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Page 2 of 9 Schuster. Plast Aesthet Res 2018;5:22 I http://dx.doi.org/10.20517/2347-9264.2018.13

INTRODUCTION
The demand for non-surgical or minimally-invasive procedures in aesthetic surgery continues to increase.
To date, the only minimally-invasive otoplasty procedure that has been described is the incisionless thread
[2]
[1]
technique described by Fritsch and modified by Haytoglu et al. . The Earfold procedure, introduced by
[3]
Kang and Kerstein , offers a new approach to minimally-invasive prominent ear correction and uses a met-
al clip to reshape the antihelical fold. In this article, the author reported his early experiences with this new
implant.

METHODS
The Earfold™ implant was inserted into the ears of 19 patients between November 2016 and February 2018.

Earfold clips (Earfold, Allergan, Clonshaugh Business and Technology Park, Coolock, Dublin, D17 E400,
Ireland) are made from thin strips of nitinol (nickel-titanium alloy) which are heat-treated and coated with
24-carat gold. The ends of the implant are fitted with tiny teeth. Once deployed, the super-elastic properties
[4]
of the material ensure that the implant returns to its predetermined form forcing the cartilage of the anti-
helix to adopt a new shape.

According to the instructions for use (IFU), the specific indication for use of the implant is an absence or
poor definition of the antihelical fold in a patient who perceives that their ears are prominent. The likely
outcome is first demonstrated to the patient by using non-sterile Prefold™ positioners. These are identical in
shape, size and elasticity to Earfold™ but do not have the tiny teeth and can therefore be easily placed onto
the ear in the region of the antihelical fold - simulating the probable outcome for the patient. Assessment of
patients with Prefold™ is an important first step to determining whether a patient is suitable for treatment
with Earfold™. If it proves difficult or impossible to produce a satisfactory aesthetic outcome for the patient,
and/or if the implant is unlikely to end up lying flush with the cartilage, the IFU advises that an alternative
to Earfold™ should be used. Once the assessment with Prefold™ is complete, the outline of the positioner is
marked on the skin. This then determines the specific site for implantation of the Earfold™ implant.

After meticulously disinfecting the skin with Octenisept (0.1 g octenidine hydrochloride, 2.0 g phenoxyetha-
nol/100 g), the site was anesthetized with xylocaine 2% and epinephrine 1:200,000. The author used a vertical
incision between the outer margin of the ear and the antihelical fold, and performed a subcutaneous and
subperichondrial dissection of the previously marked area. The author then scored the cartilage to weaken
its bending force using either a needle or scalpel.

The implant was then released subcutaneously (and hopefully sub-perichondrially) flat against the anterior
cartilage in the position of the previously marked area. Once deployed with the introducer [Figure 1], the
Earfold™ implant returned to its predetermined shape and grasped the cartilage, forcing the antihelix to
adopt a new shape, thereby correcting any associated prominence of the ear [Figure 2].

The author then closed the skin with 6-0 Prolene or skin glue such as Dermabond (Ethicon Inc., Route 22,
West Somerville, NJ, 08876, USA).

Post-operative pain and bruising was managed with a combination of ibuprofen 600 mg three times a day
and bromelain 3 tablets a day. Antibiotic prophylactic treatment was commenced one day before the proce-
dure with cefuroxime 500 mg twice a day. No dressing was used.

Post-operatively, the author advised patients to refrain from swimming or engaging in contact sports for
the 3-4 weeks following surgery. The author also advised them to avoid any contact with water during this
time. To further prevent accidental infection, any items in contact to the ear (cell phones, earplugs helmets,