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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.28 no.2 Barcelona mar./abr. 2006

 

CASO CLÍNICO

 

Treatment of rhinophyma with CO2 laser. A case report

Tratamiento del rinofima con láser de CO2. Presentación de un caso

 

 

J.L. Cebrián Carretero1, G. Demaría Martínez2, J.L. del Castillo Pardo de Vera3

1 Medico Adjunto.
2 Medico Residente. Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz, Madrid
3 Cirujano Oral y Maxilofacial. Práctica Privada, Madrid, España.

Dirección para correspondencia

 

 


ABSTRACT

Introduction. Rhinophyma is a skin alteration of the nasal region that causes considerable aesthetic problems. We describe our experience with a case of advanced rhinophyma and its resolution by means of a simple technique.
Materials and methods. The skin area was disinfected beforehand, anaesthesia infiltration and the infraorbital and ethmoidal nerve trunks were blocked. Then, using a Lumenis Sharplan CO2 laser almost the complete skin thickness was resected while preserving the deep dermis layer so as to allow second intention healing. Later, Vaseline was applied and the area was treated daily. The patient was discharged the day after the intervention.
Results. The aesthetic results were very good. Postoperative pain was controlled with standard analgesics. Adequate healing was observed during the first week. Two months later the epithelization was complete and no scabs or erythema remained.
Conclusion. The use of the CO2 laser for the treatment of advanced rhinophyma is an adequate therapy that provides excellent aesthetic results, with minimal morbidity and surgical risk.

Key words: Rhinophyma; CO2 laser.


RESUMEN

Introducción. El rinofima es una alteración cutánea de la región nasal que produce problemas estéticos importantes. Describimos nuestra experiencia en un caso de rinofima avanzado y su resolución por medio de una técnica sencilla.
Material y métodos. Previa desinfección cutánea se realizó anestesia infiltrativa y bloqueo troncular de nervios infraorbitarios y etmoidales. A continuación se realizó la resección de casi todo el espesor cutáneo con un láser de CO2 Lumenis Sharplan conservando la dermis profunda para permitir la curación por segunda intención. Posteriormente se aplicó vaselina y se realizaron curas y lavados diarios. El paciente fue dado de alta al día siguiente de la intervención.
Resultados. Los resultados estéticos fueron muy buenos. El dolor postoperatorio fue controlado con analgesia habitual. En la primera semana se objetivaba un buen grado de cicatrización. A los 2 meses la reepitelización fue completa y ya no se observaban costras ni eritema.
Conclusión. La utilización del láser de CO2 en el tratamiento del rinofima avanzado logra unos excelentes resultados estéticos con una morbilidad y riesgo operatorio mínimos.

Palabras clave: Rinofima; Láser CO2.


 

Introduction

Rhinophyma consists of a large, bulbous, "grainy" and ruddy appearance of the nose of unknown etiology. It is an entity that can occur on its own or other pinkish signs may accompany it. The pinkishness is a chronic dermatitis that tends to appear between the fourth and sixth decades in life. Its pathogeny is unknown, although various mechanisms are involved among which of note is a vasomotor hyperlability of the cutaneous vasculature that is accentuated by sharp changes in temperature, emotional changes, intake of coffee, alcohol and spicy seasoning, medicines, the presence of parasitization as a result of the demodex folliculorum mite and the application of topical steroids, among others.

Its clinical manifestations encompass an ample spectrum of symptoms and signs. At first there are noticeable and recurring episodes of reddening (blushing or swelling) in the malar region, dorsum nasi and forehead which, over time, may become persistent with the appearance of erythema, telangiectases, edema, papules and pustules. Hyperplasia of sebaceous glands, fibrosis and lymphedema are observed in severe forms of the disease, which usually affects the nose. A morphological roughness is produced with a bulbous appearance called rhinophyma, which often leads to the patient undergoing psychological changes.1

On some occasions there may be ocular changes including bloodshot eyes, blepharitis and episcleritis.

It is very important that the triggering factors are avoided, and in the initial stages this entails the topical application of keratolytic agents (benzoyl peroxide, azelaic acid) antibiotics (metronidazole), cosmetics, systemic medication with antibiotics (metronidazole, erythromycin and tetracyclines), retinoids (isotretinoin), antihypertensive drugs (atenolol, clonidine), acaricides (ivermectin) and other procedures such as lasertherapy and intense pulsating light.

For correcting the morphology of the defects produced by this disease in the nose, various methods have been used and of these dermoabrasion, electrocauterization and lasertherapy should be highlighted.2-4

 

Case report

The case is presented of a 75 year-old male that presented complaining of a skin deformation and nasal respiratory insufficiency that was progressive. His medical history included unstable angina that had been treated with vasodilation drugs, and there were no other concomitant pathologies of interest. During the interview the patient commented that the skin symptoms had begun some years previously, and that they had been developing slowly to the current state. He had decided to attend our department as his appearance made his social life difficult to the point that he avoided going out. (Fig. 1)

At first performing the surgery under general anesthesia was studied in order to carry out the excision and remodeling with a CO2 laser. With this end in mind, the appropriate preoperative studies were requested after which, and given the high anesthetic risk due to probable cardiac decompensation, local anesthesia was decided on.

