Objectives: The objective of this study is to evaluate donor-site morbidity after costal cartilage harvest for microtia reconstruction. Methods: A total of 70 patients who underwent autologous costal cartilage harvest...Objectives: The objective of this study is to evaluate donor-site morbidity after costal cartilage harvest for microtia reconstruction. Methods: A total of 70 patients who underwent autologous costal cartilage harvest for microtia reconstruction from March 2008-March 2009 were included. Anterior chest wall deformity was evaluated with chest topography, and scar quality at baseline and at 6-months follow-up, and final outcomes analyzed with SPSS. Results: In 70 patients, 52 (74%) were male, 18 (26%) were female, and altogether 40 (57%) patients developed deformity. At 6-month follow-up, the incidence of anterior chest wall deformity was highest at 80% in Block-III, and least at 0% in Block-I. The 6 - 10 years age group was the largest group at 84% (21), and also with highest incidence of deformity in association to Block-IV harvest at 83%. The incidence of donor-site deformity was higher in female gender at 66%, and 54% in males. But in the sub-group, male had higher incidence of deformity at 75% in both Block-III, and Block-IV when compared to the respective females. The 120 - 135 cm height group had the highest deformity at 67% with Block-IV costal cartilages harvested. At the three measurement points: 1) xiphisternum, 2) intersecting points between PSL and LCM, and 3) intersecting points between MCL and LCM, significant differences (mean) were observed in chest circumference from baseline to 6-month follow-up, and between the left and right chest hemi-circumference (postoperatively). Acceptable donor-site scar was observed in all but 3% (2) developed hypertrophic scar. Conclusion: The development of chest wall deformity was observed when more than one costal cartilage was harvested, particularly the 6th (complete), 7th, 8th block. Therefore, to minimize the deformity, we recommend harvesting only the necessary amount of cartilage, and at the lowest level possible to avoid injury of costochondral junction. Additionally, age, height, gender and chest development are equally important factors which influence donor-site deformity in microtia reconstruction.展开更多
The purpose of this review article is to review the reconstructive method available for the treatment of microtia and highlight the recent advances.The well established technique developed by Brent and Nagata are stil...The purpose of this review article is to review the reconstructive method available for the treatment of microtia and highlight the recent advances.The well established technique developed by Brent and Nagata are still must widely performed procedure for microtia reconstruction.Various modification of this technique has been reported in the literature.Synthetic framework is seen as an alternative to autogenous costal cartilage framework because of ease of the procedure.More recently,tissue engineering is seen as the most promising treatment.This article gives an overview of the current practice in the field of microtia reconstruction and summarizes the recent surgical developments and relevant tissue engineering research.展开更多
Managing microtia patients is always a challenge. Multidisciplinary approach, good family support, well established doctorepatient rela-tionship and well organised patient-support groups are the essential elements for...Managing microtia patients is always a challenge. Multidisciplinary approach, good family support, well established doctorepatient rela-tionship and well organised patient-support groups are the essential elements for success. With the advancement of implantable hearing devices, more options will be available for the microtia patients. Otologists play a leading role in the whole management process. They not only provide proper guidance to the patients in choosing the correct path of the treatment, but also play a key role in organising and maintaining a cost-effective multidisciplinary rehabilitation team for the microtia patients.展开更多
