The anterior marginal perforation.

The anterior tympanomeatal angle remains the main problem area in anterior marginal perforations with both conventional onlay and underlay techniques. Here we describe a variation of Gerlach's quilting technique to overcome the problem and this modification has proven to be both simple and effective. When the graft is prepared a small tag is fashioned anteriorly and later pulled through a small tunnel under the anterior-superior annulus. This prevents the graft falling away anteriorly without producing the blunting associated with more extensive undermining of the anterior annulus.