- Email: [email protected]
LASER correction of malarphyma & a brief review of literature
JPRAS Open 11 (2017) 14e19
Contents lists available at ScienceDirect
JPRAS Open journal homepage: http://www.journals.elsevier.com/ jpras-open
Case Report
LASER correction of malarphyma & a brief review of literature Ali Arnaout a, *, Thomas Dobbs b, Jeremy Yarrow a, Richard Logan c, M.S.C. Murison a a b c
Plastic and Reconstructive Surgery, Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 November 2016 Accepted 30 November 2016 Available online 9 December 2016
Introduction: We present a rare manifestation of phymatous change normally confined to the nose and anterior cheeks, which in our case had malar involvement and little in the way of nasal involvement. We have coined the term Malarphyma to describe this condition. Malarphyma is a condition of the skin of the cheeks, which is related to the more commonly presented rhinophyma. It does not have a specific underlying aetiology but is possibly linked to chronic, severe rosacea. Malarphyma is progressive, with early clinical findings including enlarged pores, thickening of the fibrous tissue and hypertrophy of the sebaceous glands. Both rhinophyma and malarphyma can lead to debilitating functional and psychosocial problems for patients affect by it. Results: We describe for the first time in the literature the use of the CO2 LASER for the management of malarphyma and review the literature pertaining to the use of LASER to treat rhinophyma and the associated malarphyma using a PRISMA 2009 checklist approach to identify eligible studies. Discussion: The management of rhinophyma and associated conditions have developed over time. Medical treatment with oral antibiotics or isotretinoin is possible, but the successful treatment of established rhinophyma more commonly requires some form of surgical treatment. CO2 LASER is recognised as the gold standard for soft tissue vaporization, with multiple reported favourable
Keywords: Malarphyma Rhinophyma LASER CO2
* Corresponding author. E-mail address: [email protected] (A. Arnaout). http://dx.doi.org/10.1016/j.jpra.2016.11.004 2352-5878/© 2016 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
15
outcomes the treatment of rhinophyma, with excellent cosmetic results and patient satisfaction. Conclusion: CO2 LASER is an effective method of tissue ablation with an excellent safety profile, as proven throughout the medical literature over a number of years, but no single method that is free of complications and no well designed studies demonstrate significant benefits of one method over another. We acknowledge that the outcome and complications associated with CO2 LASER depends on the clinician's experience with LASER treatment, in the correctly selected patient. © 2016 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction Malarphyma is a condition of the skin of the cheeks, which is related to the more commonly presented rhinophyma. It does not have a specific underlying aetiology but is possibly linked to chronic, severe rosacea. Rhinophyma is progressive, with early clinical findings including enlarged pores, thickening of the fibrous tissue and hypertrophy of the sebaceous glands. There is then a progression to single or multiple pink, bulbous, lobulated masses.1 Both rhinophyma and malarphyma can lead to debilitating functional and psychosocial problems for patients affect by it. Surgical treatment of rhinophyma with Carbon Dioxide (CO2) LASER has been well documented in medical literature, however all reported studies are confined to the nasal region only. There has been no reported use of CO2 LASER for the treatment of malarphyma. We present a case of bilateral malarphyma without rhinophyma successfully treated with CO2 LASER and review the literature pertaining to the use of LASER to treat rhinophyma and the associated malarphyma. Case Our dermatology colleagues referred a 67-year old gentleman to our unit in September 2012 with malarphyma involving both cheeks but sparing his nose. The condition had begun in his late teenage years, but had only recently requested treatment for it due to the deteriorating cosmetic appearance. He also stated that his grandchildren were frightened by his appearance. Clinical examination demonstration advanced disease with multiple pink, bulbous, confluent lobulated masses involving bilateral malar and temporal regions. There was no significant rhinophyma (Figure 1). The extent of skin involvement limited treatment options and topical therapies were thought to be of limited benefit. Other options for management included surgical excision and reconstruction as well as CO2 LASER vaporization. LASER treatment with the CO2 LASER has been the mainstay of Rhinophyma management within our unit for over a decade. This was however the first time that it was considered for use in malarphyma. The options were discussed with the patient and photographic examples of previous Rhinophyma patients were used in the consent process. The patient opted for a trial of CO2 LASER with initial surgical debulking. The patient underwent two treatments using CO2 LASER (Lumenis Ultrapulse®), both under general anaesthetic. Standard sterile skin preparation was used along with pre procedure intravenous CoAmoxiclav and local anaesthetic infiltration using 1% lidocaine with 1:200,000 adrenaline. Pre LASER surgical debulking was undertaken in the first operation utilizing a 10 blade to tangentially shave the cutaneous component. CO2 LASER vaporization and coagulation was then undertaken with a 2 mm collimated hand piece (Truespot ™) set to continuous wave at 14 watts. The
16
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
Figure 1. Pre LASER e 25/10/2012.
