Rhinophyma - Prize winning video from Morriston Hospital.
For most of us warm sunny days are what make a good summer. Unfortunately, though, for sufferers of the distressing condition rosacea, sunshine is a curse rather then a blessing. Often confused with acne, it is a separate condition altogether. It affects both sexes over 30 and although it's slightly more common in women, rosacea is more severe in men. As a result the overgrowth of the oil glands in the nose are more marked adnd the enlargement of the nose known as Rhinophyma is more common in men.
Rhinophyma is characterised by soft tissue enlargement of the nose that leads to functional, cosmetic and psychosocial concerns. The use of CO2 laser has been well described for the treatment of this disease. We report our experience of treating rhinophyma patients with CO2 laser at our regional plastic surgery centre.
A retrospective study was conducted at the Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea. Data including severity, treatment regimens and complications of all patients undergoing CO2 laser treatment for rhinophyma from 2012-2016 was recorded.
Twenty patients (exclusively male) underwent treatment of rhinophyma. Mean age was 61.7 years and 70% had history of rosacea. 55% had moderate to severe disease at presentation. 70% had cosmetic concerns and 20% had symptoms related to infection. 85% had single CO2 laser treatment for rhinophyma. Minimal complications were noted. On subjective assessment all patients had good/excellent results following the treatment.
The CO2 laser treatment successfully restores the nasal shape and cosmesis. The complications associated with this treatment are minimal.
Rhinophyma, a severe form of chronic rosacea, is a benign proliferative disorder of the nose almost exclusively affecting Caucasian men Although its pathogenesis is still not completely understood, clinical manifestations include erythema and enlargement of the nose with tumour-like growths due to sebaceous and connective tissue hypertrophy. The subsequent deformity can not only result in nasal obstruction, but also has psychosocial implications due to its unsightly appearance and perceived association with alcohol abuse, resulting in negative effects on quality of life.2,3 Numerous different treatment methods have been outlined including dermabrasion and surgical excision, however, more recently the use of a CCO2O2 laser has been described.1,4,5 This ablative laser works by targeting intracellular water resulting in cell vaporisation and subsequent tissue destruction. In this article we present our experience of treating rhinophymas with CO2 laser at the Welsh Centre for Plastic Surgery.
We retrospectively analyzed the case notes of all patients undergoing laser treatment for rhinophyma from 2012-2016 at the Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, United Kingdom. Data including patient demographics, symptoms, details of laser treatment, complications, follow-up and clinical assessment following the treatment were extracted. Microsoft Excel was used for data analysis. Formal ethical review was not required, and appropriate letters of exemption were acquired from our National Health Service Trust’s Research Ethics Committee and Research & Development office.
We perform the procedure under local anaesthetic in an outpatient setting. This allows patients to be treated who may be medically unsuitable for general anaesthetic due to other comorbidities.
The nose is prepared with an antiseptic solution and local anaesthesia administered. A single point of injection is used in the radix and infiltration proceeds ahead of the needle along the periosteum to minimise the discomfort. The needle is then withdrawn but remains in the skin and passed down the other side of the nose as far as the ala base on each occasion. Finally a second point of injection at the now numb ala base passing transversely across the nose inferior to the nasal spine. This achieves an effective ring block without any fluid infiltration of the Rhinophyma tissue.
All necessary laser safety measures are undertaken including eye protection for staff and the patient prior to commencement of the treatment. The UltraPulse® CO2 laser (Lumenis, Santa Clara, California), aided by use of the plume evacuator, is then used to ablate the main bulk of the rhinophyma. This is achieved by selecting a 2mm ‘TrueSpot’ hand piece on continuous wave settings. This may start at 12-18 watts, or as high as 30 watts, depending on the size of area to be reduced. A layer-by-layer technique is used. The high settings ensure vaporisation of the tissue and usually there is no requirement to wipe away the eschar. Early signs of adequate ablation include visible expression of the contents of the dilated glands, coined the “Gopher sign” by the senior author 6.