Following disinfection of the skin and the administration of preoperative antibiotic prophylaxis (clavulanic amoxicillin 2 g - 250 mg), the surgical field was prepared and infiltration with local anesthesia was carried out. Lidocaine 2% without adrenaline was used. The infraorbital and ethmoidal nerve trunks were blocked and local anesthetic skin infiltration was carried out. The nasal pyramid was isolated and surrounded by damp cloth, and the nasal covering was stripped from the root to the columella.

A CO2 Lumenis Sharplan laser was used. The resection included the total thickness of the skin and its surroundings, and sufficient tissue was left on the cartilages and nasal bone to allow second intention healing. The surgery took 20 minutes.

Following the surgical procedure, Vaseline was applied to the large bleeding nasal surface and the patient was sent to his room where he remained until he was discharged the next day (Fig. 2).

The postoperative period was complication-free and during the first days the patient only required the wound to be washed and treated with chlorhexidine and physiological serum. Standard painkillers were given every 8 hours, and rescue analgesic medication was not required.

A week after the intervention, the red and bloody appearance had disappeared and the nasal surface was in the process of healing nicely (Fig. 3).

The patient was advised to maintain proper hydration of the skin and to use total sun block. Three months after the intervention, there was clear re-epithelization and the nasal pyramid had a near normal appearance, although there was a large erythematous area that tends to take several months to disappear. (Fig. 4)

Currently the appearance of the nose is normal, its function is adequate, and the patient has resumed a normal social life. (Fig. 5)

 

Discussion

The term ‘laser’ is an acronym in English for Light Amplification by the Simulated Emission of Radiation, which means that it has a capacity for generating monochrome light (with a specific wave length), confluent, with spatial and temporal coherence.

The therapeutic action of the laser is determined by the particular characteristics of the active medium of the laser (ruby, erbium, carbon dioxide, argon, yttrium) and its interaction with tissue chromophores (melanin, water, etc.).

CO2 emits a light that is confluent, monochrome and coherent with a wave length of 10.600 nanometers, which causes the destruction of lesions in the epidermis and dermis. 5 It is used in for treatment of numerous benign as well as malignant skin lesions, and the CO2 laser is considered the most suitable for rhinophyma.6

The advantages of CO2 over other resective techniques is the minimal damage to adjacent tissue, the small inflammatory reaction and the small proliferative reaction during healing.7

Some authors recommend the use of CO2 laser as a first choice8 as the hypertrophic areas of the nose can be sculpted in a precise, clean and efficient manner with very satisfactory cosmetic results.9 It has also been reported that the postoperative period is less painful than with other techniques. 10,11

Cold knife treatment and electrocoagulation provide similar results in the long term, but intraoperative hemostasia is less efficient and the operating time is prolonged. During the postoperative period healing is in turn faster in the CO2 cases and there are fewer scabs.

In order to carry out this method the pain must be minimized for the patient. The patient has traditionally only been prepared with diazepam, oral painkillers, intramuscular injections of ketorolac and local topical anesthesia. In 5% of cases additional local anesthesia or local nerve blocks had to be given.12

The most important advantages are that postoperative pain, edema and wound contraction decrease when compared with other resection methods, and that surgical time is not increased.13

The most common complications include prolonged erythema, that is proportional to the depth of the procedure, the appearance of milia (a transitory and reversible process due to the disruption of sebaceous glands or the follicular epithelium), hyperpigmentation or hypopigmentation (as a result of melanocytes, substitution of photodamaged tissue with healthy tissue, or lack of suitable repigmentation of damaged tissue).

 

Conclusion

The use of CO2 laser in processes that are as advanced as the one presented in this case, is of great use as excellent results can be achieved with minimum risk for the patient given that only local anesthetic, standard analgesia and simple, local cures with Vaseline and physiological serum are needed.

 

 

Dirección para correspondencia:
Gastón Demaría Martínez
Hospital Universitario La Paz
Servicio de Cirugía Oral y Maxilofacial
Hospital General 7º planta
Paseo de la Castellana 261
28046 Madrid, España
Email: gdemaria@vodafone.es

Recibido: 03.08.2005
Aceptado: 23.02.2006

 

 

References

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10. Karim Ali M, Streitmann MJ. Excision of rhinophyma with the carbon dioxide laser: a ten-year experience. Ann Otol Rhinol Laryngol 1997;106:952-5.        [ Links ]

11. Gjuric M, Rettinger G. Comparison of carbon dioxide laser and electrosurgery in the treatment of rhinophyma. Rhinology 1993;31:37-9.        [ Links ]

12. Kilmer SL, Chotzen V, Zelickson BD, McClaren M. Full-Face Laser Resurfacing Using a Supplemented Topical Anesthesia Protocol. Arch Derm 2003;139:1279- 83.        [ Links ]

13. Liboon J. A comparison of mucosal incisions made by scalpel, CO2 laser, electrocautery, and constant-voltage electro.cautery. Otolaryngol Head Neck Surg 1997;116:379-85.        [ Links ]

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