Chapter 41: Reconstruction of the Ears

Beginner Pearls

• Canalicular cartilage creates the lateral external auditory canal (EAC) and must remain patent.

• Since the EAC is only 7 mm in diameter, any reduction in circumference from scarring can diminish hearing.

• Because the thin skin of the anterior ear adheres to the cartilage, flaps may be used to mobilize the thicker, looser skin of the helical rim and posterior ear.

Expert Pearls

• The oval contour of the free margin of the helical rim and earlobe, more so than the complex topography of the anterior ear, influences perception of an ear as normal.

• Minor variations in ear height or topography rarely impact cosmesis.

• Helical rim advancement flaps are workhorse reconstructions for full-thickness, short helical rim defects.

Don’t Forget!

• Deep defects of the concha and antitragus can be reconstructed with an island pedicle that pulls skin from the postauricular sulcus and mastoid areas into the defect.

• Chondrocutaneous advancement flaps are useful for even large defects, relying on a broad pedicle derived from the posterior auricular skin.

Pitfalls and Cautions

• Always take time to assess whether a patient regularly wears glasses, as recreating a convenient and comfortable eyeglass resting place is important for patient comfort and convenience.

• Meticulous suturing is helpful to avoid wound edge inversion along the helical rim that could otherwise lead to clinically obvious notching.

Patient Education Points

• Always gauge a patient’s willingness to undergo and recover from an extensive procedure before it is initiated.

• Some patients may prefer a small partial closure to a more involved and much larger flap.

• Warn patients against having their glasses repeatedly rub against nascent surgery sites in the immediate postoperative period.

Billing Pearls

• Random pattern single stage flaps on the ears are coded with 14060 or 14061, and these codes include the excisional component; it is not appropriate to bill both an excision and a flap repair code simultaneously, except for Mohs excision codes.

• When coding a flap, graft, or linear repair, medical necessity is the ultimate arbiter of appropriateness.