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Reconstructing the gauge earlobe defect. IMPORTANCE: The use of gauge earrings causes earlobe defects and, at times, significant contour distortion. Simple closure leads to inadequate results in most cases. We describe a stratified approach to assessing the earlobe deformity as well as specific reconstructive techniques tailored to each type of deformity to restore normal size and contour, which, to our knowledge, has not been discussed in the literature thus far. OBSERVATIONS: This case series reviewed the last 20 patients who requested earlobe reconstruction with at least 1 year of follow-up. Earlobe deformity can be classified into 3 groups: small, which can be closed primarily; medium (with radial earlobe distortion and thinning), which requires advancement flaps or wedge excisions; and large (with inferior displacement of earlobe border and vertical axis abnormalities), which requires advancement flaps and excision of redundant tissue. Excellent final earlobe appearance is usually observed at 6 months postoperatively. CONCLUSIONS AND RELEVANCE: Soft-tissue loss and contour abnormalities of medium and large defects require more complex repairs to prevent excessively narrowed lobes with loss of normal rounded contours. Obtaining a normal-appearing ear is of the utmost importance for patients who require a more professional appearance.