The retrograde mastoidectomy technique with canal wall reconstruction is described as a primary treatment for modality for cholesteatoma. This synthesis of canal wall up (CWU) and canal wall down (CWD) techniques involves removal of a portion of the canal wall for exposure and extirpation of the cholesteatoma, followed by reestablishment of the canal wall and ossicular chain during reconstruction. This technique is possible as a single stage in over 90% of cases, including children, with recurrence rates similar to CWD surgery, but with anatomic preservation similar to CWU. Recurrent disease occurred in 16% of cases reviewed in a longer term (8 year) follow-up study. Tobacco use was associated with a higher long-term complication rate.