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Syncope is a common condition that may lead to serious injuries including burns and head injury. To date, here has been no specific discussion of syncope and burns in the literature. A retrospective case-note review of consecutive patients admitted to a Tertiary Burns Centre over a 3.5-year-period was conducted. Five hundred and fifty nine patients were admitted during the study period. Six of these had burns related to alterations of consciousness that excluded alcohol/drug ingestion and epilepsy. The mean percentage body surface area burnt was 9.7%, the mean length of hospital stay was 28.5 days and the mean length of stay per percentage surface area burnt was 4.0 days per percent body surface burnt. The mean size of the injury in syncopal patients is slightly larger than the general burns patients (8.4%) but the length of stay is doubled. This is partly related to surgery being delayed due to investigation of the syncope episode. Focused investigations should reduce both the overall length of hospital stay and the number of investigations.

Primary branchiogenic carcinoma was previously a debated entity for its existence. It was a popular diagnosis for any cystic carcinoma in the neck until in 1950 Martin et al. proposed specific and strict diagnostic criteria for this condition. Only a handful of cases successfully fulfilled all the criteria were reported afterwards. We report the management of a case who was diagnosed to have cystic squamous cell metastasis from a tonsillar origin. We suggest carrying out thorough search of the upper aero digestic tract for occult primaries upon finding of a cystic metastasis in the neck. Random biopsies in the region of Waldeyer's ring are of particular importance in this situation. Bilateral tonsillectomies should be carried out in doubtful cases. Radical neck dissection and postoperative radiotherapy to the diseased side is recommended.

Objective: To evaluate the effect of an artificial skin Hyphecan (1-4,2-acetamide-deoxy-B-D-glucan polymer) on wound healing in a rodent model. Materials and Method: The prospective study was conducted at a basic science laboratory at a tertiary teaching hospital. Two 4 cm × 4 cm full-thickness wounds were created on the dorsal surface of 10 Spraque–Dawley rats and covered with Hyphecan and Kaltostat, respectively. Wounds were examined and measured on days 4, 10, 21 and 28, and would continue after day 28 until healed up completely. Punch biopsies (3 mm) were taken on days 4, 10 and 28 for histological examination of the response of healing and repair. Results: Despite the fact that the wound healing rate was similar for both groups on days 4, 10, 21 and 28, the average healing time for the Hyphecan group (29.1 ± 1.7 days) was significantly shorter statistically (P = 0.03) than the Kaltostat group (30.7 ± 2.8 days). Conversely, the marked healing response elicited by Hyphecan on day 4 persisted on days 10 and 28 in contrast to Kaltostat, which had only a mild degree of healing response on days 10 and 28. The study suggests that wounds treated by Hyphecan heal faster than Kaltostat. Conclusion: The findings provide basic scientific evidence supporting the clinical use of Hyphecan in different wounds and might also reduce the cost of wound management as Hyphecan is cheaper than Kaltostat and requires a shorter treatment time.

The evolution of care delivered by a multidisciplinary burns team is a function of the effectiveness of the professional communication between team members. In this exercise, we have explored concepts and communication between nurses and doctors in a burns team. Loosely structured weekly meetings were held over a 4-month period. The explicit objective was to determine and define the current model of burns care in a regional burn centre. The implicit objective, however, was to develop a mutual appreciation of actual and potential problems in communication. Consensus task identification was achieved at the end of each meeting with full compliance in completing the tasks before the next meeting. Although there was a unanimous commitment to the team concept, traditional, professional, paradigms persist. For nurses, the concept of holistic modelling predominated, whilst the disease centred paradigm remained the focus of medical modelling. Linguistic, cultural and professional barriers to effective communication were identified but did not readily conform to prior expectations. Experience in burns care can transcend these barriers more effectively than a common culture or profession. In conclusion, team work and team building is a complex process that can benefit from an ongoing process of re-evaluation. An obvious yet common error is to assume a level of mutual understanding that does not in fact exist. Stepping aside to re-explore fundamental principles on which team members base their personal and professional practice can help in elucidating and determining new paradigms of care, which can be evaluated and appropriately implemented. The consensus conclusion was that this approach was a very valuable investment in time in pursuing excellence in the field of burns care.

