE databases. Observational studies with a minimum of 12 months of follow-up on type I tympanoplasty or myringoplasty were included, while non-English articles, patients with cholesteatoma or specific inflammatory diseases, and ossiculoplasty cases were excluded. The protocol was registered on PROSPERO (registration number: CRD42021289240) and PRISMA reporting guideline was used. Risk of bias was evaluated with the QUIPS tool. A random effect model was used in the analyses. Primary outcome was the rate of closed tympanic cavities.

RESULTS

After duplicate removal, 9454 articles were found, of which 39 cohort studies were included. Results of four analyses showed significant effects: age (OR: 0.62, CI 0.50; 0.78, p value: 0.0002), size of the perforation (OR: 0.52, CI 0.29; 0.94, p value: 0.033), opposite ear condition (OR: 0.32, CI 0.12; 0.85, p value: 0.028), and the surgeon's experience (OR: 0.42, CI 0.26; 0.67, p value: 0.005), while prior adenoid surgery, smoking, the site of the perforation, and discharge of the ear did not. Four factors: etiology, Eustachian tube function, concomitant allergic rhinitis, and duration of the ear discharge were analyzed qualitatively.

CONCLUSIONS

The age of the patient, the size of the perforation, the opposite ear status, and the surgeon's experience have a significant effect on the success of tympanic membrane reconstruction. Further comprehensive studies are needed to analyze the interactions between the factors.

LEVEL OF EVIDENCE

Not applicable.

Comparing Myringoplasty to Type I Tympanoplasty in Tympanic Membrane Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the anatomic success rates of type I tympanoplasty (tympanoplasty) versus myringoplasty. By our definition, tympanoplasty involves entering the middle ear via elevation of a tympanomeatal flap, while myringoplasty involves surgery to the drumhead without middle ear exposure.

DATA SOURCES

PubMed, Scopus, CINAHL, Cochrane.

REVIEW METHODS

To be included, studies must have documented surgical technique, tympanic membrane (TM) perforation size (as % of TM), and success rate using tissue or alloplastic grafts. Exclusion criteria included series with more than 10% of patients with cholesteatoma or middle ear pathology. A meta-analysis of weighted summary proportions under the random effects model was performed, and proportion differences (PD) were calculated. A secondary analysis of hearing outcomes was performed.

RESULTS

Eighty-five studies met inclusion, with a tympanoplasty cohort of n = 7966 and n = 1759 for myringoplasty. For perforations, less than 50% of the TM, the success rate for tympanoplasty and myringoplasty was 90.2% and 91.4%, respectively (PD: 1.2%, p = .19). In perforations greater than 50%, tympanoplasty and myringoplasty success rates were 82.8% and 85.3%, respectively (PD: 2.5%, p = .29). For both procedures, perforations less than 50% of the TM had higher success rates than perforations greater than 50% of the TM (p < .01). Both techniques endorsed significant improvements to air-bone gap (ABG) metrics.

CONCLUSION

Our analysis suggests that the anatomic success rate is similar for tympanoplasty and myringoplasty, regardless of perforation size, and that smaller perforations experience higher success rates in both techniques. ABG outcomes were also similar between procedure techniques.

Transtympanic soft tissue tympanoplasty can replace conventional techniques elevating tympanic membranes

PURPOSE

Most traditional tympanoplasties require elevating the tympanic membrane (TM). These techniques are rather complicated and success rates are not perfect. Therefore, the authors developed a novel technique, transtympanic soft tissue (TST) tympanoplasty, which does not require raising eardrums, and evaluated its surgical efficiency compared to perichondrium underlay (PU) tympanoplasty.

STUDY DESIGN

A retrospective study was conducted in a single center.

METHODS

152 cases who underwent TST tympanoplasty (n = 70) or PU tympanoplasty (n = 82) between 2011 and 2020 were included in the study. Perforation location, pure tone audiometry, complications, and closure rates were analyzed according to the size of the TM perforations: moderate perforation (25-40%, n = 100) and large perforation (≥ 40%, n = 52).