endpoint was complete enucleation of each individual cyst. Confluent areas greater than 2 cm squared were avoided as it was felt likely to result in delayed re-epithelialisation beyond 2 weeks and a potential scar burden. Postoperative cooling was undertaken and an “open” method of wound management was used with daily showers, Dermol 500 application, and three times a day application of Polyfax ointment. A prophylactic antibiotic was provided for 1 week. Five month follow up demonstrated significant reduction in the disease burden with minimal scarring and some minor pigmentary changes (Figure 2). Residual disease was noted bilaterally and the patient requested further treatment. A trial of topical Azeleic Acid (15% gel) was prescribed twice daily for 6 months. At one year review there was no demonstrated recurrence within the treated areas but no significant clearance with topical treatment (Figure 3.) The patient requested further LASER treatment of the residual malarphyma. Eighteen months following the first surgical treatment, and under general anaesthetic, further LASER vaporization and enucleation was undertaken without tangential excision. Each remaining cysts was enucleated using the same 2 mm (Truespot™) hand piece on continuous wave setting at 10e14 watts. The endpoint was complete enucleation of each individual cyst avoiding large confluent areas. The patient received the same postoperative care. Follow up at 26 months demonstrated no significant residual disease, no recurrent disease, minimal scar burden and only minor pigmentary changes (Figure 4.)
Figure 2. Post 1st LASER 5 months e 08/05/14.
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
17
Figure 3. Post 1st LASER 11 months e taken on 25/11/15.
Figure 4. Post 2nd LASER session e 9 monthse27/07/16.
Literature review A search using Ovid MEDLINE(R) 1946 to July Week 4 2016 using terms “Malarphyma” yielded 0 papers. A further search using Google Scholar, Cochrane Library and PubMed also yielded 0 papers. Table 1. An alternative search using terms “Rhinophyma” and “LASER” on Ovid MEDLINE(R) 1946 to July Week 4 2016 yielded 3 papers, with 2 full texts available for review.2,3 and the 3rd paper4 only available in abstract form. PubMed search using terms “LASER” in ‘title’ and “Rhinophyma” in the ‘text Body e Key Terms’ yielded a further 5 papers.5e9 Google Scholar yielded multiple non-specific results, relevant studies from page 1 were only included.10e13 Discussion Rhinophyma derived from the greek e rhyis ‘nose’ and ‘phyma’ grow, is a benign disfiguring disease affecting the nose. It is thought to be related to end stage severe rosacea, although despite this, it does
18
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
Table 1 Summary of literature search. Paper
Author
Title
Journal
Year
1 2 3 4
Halsbergen Henning et al Orenstein, A et al Ries, W.R. and M.T. Speyer Campolmi, P et al
Lasers Surg Med Lasers Surg Med Otolaryngol Clin North Am Scientific World Journal
1983 2001 1996
5
Fogelman, J.P. et al
J Clin Aesthet Dermatol
2015
6
Kassir, R. et al
World J Plast Surg
2012
7 8
Krupa Shankar, D. et al Madan, V. et al
J Cutan Aesthet Surg J Cutan Aesthet Surg
2009 2013
9
Bogetti, P. et al
Aesthetic Plast Surg
2002
10 11
Laube, S et al Lazzeri, D et al
J Cosmet Dermatol J Craniomaxillofac Surg
