The ears, like the nose, have a complex three-dimensional array of ridges and valleys that must be respected if a reconstruction is to return the appearance of normal. Since the cartilaginous strut of the ear provides its basic structural integrity, the ear represents a type of free margin. Appreciating where the rigidity of the cartilaginous strut will force a dermal repair back toward the appearance of normalcy is an important principle of ear reconstruction, and may permit linear closures of larger defects.
Tissue recruitment from the posterior ear, retroauricular sulcus, and mastoid allow for complex flap repairs on the helix and beyond. When the immediate postoperative effect is pinning back the ear, this may resolve with time, and therefore retroauricular sulcus-based transposition flaps may be an excellent option for many helical repairs.
While as a general rule skin grafts should often be avoided in favor of flap repairs, repairs of the nonmargin areas of the ear, such as the conchal bowl, are readily accomplished with full-thickness skin grafts, where the retroauricular area provides a locus of plentiful donor tissue.
The ears are also unique in that flap repairs can twist in three dimensions so that an advancement or rotation flap may also have a significant twisting component, permitting even greater tissue recruitment and mobility.
These repair considerations are important when approaching suturing techniques, which serve as the fundamental building blocks of effective cosmetically appealing repairs. Many small defects along the helix may be repaired with a small complex linear repair perpendicular to the helical rim, while larger defects may necessitate a single or double advancement flap. Precise suturing techniques help hide scars along the cosmetic subunits of the ear, where eversion is critical to healing, particularly when transversely oriented repairs are used so that the suture line crosses cosmetic subunit boundaries.