RESULTS

For the moderate perforations, the closure rates of the TST (n = 45) and PU (n = 55) groups were 93.3% and 89.1%, respectively (p = 0.461), and even for the large perforations, the success rates were 88.0% in the TST group (n = 25) and 81.5% in the PU group (n = 27) (p = 0.515). The mean postoperative air-bone gap (ABG) values of the TST group for moderate and large perforations were 5.3 ± 5.8 dB and 6.6 ± 5.7 dB, respectively. There was no significant difference in postoperative ABG between the two surgical procedures (p > 0.05). The total operation time for TST tympanoplasty was significantly shorter than that for PU tympanoplasty (p = 0.002).

CONCLUSIONS

TST tympanoplasty is considered a novel, simple technique to replace traditional tympanoplasty techniques involving raising eardrums, even for large-sized perforations.

Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review

OBJECTIVE

To assess the effectiveness of tympanoplasty in treating chronic otitis media-related hearing loss, published literature was systematically reviewed to determine the clinical success rate of tympanoplasty at restoring hearing in chronic otitis media patients at a minimum follow-up period of 12-months.

DATA SOURCES

PubMed, Embase and the Cochrane Library.

METHODS

Two independent reviewers performed literature searches. Publications reporting long-term (≥12-month) hearing outcomes and complications data on adult and pediatric patients with chronic otitis media were included and assessed for risk of bias and strength of evidence. To assess how tympanoplasty influences long-term hearing outcomes, data on pure tone audiometry (air-bone gap) and complications were extracted and synthesized.

RESULTS

Thirty-nine studies met the inclusion criteria. Data from 3162 patients indicated that 14.0% of patients encountered postoperative complications. In adult patients, mean weighted air-bone gap data show closure from 26.5 dB hearing level (HL) (preoperatively) to 16.1 dB HL (postoperatively). In studies that presented combined adult and pediatric data, the mean preoperative air-bone gap of 26.7 dB HL was closed to 15.4 dB HL. In 1370 patients with synthesizable data, 70.7% of patients had a postoperative air-bone gap ˂ 20 dB HL at long-term follow-up. Finally, subgroup analysis identified that mean improvement in ABG closure for patients with and without cholesteatoma was 10.0 dB HL and 12.4 dB HL, respectively.

CONCLUSION

In patients with chronic otitis media, tympanoplasty successfully closed the air-bone gap to within 20 dB HL in 7/10 cases and had an overall complication rate of 14.0%.

LEVEL OF EVIDENCE

2a.

Long-Term Follow-Up After Fat Graft Myringoplasty: Do Size and Location Matter?

OBJECTIVE

To assess clinical and functional outcomes of a fat graft myringoplasty under local in an office setting.

STUDY DESIGN

Prospective case series.

SETTING

Tertiary care facility.

PATIENTS

Patients with a tympanic membrane (TM) perforation presenting between December 2005 and June 2019. Inclusion criteria included perforation size >25% of the surface of the pars tensa of the TM, entire perforation margins visualized through a transcanal view, and lack of spontaneous closure at the 6-month follow-up. The exclusion criteria were the presence of cholesteatoma, wet appearance of the mucosa in the tympanic cavity, ear discharge in the 3 months before surgery, or signs of ossicular inconsistency.

INTERVENTION

In-office fat graft myringoplasty technique under local anesthesia.

MAIN OUTCOME MEASURES

Complete perforation closure rate and audiometric outcomes.

RESULTS

A total of 121 patients underwent the procedure, of whom 21 had bilateral sequential procedures (total 142 ears). Average age was 51.1 ± 18.4 years (range, 3-78 years). The size of perforation was <25% of TM in 39 (27.5%) ears, 25% to 50% of TM in 49 (34.55%) ears, 50% to 75% of TM in 34 (23.91%) ears, and 75% to 100% of TM in 20 (14.10%) ears. Complete perforation closure was evident in 130 (91.55%) of the 142 ears. Preoperative mean air conduction threshold was 59.3 dB (17-95 dB) and significantly improved into 35.6 dB (10-85 dB; P < .0004) after surgery. Preoperative air-bone gap was 30.2 dB (5-70 dB) and also significantly improved into 10.2 dB (5-65 dB; P < .0001) after surgery.