Objective To investigate the application effect and manufacturing skills of autologous costal cartilage scaffold in ear reconstruction for microtia.Methods From January 2016 to January 2019,41 patients with microtia r...Objective To investigate the application effect and manufacturing skills of autologous costal cartilage scaffold in ear reconstruction for microtia.Methods From January 2016 to January 2019,41 patients with microtia reconstruction in our hospital were selected,all of whom were type II or type III pediatric deformities.All patients underwent auricle reconstruction and retroauricular skin expansion and autologous costal cartilage stent.The first stage of the operation is to insert a skin dilator behind the residual ear and inject water to expand.The second stage of the operation is to carve and repair the soft ribs(usually 6 or 7 ribs)from the body,make a three-dimensional auricle support for auricle reconstruction,place a negative pressure drainage tube,and follow up for 3 to 6 months to observe the three-dimensional shape of the reconstructed auricle and the formation of cranioauricular angle.Results 41 patients with microtia had good three-dimensional shape of auricle reconstruction,normal auricle position,moderate cranioauricular angle,good helix and triangular fossa structure,and good bilateral symmetry.Patients and their families were satisfied with the effect of auricle reconstruction.Conclusion Autologous costal cartilage is a good scaffold for auricle reconstruction.It is through efficient and elaborate carving and splicing that a good three-dimensional auricle structure can be formed.Combined with early flap expansion,a good postoperative appearance effect can be obtained,which is the appropriate method for auricle reconstruction at present.展开更多
Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework.However,complications such as skin necrosis and cartilage exposure often destroy the final contour ...Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework.However,complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle.Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results.Here,we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction.The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure.The most essential subunits survived,and the esthetic concours were harmonious and natural at 12 months postoperatively.Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction.The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.展开更多
Objective To establish the local data on the growth of ear in Hong Kong children and provide a reference for the timing of reconstruction in unilateral microtia.Methods We reviewed case notes of paediatric patients up...Objective To establish the local data on the growth of ear in Hong Kong children and provide a reference for the timing of reconstruction in unilateral microtia.Methods We reviewed case notes of paediatric patients up to 18 years of age who had attended our Ear,Nose and Throat Out-patient Clinic from March to November 2017.We recorded the pinna length of these patients and that of their parents,compared the patients’ear length against that of their parents,and investigated any discrepancy of pinna.Results We recruited 226 local individuals(139 males and 87 females).The patients were divided into different age groups.The means of ear length of patients were compared with the mean length of pinna of their parents.Data of boys and girls are analyzed separately.Boys at 7-8 years old achieved 87.33%and 93.54%of their fathers’and mothers’ear length respectively.Girls at 7-8 years old achieved 83.00%and 90.80%of their fathers’and mothers’ear length respectively.Moreover,the average ratio of the length of left and right ear ratio is 97.3%in all groups of children.Conclusions In Hong Kong children,at the age of 7-8 the ear approaches the size of normal adult ear and is the feasible age with less asymmetry after reconstruction of the microtia.展开更多
Aim:Ear reconstruction is a challenge for plastic and reconstructive surgeons.The ear requires sufficient skin coverage and a three-dimensional(3D)cartilage framework.In this paper,the authors present their 10-year ex...Aim:Ear reconstruction is a challenge for plastic and reconstructive surgeons.The ear requires sufficient skin coverage and a three-dimensional(3D)cartilage framework.In this paper,the authors present their 10-year experience in microtia reconstruction using tissue expansion and an autogenous rib cartilage framework.Methods:Ear reconstruction was performed in 3 operative stages.During the first procedure,a 50-80 mL kidney or cylinder-shaped expander was implanted deep to the subcutaneous fascia of the retroauricular mastoid region.Over a period of 3-5 months,the expander was filled to a final volume of 80-110 mL.In the next operation,the retroauricular