Basta-Juzbašić, Aleksandra

Bilić, Mario

Kovač, Lana

Peršić-Vojinović, Sanja

Vojinović, Mario

Mario Vojinović

Mario Bilić

Lana Kovač

Sanja Peršić-Vojinović

Aleksandra Basta-Juzbašić

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20Acta Dermatovenerol Croat              2009;17(1):20-24                                    CASE REPORTTreatment of Massive Rhinophyma by Combined Electrosurgery and CO2 Laser	Mario Vojinović1, Mario Bilić2, Lana Kovač2, Sanja Peršić-Vojinović3,  Aleksandra Basta-Juzbašić41ENT Department, Zabok General Hospital, Zabok; 2University Department of ENT, Head and Neck Surgery, Zagreb University Hospital Center; 3Centar Health Center; 4University Department of Dermatology and Venereology, Zagreb University Hospital Center and School of Medicine, Zagreb, CroatiaCorresponding author: Mario Vojinović, MDENT DepartmentZabok General HospitalBračak bbHR-49210 ZabokCroatiamario.vojinovic1@zg.t-com.hrReceived: April 3, 2008Accepted: February 20, 2009SUMMARY A case of massive rhinophyma that produced significant functional and cosmetic difficulties was treated using electrosurgery and carbon dioxide laser. Minimal bleeding occurred during the operative procedure despite grotesque enlargement and high degree of vascularity of the skin and soft tissue. Using this technique, restoration of normal function and excellent cosmetic effect was achieved without any complication.KEY WORDS: rhinophyma, rosacea, multidisciplinary approach, elec-trosurgery, CO2 laser procedure, malignant potential, preventionINTRODUCTION Rhinophyma is a slowly progressive, disfigur-ing disorder of the nose occurring more frequently in males than in females. It is characterized by hy-perplasia and hypertrophy of sebaceous glands, and hyperplasia of connective tissue and blood vessels of the nose. Flushing and increased blood flow in the superficial dermis leads to an increase in the extracellular fluid that may be involved in rhinophyma (1).	On clinical and histologic basis, four variants of rhinophyma can be recognized: glandular, fibrous, fibroangiomatous and actinic. Although the precise etiology is unclear, it is gen-erally accepted that rhinophyma represents the final stage of rosacea. Chronic infection by the saprophytic parasite Demodex folliculorum, gas-trointestinal interference, androgenic hormone, al-cohol, caffeine, spicy foods, and other vasoactive influences such as climate have been implicated as factors that can affect the course of rosacea. In our current society, however, rhinophyma can be a social stigma that prompts patients to seek treatment for this cosmetic problem. It also causes functional problems including obstruction of the nares (one or both) and difficulty in breath-ing, and is a disorder with a malignant potential. Basal cell carcinoma has been reported in 3% to 21up to 10% of patients (2). Squamous cell carci-noma has also been noted in biopsy specimens of patients with long-standing rhinophyma (3). Rhinophyma may be treated with both medical and surgical treatment modalities (4). Most appro-priate treatment depends on the assessment of the disease progression from minimal thickening of advanced rosacea to a massive tumorous con-dition (2). We report on a patient with massive rhinophy-ma treated with electrosurgery and CO2 laser.CASE REPORT A 52-year-old man with chronic rosacea ob-served gradual enlargement of his nose 18 months before. Medical treatment failed and after multidis-ciplinary discussion about treatment options, risks, benefit, complications and scarring the patient ac-cepted the treatment with CO2 laser at our ENT Department. His medical history included arterial hypertension, diabetes, hepatotoxic lesion and nephrolithiasis. Ten years before he was treated with radiotherapy at our Dermatology Department for histologically confirmed squamous cell carci-noma of the lower lip. There was no family history of a similar disease. The patient admitted alcohol consumption. Laboratory tests yielded normal findings, except for increased transaminases.  Physical examination revealed marked en-largement of the patient’s nose with loss of normal nasal contours. The columella and nasal rim were enlarged with partial collapse of the columella and narrowing of the external nares (Fig. 1a, b). All pro-cedures were performed in operating room setting under local anesthesia; 1% lidocaine with 1:100 000 adrenalin solution was used to block infraor-bital nerves, infratrochlear and external branch of the nasal ciliary nerves, and branches of anterior ethmoid. A unipolar electrosurgical unit was used in the cutting mode. With the loop attachment, the nose was sequentially sculptured by removal of the massive tissue. The removed masses were referred for histopathologic examination. Histopa-thology findings showed no signs of malignancy.  