CONCLUSION

In office fat graft myringoplasty, in adult and pediatric patients with variable perforation sizes, is a well-tolerated procedure with very satisfactory clinical results.

Myringoplasty without tympanomeatal flap elevation in children: A systematic review

OBJECTIVES

Systematic review of the literature on myringoplasty techniques without tympanomeatal flap elevation in children.

MATERIAL AND METHODS

A systematic review following PRISMA guidelines reported papers on patients under 18years of age undergoing myringoplasty for chronic tympanic perforation on a transcanal approach without tympanomeatal flap elevation. Tympanic closure rates and audiometric results were analyzed.

RESULTS

Twenty studies were included. Nine reported the butterfly technique, using a microscope or endoscope, with closure rate of 82.3% (246/299), for perforations of various sizes. Ten reported the fat-plug technique, with closure rate of 86.8% (869/1001), mostly for perforations of less than one-third of the tympanum. Both techniques improved audiometric results. Morbidity was very low. The absence of chronic otitis or co-morbidities (contralateral otitis media with effusion, craniofacial malformations, Down's syndrome) implies that patient selection technique may be necessary to obtain the best results.

CONCLUSION

Fat-plug myringoplasty, for small perforations, and butterfly cartilage myringoplasty seem to be reliable procedures in selected patients, with low morbidity in children.

Cost of closure: Comparing success and spending of fat graft myringoplasties with and without hyaluronic acid

INTRODUCTION

Myringoplasties are common pediatric procedures used to surgically close a perforated tympanic membrane. While a wide variety of graft materials are available to surgeons, the cost effectiveness of these different techniques is not well studied.

OBJECTIVES

To compare the cost effectiveness of the fat graft myringoplasty (FGM) with the hyaluronic acid fat graft myringoplasty (HAFGM).

METHODS

Retrospective chart review of patients ages 31 days to 18 years who had undergone either FGM or HAFGM from 2006 to 2016.

RESULTS

We identified 85 patients who had undergone FGM and 51 patients who had undergone HAFGM. The two groups were statistically similar in age (CI -0.51, 1.9; p = 0.23), sex (CI 0.3, 1.4; p = 0.27), and history of prior tympanostomy tube placement (CI -0.07, 0.07; p = 0.69). Both groups had a similar number of total comorbidities (40.0% of patients in the FGM group and 27.5% of patients in the HAFGM; CI -0.04, 0.29; p = 0.19). The FGM and the HAFGM procedure did not have statistically significant differences in perforation closure rates, 82.4% and 92.2% respectively (CI 0.81, 7.3; p = 0.13). In comparing the total surgeons' cost of closing a tympanic membrane deficit, the FGM incurred a greater cost per perforation. The cost/tympanic membrane perforation closure for the FGM totaled $3011.88 per deficit, whereas the HAFGM totaled $2742.98.

CONCLUSION

As financial stewardship becomes more important for medical decision making, it is imperative that providers consider cost and outcomes data together when comparing similar treatment options. The FGM and the HAFGM have statistically similar rates of success in closing tympanic membrane perforations. In this study, the FGM cohort consumed more health care dollars per perforation secondary to the need for revision surgeries. As such, this study offers that the additional use of a hyaluronic disc does not increase overall cost to the healthcare system when performing a fat graft myringoplasty over a large cohort of patients.

Can Fat-plug Myringoplasty Be a Good Alternative to Formal Myringoplasty? A Systematic Review and Meta-analysis

OBJECTIVE

This study reviewed available literature to evaluate the success rate of fat myringoplasty compared with methods using other graft materials and suggests proper indications for this procedure.