fascia was eliminated or reserved following expander removal,and the autogenous costal cartilage framework was placed below the expanded skin flap.At the third and final stage,the earlobe transposition,tragus construction and conchal deepening were performed.Results:A total of 165 patients(166 ears)were reconstructed using tissue expansion and an autogenous rib cartilage framework.Complications included hematomas in 3 cases,expander exposure in 8 cases,cartilage exposure in 6 cases,infection and cartilage resorption in 2 cases,exposure of steel wire in 4 cases,and aseptic seroma in 2 cases.Follow-up ranging from 3 months to 5 years showed that 159 patients were satisfied with the reconstructed ear including size,location,projection,convolution,skin-colour matching,symmetry with opposite ear.Conclusion:Expansion of the retroauricular skin and fascia can provide sufficient non-hair-bearing skin and tissue for coverage of a three-dimensional costal cartilage framework.Avoidance and prompt treatment of complications are advised in order to obtain a satisfactory reconstruction of the ear.展开更多
Background：The optimal age at which to initiate for auricular reconstruction is controversial.Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction.We ...Background：The optimal age at which to initiate for auricular reconstruction is controversial.Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction.We developed a method to guide the timing of auricular reconstruction in children with microtia ranging in age from 5 to 10 years.Methods：Rib cartilage and the healthy ear were assessed using low-dose multi-slice computed tomography.The lengths of the eighth rib cartilage and the helix of the healthy ear （from the helical crus to the joint of the helix and the earlobe） were measured.Surgery was performed when the two lengths were approximately equal.Results：The preoperative eighth rib measurements significantly correlated with the intraoperative measurements （P 〈 0.05）.From 5 to 10 years of age,eighth rib growth was not linear.In 76 （62.8%） of 121 patients,the eighth rib length was approximately equal to the helix length in the healthy ear;satisfactory outcomes were achieved in these patients.In 18 （14.9%） patients,the eighth rib was slightly shorter than the helix,helix fabrication was accomplished by adjusting the length of the helical crus of stent,and satisfactory outcomes were also achieved.Acceptable outcomes were achieved in 17 （14.0%） patients in whom helix fabrication was accomplished by cartilage splicing.In 9 （7.4%） patients with insufficient rib cartilage length,the operation was delayed.In one （0.8%） patient with insufficient rib cartilage length,which left no cartilage for helix splicing,the result was unsatisfactory.Conclusions：Eighth rib cartilage growth is variable.Rib cartilage assessment relative to the healthy ear can guide auricular reconstruction and personalize treatment in young patients with microtia.展开更多
目的探讨先天性小耳畸形发病的危险因素以及临床听力学特征。方法对2018~2024年我院儿童听力保健门诊就诊的50例先天性小耳畸形患儿及同期来院就诊的90例健听儿童的临床资料进行回顾性分析。结果50例小耳畸形患儿中,54%为男性,60.9%的...目的探讨先天性小耳畸形发病的危险因素以及临床听力学特征。方法对2018~2024年我院儿童听力保健门诊就诊的50例先天性小耳畸形患儿及同期来院就诊的90例健听儿童的临床资料进行回顾性分析。结果50例小耳畸形患儿中,54%为男性,60.9%的单侧畸形为右侧受累,70.4%小耳畸形伴外耳道狭窄或闭锁,82%为单发小耳畸形。50例小耳畸形患儿按照Marx分级:Ⅰ级7例,Ⅱ级15例,Ⅲ级28例;平均ABR气导阈值分别为Ⅰ级60.71±7.51 dB nHL、Ⅱ级75.33±2.56 dB nHL、Ⅲ级83.74±2.22 dB nHL,不同分级听力阈值存在显著差异。生活在矿区、孕期前3个月服用上感药物、孕期用药史、出生时低体重等发生小耳畸形的可能性更高。结论生活在矿区、孕期患病、孕期前3个月服用上感药物、孕期用药史、低体重儿等是小耳畸形的高风险因素;小耳畸形程度越重,听力损失越重。展开更多
Apart from listening to the cry of a healthy newborn,it is the declaration by the attending paediatrician in the labour room that the child is normal which brings utmost joy to parents.The global incidence of children...Apart from listening to the cry of a healthy newborn,it is the declaration by the attending paediatrician in the labour room that the child is normal which brings utmost joy to parents.The global incidence of children born with congenital anomalies has been reported to be 3%-6%with more than 90%of these occurring in low-and middle-income group countries.The exact percentages/total numbers of children requiring surgical treatment cannot be estimated for several reasons.These children are operated under several surgical disciplines,viz,paediatric-,plastic reconstructive,neuro-,cardiothoracic-,orthopaedic surgery etc.These conditions may be life-threatening,e.g.,trachea-oesophageal fistula,critical pulmonary stenosis,etc.and require immediate surgical intervention.Some,e.g.,hydrocephalus,may