2002 2013
12
Madan, V et al
Rhinophyma treated by argon laser Treatment of rhinophyma with Er: YAG laser Cutaneous applications of lasers Highlights of thirty-year experience of CO2 laser use at the Florence (Italy) department of dermatology. Idiopathic Flushing with Dysesthesia: Treatment with the 585 nm Pulsed Dye Laser Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma, 2012 Carbon dioxide laser guidelines Dermatological applications of carbon dioxide laser Surgical treatment of rhinophyma: a comparison of techniques Laser treatment of rosacea Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience Carbon dioxide laser treatment of rhinophyma: a review of 124 patients
Br J Dermatol
2009
occur in patients with few or no features of rosacea.2,3,12 Variants of the disease have been described, including; gnatophyma (chin), malarphyma (cheeks), blepharophyma (eyelids) otophyma (ear) and metophyma (forehead), but are rarely seen.1,12 The management of rhinophyma and associated conditions have developed over time. Medical treatment with oral antibiotics or isotretinoin is possible, although is limited to the very early stages of the disease.12 The successful treatment of established rhinophyma more commonly requires some form of surgical treatment, with a spectrum of options having been described; cryosurgery, chemical peels, dermaplaning with a dermatome, cold scalpel, the shaw knife, the Bovie hot wire loops, the argon beam, CO2 LASER and more recently Er: YAG LASER.1e3,11e13 No single method that is free of complications and no well-designed studies demonstrate significant benefits of one method over another. The newer Erbium: YAG LASER was developed as a less invasive LASER, achieving 5e15 mm of ablation per pass and a residual thermal damage of 15 mm, which is one tenth of that achieved by the CO2 LASER. It is reported that Er: YAG LASER has faster healing and fewer complications due to its reduced penetration range, however this comes at the cost of poorer results and worse haemostasis throughout the procedure.3,5,9 The CO2 LASER seems to be a system that has stood the test of time, and has been used for over 30 years. It is recognised as the gold standard for soft tissue vaporisation.5,9,12,13 Several advancements in CO2 LASER have increased its safety profile over the years, with newer machines now on the market. Many studies5,7e9,11e13 report favourable outcome using the CO2 LASER for the treatment of rhinophyma, with excellent cosmetic results and patient satisfaction, a semi-bloodless fields throughout the procedure and lower complication rates. Conclusion CO2 LASER is an effective method of tissue ablation with an excellent safety profile, as proven throughout the medical literature over a number of years. We describe for the first time in the literature the use of the CO2 LASER for the management of malarphyma. As shown in this case study, the CO2 LASER is an effective and durable method for the treatment of large areas of malarphyma with a low side effects profile and excellent cosmetic results. We acknowledge that the outcome and complications associated with CO2 LASER depends on the clinician's experience with LASER treatment, in the correctly selected patient its use can have a dramatic impact on their quality of life.