DATA SOURCES

Studies reporting the success rate of fat myringoplasty were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases for studies published from database inception to 2017.

STUDY SELECTION

The following terms were used for the literature search: ("Fat" OR "Adipose") and ("Myringoplasty" OR "Tympanoplasty").

DATA EXTRACTION

Eight case series reported the data of perforation size and audiologic results. The success rate varied according to the perforation size with a cutoff value of 3 to 5 mm in length or 30% of the total tympanic membrane area. The success rate in anterior perforation was lower than that in other sites, ranging from 76.7 and 85.2% to 84.5 and 91.7%, respectively. The meta-analysis was performed on 10 articles. The overall success rate in fat myringoplasty and paper patch technique was not significantly different, while the success rate of fat myringoplasty was lower than that for the conventional myringoplasty technique using fascia or perichondrium (OR 0.63, 95% CI 0.49-0.80). Hyaluronic acid showed a significantly higher success rate than fat myringoplasty (90.1% versus 69.9%) (OR 0.20, 95% CI 0.09-0.46).

CONCLUSIONS

The success rate of fat myringoplasty may be associated with the perforation site and size. The success rate of fat myringoplasty was equivalent to that of the paper patch but inferior to a conventional method using perichondrium or fascia.

Factors affecting the treatment outcomes of myringoplasty in patients with small tympanic membrane perforations

PURPOSE

Factors affecting the outcomes of myringoplasty have been widely discussed but remain controversial. In this study, we retrospectively analyzed the factors associated with the outcomes of myringoplasty treating small tympanic membrane perforations (defined as those involving less than 30% of the whole eardrum area) in patients with a history of chronic otitis media.

METHODS

The clinical demographic data, preoperative pure tone audiometry, surgical procedures, and surgical outcomes of patients with small tympanic perforations were analyzed statistically. Overlay myringoplasty was performed in 24 ears (45.27%); Gelfoam^® plugs were placed in 29 ears (54.73%). Univariate and multivariate tests among demographic, surgical procedure-related, hearing test-related factors were performed.

RESULTS

A total of 53 patients (22 males and 31 females) were enrolled (mean age 54.84 ± 15.51 years). Fourteen patients (26.41%) had the habit of cigarette smoking, 8 (15.09%) had diabetes mellitus, 20 (37.73%) had a past history of chronic otitis media, 5 (9.43%) had a history of grommet insertion, 5 (9.43%) had received radiotherapy in the head and neck region, and 1 (1.88%) had microtia. The success rate for overlay myringoplasty using Silastic^® sheets was 54.16%; the success rate for Gelfoam^® plugs was 54.16%. On univariate analysis, smoking, older age, and the mean air conduction and bone conduction hearing levels significantly affected the surgical outcomes. Cigarette smoking was the only independent (negative) prognostic factor of surgical success on multivariate analysis (OR  = 0.1614, 95% CI: 0.0336-0.7762, p = 0.0228).

CONCLUSION

As for surgical repair for the small tympanic membrane perforations with a history of chronic otitis media, age, cigarette smoking, mean air conduction threshold, and mean bone conduction threshold were associated with surgical outcomes; cigarette smoking was the independent predictive prognostic factor for the surgical outcomes.

Surgical outcomes of myringoplasty using platelet-rich plasma and evaluation of the outcome-associated factors

OBJECTIVE

Tympanic membrane perforations must be closed with surgery; however, most surgical procedures are considerably invasive in nature. The aim of this study was to evaluate the outcomes of minimally invasive myringoplasty using platelet-rich plasma (PRP) and an atelocollagen sponge for closure of chronic tympanic membrane perforations, as well as to identify the factors affecting the surgical outcome.

METHODS

The records of 118 patients who underwent surgical closure of chronic tympanic membrane perforation at an ear-nose-throat clinic were reviewed retrospectively. After removing the margin of the perforation via a transcanal approach under local anesthesia, an atelocollagen sponge injected with PRP was inserted into the perforation as a scaffold. If the size of the perforation decreased after the surgery, the same surgical procedure was repeated. The success rate of closure after the last surgery was evaluated in terms of the size of the perforation. In addition, the relationships of the success rate with the cause and duration of perforation and patient age were also examined.