need intervention as soon as the patient is fit for surgery.Some,e.g.,patent ductus arteriosus need‘wait and watch’policy up to a certain age in the hope of spontaneous recovery.Another extremely important category is that of patients where the operative intervention is done based on their age.Almost all the congenital anomalies coming under care of a plastic surgeon are operated as elective surgery(many as multiple stages of correction)at appropriate ages.There are advantages and disadvantages of intervention at different ages.In this article,we present a review of optimal timings,along with reasoning,for surgery of many of the common congenital anomalies which are treated by plastic surgeons.Obstetricians,paediatricians and general practitioners/family physicians,who most often are the first ones to come across such children,must know to guide the parents appropriately and convincingly impress upon the them as to why their child should not be operated immediately and also the consequences of too soon or too late.展开更多
文摘Objectives: The objective of this study is to evaluate donor-site morbidity after costal cartilage harvest for microtia reconstruction. Methods: A total of 70 patients who underwent autologous costal cartilage harvest for microtia reconstruction from March 2008-March 2009 were included. Anterior chest wall deformity was evaluated with chest topography, and scar quality at baseline and at 6-months follow-up, and final outcomes analyzed with SPSS. Results: In 70 patients, 52 (74%) were male, 18 (26%) were female, and altogether 40 (57%) patients developed deformity. At 6-month follow-up, the incidence of anterior chest wall deformity was highest at 80% in Block-III, and least at 0% in Block-I. The 6 - 10 years age group was the largest group at 84% (21), and also with highest incidence of deformity in association to Block-IV harvest at 83%. The incidence of donor-site deformity was higher in female gender at 66%, and 54% in males. But in the sub-group, male had higher incidence of deformity at 75% in both Block-III, and Block-IV when compared to the respective females. The 120 - 135 cm height group had the highest deformity at 67% with Block-IV costal cartilages harvested. At the three measurement points: 1) xiphisternum, 2) intersecting points between PSL and LCM, and 3) intersecting points between MCL and LCM, significant differences (mean) were observed in chest circumference from baseline to 6-month follow-up, and between the left and right chest hemi-circumference (postoperatively). Acceptable donor-site scar was observed in all but 3% (2) developed hypertrophic scar. Conclusion: The development of chest wall deformity was observed when more than one costal cartilage was harvested, particularly the 6th (complete), 7th, 8th block. Therefore, to minimize the deformity, we recommend harvesting only the necessary amount of cartilage, and at the lowest level possible to avoid injury of costochondral junction. Additionally, age, height, gender and chest development are equally important factors which influence donor-site deformity in microtia reconstruction.
文摘The purpose of this review article is to review the reconstructive method available for the treatment of microtia and highlight the recent advances.The well established technique developed by Brent and Nagata are still must widely performed procedure for microtia reconstruction.Various modification of this technique has been reported in the literature.Synthetic framework is seen as an alternative to autogenous costal cartilage framework because of ease of the procedure.More recently,tissue engineering is seen as the most promising treatment.This article gives an overview of the current practice in the field of microtia reconstruction and summarizes the recent surgical developments and relevant tissue engineering research.
文摘Managing microtia patients is always a challenge. Multidisciplinary approach, good family support, well established doctorepatient rela-tionship and well organised patient-support groups are the essential elements for success. With the advancement of implantable hearing devices, more options will be available for the microtia patients. Otologists play a leading role in the whole management process. They not only provide proper guidance to the patients in choosing the correct path of the treatment, but also play a key role in organising and maintaining a cost-effective multidisciplinary rehabilitation team for the microtia patients.
