Prominent
Ear
Correction

Learning objective

Given a case with obvious bilateral protrusion and an observer's referral, produce a six-field note that distinguishes the patient's own goal, the observer's concern, bilateral findings, symptoms, uncertainty, and a justified next step.

In this lesson

• A visible feature is an observation, not a request for correction. The consultation should identify who initiated it, what that person hopes to change, and whether the patient experiences any problem. Ask the patient in neutral language how they describe their ears and whether they want information, assessment, or no intervention. If a relative, photographer, or clinician raises prominence, label that as an attributed view rather than silently converting it into the patient's goal. A decision record should make a decision to do nothing intelligible, while leaving the patient free to return with a self-defined concern.
• Describe each side by region: antihelical contour, conchal contribution, lobular position, and overall relation to the head. These observations can explain why an ear looks prominent in a particular view, but no measurement alone establishes candidacy. The volunteer morphometry study found that its measured features did not reliably predict whether people judged their own ears prominent. The appropriate analytical task is to document what is seen and what remains uncertain, rather than apply a numerical cutoff or a preferred appearance. Record a pre-existing asymmetry without declaring it a defect the patient must fix.
• Protrusion itself is not a hearing-loss diagnosis. A patient who has no wish to change appearance may nevertheless report pain, discharge, recent trauma, or hearing difficulty. Those complaints require their own assessment and, where appropriate, a different service or urgent pathway; they do not become reasons for automatic cosmetic correction. Conversely, an uncomplicated prominent contour need not be medicalized because someone else dislikes it. The intake note should separate appearance description, symptoms, examination findings, and any referral question, marking what was actually assessed and what still needs review.
• A useful close states the patient's decision in their own terms, the information offered, and any agreed follow-up. Avoid reassurance that dismisses a concern or language that invents one. If the patient requests no appearance treatment, do not present surgical planning as a foregone conclusion. If photographs are considered, explain why they are needed and obtain permission under local policy; a photograph cannot speak for the patient. A short baseline note should support later comparison if the person's view changes while remaining clear that the present choice is valid. Documenting a decision to take no action is itself important for continuity.

Learning objective

Given an adult's urgent request despite modest visible difference, write a contested-request formulation that records the adult's goal, observed findings, distress and context, questions for psychosocial review, and a justified proceed/defer/refer position.

In this lesson

• A small measured difference can matter greatly to a person, while a marked difference may not. Ask the adult to describe the moment, setting, and life impact of the concern, including what they hope a change would accomplish. Document the person's words separately from standardized photographs and measurements. Do not use “minor” as a synonym for unimportant, nor infer that a request is invalid because it is visually subtle. At the same time, avoid telling the person that surgery will resolve distress; the assessment concerns readiness, plausible goals, and alternatives.
• An adult may want an operation while a partner, employer, or referring clinician disagrees. The relevant conflict is not settled by voting or by a photograph. Explore whether the patient's request is voluntary and stable, whether another person's pressure or ridicule shapes the request, and whether the desired change is anatomically identifiable. Ask what outcome the person would regard as acceptable and what unchanged concerns might remain. The record should distinguish the patient's autonomy from the clinician's obligation to decline or defer an elective plan when the rationale, safety, or consent is incomplete.
• Intense distress, repetitive checking, social avoidance, or a belief that one subtle feature explains every difficulty warrants a careful conversation. These observations are prompts for assessment, not a remote diagnosis. Ask about previous attempts to manage the concern, support, safety, and expectations. Where body dysmorphic disorder is suspected, NICE recommends assessment by a mental-health professional with relevant expertise before cosmetic treatment; adapt the route to local services. Explain that referral can clarify needs regardless of a later cosmetic decision. A small pediatric study that found persistent dissatisfaction cannot be transferred into an adult prognosis.
• A contested case can end with information gathering, a planned review, psychosocial support, a second clinical opinion, or a carefully justified elective discussion. The note should state which evidence supports the current recommendation and what unresolved facts would alter it. If the person remains distressed but cannot describe an achievable appearance goal, a pause can be a substantive clinical decision, not dismissal. If they can identify a narrow goal, informed consent still requires alternatives, risks, and uncertainty. A patient-reported account complements examination; a questionnaire score or image cannot substitute for that conversation.

Learning objective

Given discordant accounts and images, complete a baseline discrepancy note that ranks each data source's reliability, describes both ears by region, identifies one unresolved question, and specifies a proportionate next step.