The physician must be careful in the initial marking procedure and during the formal resec-tion to leave at least 1 cm of healthy tissue around the nares, thereby preventing scar contracture that can cause nasal deformity. After complet-ing resection of the main bulk of the rhinophyma, Figure 1a, b. Enlargement of the patient’s nose with loss of normal nasal contours. The columella and nasal rim were enlarged with partial collapse of the columella and narrowing of the external na-res.a ba bc dFigure 2a, b, c, d. On postoperative day 3, the patient suffered no pain at all.  Vojinović et al.     Acta Dermatovenerol CroatTreatment of rhinophyma with CO2 laser        2009;17(1):20-24ACTA DERMATOVENEROLOGICA CROATICA22refinements were made with CO2 laser in a de-focused mode by raising the beam further from the operative site. The wound was covered with vaseline gauze, which was removed on the third postoperative day (Fig. 2a, b, c, d).  The patient had no postoperative complications and experienced minimal postoperative pain. He accepted systemic therapy with cefazolin 3x1 g, in-travenous, for two days and nonsteroidal antirheu-matic therapy (ketoprofen) per os. After 6 weeks, complete re-epithelialization of the patient’s nose surface was observed (Fig. 3a, b, c, d).DISCUSSION Hebra (1845) has been credited with the ini-tial description of rhinophyma, a word derived from the Greek terms for nose (rhis) and growth (phyma). A famous portrait by Girlandajo (1449-1494), however, illustrates that this condition was well recognized a long time ago (5,6). Phymas are slowly progressive, disfiguring disorders of the face and ears, probably as sequels of chronic edema and related connective tissue and seba-ceous gland hypertrophy. Rhinophyma is most common among them, occasionally resulting in nasal airway obstruction. Analogous swellings may occur on the chin (gnathophyma), forehead (mentophyma), one or both ears (otophyma), and eyelids (blepharophyma).  Rhinophyma represents the final stage of ro-sacea, and may be treated with both medical and surgical treatment modalities. Patients with early rhinophyma consisting of minimal skin thickening without nasal deformity are not treated surgically and may benefit from medical therapy. The patient should be instructed to practice good hygiene, avoiding predisposing factors, stress, and pre-venting infection. Treatment with antibiotics may prevent secondary infections and isotretinoin may suppress the activity of sebaceous glands and substantially reduce sebum production (7-9). Sub-stantial regression of established disease, with or without medical treatment does not occur due to limited success of medical therapy, thus sur-gery has become the accepted treatment for this stage. Surgical methods are divided into two main groups (10). The first is complete excision, with primary closure for small lesions, or skin grafting for large lesions. The second group includes in-complete excision followed by re-epithelialization from the remaining glandular epithelium; better cosmetic results have been reported and it is now the treatment of choice. The methods of incom-plete excision include cryosurgery, dermabrasion, electrosurgery, sharp blade excision, shaving with a razor and laser surgery. Nonsurgical methods include chemical destruction and irradiation. Ex-cept for laser, all methods of incomplete excision have some drawbacks, including excessive blood loss and poor visualization, which results in inac-curate removal and, often, the need for general anesthesia.  Electrosurgery destroys tissue with heat pro-duced when the current passing through the tis-sue encounters electrical resistance. With elec-trosection, local tissue is destroyed with minimal dispersion of heat to the surrounding areas. The duration of exposure to electrosection current af-fects scar production. Slow passage of the loop maximizes heat conduction and tissue destruction. Short, rapid, shallow strokes produce thin shav-ings of tissue and minimize heat conduction (11). Removal of most, but not all sebaceous hyperpla-a bc dFigure 3a, b, c, d. After 6 weeks, the patient showed complete re-epithelialization of his nose surface.Vojinović et al.     