文摘Objective To investigate the application effect and manufacturing skills of autologous costal cartilage scaffold in ear reconstruction for microtia.Methods From January 2016 to January 2019,41 patients with microtia reconstruction in our hospital were selected,all of whom were type II or type III pediatric deformities.All patients underwent auricle reconstruction and retroauricular skin expansion and autologous costal cartilage stent.The first stage of the operation is to insert a skin dilator behind the residual ear and inject water to expand.The second stage of the operation is to carve and repair the soft ribs(usually 6 or 7 ribs)from the body,make a three-dimensional auricle support for auricle reconstruction,place a negative pressure drainage tube,and follow up for 3 to 6 months to observe the three-dimensional shape of the reconstructed auricle and the formation of cranioauricular angle.Results 41 patients with microtia had good three-dimensional shape of auricle reconstruction,normal auricle position,moderate cranioauricular angle,good helix and triangular fossa structure,and good bilateral symmetry.Patients and their families were satisfied with the effect of auricle reconstruction.Conclusion Autologous costal cartilage is a good scaffold for auricle reconstruction.It is through efficient and elaborate carving and splicing that a good three-dimensional auricle structure can be formed.Combined with early flap expansion,a good postoperative appearance effect can be obtained,which is the appropriate method for auricle reconstruction at present.
基金This work was supported by the National Natural Science Foundation of China(no.81974291)the Clinical Research Program of Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine(JYLJ201914).
文摘Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework.However,complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle.Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results.Here,we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction.The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure.The most essential subunits survived,and the esthetic concours were harmonious and natural at 12 months postoperatively.Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction.The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.
基金Ethical approval was given by the medical ethics committee of Kowloon Central/Kowloon Eas(KCKE SOP 001F6a).
文摘Objective To establish the local data on the growth of ear in Hong Kong children and provide a reference for the timing of reconstruction in unilateral microtia.Methods We reviewed case notes of paediatric patients up to 18 years of age who had attended our Ear,Nose and Throat Out-patient Clinic from March to November 2017.We recorded the pinna length of these patients and that of their parents,compared the patients’ear length against that of their parents,and investigated any discrepancy of pinna.Results We recruited 226 local individuals(139 males and 87 females).The patients were divided into different age groups.The means of ear length of patients were compared with the mean length of pinna of their parents.Data of boys and girls are analyzed separately.Boys at 7-8 years old achieved 87.33%and 93.54%of their fathers’and mothers’ear length respectively.Girls at 7-8 years old achieved 83.00%and 90.80%of their fathers’and mothers’ear length respectively.Moreover,the average ratio of the length of left and right ear ratio is 97.3%in all groups of children.Conclusions In Hong Kong children,at the age of 7-8 the ear approaches the size of normal adult ear and is the feasible age with less asymmetry after reconstruction of the microtia.
基金supported by the grants of National Natural Science Foundation of China(No.81660319)Health Science and Technology Plan Projects of Yunnan province(No.2016NS266).
文摘Aim:Ear reconstruction is a challenge for plastic and reconstructive surgeons.The ear requires sufficient skin coverage and a three-dimensional(3D)cartilage framework.In this paper,the authors present their 10-year experience in microtia reconstruction using tissue expansion and an autogenous rib cartilage framework.Methods:Ear reconstruction was performed in 3 operative stages.During the first procedure,a 50-80 mL kidney or cylinder-shaped expander was implanted deep to the subcutaneous fascia of the retroauricular mastoid region.Over a period of 3-5 months,the expander was filled to a final volume of 80-110 mL.In the next operation,the retroauricular fascia was eliminated or reserved following expander removal,and the autogenous costal cartilage framework was placed below the expanded skin flap.At the third and final stage,the earlobe transposition,tragus construction and conchal deepening were performed.Results:A total of 165 patients(166 ears)were reconstructed using tissue expansion and an autogenous rib cartilage framework.Complications included hematomas in 3 cases,expander exposure in 8 cases,cartilage exposure in 6 cases,infection and cartilage resorption in 2 cases,exposure of steel wire in 4 cases,and aseptic seroma in 2 cases.Follow-up ranging from 3 months to 5 years showed that 159 patients were satisfied with the reconstructed ear including size,location,projection,convolution,skin-colour matching,symmetry with opposite ear.Conclusion:Expansion of the retroauricular skin and fascia can provide sufficient non-hair-bearing skin and tissue for coverage of a three-dimensional costal cartilage framework.Avoidance and prompt treatment of complications are advised in order to obtain a satisfactory reconstruction of the ear.