Assault by burning is a serious form of trauma that often results in higher incidence of inhalation injury, longer intensive care unit (ICU) and hospital stay, and higher mortality rate than is observed in the general burn population. We evaluated the epidemiology and outcome of assault burn victims treated in a tertiary burn center over a 6-year period. Among the 1063 acute burn patients who had been admitted to the Burns Unit between March 1993 and February 1999, 28 (2.6%) had assault burn injuries either by scald, chemical or fire. The mean extent of burn was 21.9%+/-20.8% (range 2-90%) total body surface area and the mean length of hospital stay was 65.2+/-107.3 days (range 1-565). Nineteen out of 25 patients (67.9%) underwent 76 operations. Nine patients had inhalation injuries requiring intubation and ICU admission. Three patients died in the series, which yielded a mortality rate of 10.7%. Compared to the general burn population, the assault burn group had significantly larger burn size (P

A total of 1063 acute burn patients were admitted to the Burns Unit of Prince of Wales Hospital, Hong Kong between March 1993 and February 1999. There were 678 males and 385 females with a male to female ratio of 1.76:1. The median age was 13.1 year-old and the median burn size was 6% total body surface area (TBSA). Pediatric patients under the age of 15 year-old accounted for 550 (51.7%) admissions and 235 (42.7%) of them were toddlers

Ameloblastomas are rare tumours of the jaw. They are usually asymptomatic so, generally, present late. Treatment is predominantly surgical, although some controversy exists over the choice of radical or conservative surgery. A 79-year-old woman presented to the Prince of Wales Hospital, Chinese University of Hong Kong, unable to eat because of a massive mandibular ameloblastoma that had grown over a decade. The lesion was excised and the mandible was reconstructed with a reconstruction plate. The patient made a good recovery and was able to eat a soft diet.

We report our experience with 50 patients who were burned as a result of playing with fire over the period of January 1993 to December 1999. There were 43 males and 7 females with a male to female ratio of 6.1:1. The average age was 12.3+/-10.3 year with 39 (78%) patients under the age of 15. The mean extent of burn was 6.4+/-10.7% total body surface area (TBSA) and 2 children had extensive burns >30%. The burns predominantly involved the head and neck region, upper limb, hand and lower limb. There was no mortality in our series. Wax and fireworks were recognized as the two major burn causing agents in these 50 patients. Risk factors associated with these injuries as well as preventive measures were also presented.

There have been few reports on microsurgical procedures performed on children who have been left with disability and deformity as a result of burn injury. The reality is that whilst there are many children who could benefit from such procedures they do not have access to the resources that can provide them. Where these resources are available there has been a reluctance to use them partially due to a misconception that such procedures are technically challenging and carry significant risk. This paper presents a series of 21 children in whom 29 microsurgical procedures were performed. There were two failures but in all other cases there was significant improvements in the functional ability and/or the aesthetic appearance of the child. This series includes novel variations on the antero-lateral thigh flap; tissue engineering, dual flap harvest, size and age. Refinements of inset are described to prevent pin-cushioning and linear scar contracture. In selected cases microsurgical reconstruction can produce life long benefits, with minimal surgical and donor site morbidity.

The concept of escharotomy has long been associated with acute burns care. Nevertheless the practice of escharotomy is frequently flawed and there is considerable diversity in the teaching of the procedure. It is proposed that there should be a fundamental change in the teaching of acute burn management and the concept of decompression should be promoted. The justification for this change comes from a review of the present knowledge base using indexed, library and web-based information sources and also a review of a series of patients transferred to a regional burns unit over a five-year period which revealed that 37% of patients who required surgical decompression had not been appropriately treated prior to transfer. Based on relevant compartmental anatomy a change in the surgical decompression of limbs is proposed to allow safer and more effective management.

Biological dressings (xenografts and allografts) are an integral part of modern burn care. Although viable allograft is often regarded as the ‘gold standard’ in temporary skin coverage, possessing many of the qualities of the ‘Ideal’ burns dressing (Table 1) [1], the supply may be limited depending on local cultural factors and there are concerns about viral transmission [2]. Porcine skin xenograft on the other hand is cheap and widely available [3]. Biological dressings can be used as

The aim of this study was to assess the patients admitted to Prince of Wales Hospital Burns Unit, Hong Kong between September 1991 and August 2001 following chemical assault. A total of 2319 burns were admitted during the study period of which 19 had been subjected to chemical assault. All victims sustained a burn injury to the head and neck area and 47% of victims' eyes were burnt. A total of 84% required surgical intervention. Where a reason for the attack was admitted most were due to relationship difficulties. This study has defined the victims of chemical assault in Hong Kong. At a time when the overall number of assaults in Hong Kong is at its lowest level for 5 years it is of concern that there appears to have been a recent increase in the number of chemical assaults in Hong Kong.