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
19
Conflicts of interest None. Funding None. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Niamtu J. Treatment options for mild to moderate rhinophyma. prime-journal.com. 2013;(1). Halsbergen Henning JP, van Gemert MJ. Rhinophyma treated by argon laser. Lasers Surg Med. 1983;2(3):211e215. Orenstein A, Haik J, Tamir J, et al. Treatment of rhinophyma with Er: YAG laser. Lasers Surg Med. 2001;29(3):230e235. Ries WR, Speyer MT. Cutaneous applications of lasers. Otolaryngol Clin North Am. 1996;29(6):915e929. Campolmi P, Bonan P, Cannarozzo G, et al. Highlights of thirty-year experience of CO2 laser use at the Florence (Italy) department of dermatology. ScientificWorldJournal. 2012;2012:546528. Fogelman JP, Stevenson ML, Ashinoff R, Soter NA. Idiopathic flushing with dysesthesia: treatment with the 585 nm pulsed dye laser. J Clin Aesthet Dermatol. 2015;8(8):36e41. Kassir R, Gilbreath J, Sajjadian A. Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma. World J Plast Surg. 2012;1(1):36e40. Krupa Shankar D, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg. 2009;2(2):72e80. Madan V. Dermatological applications of carbon dioxide laser. J Cutan Aesthet Surg. 2013;6(4):175e177. Bogetti P, Boltri M, Spagnoli G, Dolcet M. Surgical treatment of rhinophyma: a comparison of techniques. Aesthetic Plast Surg. 2002;26(1):57e60. Laube S, Lanigan SW. Laser treatment of rosacea. J Cosmet Dermatol. 2002;1(4):188e195. Lazzeri D, Larcher L, Huemer GM, et al. Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience. J Craniomaxillofac Surg. 2013;41(5):429e436. Madan V, Ferguson JE, August PJ. Carbon dioxide laser treatment of rhinophyma: a review of 124 patients. Br J Dermatol. 2009;161(4):814e818.
Contents lists available at ScienceDirect
JPRAS Open journal homepage: http://www.journals.elsevier.com/ jpras-open
Case Report
LASER correction of malarphyma & a brief review of literature Ali Arnaout a, *, Thomas Dobbs b, Jeremy Yarrow a, Richard Logan c, M.S.C. Murison a a b c
Plastic and Reconstructive Surgery, Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK Princess of Wales Hospital, Bridgend, CF31 1RQ, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 November 2016 Accepted 30 November 2016 Available online 9 December 2016
Introduction: We present a rare manifestation of phymatous change normally confined to the nose and anterior cheeks, which in our case had malar involvement and little in the way of nasal involvement. We have coined the term Malarphyma to describe this condition. Malarphyma is a condition of the skin of the cheeks, which is related to the more commonly presented rhinophyma. It does not have a specific underlying aetiology but is possibly linked to chronic, severe rosacea. Malarphyma is progressive, with early clinical findings including enlarged pores, thickening of the fibrous tissue and hypertrophy of the sebaceous glands. Both rhinophyma and malarphyma can lead to debilitating functional and psychosocial problems for patients affect by it. Results: We describe for the first time in the literature the use of the CO2 LASER for the management of malarphyma and review the literature pertaining to the use of LASER to treat rhinophyma and the associated malarphyma using a PRISMA 2009 checklist approach to identify eligible studies. Discussion: The management of rhinophyma and associated conditions have developed over time. Medical treatment with oral antibiotics or isotretinoin is possible, but the successful treatment of established rhinophyma more commonly requires some form of surgical treatment. CO2 LASER is recognised as the gold standard for soft tissue vaporization, with multiple reported favourable
Keywords: Malarphyma Rhinophyma LASER CO2
* Corresponding author. E-mail address: [email protected] (A. Arnaout). http://dx.doi.org/10.1016/j.jpra.2016.11.004 2352-5878/© 2016 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
15