In this lesson

• Organize the patient's narrative, other people's descriptions, standardized bilateral examination, and measurements as distinct streams. Dates, image conditions, who supplied the data, and whether a view is comparable matter more than a solitary number. A parent, partner, or referring clinician may notice something the patient does not, but their perspective needs attribution. The patient's goal should be quoted or carefully paraphrased. By keeping streams separate before synthesis, the learner can explain a discrepancy without forcing an artificial agreement or turning an attractive image into proof that no concern exists.
• Bilateral views may reveal upper-pole projection, conchal prominence, lobular divergence, or different patterns on each side. A global label such as “ears stick out” obscures which finding relates to a person's stated concern. Describe the region, side, view, and confidence of each observation. If an image hides hair, compresses an ear, or differs in camera angle, say so. Measurements can corroborate the visible description but should not be translated into an operative eligibility threshold. The learner's product is an interpretable baseline against which later options can be discussed.
• A person may want less visibility in profile, easier use of headwear, or no change at all. These are different goals even if examination findings overlap. Patient-reported outcome research shows that appearance and adverse effects can be captured as distinct domains, but the EAR-Q validation does not prove that intervention works for a particular patient. Do not copy proprietary item wording into the course or treat a score as consent. Record what the patient wants to change, what they want preserved, and how they would recognize an unwanted result.
• Synthesis should identify where evidence converges, where it conflicts, and what action follows. If the patient says the right ear bothers them but the only available close-up shows the left, repeat the relevant view instead of rewriting the concern. If hearing difficulty or pain enters the history, separate that health question for appropriate assessment. If appearance change is not the patient's goal, no cosmetic proposal is required. A strong discrepancy note gives the next reviewer enough context to understand why the decision was made and what observation or conversation might change it.

Learning objective

Given a parent-initiated request and a child who objects, write a jurisdiction-qualified decision record that quotes the child's view, separates parent goals, identifies consent and best-interest questions, and defers elective correction while arranging a respectful follow-up.

In this lesson

• Ask a child, in developmentally suitable language, what they think about their ears and the proposed change. Record the answer without using a parent as the sole interpreter. A parent may report teasing or fear of future teasing while the child feels comfortable with their appearance, and both perspectives matter. The child's objection is not an administrative inconvenience to be overcome by a signature. The ASPS overview emphasizes children's ability to express their own feelings without objections; a UK professional standard explicitly prohibits elective cosmetic intervention when a child does not want it. Apply the local law and professional code.
• Explore what the parent has observed, what change they expect, and whether anxiety about social judgment is being placed onto the child. A request made in the child's name can contain a legitimate concern about bullying, but the proposed operation may not address the social problem. Ask whether there is current harm, coercion, or a health symptom that needs a separate response. Avoid characterizing a parent as malicious from one account; instead document the disagreement and any safeguarding or psychosocial questions that require local pathways.
• Pediatric consent rules vary by jurisdiction and by the child's understanding and circumstances. Do not teach a single age at which correction becomes lawful, or imply that parental authorization alone makes an elective procedure appropriate. Record who can legally authorize care, how the child's understanding and preference were elicited, and whether an independent assessment is needed. In a contested elective case, the current educational conclusion is deferral while these questions are resolved, not an operative workaround. If a separate health problem exists, assess its urgency independently of the cosmetic dispute.
• Explain the difference between postponing an elective appearance decision and abandoning the family. Offer information about anatomy and reasonable alternatives, discuss how teasing can be addressed with school or psychosocial support, and identify who will review the situation if the child's own view changes. Avoid a promise that correction would resolve social distress: a small prospective child-family study included children who remained dissatisfied. Record an agreed route for questions, the current objection, and any review boundary without scheduling a procedure in anticipation of consent.

Learning objective

Given social pressure and uncertain motivation, separate the ear-related request from the social harm, document at least three nonoperative supports, and justify whether psychosocial assessment or safeguarding referral should precede any cosmetic decision.

