Background <p>Generally, a scalpel is used for postauricular skin incisions in tympanoplasty. The present trial aimed to compare electrocautery and scalpel skin incisions in terms of wound complications and cosmetic results in tympanoplasty.</p> Settings and design <p>Chronic otitis media patients who were candidates for tympanoplasty with a postauricular approach were assigned to skin incisions with either electrocautery (<i>n</i> = 31) or scalpel (<i>n</i> = 28).</p> Methods <p>The initial result of the initial incision site and its cosmetic outcomes were recorded. A single-blind observer performed subjective and objective assessments of the incision site scar at the end of the first and sixth postoperative months.</p> Statistical analysis used <p>All data were analyzed by IBM SPSS Statistics for Windows, Version 23.0. The chi-square test and <i>t</i>-test were used to compare the results. A two-sided <i>P</i>-value of ≤ 0.05 was set as a statistically significant threshold. The study was approved by the local Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1398.565) on 2019 September 24 and a randomized clinical trial registry (IRCT20210210050316N1) on 2021 February 24.</p> Results <p>Blood loss during skin incision was lower in the electrocautery group (<i>P</i> &lt; 0.05). Incision site infection, wound dehiscence, hematoma, seroma formations, and postoperative pain were similar in both groups. Subjective and objective scar scores did not significantly differ between the two groups at the end of the first and sixth postoperative months.</p> Conclusions <p>Compared to scalpel, electrocautery indicates better surgical site homeostasis with similar results in incision site complications and cosmetic outcomes. Thus, electrocautery can be considered an alternative to a scalpel for postauricular skin incisions in tympanoplasty.</p>