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This picture shows an eardrum with a large perforation. The patient was a 71 year old male who was working in his yard five years ago and had a stick go into his ear canal. Traumatic perforations of the eardrum usually heal on their own, but this one did not.
The ear canal is injected with 1% Xylocaine with epinephrine in four quadrants using a 27 gauge needle. The injection controls bleeding and provides anesthesia. Care must be taken not to inject to fast or the ear canal will blister with will cause bleeding and decreased visualization.
A post auricular approach was performed. The mastoid tip is palpated and a scalpel incises down to bone inferiorly (left side of picture). Superiorly, the incision is more superficial so the Temporalis Fascia is not injured. The Posterior Auricular Muscle is shown in the picture on the left.
Inferiorly (left side of the picture), the incision extends down to the mastoid bone. Superiorly, the scalpel is gently moved horizontally (right to left) to spread and slowly divided the tissue over the Temporalis Muscle's Fascia. 
The fascia over the Temporalis Muscle is exposed. An incision is made at the lower margin of the Temporalis Muscle (Linea Temporalis). This incision extends through the periosteum of the mastoid bone.
An incision is then made through the mastoid periosteum, at a right angle to the Linea Temporalis incision. 
A periosteal elevator is used to elevate the periosteum off the anterior mastoid tip. The elevation is from posterior to anterior and will expose the skin of the posterior ear canal.
The resultant exposure shows the posterior ear canal skin, mastoid bone and Temporalis Muscle Fascia. 
Using a scalpel, an incision is made through the lower board of the Temporalis Fascia.
A Freer Elevator is used to separate the Temporalis Fascia from the underlying Temporalis Muscle.
The Freer Elevator is used to elevate the Temporalis Fascia off of the Temporalis Muscle.
Using a pair of scissors the Temporalis Fascia is removed from the Temporalis Muscle.
The Temporalis Fascia is spread onto a tongue blade and excess tissue and fat is gently removed using a pair of scissors.
The graft is compressed between two tongue blades. The tongue blades are secured with pressure using a Rochester Clamp. 
The ear canal skin is elevated off the posterior canal wall using a Freer Elevator.
The posterior ear canal skin is incised with a #15 Bard Parker Blade and the inside of the ear canal is exposed.
The eardrum perforation is exposed through the post-auricular incision. The incision is held open by a self-retaining retractor (SRR).
To allow healing, the margins of the perforation must be removed. A Rosen Needle is used to place a series of perforations in the tissue next to the margin of the perforation.
A pair of Micro-Cup Forceps is used to remove the tissue along the perforation's rim.
A Duckbill Flap Elevator elevates an atticotomy flap. An incision is made extending along the inferior portion of the ear canal skin and connected with the incision used to enter the ear canal. 
The Duckbill Flap Elevator elevates the skin off the posterior wall. 
The Annular Ligament is elevated and the middle ear is entered. The Long Arm of the Incus, Annular Ligament and Promontory can be seen in the picture.
Micro-Cup Forceps are used to insert the Temporalis Fascia Graft into the middle ear.
Using a Derlacki Mobilizer, Gelfoam is inserted into the middle ear (between the eardrum and promontory) to hold the Temporalis Fascial Graft against the undersurface of the eardrum.
The Temporalis Fascial Graft and elevated ear canal skin are laid back onto the posterior canal wall. The perforation is then checked to make sure it has been closed with the Temporalis Fascial Graft. 
Gelfoam is placed over the eardrum and the elevated ear canal skin.
Antibiotic ointment is placed over the Gelfoam and fills the medial portion of the ear canal.
The lateral portion of the ear canal is packed with 1/4 inch gauze with antibiotic ointment through the external auditory meatus. This prevents the closing of the ear canal during healing.
The deep fascial tissues in the post-auricular incision are closed using a 3-0 chromic stitch.
The post auricular skin is closed with a 4-0 nylon stitch. A mastoid dressing is then applied.