As the bulk is reduced, it is important to progressively lower the energy to maintain control and minimise the potential of over reduction and scarring. This usually follows a pattern of 8 watts, 6 watts and 3 Watts until a satisfactory end point is achieved. Finally, the CO2 laser is changed to the UltraPulse® mode. Using a 2mm hand piece and settings of 125-175 Jcm2 and 10-15 Hz, finer shaping, ‘feathering in’ and blending of treated areas into normal surrounding tissue is achieved. The patient is usually given a mirror in order to be sure that the outcome of the ablation is satisfactory.
An antibacterial ointment is applied to the treated area, which remains covered with a brown eschar that gradually separates over a period of 3 weeks. Written instructions for aftercare are also given and discussed with the patient. The following cases demonstrate our technique and results.
Rhinophyma is a progressive proliferative disorder with an incompletely understood aetiology that can lead to significant deformity of the nose. Despite the common belief that it is associated with alcohol excess, none of our cohort demonstrated a history of this. This finding is supported by existing literature outlining that little evidence exists supporting this association.7,8 Various different modalities exist for its management, including topical medications, however, it is widely accepted that for severe cases surgical intervention is required.4,9 Techniques including electrosurgery, cryosurgery and scalpel excision have all been described, although more recently the use of CO2 ablative lasers have been utilised. Both fractionated and non-fractionated lasers can be used, with fractionated devices delivering the laser energy as interspacing columns creating areas of tissue that remain unaffected.4 For this reason the amount of debulking may be less resulting in more modest outcomes if used alone. Serowka et al4 advocated its use in early to moderate cases of rhinophyma due to previous concerns regarding the side effect profile of non-fractionated ablative lasers, including prolonged oedema, permanent pigmentary changes and scarring.
In our experience, CO2 laser’s continuous wave (CW) mode for tissue ablation followed by UltraPulse® mode for feathering and finer sculpting produces excellent results. In the first few cases treated by our laser service alar notching was observed following treatment and this was due to overtreatment of the areas. This was corrected by adjusting the continuous wave mode settings and a careful layer by layer approach. In some cases, pigmentary changes were also noted. Hyperpigmentation was usually self-limiting and settled by three months. Such changes were further reduced by advocating the use of sunscreen in the post treatment period. Hypopigmentation changes were also observed and were more obvious in the background of remaining rosacea. If needed, this redness could be addressed with a vascular laser however none of our patients requested further treatment. We found that the majority of complications encountered are minor and widely acceptable to patients, with the cohort reported in this study being universally pleased with the outcome following treatment. This is, albeit, user dependent and experience is paramount along with a sound knowledge of nasal aesthetic subunits. Based on our experience of treating rhinophyma at our centre, we formulated the Welsh centre of plastic surgery criteria for rhinophyma. This was used to determine clinical severity and treatment strategy of rhinophyma patients.
The main advantages that we find to using a CO2 laser is the immediate haemostasis and the precision that can be obtained with regards to the depth and area of tissue destruction when compared to other surgical treatment methods. Van Gemert et al12 demonstrated this through histological analysis and found vaporisation of tissue with a CO2 laser occurs within a 0.5mm error in the desired treatment area. Because the treated area resulted in a dry eschar requiring only antibacterial or paraffin-based ointment, no wound dressing was necessary and minimal to no hospital visits for wound care were required. Although no cost analysis was performed as part of this study, one can safely assume reduced healthcare cost due to less hospital visits.
We do concede, however, there are limitations to our case series. It is firstly retrospective, our patient numbers are relatively small and there was single assessor grading the outcomes. Additionally, although all patients reported high levels of satisfaction following their treatment, we did not quantify this and future work by ourselves should focus on the distribution of pre and post-treatment questionnaires to patients and independent assessment of the outcomes.
In our experience, the CO2 laser is an extremely effective modality for the treatment of rhinophyma of all severities. Its marked haemostatic effects and precision allow for controlled and safe ablation of the intended tissue. The Welsh Centre for Plastic Surgery Rhinophyma Criteria was successfully used to assess and treat patients.