A couple of years ago at Hearing International we discussed a relatively new surgical procedure that was being conducted in the UK for protruding/prominent ears. The discussion of the Earfold procedure was so popular that in 2014 it was the Reader’s Choice for the year. There have been so many comments to us on this topic 
that it seemed fitting at the beginning of a new year to see exactly where this procedure has gone and its success. For those that missed out on the first presentation here are the details of the protruding/prominent ear, the traditional treatments and the alternative which was originally available just in the UK. Now the availability has been expanded into other parts of the world.
What are Protruding Ears?
While the diagnosis of protruding or prominent ears is somewhat subjective, it is typically an inherited problem that affects 1-2% of the population (Scott & Newson, 2014). It is caused by the lack of, or malformation of, cartilage during intrauterine 
development and may be unilateral or bilateral. The result is an external ear anatomy with thin skin and resilient cartilage with abnormal helical folds and/or that grows laterally or outward. When observed at birth, these prominent or protruding ears may resolve themselves on their own. In about 30% of the babies born with normal looking ears, the problem usually arises in the first three months of life. The condition may be exacerbated when the soft cartilage is repeatedly bent over in certain sleep patterns or during breast-feeding. While these ears look different, there are usually no functional or hearing problems associated with prominent ears.
The Psychological Effects
The psychological distress caused by protruding or prominent ears can be considerable. Handler, Song & Shih (2013) present that the main clinical significance of
prominent ears is the aesthetic problems, which can lead to a reduced quality of life, reduced self-esteem, social avoidance behavior and poor performance in school. Scott & Newson (2014) and others feel that this leads to teasing or bullying at school causing both short-term unhappiness and a potential long-term impact on perception of self-image and self-worth. Children and adults alike with ears that stick out may experience a damaged psyche secondary to outside ridicule and self-criticism.
Methods for Correction
Traditional Methods involve Ear Pinning and Reconstructive Otoplasty. According to the references, ear pinning and ear reshaping surgery is usually performed under a
local anesthetic with a sedative for adults and general anesthesia for children. In the ear pinning procedure, the surgeon makes an incision behind the ear to expose the cartilage. The surgeon then reshapes the cartilage removing excess skin. In many cases the ear requires repositioning closer to the head and the incision is closed. These surgeries usually last 1-2 hours depending on the difficulty and extent of the surgical intervention. For protruding ears, an ear pinning procedure positions the ears closer to the side of the head. In ear pinning skin is removed from the back of the ear using cartilage sparing and scoring techniques. The combination of the traditional 
otoplasty and ear pinning fusion of techniques allows the surgeon the flexibility to shape and position the patients ears ideally. While the actual surgical technique depends upon the amount of correction required to rectify the ears position, the surgeon makes the decision as to whether the reshaping is to be conducted by cartilage sparing or cartilage scoring or cutting. (Click on the picture at left for a video of traditional Otoplasty). Some surgeons feel that this method, while riskier, surgically has more of a permanent result.
Incision-less methods involve the use of sutures to pin the pinnae to a more acceptable position and in studies offer results that are 90% + acceptable. As 
presented in the video (at left), the technique uses strategically placed sutures to pin the pinna in place and involves no incision or cutting of the pinna itself. Haytoglu et al (2015) found this procedure to be a good option in the treatment of prominent ears, especially in pediatric patients with isolated inadequate development of antihelical ridge, and with soft auricular cartilage. While some cosmetic surgeons feel that there is much less risk with the incision less treatment, others feel that the patient is totally dependent upon the sutures to hold the desired look and if the sutures fail, so does the procedure.
EarFold™ Implant Procedure is usually performed by a plastic surgeon in less than 20 minutes under local anesthesia and is presented as offering immediate correction of protruding/prominent ears and rapid recovery. The EarFold™ implant web site indicates that that the procedure has consistent outcomes with less discomfort, fewer side effects and less risk than traditional otoplasty surgery. (Click on the EarFold™ procedure picture at right for a video). The implant actually reshapes the patient’s pinna by its placement under the involved ear through a small incision. While in place, EarFold™ re-molds the cartilage of the ear allowing it to maintain its new
shape and with its excellent flexibility offers a natural movement of the pinna. According to the manufacturer, EarFold™ of the UK, made of a short strip of nitinol metal alloy. Nitinol alloy is made of two metals, titanium and nickel, that are widely used in medical fields. The EarFold™ implant is made from the same material used for coronary artery stents (for patients with heart disease or vascular disease due to a blockage of their arteries) and also for unbreakable spectacles. The implant is a simple curved, wafer-thin strip of metal which is plated with 24-carat gold to reduce its visibility when implanted under the skin. 
It is presented in the photo to the left compared to a one-pound coin. Over the past few years it appears that the main limitation of the EarFold™ implantable device has been its limited availability. Since our last discussion, however, it has now become available in the UK, South Africa, Portugal, Croatia, Spain and Switzerland. While now available in more countries, the EarFold™ implant is not yet approved by the Food and Drug Administration (FDA) for use in the United States.
References:
Earfold (2016). Website. Retrieved January 4, 2016.
Haytoglu S., Haytoglu, T., Bayar, M., Kuran, G., & Arikan, O. (2015). Comparison of two incisionless otoplasty techniques for prominent ears in children. International Journal of Pediatric Otolaryngology. Retrieved January 4, 2016.
Scott, O. & Newson, L. (2014). Prominent Ears. Patient. Retrieved January 4, 2016.
Traynor, RM (2014). A cure for badly protruding/prominent ears. Hearing International. Hearing Health and Technology Matters. Retrieved January 4, 2016.
Videos:
McClelland, T., (2013). Live Surgery: Otoplasty (Ear pinning, Ear Shaping, Ear Repair) for prominent ears. You Tube. Retrieved January 4, 2016.
Mehta, S., & Gantous, A., (2014). Incisionless otoplasty: A reliable method and replicatable technique for the correction of prominauris. JAMA Facial Plastic Surgery. Retrieved January 4, 2016.
Images:
Ambro, B. (2014). Otoplasty can prevent the embarrassment of protruding ears. Annapolis facial plastic surgery. Retrieved January 5, 2016.
Dhar, M. (2013). Bullying Syndrome? How maltreatment affects health. LiveScience. Retrieved January 5, 2016.
Realself (2016). Featured Photo. Otoplasty: Traditional vs. incisionless. Retrieved January 4, 2016.
We can do a great deal to improve the look and shape of your ears with our surgical procedures all of which are performed either entirely under local anesthesia or with the addition of minimal conscious sedation (twilight sleep). Following ear surgery our patients experience very little postoperative discomfort, short recovery periods, and almost universally satisfying results.