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