RESULTS

The perforation was closed after initial or repeat surgeries in 95.8% (68/71) of cases with small-sized perforations, 80.0% (32/40) of cases with middle-sized perforations, and 85.7% (6/7) of cases with large-sized perforations. Multiple surgeries (up to four times) were required for middle- and large-sized perforations, and even for some small-sized perforations. The number of re-operations required for closure significantly increased with increase in the size of the perforation (Kruskal-Wallis test, p<0.01). The cause and duration of perforation were not predictors of the surgical outcome. However, patient age was a significant predictor of the surgical outcome; patients older than 80years had a significantly worse success rate than younger patients (Fisher's exact test, p<0.01).

CONCLUSION

Minimally invasive myringoplasty using PRP has a satisfactory success rate even for large-sized tympanic membrane perforations. PRP is autologous and its use is non-toxic and safe. Although informed consent from the patient is necessary for the repetition of the surgery and for patients older than 80years, this technique appears to be a promising office-based procedure for closure of chronic tympanic membrane perforations.

Application of Platelet Rich Fibrin Matrix to Repair Traumatic Tympanic Membrane Perforations: A Pilot Study

Trauma in the form of instrumentation, slap, blast, accident, and sporting injury can result in tympanic membrane (TM) perforations which spontaneously recover in 53-94%. The closure rates of TM perforation due to above causes do not vary greatly; however, some otolaryngologists prefer to perform immediate microsurgical procedures to accelerate the recovery process. Our aim is to study the efficacy of Trichloroacetic acid (TCA) Chemical Cauterization (50%) and Platelet rich fibrin (PRF) Plug Myringoplasty technique in healing traumatic tympanic membrane perforations. To evaluate the preoperative and postoperative hearing outcome from the procedure and compare them. Study design is prospective study. A pilot study was carried out amongst selected 25 patients with central perforations in the Department of ENT, for duration of 2 years from July 13 to July 15. All 25 patients underwent PTA assessment & TCA (50%) and Autologous PRF Plug Myringoplasty technique done and follow up to 6 months postoperatively. The success rate traumatic tympanic membrane closure was found to be 92%. Pre- and post-operative hearing assessments of each patient were done & showed statistically significant air-bone gap closure with success rate of 88% (p < 0.05). From this study, the closure rate in traumatic tympanic membrane perforation by TCA (50%) and PRF Plug Myringoplasty technique was 92% with statistically significant hearing improvement (88%). This technique can be recommended as a time and cost effective office based procedure for treatment of traumatic tympanic membrane perforations.

Clinical and audiological short-term and long-term outcomes of fat graft myringoplasty

INTRODUCTION

Results of fat graft myringoplasty are often reported with only short-term follow-up. Audiological results are less commonly reported, as well as long-term follow-up results.

MATERIALS AND METHODS

One hundred consecutive patients scheduled for fat graft myringoplasty were included in a prospective cohort study. Clinical and audiological outcomes were assessed at six weeks and one year postoperatively.

RESULTS

Perforation sizes ranged from 0.5 to 4 mm. The six-week follow-up showed a total perforation closure rate of 72.9% with a statistically significant (p = .03) higher rate for the pediatric age group (83.0%). 64.4% of all patients were healed at one-year follow-up. Statistical analyses for background factors did not reveal any significant difference in healing rates with regard to patient sex or location or cause of the perforation. The mean preoperative air-conduction (AC) threshold was 25 dB with an air-bone gap of 12 dB. At the one-year follow-up the mean air conduction threshold for healed ears was improved to 16.6 dB, still 54.2% of them had a type B tympanogram.

CONCLUSIONS

Children had a higher perforation closure rate at six-week follow-up than adult patients. Recurrent tympanic membrane perforations were common after initially successful fat graft myringoplasties. Long-term hearing was improved after successful fat graft myringoplasty, resulting in a mean AC threshold of 16.6 dB.