The effect of Hyphecan (1-4,2-acetamide-deoxy-B- d -glucan) on skin donor site healing was compared with the standard skin donor site dressing Kaltostat (calcium sodium alginate) in 35 burn patients with 70 skin donor sites prospectively. The median time of wound healing for the Hyphecan group was 12 days with an average of 13.1±4.0 days (ranged from 9 to 28 days) while the Kaltostat group had a median healing time of 12 days (ranged from 8 to 28 days) with a mean of 13.0±4.1 days. The difference in healing time between these two groups was statistically insignificant with a P -value of 0.95. The infection rate was 2.9% for both Hyphecan and Kaltostat. These 35 patients had been followed up from 10 to 16 months and no difference in long-term donor site morbidity between Hyphecan and Kaltostat had been observed. This finding was encouraging because the cost of Hyphecan is less than 50% of Kaltostat and it may be worthwhile to explore the clinical application of Hyphecan in other area of burns treatment.

A 23-yr-old lady was inadvertently burned during an attempted suicide. After quarrelling with her boyfriend, she attempted to commit suicide by using alcohol, benzodiazepine and burning charcoal within her sealed bedroom. Her left leg fell over the edge of the bed while she was half-conscious, that resulted in direct contact with the hot pot causing 1% full thickness burn and burn of her left tibialis anterior and extensor digitorum longus. She was initially resuscitated with 100% oxygen and gastric lavage and subsequently was managed in the Burns Unit for wound care, surgical debridement of the burn wound and skin graft, and psychological support. Burning charcoal in a sealed room is an emerging form of suicide in Hong Kong and this is the first case complicated by a burn wound in our locality. A holistic approach to tackle the bio-psycho-social aspects of individual's problem is advocated.

There were 1063 acute burn patients admitted to the Burns Unit of Prince of Wales Hospital, Hong Kong, between March 1993 and February 1999. Eleven patients (1%) were burned due to attempted suicide. Seven were males and four were females, with a male:female ratio of 1.75:1. The median age was 38 years (range: 20-49 years) and the median extent of the burns was 55% total body surface area (range: 1-95%). Ten patients (90.9%) were self-incinerated and one patient attempted suicide by jumping into a hot bath. Seven patients (63.6%) suffered from severe smoke inhalation injury that required immediate intubation for ventilatory support. The average number of operations for the survivors was 3.7 (range: 0-8) and their median hospital stay was 42 days (range: 2-92 days). Four patients (36.4%) died from their injuries. Suicidal burns were more common among unemployed males with a history of psychiatric illness and substance abuse. Town gas (naphtha: a mixture of 49% hydrogen, 28.5% methane, 19.5% carbon dioxide and 3.0% carbon monoxide) was the most frequently used agent for self-immolation because it is probably the most convenient source of a fire accelerant in Hong Kong. Compared to the general burn population, this suicide group had a larger extent of burns, higher incidence of inhalation injury, required more operative treatment and longer hospital stay with a higher mortality rate.

The incidence of ophthalmologic injuries has been reported to be between 20 and 25% in all the burn patients. As most of the eye injuries are associated with severe burns, attention is often directed towards the life-threatening events and eye injuries may be overlooked and undertreated. This case report presents a patient who had 40% flame burn and had recently been transferred from another hospital. He was examined by an ophthalmologist at the referring hospital and it was documented that both of his eyes were normal. He was transferred into the Burns Unit at the Prince of Wales Hospital 8 h later. Unfortunately, all the attention was directed to save his life and it was not until post-burn day 11 that he was found to have right corneal ulceration. Despite vigorous ophthalmologic treatment, the cornea perforated 2 days later with subsequent extrusion of the lens. In view of his grave prognosis with multi-organ failure, he was treated conservatively and he died the following day. It is mandatory to refer patients with facial burns to the ophthalmologist for ocular examination. We recommend that serial eye examinations should be carried out in burn patients who are unconscious or intubated for ventilatory support even if the initial ophthalmologic examinations are normal as the potential risk of serious ocular injuries are high in this particular group of patients.