In this lesson

• Teasing, online comments, or pressure from family can contribute to distress, but surgery does not erase the behavior of others. Ask when the comments started, whether they continue, how they affect school, work, or relationships, and what the patient independently wants. Record the social exposure as a problem in its own right. A visible difference may be relevant without becoming the only explanation for distress. The clinician can discuss a possible appearance intervention while also recognizing that protective, educational, or psychosocial responses may be needed regardless of a cosmetic decision.
• A request can be both patient-owned and influenced by others. Ask what the person would want if the teasing stopped, who is pushing for a specific treatment, and whether they feel able to decline. For a child, hear the child's account apart from the parent's; for an adult, clarify whether a partner, employer, or social-media audience is shaping an urgent deadline. The goal is a transparent consent assessment, not a claim that all socially influenced requests are invalid. Document the person's answer and any unresolved coercion concern before accepting an elective plan.
• Mark persistent, disabling distress, possible self-harm concern, or a safety problem as reasons for assessment through the service's established mental-health or safeguarding pathways. Do not make a psychiatric diagnosis from an appearance consultation or use a referral as punishment for disagreement. Explain why another professional's input could clarify needs and support the patient while an elective decision is paused. The small child-family outcome study supports caution about assuming psychological benefit, but it does not provide a screening threshold. Actual urgency and referral destination must follow local practice and the patient's presentation.
• A complete discussion may include no appearance treatment, time to reconsider, school or workplace response to harassment, counseling or mental-health assessment, another opinion, and a later surgical consultation if the patient independently seeks one. State what each option addresses and what it cannot promise. If the patient chooses support first, record who makes the referral and who checks that contact occurred. If the case is a child, continue to respect the child's view and local consent requirements. The decision record should remain open to change while guarding against pressure to book first and ask later.

Learning objective

Given a newborn with an external-ear shape difference and a separate older-child case, distinguish time-sensitive specialist assessment for selected infants from a later elective discussion, including evidence limits and consent questions in both pathways.

In this lesson

• Some congenital external-ear shape differences can be evaluated for nonoperative molding or splinting soon after birth. The relevant first step is timely assessment by a service with appropriate infant-ear experience, not a promise that every prominent ear is moldable. Describe the observed shape and side, establish the infant's age and relevant health context, and refer without a fixed universal deadline. The 2025 prospective series involved several kinds of auricular deformity and a particular device; its reported association between earlier treatment and better correction cannot be assigned as a prognosis to this individual infant.
• Ask whether a quoted study included isolated prominent ears, mixed deformities, or another condition; whether the outcome was shape correction, patient experience, or a long-term result; and whether follow-up supports the claim. A mixed-deformity infant series may justify prompt referral for assessment but not a percentage success claim for a specific infant or an assertion that molding and later surgery have equivalent outcomes. This lesson uses evidence appraisal to prevent a parent-facing counseling sheet from overstating certainty. Record the possibility that the infant's anatomy or presentation may fall outside the local molding service's criteria.
• An older child or adult presenting with prominence should not be told that infant molding remains an interchangeable option. Instead, explore the person's own goal, developmental understanding, parent or guardian perspective if applicable, available alternatives, and local consent law. There is no universal birthday that automatically authorizes an elective operation. Clinical examination and psychosocial context remain relevant, but the later decision is not made urgent by a newborn's time-sensitive referral window. Keep the discussion conceptual; procedural execution belongs to trained treating teams.
• For the infant, write what was observed, what is unknown, why a specialist assessment is time-sensitive, and who will ensure referral receipt. For the older person, record the person's own view and the present elective alternatives without implying a lost chance must now be compensated by surgery. Both records should include uncertainty and an accountable next step. If hearing symptoms, pain, infection, trauma, or a complex congenital difference are present, use appropriate diagnostic or specialist pathways rather than conflating them with a simple cosmetic prominence decision.

Learning objective

Given an adult contested request with incomplete safety information, write a decision memo with an explicit proceed/defer/refer disposition, patient-owned goal, evidence and uncertainty, alternatives, material risks, consent status, referral or review owner, and change conditions.

