Consent information for Otoplasty (Pinnaplasty)

CONSENT INFORMATION – PATIENT COPY

OTOPLASTY (also known as Pinnaplasty)

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having an Otoplasty. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.
What is “Otoplasty”?

Ear surgery, or otoplasty, is a surgery that is usually done to set prominent ears back closer to the head or to reduce the size of large ears.
For the most part, the operation is done on children between the ages of four and 14. Ears are almost fully grown by age four, and the earlier the surgery, the less teasing and ridicule the child will have to endure. Ear surgery on adults is also possible, and there are generally no additional risks associated with ear surgery on an older patient.
Are there any alternatives?
In adults and children, Otoplasty is the only way to permanently "pin back" the ears. In babies younger than about six months, it is possible to flatten the ears using special moulds, e.g. Ear Buddies to reshape the cartilage while it is still soft. Splints are fitted into the baby's ears, and left in place for weeks or months, depending on the age of the baby.

Understanding what does Otoplasty offer:
General good health and realistic expectations are prerequisites. It is also important to understand the surgery. Otoplasty will not alter hearing ability. What is important for successful otoplasty is that the ears be in proportion to the size and shape of the face and head.
When considering otoplasty, parents must be confident that they have their child's best interests at heart. A positive attitude toward the surgery is an important factor in all facial plastic surgery, but it is especially critical when the patient is a child or adolescent.
Adult candidates for otoplasty should understand that the firmer cartilage of fully developed ears does not provide the same molding capacity as in children. Timing is always an important consideration. Having the procedure at a young age is highly desirable in two respects: the cartilage is extremely pliable, thereby permitting greater ease of shaping; and secondly, the child will experience psychological benefits from the cosmetic improvement.
Will the surgery hurt?
If your child is young, your surgeon may recommend general anesthesia, so the child will sleep through the operation. For older children or adults, the surgeon may prefer to use local anesthesia, combined with a sedative, so you or your child will be awake but relaxed.
What happens during the procedure?

Ear surgery usually takes about two to three hours, although complicated procedures may take longer. The technique will depend on the problem.
With one of the more common techniques, the surgeon makes a small incision in the back of the ear to expose the ear cartilage. He or she will then sculpt the cartilage and bend it back toward the head. Non-removable stitches may be used to help maintain the new shape. Occasionally, the surgeon will remove a larger piece of cartilage to provide a more natural-looking fold when the surgery is complete.
Another technique involves a similar incision in the back of the ear. Skin is removed and stitches are used to fold the cartilage back on itself to reshape the ear without removing cartilage.
In most cases, ear surgery will leave a faint scar in the back of the ear that will fade with time. Even when only one ear appears to protrude, surgery is usually performed on both ears for a better balance.
What happens after the procedure?
Adults and children are usually up and around within a few hours of surgery, although you may prefer to stay overnight in the hospital with a child until all the effects of general anesthesia wear off.
The patient's head will be wrapped in a bulky bandage immediately following surgery to promote the best molding and healing. The ears may throb or ache a little for a few days, but this can be relieved by medication.
Within a few days, the bulky bandages will be replaced by a lighter head dressing similar to a headband. Be sure to follow your surgeon's directions for wearing this dressing, especially at night. Stitches are usually removed, or will dissolve, in about a week.
Any activity in which the ear might be bent should be avoided for a month or so. Most adults can go back to work about five days after surgery. Children can go back to school after seven days or so, if they're careful about playground activity. You may want to ask your child's teacher to keep an eye on the child for a few weeks.
 Deciding to have Otoplasty
Otoplasty is a commonly performed and generally safe surgical procedure. For most people, the benefits in terms of improved appearance are greater than any disadvantages. However, in order to give informed consent, anyone deciding whether or not to have this procedure needs to be aware of the possible side effects and the risk of complications.
General Risks of having the procedure:
These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.
What are the risks of the procedure?
While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may result in the formation of a blood clot (hematoma) in the wound, which will require another operation to remove it. It may rarely lead to necrosis or destruction of the skin or cartilage causing severe cosmetic deformity.
(b) Infection of the wound or ear cartilage. This may rarely lead to death or breakdown of the skin or cartilage causing severe cosmetic deformity.
(c) Change in sensation of the ear (pinna) or low grade local discomfort.
(d) Abnormal scar tissue formation. This may result in a thickened, wide red scar which may require further surgery.
(e) Unsatisfactory cosmetic appearance. The original deformity may come back, or the deformity may be over–corrected or under– corrected requiring further surgery. The two sides may continue to be unequal. This may need minor revision surgery. Slightly unequal ears are common and usually not a problem.
(f) The stitches may come out. Stitches placed to keep the new shape of the cartilage may occasionally fall out and the deformity comes back.
(g) Hearing loss due to change in shape of the ear canal.
Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date…………………


INFORMED CONSENT: OTOPLASTY


Patient Identification Label to be affixed here








A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Otoplasty” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may result in the formation of a blood clot (hematoma) in the wound, which will require another operation to remove it. It may rarely lead to necrosis or destruction of the skin or cartilage causing severe cosmetic deformity.
(b) Infection of the wound or ear cartilage. This may rarely lead to death or breakdown of the skin or cartilage causing severe cosmetic deformity.
(c) Change in sensation of the ear (pinna) or low grade local discomfort.
(d) Abnormal scar tissue formation. This may result in a thickened, wide red scar which may require further surgery.
(e) Unsatisfactory cosmetic appearance. The original deformity may come back, or the deformity may be over–corrected or under– corrected requiring further surgery. The two sides may continue to be unequal. This may need minor revision surgery. Slightly unequal ears are common and usually not a problem.
(f) The stitches may come out. Stitches placed to keep the new shape of the cartilage may occasionally fall out and the deformity comes back.
(g) Hearing loss due to change in shape of the ear canal.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………



Patients Initials ______________