Objectives To identify 'on-table optimal meatal opening size' that predicts postoperative mastoid cavity healing in canal wall down tympanomastoidectomy. To develop a specific, measurable, achievable, acceptable, replicable and time-bound (SMAART) meatoplasty Method A double blind randomized control trial where patients were randomly assigned to standard Portman 3 flap and new SMAART 2 flap technique Results There were 18 and 17 participants in former and latter respectively. Dry ear was achieved when on-table ratio of tympanomastoid cavity volume to meatal opening size was 2:1. Mastoid cavity 6 ml or less, among the 2 flap, majority had epithelialization completed by first month, meatoplasty having significantly shorter duration (12.2 versus 32.3 minutes) and cosmetically better than 3 flap Conclusion Optimal meatoplasty is when tympanomastoid cavity volume ratio to meatal opening size is 2:1. When on-table mastoid cavity is, or obliterated to 6ml and less, the new SMAART 2 flap meatoplasty to be considered. © 2025 Elsevier B.V., All rights reserved.