In this lesson

• Start the memo with the patient's own words, the observed bilateral pattern, relevant symptoms, health history, outside pressure, and unresolved data. A photograph or measurement can support description but cannot decide for the person. For an adult contested request, record the adult's preference and the nature of disagreement with a relative or clinician without allowing either view to erase the other. Specify what examination or prior records are missing, and distinguish a cosmetic goal from a health complaint. A disposition should follow this evidence summary, not precede it because a booking exists.
• “Proceed” means further elective planning is defensible after a patient-specific assessment and valid informed consent; it does not mean an operation is scheduled by this course. “Defer” means a named uncertainty, safety issue, coercion concern, or expectation gap must be resolved before a new decision. “Refer” means another clinician or service is needed for a question outside the current scope, such as hearing symptoms or a psychosocial concern. More than one action may coexist: defer elective planning while referring a health symptom. State the owner, destination, and condition that triggers reassessment.
• The memo should record discussion of no procedure, observation, support or further assessment, and an individualized elective option only where appropriate. Material risks include asymmetry, hematoma, infection, altered sensation, contour change, scarring, persistent pain, healing problems, and possible revision, without assigning an individual probability from a small study. Ask the adult to describe the hoped-for change and what residual difference or burden would be unacceptable. Note whether consent is complete or pending, which questions remain, and the local team's process for updating it. A signed form alone does not resolve unclear motivation or an unassessed symptom.
• Use fields that another reviewer can trace: patient goal, source of competing views, anatomy and symptoms, quality of data, decision and reason, alternative options, material risks, consent and local-law status, next owner, and review trigger. Include a short uncertainty statement rather than implying that all evidence aligns. A GMC standard specifically includes decisions to take no action in the clinical record. If a child is the patient, their view and jurisdiction-specific lawful authority are indispensable; an adult case still requires voluntariness and decision capacity. The final sentence should state what happens next and whom to contact through local pathways.

Learning objective

Score a fictional proposed correction against a five-part evidence trace—patient-owned goal, bilateral observation, interpretation, proposed change and unresolved uncertainty—and write at least three actionable review questions.

In this lesson

• A proposed plan should be intelligible from the patient's own complaint back through bilateral observations and forward to the change being discussed. Reviewers should first quote the goal in the patient's language, then identify the region and view that matter, the described anatomical contributors, and the proposed response. A missing link is a question for the author, not a license to invent an examination. The review asks whether the plan addresses the recorded concern; it does not teach an operation or declare one technique superior from a photograph.
• The right and left ears may differ in fold, conchal, lobular or positional appearance, and a patient may care about only one region. Ask whether each proposed side has its own rationale or whether a generic bilateral template was copied into the record. A numerical attempt to make sides identical can conflict with a patient's preference to preserve a familiar contour. Measurements may describe a baseline but cannot decide candidacy by themselves; the volunteer morphometry study found a poor correspondence between measured features and self-perceived prominence in its sample.
• A useful peer review labels what was directly observed, what the patient reported, and what the clinician inferred. Standardized photographs can help locate a concern, but head turn, hair and camera perspective limit comparison. If images are used in peer review, confirm permission, secure handling, and any restriction on secondary use. If the proposed plan refers to a feature not documented in examination or to a preference not stated by the patient, mark the inference as unverified. Request the missing view, consultation note or clinical reassessment, and state how a different finding would alter the recommendation. Do not treat an attractive edited image as evidence of feasibility.
• Finish the critique with a bounded disposition: the reasoning is adequately documented, a specified element needs clarification, or the decision should wait for new assessment. Name the question, the clinician who can answer it, and the point at which the patient will hear the revised options. A review should acknowledge uncertainty about achievable contour, asymmetry and tradeoffs rather than converting broad treatment families into technical instructions. This makes the critique usable for consent while preserving the treating clinician's responsibility for examination, judgement and any eventual operative plan. A retrospective comparison of broad otoplasty families illustrates a question to appraise, but historical selection and photographic ratings cannot establish a universally superior choice.

Learning objective

Produce a tradeoff matrix for a fictional plan with at least four patient-relevant unwanted changes, the baseline feature each affects, a mitigation discussion and a residual uncertainty.

In this lesson

• Overcorrection is not merely a departure from a standard ear-to-head value. It may mean a result that hides a contour the patient wanted to keep, makes an upper or lower region look unnaturally constrained, or introduces a side-to-side difference more troubling than the original concern. The reviewer should ask which views the patient uses to judge success and which changes they explicitly reject. A plan that says only 'less prominent' has not yet defined the acceptable tradeoff. No course can promise that every desired boundary is technically achievable.
• Challenge the plan with possible outcomes: the prominent region improves but another region attracts attention; one ear is altered when the patient wanted only the other; a familiar asymmetry becomes more visible; or a close-set appearance is disliked despite reduced projection. These are prompts for consent, not predicted events for the individual. Compare each counterfactual with the recorded baseline and ask whether the patient would still choose treatment. The reviewer should make room for observation or a narrower goal, and should not infer that perfect bilateral similarity is attainable or desired.
• A change in projection also brings possible scarring, altered sensation, pain, infection, hematoma, healing concerns or later revision. The critique should name material risks relevant to this patient without assigning probabilities from a small series or implying that the risks vanish with a particular broad approach. Ask whether the decision record explains that the desired benefit is uncertain and that avoiding surgery is an option. The adverse-effects domain must remain visible even when a simulated after photograph looks favorable. Aesthetics alone should not suppress a patient's later symptom report. A retrospective scoring-versus-sparing comparison cannot isolate technique effects from case selection or predict this patient's appearance and risk.
• A tradeoff matrix is useful only if it changes the conversation. For each proposed modification, record the patient's valued feature, a plausible unwanted change, what needs verification, and the question to ask the patient before consent. Consider photographs as communication aids, with their limitations explained, rather than guarantees of a post-treatment outline. A reviewer may recommend that the author reframe the goal, document alternatives and let the patient revisit the decision. The final plan remains conditional on clinical assessment, informed preference and local professional standards.