Iatrogenic injury is an intrinsic risk of all medical procedures. Various kinds of iatrogenic complications have been extensively reported and recognized. Two patients were referred to the Prince of Wales Hospital for iatrogenic flame burn caused by the breakage of an alcohol lamp during ENT examination. They were 8 and 9 years old and sustained 12 and 17% intermediate to deep dermal burns respectively. There was no eye or inhalation injury. They were treated initially at the referring hospital. Despite having the best possible treatment, the parents were hostile to and demanding of the medical attendants and the patients were uncooperative throughout the whole treatment period. Rehabilitation of the two children was jeopardized. The situation was very difficult when they were first seen at the Prince of Wales Hospital. The burn surgeon at the Prince of Wales Hospital, as a third party, managed to act as a bridge between the referring hospital and the patients and their families. Several meetings were held and the best interests of the two patients was addressed. The compensation issue was also settled without formal legal prosecution.

Child abuse and neglect account for a significant number of paediatric burn injuries. It is of great importance because of the high mortality, high frequency of repeated abuse, as well as the physical, psychological and social sequelae that it causes. Burn abuse is often under-recognized and under-reported because it is difficult to define non-accidental injury. On the other hand, false accusation of burn abuse is extremely damaging to the family. Bizarre and unusual burn injuries can be caused by accident and should not automatically be assumed to be deliberate injury. Three boys of age 1-7 years with bizarre facial burns were admitted to the Burns Unit at the Prince of Wales Hospital between February 1995 and July 1999. One was burned by his baby-sitter with hot water steam and the other two were burned by their mothers with hot boiled eggs. The unusual causes of their burns raised the suspicion of child abuse and formal investigations were carried out by the Social Services Department. Detail assessment including a developmental history of the child and the psychosocial assessment of the family revealed that these three boys were burned because of poor medical advice and innocent cultural belief.

Background: Endoscopic surgery has been applied successfully in breast lump excision, breast augmentation, subcutaneous mastectomy for gynecomastia, and axillary dissection. Since subcutaneous mastectomy has been proven to be oncologically safe for early breast cancer, we have sought to develop a reproducible minimally invasive endoscopicassisted technique to address this condition. Methods: Between December 1998 and May 1999, endoscopic- assisted subcutaneous mastectomy and axillary dissection with immediate reconstruction using a mammary prosthesis was performed in nine patients with early breast cancer at the Prince of Wales Hospital, Hong Kong. A 5-cm skin incision was made along the line of the lowest axillary skin crease. Dissection was continued down to the lateral border of the pectoralis major muscle. A subpectoral pocket was gently created by an endoscopic breast dissector. The endoscopic breast retractor and 10-mm/30° scope were introduced into the subpectoral pocket, and further dissection was carried out using a 7-in harmonic scalpel under endoscopic vision down to a level 1 cm caudal to the inframammary fold. This subpectoral space was used for the insertion of the mammary prosthesis later on. Endoscopicassisted subcutaneous mastectomy was performed afterward. Combined level I and level II axillary dissection was carried out via the same incision under direct vision. Results: Apart from minor skin flap bruises in our first two patients, there were no major complications. Histological examination of all the specimens showed clear margins. Postoperative radiotherapy and chemotherapy were given in the usual manner. All patients were satisfied with the reconstructive outcome. Conclusions: We have described a novel endoscopic technique for subcutaneous mastectomy with immediate mammary prosthesis reconstruction in treating early breast cancer patient. This technique can minimize skin incision, reduce blood loss, and improve reconstructive outcome. It is easy to learn and well accepted by patients.

The antero-lateral thigh (ALT) flap was originally reported by Song et al. in 1984. It is only in the last 5 to 6 years, however, that the ALT flap has become established as a highly versatile “work-horse”, in surgical reconstruction. Our experience in various reconstructions with ALT flap in various parts of the body is discussed. Twenty seven patients with 17 male and 10 female were studied. Their age ranged from 2 to 78. Fifteen ALT flaps were used for head and neck reconstruction (11 in head region, four in neck region). 10 for limbs reconstruction (five in upper limb, five in lower limb) and two for trunk reconstruction. Out of the 27 ALT flaps, there were 24 free flaps and five pedicle flaps. There was no morbidity associated with all the 27 operations. Nine patients had primary reconstruction after tumor excision. Eighteen ALT flaps were used to reconstruct tissue with previous surgery or radiotherapy. There was no flap failure. There were two wound infection which treated conservatively with dressing. Anterolateral lateral thigh flap is a reliable flap for various reconstruction with minimal morbidity.