outcomes the treatment of rhinophyma, with excellent cosmetic results and patient satisfaction. Conclusion: CO2 LASER is an effective method of tissue ablation with an excellent safety profile, as proven throughout the medical literature over a number of years, but no single method that is free of complications and no well designed studies demonstrate significant benefits of one method over another. We acknowledge that the outcome and complications associated with CO2 LASER depends on the clinician's experience with LASER treatment, in the correctly selected patient. © 2016 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction Malarphyma is a condition of the skin of the cheeks, which is related to the more commonly presented rhinophyma. It does not have a specific underlying aetiology but is possibly linked to chronic, severe rosacea. Rhinophyma is progressive, with early clinical findings including enlarged pores, thickening of the fibrous tissue and hypertrophy of the sebaceous glands. There is then a progression to single or multiple pink, bulbous, lobulated masses.1 Both rhinophyma and malarphyma can lead to debilitating functional and psychosocial problems for patients affect by it. Surgical treatment of rhinophyma with Carbon Dioxide (CO2) LASER has been well documented in medical literature, however all reported studies are confined to the nasal region only. There has been no reported use of CO2 LASER for the treatment of malarphyma. We present a case of bilateral malarphyma without rhinophyma successfully treated with CO2 LASER and review the literature pertaining to the use of LASER to treat rhinophyma and the associated malarphyma. Case Our dermatology colleagues referred a 67-year old gentleman to our unit in September 2012 with malarphyma involving both cheeks but sparing his nose. The condition had begun in his late teenage years, but had only recently requested treatment for it due to the deteriorating cosmetic appearance. He also stated that his grandchildren were frightened by his appearance. Clinical examination demonstration advanced disease with multiple pink, bulbous, confluent lobulated masses involving bilateral malar and temporal regions. There was no significant rhinophyma (Figure 1). The extent of skin involvement limited treatment options and topical therapies were thought to be of limited benefit. Other options for management included surgical excision and reconstruction as well as CO2 LASER vaporization. LASER treatment with the CO2 LASER has been the mainstay of Rhinophyma management within our unit for over a decade. This was however the first time that it was considered for use in malarphyma. The options were discussed with the patient and photographic examples of previous Rhinophyma patients were used in the consent process. The patient opted for a trial of CO2 LASER with initial surgical debulking. The patient underwent two treatments using CO2 LASER (Lumenis Ultrapulse®), both under general anaesthetic. Standard sterile skin preparation was used along with pre procedure intravenous CoAmoxiclav and local anaesthetic infiltration using 1% lidocaine with 1:200,000 adrenaline. Pre LASER surgical debulking was undertaken in the first operation utilizing a 10 blade to tangentially shave the cutaneous component. CO2 LASER vaporization and coagulation was then undertaken with a 2 mm collimated hand piece (Truespot ™) set to continuous wave at 14 watts. The
16
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
Figure 1. Pre LASER e 25/10/2012.
endpoint was complete enucleation of each individual cyst. Confluent areas greater than 2 cm squared were avoided as it was felt likely to result in delayed re-epithelialisation beyond 2 weeks and a potential scar burden. Postoperative cooling was undertaken and an “open” method of wound management was used with daily showers, Dermol 500 application, and three times a day application of Polyfax ointment. A prophylactic antibiotic was provided for 1 week. Five month follow up demonstrated significant reduction in the disease burden with minimal scarring and some minor pigmentary changes (Figure 2). Residual disease was noted bilaterally and the patient requested further treatment. A trial of topical Azeleic Acid (15% gel) was prescribed twice daily for 6 months. At one year review there was no demonstrated recurrence within the treated areas but no significant clearance with topical treatment (Figure 3.) The patient requested further LASER treatment of the residual malarphyma. Eighteen months following the first surgical treatment, and under general anaesthetic, further LASER vaporization and enucleation was undertaken without tangential excision. Each remaining cysts was enucleated using the same 2 mm (Truespot™) hand piece on continuous wave setting at 10e14 watts. The endpoint was complete enucleation of each individual cyst avoiding large confluent areas. The patient received the same postoperative care. Follow up at 26 months demonstrated no significant residual disease, no recurrent disease, minimal scar burden and only minor pigmentary changes (Figure 4.)
Figure 2. Post 1st LASER 5 months e 08/05/14.
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
17
Figure 3. Post 1st LASER 11 months e taken on 25/11/15.
Figure 4. Post 2nd LASER session e 9 monthse27/07/16.