Learning objective

Identify at least six omissions in a fictional preoperative record, rank each by patient-safety consequence, and assign a responsible person and closure evidence before any elective decision.

In this lesson

• A signed form cannot replace evidence that the patient heard the proposed change, alternatives, material risks and uncertainty in a form they could understand. Check whose goal is recorded, what outcome is considered acceptable, and whether the discussion changed after a new concern arose. A reviewer should flag unexplained assumptions and request a conversation, not simply add boilerplate to a chart. For a child, participation, lawfulness and best interests require jurisdiction-specific review; a child's opposition to an elective cosmetic intervention is a stopping point under the cited UK standard. The decision record should capture the information exchanged and agreed actions, including a decision to take no action.
• The proposed correction may be anatomically coherent while the wider pathway remains unsafe. Check health history, new symptoms, previous procedures, allergies, local team readiness and unresolved diagnostic questions at a level appropriate to a plan review. A new hearing complaint, painful swelling, drainage or suspected infection calls for clinical assessment rather than aesthetic reassurance; the urgency follows the symptom and local pathway. Distinguish a missing baseline photograph, which weakens later comparison, from an unaddressed health concern or absent emergency access, which may change whether to proceed at all.
• A complete decision record says who explains individualized instructions, who receives a patient call after hours, who examines a worsening concern, and who reviews the eventual result. If the patient will travel or receive care in another service, the handoff must be explicit and acknowledged rather than assumed. The reviewer need not prescribe dressings, medicines or a fixed recovery schedule. Instead, ask whether the treating team has supplied its actual orders, warning signs and reachable contacts. A gap without an owner remains open even if it appears on a checklist. Clinical photographs require appropriate consent, secure storage and a separate check before any secondary teaching use under the cited UK guidance.
• Rank findings as immediate clinical assessment, pre-decision clarification, or documentation improvement, and state the evidence needed to close each item. Record whether the proposed elective decision can be revisited only after the safety issue is resolved. A revision to the plan should be explained to the patient and reflected in consent; the peer reviewer should never silently authorize a different intervention. End with a named reviewer or service, a communication route, and a condition for re-review. This turns criticism into an accountable safety handoff rather than an unactioned list.

Learning objective

Classify six fictional follow-up messages into urgent clinical assessment, prompt treating-team review or routine outcome discussion, and name the contact owner plus a failed-contact backup for each.

In this lesson

• A patient may report that an ear still appears prominent while also describing worsening pain, expanding swelling, bleeding, discharge, fever or a wound change. The latter are clinical signals that need assessment; the cosmetic complaint does not downgrade them. Ask when the symptom began, whether it is changing, what side is affected, and whether the patient can reach the treating team. This lesson teaches routing and accountability, not diagnosis or home treatment. When the concern suggests a serious or rapidly evolving problem, use the local urgent or emergency pathway.
• A stable contour question without concerning symptoms may be suitable for planned review, while new or worsening unilateral pain and swelling, bleeding or drainage can require prompt clinical contact. Avoid a universal clock or reassurance based on a generic healing timeline; the treating service must judge urgency from the actual presentation. The reviewer should document the initial message, follow-up questions, classification and reason. If information is incomplete, choose a safe route to clinical assessment rather than silently assigning 'expected recovery' in a portal queue.
• Name who receives telephone, portal and out-of-hours messages, who calls the patient back, and which service provides an examination if the original team is unavailable. An automated acknowledgement is not clinical review. If a message is misfiled as a cosmetic complaint, the responsible service should correct the classification, contact the patient and record the handoff. Travelers and patients seen by multiple teams need a receiving clinician and a fallback. The audit should make the escalation path visible without giving drug, dressing or activity instructions.
• A later favorable appearance photograph cannot erase an earlier unreviewed symptom. In a longitudinal audit, preserve the date of each patient report, the staff response, the actual assessment and any gap between them. Identify whether the problem was unclear guidance, an unreachable contact, a failed triage rule or lost ownership; recommend a process correction suited to the service. Do not turn the audit into blame without evidence or a claim that a complication definitely occurred. The practical endpoint is a named owner and a safer response to the next similar report. A service-level review should monitor outcomes and complications, while adapting the cited UK safety standard to local governance.

