Two-case report of surgical treatment of rhinophyma with coblation

30 Abstract Introduction: Rhinophyma is a tumor-like enlargement of the skin of the nose, affecting dorsum nasi and the apex. While the aetiology is unknown, dermatosis rosacea can be indicated as one of the main causes. Rhinophyma is characterized by reddish, swollen bumpy surface of the nose, overgrowing of scar-like tissue and augmentation of the sebaceous glands. Epidemiologically, rhinophyma affects mainly men between the ages of 50 and 70.


INTRODUCTION:
Rhinophyma is a benign lesion of the skin of the nose that does not affect the airway.It is characterized by bulbous hypertrophy of the soft tissue of the nose including the sebaceous glands found there with exophytic growth.The progressive disfiguring condition substantially affects patients' quality of life.
The condition has supposedly been known since medieval times as it was first illustrated in the portrait called "An Old Man and his Grandson" by Domenico Ghirlandaio in 1490.The picture depicted a noticibly deformed bulbous nose which strongly resembles what is to-day known as a rhinophyma.[1] The medical term itself was coined by the Austrian dermatologist Ferdinand von Hebra back in 1845 -he described the condition as third degree acne rosacea.(rhis: Greek for nose; phyma: Greek for growth) [1,2] The gold standard of providing treatment for rhinophyma is surgical intervention, while the techniques of excision vary.Conservative treatment shows no results once the rhinophyma has formed.[2] MATERIALS AND METHODS: Our findings are based on a retrospective study which follows the cases of 4 patients over a period of 2 years (2015-2017) diagnosed with the condition.All of the subjects underwent surgical treatment at Saint Marina Hospital in Varna.Two of the patients' medical history relating to the condition will be presented in full detail.The goal of this study is to report on the findings, provide commentary on the hands-on experience and propose an alternative in the treatment of rhinophyma.The research work has been reported in line with the process criteria.The UIN (unique identifying number) of this case report is 3250.
We report our experience with the recent two patients.Patient One is a 74-year-old male with a history of rhinophyma spanning 3 years with no sign of preceding rosacea, nor alcohol abuse or excessive intake.The patient reported the condition as a small papule in the beginning.The bulbous growth on his lower nose, engaging the tip of the nose, was disturbing his appearance and recently started causing difficulty breathing.(Fig. 1) Patient Two is a 78-year-old male presented with a 10-year history of a growing mass on the nose.Physical examination revealed large, bulbous and erythematousappearing nose, constituting a severe case of rhinophyma.The nasal lesion, due to its size and mass, caused nasal deformity, nasal obstruction of the external nasal orifices, difficulty in eating due to ptosis through lips and also troubling the sight of the patient.The medical history revealed neither heavy alcoholism nor any previous dermatological disease.(Fig. 2) Both patients underwent surgery under general anaesthesia with the surgical technique -"Coblator II system", the main advantage of which is that it cuts and stops bleeding simultaneously, reducing blood loss to a minimum.The surgical treatment consisted in the excision of the nasal formation, with preservation of the cartilages, perichondrium and periosteum.The surgical specimen was sent for histopathological examination.Both patients responded well to the procedure.The patients were prescribed Cicatridina spray 125 ml for local application on the surgical wound for better and faster healing, and Oxycort spray 30 ml which is composed of Oxytetracycline hydrochloride and Hydrocortisone in order to prevent infections.

RESULTS:
All patients were successfully treated with satisfying functional and aesthetic results.The diseased tissues examined by the anatomopathologist display the histological presentation of rhinophyma.Presence of neoplastic cells was not observed.The nasal dorsum was re-epithelialized within 25 days.The surgical wound healed successfully with secondary intention and a restored normal nasal architecture.In both cases, their condition was followedup, and the patients reported improved breathing and contentment with their appearance.No recurrence was observed during the follow-up period.(Fig. 3 and 4) With the "Coblator II system" focused low heat dissection is applied.As the energized plasma demolishes the diseased tissue at low temperature, hemostasis and minimal damage to the healthy neighboring tissue is observed.
[8] The coblation technique, unlike previous radiofrequency methods, uses the bipolar current to create a plasma field, which can then split tissue.Creation of the field occurs at temperatures of only 60 o C to 70 o C, which is less than those produced with conventional radiofrequency and electrocautery.[9] The morphologic characteristics of rhinophyma are a thick nasal cutaneous layer, nodularity covered by atrophic skin with expanded pores.The tumor is painless and while pressing it can appear an increased quantity of whitish sebum with the fetid smell.The need for histologic examination of all surgically removed tissue in patients with rhinophyma is highlighted.Several macroscopic changes, including ulceration, drainage and a rapid growth pattern, should alarm the physician and be considered as suspicious of malignant degeneration.Unexpected clinical modifications of a preexisting long-lasting silent rhinophyma could indicate the possibility of hidden malignancy rather than a full sense rhinophyma condition.[10] Histophatologically, massive hyperplasia of sebaceous glands filed with keratin and sebum can be observed with marked dermal fibrosis and telangiectasia accompanied by a perivascular and perifollicular inflammatory infiltrate with lymphocytes and histiocytes.(Fig. 5) Rhinophyma is a rare condition affecting almost exclusively males as its incidence is with a male-female ratio of 12:1.It usually occurs between ages 50-70.[3] The etiology of the disease is currently In the past rhinophyma was considered a clinical sign of heavy alcohol consumption in males but this relationship has never been proven as the condition occurs as frequently as in people who do not drink alcoholic beverages.Another suspicious etiological factor is the presence of acne rosacea as some authors classify rhinophyma as a late-stage manifestation of rosacea.[4, 5, 6] Fortunately, only a small minority of patients suffering from rosacea progress to develop rhinophyma later on.Other possible factors correlating with rhinophyma are high levels of steroid hormones, the microorganism Demodex Follicolorum and vitamin deficiency.[7] Currently, these are only speculations, the real cause is still unclear.It is safe to state that this disease is multifactorial in its origin.
The surgical treatment includes total excision or subtotal eradication of the affected nasal tissue.Different surgical techniques may be applied, but there is still no established gold standard among them.Some of the treatment options include: conventional dermabrassion, monoor bipolar electroknife, carbon dioxide laser, ultrasonic scalpel, cryosurgery and coblation surgery.Our surgical approach is based on the latter technique: coblation.Skin

Fig. 5 .
Fig. 5. Histopathological examination, HE, x10 DISCUSSION:Rhinophyma is a rare condition affecting almost exclusively males as its incidence is with a male-female ratio of 12:1.It usually occurs between ages 50-70.[3]The etiology of the disease is currently In the past rhinophyma was considered a clinical sign of heavy alcohol consumption in males but this relationship has never been proven as the condition occurs as frequently as in people who do not drink alcoholic beverages.Another suspicious etiological factor is the presence of acne rosacea as some authors classify rhinophyma as a late-stage manifestation of rosacea.[4, 5, 6] Fortunately, only a small minority of patients suffering from rosacea progress to develop rhinophyma later on.Other possible factors correlating with rhinophyma are high levels of steroid hormones, the microorganism Demodex Follicolorum and vitamin deficiency.[7]Currently, these are only speculations, the real cause is still unclear.It is safe to state that this disease is multifactorial in its origin.The surgical treatment includes total excision or subtotal eradication of the affected nasal tissue.Different surgical techniques may be applied, but there is still no established gold standard among them.Some of the treatment options include: conventional dermabrassion, monoor bipolar electroknife, carbon dioxide laser, ultrasonic scalpel, cryosurgery and coblation surgery.Our surgical approach is based on the latter technique: coblation.Skin