The effect of platelet-rich fibrin membrane on the repair of perforated tympanic membrane: an experimental study

CONCLUSION

Platelet-rich fibrin (PRF) membrane could be used successfully in the repair of tympanic membrane perforation and wound healing.

OBJECTIVES

To evaluate the effect of platelet-rich fibrin membrane in the repair of perforated tympanic membrane.

METHODS

After otoscopic examination, a 3-mm perforation was made in the posterior quadrant of both tympanic membranes of 50 adult male Sprague-Dawley rats. Venous blood was withdrawn from the rats, then centrifuged. PRF was obtained in membrane form. The membrane was placed on the right tympanic membrane perforation. The perforations on the left side were left to spontaneously heal and, thus, formed the control group. Daily examinations were made of 20 rats and the time to healing of the tympanic membrane was recorded. The remaining 30 rats were separated into five groups of six, and histopathological examination was made. Evaluation was made in respect of the presence of oedema in the lamina propria, neovascularization, fibroblastic reaction, and inflammatory cells.

RESULTS

The healing time of the tympanic membrane perforation was determined as mean 10.3 ± 2.18 days in the study group applied with PRF and 17 ± 2.40 days in the control group. Higher values in respect of fibrosis and neovascularization were obtained in the study group.

Myringoplasty Outcomes From the Swedish National Quality Registry

OBJECTIVES/HYPOTHESIS

Data from patients registered for myringoplasty during 2002 to 2012 in the Swedish National Quality Registry for Myringoplasty.

STUDY DESIGN

Both conventional myringoplasty and fat-graft techniques were used aimed at healing the tympanic membrane in noninfected ears.

METHODS

Analysis was performed on data in a national database collected from 32 ear, nose, and throat clinics. Surgical procedures and outcomes, and patient satisfaction from a questionnaire were studied.

RESULTS

The database was comprised of 3,775 surgical procedures, with follow-up available for analysis. One-third were children under the age of 15 years. The most common indication for surgery was infection prophylaxis. The overall healing rate of the tympanic membrane after surgery was 88.5%, with a high mean patient satisfaction. Complications registered were postoperative infection, tinnitus, or taste disturbance that occurred in 5.8% of patients.

CONCLUSIONS

Swedish results for a large number of patients who completed myringoplasty are presented. The success rate in this study is comparable to other studies, and good patient-reported outcome measures of myringoplasty are presented. Databases for surgical procedures and clinical audits are systematic processes for continuous learning in healthcare. This study shows that clinical databases can be utilized to analyze national results of surgical procedures.

LEVEL OF EVIDENCE

2b Laryngoscope, 127:2389-2395, 2017.

Use of a platelet-rich fibrin membrane to repair traumatic tympanic membrane perforations: a comparative study

OBJECTIVES

(1) To evaluate the effects of a platelet-rich fibrin (PRF) membrane in the repair of traumatic tympanic membrane (TM) perforations; and (2) to compare the use of a PRF membrane with the paper patch technique with regard to recovery rates, healing time, and correction of the mean air-bone gap.

METHODS

A randomized, prospective analysis was performed for 60 patients who were treated for traumatic TM perforations using one of the two methods. Closure rate, speed of healing, and hearing gain were compared between the PRF (Group 1) and paper patch (Group 2) groups.

RESULTS

Closure was obtained in 28 (93%) perforations in Group 1 and 25 (83%) perforations in Group 2 (p > 0.05). On day 10, full closure of the TM was observed in 24 (80%) patients in Group 1 and 16 (53%) patients in Group 2 (p < 0.05). The improvement in the mean air-bone gap was 14.1 dB in Group 1 and 12.4 dB in Group 2 on post-operative day 45 (p < 0.05).

CONCLUSIONS

In comparison with the paper patch method, PRF, a new method, provided more rapid healing with more successful audiological results, and with no requirement for a second procedure.