文摘Background：The optimal age at which to initiate for auricular reconstruction is controversial.Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction.We developed a method to guide the timing of auricular reconstruction in children with microtia ranging in age from 5 to 10 years.Methods：Rib cartilage and the healthy ear were assessed using low-dose multi-slice computed tomography.The lengths of the eighth rib cartilage and the helix of the healthy ear （from the helical crus to the joint of the helix and the earlobe） were measured.Surgery was performed when the two lengths were approximately equal.Results：The preoperative eighth rib measurements significantly correlated with the intraoperative measurements （P 〈 0.05）.From 5 to 10 years of age,eighth rib growth was not linear.In 76 （62.8%） of 121 patients,the eighth rib length was approximately equal to the helix length in the healthy ear;satisfactory outcomes were achieved in these patients.In 18 （14.9%） patients,the eighth rib was slightly shorter than the helix,helix fabrication was accomplished by adjusting the length of the helical crus of stent,and satisfactory outcomes were also achieved.Acceptable outcomes were achieved in 17 （14.0%） patients in whom helix fabrication was accomplished by cartilage splicing.In 9 （7.4%） patients with insufficient rib cartilage length,the operation was delayed.In one （0.8%） patient with insufficient rib cartilage length,which left no cartilage for helix splicing,the result was unsatisfactory.Conclusions：Eighth rib cartilage growth is variable.Rib cartilage assessment relative to the healthy ear can guide auricular reconstruction and personalize treatment in young patients with microtia.
文摘目的探讨先天性小耳畸形发病的危险因素以及临床听力学特征。方法对2018~2024年我院儿童听力保健门诊就诊的50例先天性小耳畸形患儿及同期来院就诊的90例健听儿童的临床资料进行回顾性分析。结果50例小耳畸形患儿中,54%为男性,60.9%的单侧畸形为右侧受累,70.4%小耳畸形伴外耳道狭窄或闭锁,82%为单发小耳畸形。50例小耳畸形患儿按照Marx分级:Ⅰ级7例,Ⅱ级15例,Ⅲ级28例;平均ABR气导阈值分别为Ⅰ级60.71±7.51 dB nHL、Ⅱ级75.33±2.56 dB nHL、Ⅲ级83.74±2.22 dB nHL,不同分级听力阈值存在显著差异。生活在矿区、孕期前3个月服用上感药物、孕期用药史、出生时低体重等发生小耳畸形的可能性更高。结论生活在矿区、孕期患病、孕期前3个月服用上感药物、孕期用药史、低体重儿等是小耳畸形的高风险因素;小耳畸形程度越重,听力损失越重。
文摘Apart from listening to the cry of a healthy newborn,it is the declaration by the attending paediatrician in the labour room that the child is normal which brings utmost joy to parents.The global incidence of children born with congenital anomalies has been reported to be 3%-6%with more than 90%of these occurring in low-and middle-income group countries.The exact percentages/total numbers of children requiring surgical treatment cannot be estimated for several reasons.These children are operated under several surgical disciplines,viz,paediatric-,plastic reconstructive,neuro-,cardiothoracic-,orthopaedic surgery etc.These conditions may be life-threatening,e.g.,trachea-oesophageal fistula,critical pulmonary stenosis,etc.and require immediate surgical intervention.Some,e.g.,hydrocephalus,may need intervention as soon as the patient is fit for surgery.Some,e.g.,patent ductus arteriosus need‘wait and watch’policy up to a certain age in the hope of spontaneous recovery.Another extremely important category is that of patients where the operative intervention is done based on their age.Almost all the congenital anomalies coming under care of a plastic surgeon are operated as elective surgery(many as multiple stages of correction)at appropriate ages.There are advantages and disadvantages of intervention at different ages.In this article,we present a review of optimal timings,along with reasoning,for surgery of many of the common congenital anomalies which are treated by plastic surgeons.Obstetricians,paediatricians and general practitioners/family physicians,who most often are the first ones to come across such children,must know to guide the parents appropriately and convincingly impress upon the them as to why their child should not be operated immediately and also the consequences of too soon or too late.
