“DOWNWARD STEPS TECHNIQUE” WITH CO₂ ULTRAPULSED LASER FOR THE TREATMENT OF RHINOPHYMA: OUR PROTOCOL

INTRODUCTION

The authors describe their experience in the treatment of rhinophyma with CO₂ ultrapulsed laser.

The term “rhinophyma” derives from the Greek words rhis (meaning nose) and phyma (meaning growth) and describes an important soft-tissue hypertrophy of the nose (disfigured nose). Primarily, disease affects Caucasian men in the fifth to seventh decade of life and it’s considered the end stage of acne rosacea.

Patients affected by this condition present with hypertrophy of the nasal skin with deformation of the tip and of the wings because of nodularity and newly formed folds (1, 2).

To date, the etiology is controversial thus several predisposing factors have been proposed including vitamin deficiencies, infections, invasion by the follicular mite Demodex folliculorum, stress, androgenic hormones, coffee and alcohol excess.

In predisposed individuals, an altered vasomotor response to non-specific stimuli determines an initial tissue congestion of the midface that triggers a cascade of events responsible for the clinical signs of acne rosacea first and rhinophyma later (1, 3).

Two different clinical scenarios can be observed, one with a predominance of a vascular-connective component (so called rhinophyma) and one with a predominance of glandular component (so called hypertrophic acne of Vidal).

Histologically, the rhinophyma is characterized by an increased size and number of sebaceous glands of the nose with hypervascularity. Also ducts dilation is present and cyst formation with foul-smelling thickened sebum and surrounding connective tissue proliferation, giving the appearance of nodularity. An inflammatory cell infiltrate with lymphocytes and monocytes is always found (2, 4).

Rhinophyma has a chronic course in which periods of remission are alternated by periods of reactivation of symptoms.

In literature a wide range of surgical approaches to rhinophyma has been described such as dermoabrasion, scalpel shave, cryosurgery, electrocautery, near total excision with skin grafting, and laser excision (4, 5, 6).

PATIENTS AND METHODS

Fourteen adult male patients suffering from rhinophyma were treated in our center (centre) in the period between 2005 and 2008 using CO₂ ultrapulsed laser. The patients were Caucasians, aged 50 to 82 years, usually coffee and alcohol abusers.

In 13 cases, vascular-connective type of rhinophyma was observed, while in only one case the type with predominance of glandular component was observed.

The only common symptom was a disfigured nose.

The laser session was accomplished under nerve block anaesthesia (mepivacaine 1%) in a day surgery setting. All cases required only single laser session (average duration of treatment: 35 minutes) after which the patient was discharged.

CO₂ ultrapulsed laser was used in all cases and it is referred to as vaporization.

CO₂ laser was set to 10 Watts, 100 Hertz, 70 Joules with a 3mm spot. After nerve block anaesthesia with 1% mepivacaine, we delimited the peripheral areas of the lesion with the laser and then we removed the central bulk of the lesion. In this step, it is necessary to repeat the application of laser 4−6 times at 10 W to remove the hypertrophic tissue.

Gradually, we reduced the laser power to 2.5 W to remove the deepest parts of the lesion (reticular dermis) (Chart 1).

From time to time, cellular residues are removed by a saline-soaked piece of gauze to prevent overheating of the tissues and block the penetration of laser into the deeper tissues. The laser session ended when no sebum was seen during laser application on the lesion. At the end of the laser excision, antibiotic ointment and petroleum gauze are applied on the wound. The dressing is changed every other day by the patient himself for about three weeks. During this time, the patient will continue with antibiotic therapy initiated three days before the laser session using aminocycline 100 mg, 1 capsule per day.

The scarring-free re-epithelialization is complete within 30 days.

RESULTS

In all cases treated with our protocol (DST), morphological and aesthetic results were satisfactory in a follow-up of 3 years. Major complications such as hypertrophic scars, infections, hyperpigmentation were not observed. (Fig. 1, 2 ,3 ,4.)

DISCUSSION

Rhinophyma is a nose hypertrophic condition that is considered the end stage of acne rosacea.

It typically affects white males between the age of 50 and 70, often alcohol and coffee abusers.

Histopathologically, there is hyperplasia and hypertrophy of the sebaceous glands of the nose with hypervascularity and inflammatory cell infiltrate associated with an excessive growth of surrounding connective tissue (irregular fibrous tissue proliferation), ducts dilation and cyst formation. This leads to a severe form of bulky nose (disfigured nose) (7).

Various surgical approaches to rhinophyma have been proposed and investigated: dermoabrasion, scalpel shave, cryosurgery, electrocautery, near total excision with skin grafting, and laser excision.

From a literature review and from our personal experience, total excision of rhinophyma and skin grafting involves a large destruction of the nasal skin (sometimes under general anaesthesia) with increased risk of hyperpigmentation and hypertrophic scars of the nose. Morbidity of the donor site must also be considered in such cases requiring full-thickness or split-thickness skin grafting, which requires patient hospitalization and prolonged surgical times (5, 6).

The use of ultrapulsed CO₂ laser, in one single session, allows us to reduce the rate of major complications (hyperpigmentation, hypertrophic scars) and to work under nerve block anaesthesia with small intraoperative bleeding, while hemostasis and vaporization of rhinophyma are accomplished simultaneously by the laser action.

The laser beam, in fact, acts as a cutting knife and simultaneously closes the vessels by means of tissue proteins coagulation that causes vessels closure and vaporization of intra and extra-cellular fluid (4).

The laser resurfaces the nose tissue and the consequences are less severe than using surgical approaches. The post-operative course is also easier to manage from the patient at home, besides the patient can be discharged after the laser session and he can continue the dressing changes at home for about three weeks. The re-epithelialization will be complete after 30 days.

CONCLUSIONS

The use of CO₂ ultrapulsed laser for the treatment of rhinophyma offers, certainly, several advantages such as the possibility to work under nerve block anaesthesia, a day-surgery setting and it is therefore suitable for the elderly patient. It is also possible to control possible relapses (in our experience only one recurrence occurred).

Our experience in the treatment of rhinophyma with CO₂ ultrapulsed laser is extremely positive. We obtained satisfactory and safe results that suggest laser treatment as the gold standard approach in the treatment of rhinophyma, which corresponds to recent literature.

Address for correspondence:

Sara Di Lorenzo

via del Vespro 129

90127 Palermo, Italy

E-mail: dilsister@libero.it,

bartolocorradino@unipa.it