Learning objective

Build a three-column outcome record separating baseline and current appearance, clinical symptoms, and patient-reported experience, while rating the reliability of every comparison and stating at least two unresolved questions.

In this lesson

• The original goal is the anchor for outcome review: quote what the patient wanted changed, preserved and avoided. Then locate the corresponding pre-treatment examination, bilateral views and symptoms. A filtered, rotated or incomplete photograph may still explain a conversation but cannot establish a precise contour change. Document missing records rather than filling them with the clinician's recollection. When present and current images differ in pose, hair or lighting, describe only what can reasonably be compared and seek a fresh clinical review for the rest. Treat real clinical images as protected records; obtaining them for care and reusing them for teaching raise distinct consent questions.
• Record visible contour, physical symptoms and the patient's lived experience in separate fields before drawing an overall conclusion. An ear can look less prominent in a photograph while the patient reports pain or discomfort with glasses; conversely, a patient may value a modest change even if a reviewer sees residual asymmetry. Ask what changed in daily use, what remains troubling, and whether a new goal has replaced the old one. Neither the clinician's aesthetic judgement nor a patient score alone proves health or satisfaction. Unresolved symptoms need clinical assessment.
• The EAR-Q field test included people aged 8–29 with several ear conditions, including prominent ears, and developed appearance and adverse-effects scales. It can structure patient-reported information in an appropriate setting, with authorization to use the instrument, but its validation is not evidence that this particular operation succeeded. Do not copy questionnaire items into course work or treat a score as a surgical indication. Outside the studied age range or in another language or context, explain why direct transfer is uncertain and retain the patient's own narrative.
• If photographs suggest improvement but the patient feels worse, the disagreement is a finding to investigate. Check image comparability, the stated goal, symptoms, social context and whether the same contour was being assessed. A short follow-up sample or an unvalidated survey cannot erase a new pain complaint or guarantee long-term satisfaction. Mark what is observed, reported and inferred, plus the next assessment needed. The audit should preserve both positive and negative experiences and state why a decision remains provisional when records or clinical examination are incomplete.

Learning objective

Write a conditional next-step memo for three residual-prominence scenarios, justifying observation, specialist revision assessment or second opinion only after symptoms, baseline evidence and patient goals are reviewed.

In this lesson

• Residual prominence may refer to the same region the patient originally wanted changed, a different ear region, a recurrence after an initial improvement, or a new perception shaped by photographs and social context. Identify the side, region, view and time course before using the label 'failed correction.' Compare the current observation with the original goal and baseline findings, including any acceptable asymmetry the patient recorded. A new contour concern deserves a fresh conversation, but it does not automatically justify another operation. Unreliable images or missing records make the conclusion provisional.
• Tenderness, drainage, an evolving scar, wound change or new hearing symptoms change the order of work: arrange appropriate clinical assessment through the treating or local service before debating another aesthetic procedure. The course does not diagnose infection, prescribe treatment or set a universal waiting interval. Review the actual clinical findings, prior course and any records needed by a receiving specialist. Small retrospective complication series show that problems can occur, but their frequencies do not predict this patient's risk or establish which revision choice is best.
• Observation can be reasonable when the concern is stable, health issues have been assessed, uncertainty about appearance remains and the patient prefers no further intervention. Revision assessment is a specialist evaluation of whether a defined patient-owned goal is feasible and worth additional burden; it is not a booking decision. A second opinion can help when the explanation is unclear, the prior course is complex or trust has been affected. For each path, state what information is missing, who owns follow-up and what event would prompt re-evaluation.
• A safe referral includes the person's own desired change and unacceptable tradeoffs, bilateral baseline and current findings, comparable images when available, prior treatment record, symptom and complication history, and unresolved questions. Tell the patient that further surgery could bring additional scarring, altered sensation, contour uncertainty and another revision need. Do not promise a permanent correction or perfect symmetry. The receiving clinician should be clearly identified, and the original team must retain responsibility for active symptoms until care is accepted. The audit should record why a referral improves decision quality. Record even a decision to observe, including what information was shared and what action was agreed.