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Coblation‐assisted decortication for the treatment of rhinophyma

2009; Wiley; Volume: 119; Issue: 6 Linguagem: Inglês

10.1002/lary.20194

1531-4995

Hugh E. Hetherington,

Dermatologic Treatments and Research

Rhinophyma, considered to be the fourth stage of rosacea,1, 2 is a benign, disfiguring, inflammatory disorder that results from hypertrophy of the soft tissues of the nose (Figs. 1 and 2). The condition is more common in men than in women, probably due to the influence of androgenic hormones on the sebaceous glands.3 Rhinophyma occurs more frequently among people of English or Irish descent and is rare in blacks.3 Recent statistical evidence has refuted an association with alcoholism,4 but the disorder has been associated with colonization by the mite Demodex folliculorum and with bacteria.3, 5 Frontal view, preoperatively. Lateral view, preoperatively. Medical treatment has little effect on established rhinophyma.5 Anecdotal reports have demonstrated the efficacy of radiation for treating rhinophyma, but radiation may induce malignancy.6 Surgical options include total excision with skin grafting and subtotal excision with healing by secondary intention. Because total excision with skin grafting results in significant scarring, poor color and texture match, and an overall inferior cosmetic result,5, 7-9 decortication with healing by secondary intention is more commonly used. A variety of techniques have been described to remove the bulk of the hypertrophied tissue while retaining the sebaceous follicle bases from which the epithelial tissue is regenerated.7, 8, 10 Excision below the level of the pilosebaceous units results in a smooth, atrophic scar instead of porous-appearing nasal skin. The nasal ala and supratip area are at greatest risk.11 Decortication can be performed by cold excision or with a variety of devices that simultaneously cauterize as they cut or ablate. Cold excision decortication methods may cause significant intraoperative bleeding, which can obscure the operative field and jeopardize the precision of the procedure.12 Electrocautery, on the other hand, results in a relatively bloodless field but causes significant heat spread, which can lead to scarring. Coblation (ArthroCare, Sunnyvale, CA) offers a practical alternative to these methods. In a controlled, non–heat-driven process, radiofrequency energy excites the electrolytes in a conductive medium such as saline, creating a precisely focused plasma. According to the manufacturer, the energized particles of this plasma destroy the molecular bond within tissue, causing it to dissolve at relatively low temperatures (40°C–70°C), with minimal damage to surrounding tissue. This mode of action has not been proven, however. It is likely that the direct action of the electric current on the tissue causes the ablation, and the reduced collateral tissue heating may be due simply to the cooling effect of the saline.13 Regardless of the exact mechanism of tissue interaction, Coblation results in minimal thermal penetration and, therefore, minimal damage to adjacent tissue, which in theory reduces the likelihood of scarring. The constant irrigation and suction also produce a bloodless field with no smoke. The capital cost of the equipment required for the procedure is much less than the cost for lasers and other devices. The Coblation procedure can be performed with local anesthesia in an office setting. The patient's nose is infiltrated with local anesthetic in the same fashion as for rhinoplasty. Intravenous sedation or general anesthesia may be administered. The author uses the EVac 70 Xtra device (ArthroCare) on a power setting of 7 for Coblation and a setting of 3 for coagulation. Coblation of the tissue is initially performed on one side of the nose only (Fig. 3), so that the surgeon can visualize how much tissue has been removed. The Coblation wand is brushed on the tissue in circular strokes, avoiding excessive tissue removal at any one site. There is no need to wipe away the eschar as with the carbon dioxide laser technique. The Coblation wand simultaneously irrigates and suctions away the ablated tissue The rhinophymatous tissue has a yellow sebaceous appearance, and as long as this is visible, the surgeon can be confident that the decortication is not full thickness. Palpation of the thickness of the ala between the thumb and forefinger helps assess the thickness of the remaining tissue. Right side of nose intraoperatively. The second side of the nose is treated in a similar manner (Fig. 4), and the finishing touches are then applied to both sides to ensure that they are symmetrical and smooth. At the completion of the procedure, Aquaphor (Beiersdorf, Hamburg, Germany) ointment is applied to the wound. The patient is instructed to wash the wound daily with water in the shower and to keep it covered with Aquaphor. Frontal view, immediately postoperatively. The author has treated three patients to date using this method. Operative time using local anesthesia and intravenous sedation has been approximately 2 hours. The patients reported minimal pain, using oxycodone/acetaminophen analgesia only at night for 2–3 nights after the surgical procedure. Pruritis was considered more annoying than pain in the early postoperative period. Re-epithelialization was complete within 3–4 weeks. The new skin remained erythematous for several months after re-epithelialization. Coblation-assisted rhinophyma decortication is quick and bloodless, with minimal thermal penetration and a quick recovery. The procedure can be done in an office setting using local anesthesia and intravenous sedation. Laser precautions are not necessary. The scar contracture continues to relax and erythema continues to improve for about 3 months following the procedure (Figs. 5 and 6). The healing time is similar to that of other decortication techniques, and the final results compare favorably with those of other methods. This method offers several advantages over carbon dioxide laser decortication, including almost no bleeding, no wiping, no smoke, no requirement for laser precautions, and a much lower capital equipment cost. Frontal view, 11 weeks postoperatively. Lateral view, 11 weeks postoperatively.