INSURANCE ISSUES: EAR DEFORMITY, PROMINENT EARS: RECOMMENDED CRITERIA FOR THIRD-PARTY PAYER COVERAGE

Background
The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery as recognized by the American Board of Medical Specialties.

ASPS represents 97 percent of the board-certified plastic surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.

Definitions and Analysis of Ear Deformity
Patients that have a need for otoplasty usually complain of ear prominence. The patient is frequently a child and is usually the subject of ridicule by the child's peers. Surgery is usually performed at an early age to avoid social and psychological problems. Most ear operations occur around the age of 5. At this time the ear is at its complete growth and usually by this age, social problems begin. Surgery is not limited to children and can be performed on adults.

Prominent ears (ICD-9 code 744.29) may occur for several reasons including an inadequately formed helix, an enlarged concha or abnormal conchal angle, an enlarged lobe, or combination of these abnormalities. Usually one ear is more prominent than the other. The defects may be unilateral or bilateral.

The normal protrusion of the ear is between 1.5 cm to 2.0 cm from the post-auricular scalp to the lateral aspect of the superior helix. The ear is prominent when the helix protrudes 2 cm or more from the post-auricular scalp. The helix is the "outer frame" of the auricle. It is the rounded portion of the external ear. The concha is the hollow portion of the outer ear.

Cosmetic and Reconstructive Surgery
For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.

Indications
The indications for an otoplasty are the appearance of the patient's ear when there is the presence of a defined anatomical deformity. An anatomical ear deformity is an inadequately formed helix, and enlarged concha or abnormal conchal angle, an enlarged lobe or combination of these abnormalities. Correction is generally performed at the age of five to allow near complete growth of the ear prior to surgery. Surgery is performed early to avoid social problems.

Procedures
Otoplasty: CPT Code: 69300

Otoplasty is performed under general anesthesia for children and under local anesthesia for adults. Generally, the more protruding ear is operated first, and the position configuration of the other ear is tailored to match as close as possible. This is generally a bilateral procedure. A variety of techniques are available to shape the auricular cartilage that forms the framework of the ear. However, it is recognized that the key to a successful result is controlling the folding, since folding in one direction can produce distortion, undercorrection or overcorrection in another direction.

No one procedure or technique is correct for all patients. Combinations of techniques may be required. Below are various treatment options for the prominent ears patient:

· Scaphal Folding: Various methods of scaphal folding can be done. Most involve a combination of weakening of the cartilage either by anterior scoring or cartilage resection followed by placement of sutures to correct the conchal-scaphal angle to approximately 90 degrees.

· Conchal Reduction: In the presence of a prominent conchal cartilage, resection is generally required. This may be done either through an anterior or posterior approach. Care must be taken to excise cartilage only in the portion of the conchum that is prominent.

· Conchal Setback: In cases of anteriolateral rotation of the conchum, the conchum may be setback to the mastoid region by various techniques.

· Lobule Repositioning: Lobule repositioning is generally accomplished by extending the post-auricular incision down onto the lobule and suturing the lobule back to the post-auricular skin. The goal is to bring the lobule into the same plane as the antihelix.

A goal common to all methods of otoplasty is achievement of a symmetrical, softly contoured ear with an unoperated appearance and the recreation of a normal appearing ear.

Position Statement
Because prominent ears are congenital in origin, patients seek otoplasty primarily for correction of the congenital ear deformity - prominent ears. Most ear operations are carried out at an early age to avoid any social and psychological problems from developing as the child begins school. However, this procedure is not limited to children and can be performed on adults. It is the position of the American Society of Plastic Surgeons that the correction of a congenital abnormality such as prominent ears is considered reconstructive in nature and should be compensable by third-party payers, regardless of the patient's age.

References
Kon, M. "Fascia lata suspension of malpositioned ears." Plastic and Reconstructive Surgery, 98(1):167, July 1996.

Wood-Smith, D., et al. "Reconstruction of acquired ear defects with transauricular flaps." Plastic and Reconstructive Surgery, 95(1):173, January 1995.

Ohsumi, N., et al. "Earlobe reconstruction with a reversed-flow chondrucutaneous postauricular flap and a local flap." Plastic and Reconstructive Surgery, 94(2):364, August 1994.

Wilkes, GH., et al. "Osseointegrated alloplastic versus autogenous ear reconstruction: criteria for treatment selection." Ann. Plast. Surg., 33(6):677, December 1994.