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The aim of this chapter is to provide an overview of consent as relevant to laser therapy. This is especially relevant because lasers and laser treatment can be complex and difficult to explain, may require multiple sessions and have a distinct risk of complications that can be mitigated through good communication, safe practice and appropriate documentation.

This chapter explores the topic of non-accidental injury burns in children. It is important to consider the possibility of non-accidental injury and recognize injury patterns. The chapter gives a concise overview of the patient and parent characteristics, assessment of such patients and differential diagnoses to consider in the process of managing children in these situations. Patterns of injury in non-accidental burns are described.

BACKGROUND Classic teaching of ear anatomy in the context of otoplasty states that if the antihelical fold is more prominent than the helical fold after surgery then the ear is "overcorrected." We set out to explore the role of the antihelix in normal ear anatomy, its relevance to aesthetic perceptions of the ear, and a snapshot of its incidence in nonoperated ears. METHODS To readily identify junior staff in our department, their color photographs, names, and contact details are posted on every ward. Using digital methods, we cropped the left ear out of the source images, making them unidentifiable. Clinical and nonclinical staff in our unit were asked to choose their favorite and their least favorite ears based on their aesthetic appeal. Responses were tabulated and the 2 most popular ears were compared. RESULTS The preferred ear did not conform to the traditional dogma because it had a prominent antihelix and was statistically significant when compared to other choices. We also noted that a prominent antihelix is common among the general population and among colleagues within the department, and hence "normal." Also interesting was that the helix of the ear chosen as the most aesthetic was also the ear where the helix was almost touching the side of the head. CONCLUSIONS We found that when judging the aesthetic nature of the "virgin" ear, antihelical fold prominence did not appear to be a negative attribute. Indeed, we noted that a prominent antihelix was a common attribute, and we conclude that this was a normal variant without undue negative aesthetic stigma. A surgically corrected ear should not necessarily be regarded as a poor outcome simply on the basis of antihelical prominence. Furthermore, we postulate that patients who have a prominent antihelix might be part of a spectrum of individuals who might have had the subtype of prominent ears featuring a deep conchal bowl. Finally, although not tested directly, it appears that we do not have an idea of our own ear shape, as none of the participants was able to recognize their own ear from the photographs.

Introduction Various postauricular incision sites can be used for prominent ear correction depending on technique and surgeon preference. No study has previously looked at the most aesthetic (least visible) location for the postauricular scar. We investigated the visibility of various scar locations on the posterior ear from a third person perspective through a “Visibility Arc”—a formal assessment of the range of degrees where a particular scar is visible. The objective was to determine the least visible incision—that is, the scar with the shortest visibility arc. Methods Normal ears were marked with 3 different color markers to simulate postoperative scar position, namely, (1) black in auriculocephalic sulcus, (2) blue in the sulcus of the antihelical fold/groove, and (3) green between black and blue. Starting laterally from the right ear toward the left ear, each head was photographed across 180 degrees posteriorly, at 10-degree intervals to determine which colored line (corresponding to a particular scar location) was visible over what “visibility arc.” Results Forty individual ears were analyzed. Scars located in the sulcus of the antihelical fold had the shortest average visible arc, which was a 70-degree arc. The auriculocephalic sulcus had the largest visibility arc, and was most obvious of all of the scar locations—a 100-degree arc. The scar location in between these 2 locations had an 80-degree arc. Conclusions The least visible scar for pinnaplasty rests in the groove of the antihelix posteriorly, with scars slightly medial to this almost as discrete. The most visible scars when viewed from behind will be those in the “traditional” location of the auriculocephalic sulcus.

Consent is an essential part of surgical practice. However, it suffers from a number of problems. Firstly, the consent form does not tend to hold significant weight in evidence to demonstrate informed consent was obtained despite the fact that this is almost its sole purpose. The consent process tends to focus on negative aspects, such as complications, and is often timed immediately preceding surgery which is not ideal for patients whom are already anxious and often told a long list of potential complications immediately before surgery. A request-based system of consent has recently been published that allows a more constructive and patient-centric approach, provides powerful evidence of consent and understanding as it is written by patients in their own handwriting and vocabulary, and takes very little time to obtain as it is often undertaken as “homework” by patients armed with good quality information resources prior to admission. An overview of consent and request for treatment (RFT) is provided in the context of otoplasty.

A 26 year old man presented to the emergency department with a painful right ear after having been bitten three hours earlier during an altercation. He also reported receiving a blow to his right eye during the incident. He was normally fit and well and not taking any regular drugs. On examination, he was alert, orientated, and afebrile. His right ear and the immediate surrounding tissue were erythematous and swollen. Soft tissue from the helix was missing superiorly, and about a third of the skin covering the posterior surface of the auricle was absent. His right eye was purple and swollen, with conjunctival haemorrhage present. He had normal visual acuity and a score of 15 out of 15 on the Glasgow coma scale. ### 1 What are your most immediate concerns? #### Short answer The most immediate concern is the presence of a life threatening injury or fracture sustained through the head trauma. Human (and animal) bite wounds are also particularly susceptible to infection because of the multiple organisms found in saliva. #### Long answer The most immediate concern is the presence of a life threatening head injury and the next is the risk of infection. This patient sustained a traumatic insult to his right eye with periorbital bruising present on examination. The general principles of trauma management therefore apply. This should begin with an ABCDE (airway, breathing, circulation, disability, exposure) approach (according to Advanced Trauma Life Support guidelines) to rule out any life threatening injuries. The bruised eye should then be clinically assessed during the secondary survey, and …

Sir, I read Mashhadi et al.’s [1] communication: ‘Dog Ears— inappropriate terminology used to describe wound edges’ with interest and curiosity. I agree that calling the resultant raised areas following wound closure ‘dog ears’ may cause patient distress and dissatisfaction. In the litigious culture in which we practice, we may be leaving ourselves vulnerable to legal action. Rather than simply changing the way we describe the deformity, I would prefer to seek alternative means of avoiding ‘dog ear’ formation (or ‘topped peak’). I have concentrated on skin lesion excision in this instance. During my old-fashioned basic surgical training and in my plastic surgery training, I was taught to plan excision by first defining the boundary of the lesion and the necessary excision margins and then design an appropriate ellipse to enable direct closure whilst minimising excess tissue (dog ear or topped peak) formation. I performed a literature search and discovered two publications which compared elliptical excision and closure with a round excision with the necessary dog ear excision at the primary surgery. Hudson-Peacock et al. [2] showed that by performing circular excision and direct closure, 28% of lesions could be closed flat without the need for dog ear repair, 38% of excisions required one dog ear repair and 34% required two dog ear repairs at time of surgery to achieve a flat closed wound. More significant were the findings that the overall wound lengths were 21% shorter than if a traditional ellipse was used, and in 45% of cases, the wound was closed in a different orientation to the original planned elliptical excision. Seo et al. [3] reported 14% shorter wounds compared to elliptical excisions and 12% of wounds being closed flat without need for dog ear repair. Twenty-two percent of wounds were closed in a different orientation to the original plan. I propose the following approach to skin lesion excision