Acta Dermatovenerol CroatTreatment of rhinophyma with CO2 laser        2009;17(1):20-24ACTA DERMATOVENEROLOGICA CROATICA23sia is sufficient to stop the inflammatory response. Oversized removal of sebaceous tissue will con-sistently result in scarring (12). In their comparison study, Greenbaum et al. demonstrated electro-surgery and laser therapy to produce equivalent cosmetic results (13). Electrosurgery shares with laser surgery controlled tissue destruction needed to reshape the nose while maintaining hemostasis. Electrosurgery has greater heat dispersion through the tissue than CO2 laser in the cutting mode and therefore is a less precise method. The CO2 laser has demonstrated usefulness in the treatment of rhinophyma (14-23). Bleeding from small vessels is not a problem with this technique, allowing for more precise tissue removal, especially when the layer-by-layer vaporization technique is employed for final sculpturing. Since the thermal effect is extremely limited, the risk of scarring is reduced. Thus defocused beam permits easy feathering of the wound margins, which can be blended into the adjacent tissue. The patients report minimal postoperative pain, probably due to the ability of the CO2	 laser to seal nerve endings (19). Since healing occurs by second intention, additional sur-gical procedures such as grafting are not neces-sary to obtain excellent cosmetic results. For all of these reasons, CO2 laser offers significant ad-vantages over traditional treatment of disfiguring 	rhinophyma.CONCLUSION Besides an excellent cosmetic result after CO2	laser treatment, we consider such therapy for rhinophyma as a preventive one. In view of the malignant potential of rhinophyma and a history of squamous cell carcinoma of the lower lip, de-spite negative histopathology findings, we strongly recommend further follow-up examinations. In ad-dition, we have to continue our education and mul-tidisciplinary approach in spite of the prevention and early cancer detection. 	References1.   Laughlin SA, Dudley DK. Laser therapy in the menagement of rosacea. J Cutan Med Surg 1998;2:24-9.2.   Wiemer RD. Rhinophyma. Clin Plast Surg 1987;14:357-65.3.   Broadbent NRG, Cort DF. Squamous carci-noma in long standing rhinophyma. Br J Plast Surg 1977;30:308-9.4.   Hoasjoe DK, Stucker FJ. Rhinophyma: review of pathophysiology and treatment. J Otola-ryngol 1995;24:51-6.5.   Roenigk RK. CO2 laser vaporization for treatment of rhinophyma. Mayo Clin Proc 1987;62:676-80.6.   Haas A, Wheeland RG. Treatment of massive rhinophyma with the carbon dioxide laser. J Dermatol Surg Oncol 1990;16:645-97.   Gomez EC. Actions of isotretinoin and etre-tinate on the pilosebaceous unit. J Am Acad Dermatol 1982;6:746-50.8.   Strauss JS, Stranieri AM. Changes in long-term sebum production from isotretinoin th-erapy. J Am Acad Dermatol 1982;6:751-6.9.   Goldstain JA, Conite H, Mercon H, Pochi PE. Isotretinoin in the treatment of acne. Arch Der-matol 1982;118:555-8.10. Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Der-matol Venereol 2005;19:308-18.11. Clark DP, Hanke CW. Electrosurgical treat-ment of rhinophyma. J Am Acad Dermatol 1990;22:831-7.12. Bennett RG, ed. Fundamentals of cutaneous surgery. St. Louis: CV Mosby;1988. pp. 575-7.13. Greenbaum SS, Krull EA, Watnick K. Compa-rison of CO2 laser and electrosurgery in the treatment of rhinophyma. J Am Acad Dermatol 1988;18:363-8.14. Har-El G, Shapshay SM, Bohigian RK, Krespi YP, Lucente FE. The treatment of rhinophyma: “cold” vs laser techniques. Arch Otolaryngol Head Neck Surg 1993;119:628-31.15. Ali KM, Callari RH, Mobley DL. Resection of rhinophyma with CO2 laser. Laryngoscope 1989;99:453-5.16. Bohigian RK, Shapshay SM, Hybels RL. Ma-nagement of rhinophyma with carbon dioxide laser: Lahey Clinic experience. Lasers Surg Med 1988;8:397-401.17. Wheeland RG, Bailin PL, Ratz JL. Combined carbon dioxide laser vaporization in the treat-ment of rhinophyma. J Dermatol Surg Oncol 1987;13:172-7.18. Shapshay SM, Strong MS, Anastasi GW, Vaughan CW. Removal of rhinophyma with the carbon dioxide laser. Arch Otolaryngol 1980;106:257-9.19. Goldman L, Perry E, Stefanovsky D. A flexibile sealed tube transverse radiofrequency excited Vojinović et al.     Acta Dermatovenerol CroatTreatment of rhinophyma with CO2 laser        2009;17(1):20-24ACTA DERMATOVENEROLOGICA CROATICA24 ACTA DERMATOVENEROLOGICA CROATICAcarbon dioxide laser for dermatologic surgery. Lasers Surg Med 1983;2:317-22.20. Amedee RG, Routman MH. Methods and complications of rhinophyma excision. La-ryngoscope 1987;97:1316-8.21. Hassard AD. Carbon dioxide laser treatment of acne rosacea and rhinophyma. How I do it. J Otolaryngol 1988;17:336-7.22. Hallock GG. Laser treatment of rhinophyma. Aesth Plast Surg 1988;12:171-4.23. Eisen RF, Katz AE, Bohigian RK, Grande DJ. Surgical treatment of rhinophyma with the Shaw scalpel. Arch Dermatol 1986;122:307-9. Vojinović et al.     Acta Dermatovenerol CroatTreatment of rhinophyma with CO2 laser        2009;17(1):20-24Interesting advice of Miss Pearl White - Taky cream for removal of hair; year 1929.(From the collection of Mr. Zlatko Puntijar)

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Treatment of Massive Rhinophyma by Combined Electrosurgery and CO2 Laser

Treatment of Massive Rhinophyma by Combined Electrosurgery and CO2 Laser

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