Literature review A search using Ovid MEDLINE(R) 1946 to July Week 4 2016 using terms “Malarphyma” yielded 0 papers. A further search using Google Scholar, Cochrane Library and PubMed also yielded 0 papers. Table 1. An alternative search using terms “Rhinophyma” and “LASER” on Ovid MEDLINE(R) 1946 to July Week 4 2016 yielded 3 papers, with 2 full texts available for review.2,3 and the 3rd paper4 only available in abstract form. PubMed search using terms “LASER” in ‘title’ and “Rhinophyma” in the ‘text Body e Key Terms’ yielded a further 5 papers.5e9 Google Scholar yielded multiple non-specific results, relevant studies from page 1 were only included.10e13 Discussion Rhinophyma derived from the greek e rhyis ‘nose’ and ‘phyma’ grow, is a benign disfiguring disease affecting the nose. It is thought to be related to end stage severe rosacea, although despite this, it does
18
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
Table 1 Summary of literature search. Paper
Author
Title
Journal
Year
1 2 3 4
Halsbergen Henning et al Orenstein, A et al Ries, W.R. and M.T. Speyer Campolmi, P et al
Lasers Surg Med Lasers Surg Med Otolaryngol Clin North Am Scientific World Journal
1983 2001 1996
5
Fogelman, J.P. et al
J Clin Aesthet Dermatol
2015
6
Kassir, R. et al
World J Plast Surg
2012
7 8
Krupa Shankar, D. et al Madan, V. et al
J Cutan Aesthet Surg J Cutan Aesthet Surg
2009 2013
9
Bogetti, P. et al
Aesthetic Plast Surg
2002
10 11
Laube, S et al Lazzeri, D et al
J Cosmet Dermatol J Craniomaxillofac Surg
2002 2013
12
Madan, V et al
Rhinophyma treated by argon laser Treatment of rhinophyma with Er: YAG laser Cutaneous applications of lasers Highlights of thirty-year experience of CO2 laser use at the Florence (Italy) department of dermatology. Idiopathic Flushing with Dysesthesia: Treatment with the 585 nm Pulsed Dye Laser Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma, 2012 Carbon dioxide laser guidelines Dermatological applications of carbon dioxide laser Surgical treatment of rhinophyma: a comparison of techniques Laser treatment of rosacea Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience Carbon dioxide laser treatment of rhinophyma: a review of 124 patients
Br J Dermatol
2009
occur in patients with few or no features of rosacea.2,3,12 Variants of the disease have been described, including; gnatophyma (chin), malarphyma (cheeks), blepharophyma (eyelids) otophyma (ear) and metophyma (forehead), but are rarely seen.1,12 The management of rhinophyma and associated conditions have developed over time. Medical treatment with oral antibiotics or isotretinoin is possible, although is limited to the very early stages of the disease.12 The successful treatment of established rhinophyma more commonly requires some form of surgical treatment, with a spectrum of options having been described; cryosurgery, chemical peels, dermaplaning with a dermatome, cold scalpel, the shaw knife, the Bovie hot wire loops, the argon beam, CO2 LASER and more recently Er: YAG LASER.1e3,11e13 No single method that is free of complications and no well-designed studies demonstrate significant benefits of one method over another. The newer Erbium: YAG LASER was developed as a less invasive LASER, achieving 5e15 mm of ablation per pass and a residual thermal damage of 15 mm, which is one tenth of that achieved by the CO2 LASER. It is reported that Er: YAG LASER has faster healing and fewer complications due to its reduced penetration range, however this comes at the cost of poorer results and worse haemostasis throughout the procedure.3,5,9 The CO2 LASER seems to be a system that has stood the test of time, and has been used for over 30 years. It is recognised as the gold standard for soft tissue vaporisation.5,9,12,13 Several advancements in CO2 LASER have increased its safety profile over the years, with newer machines now on the market. Many studies5,7e9,11e13 report favourable outcome using the CO2 LASER for the treatment of rhinophyma, with excellent cosmetic results and patient satisfaction, a semi-bloodless fields throughout the procedure and lower complication rates. Conclusion CO2 LASER is an effective method of tissue ablation with an excellent safety profile, as proven throughout the medical literature over a number of years. We describe for the first time in the literature the use of the CO2 LASER for the management of malarphyma. As shown in this case study, the CO2 LASER is an effective and durable method for the treatment of large areas of malarphyma with a low side effects profile and excellent cosmetic results. We acknowledge that the outcome and complications associated with CO2 LASER depends on the clinician's experience with LASER treatment, in the correctly selected patient its use can have a dramatic impact on their quality of life.
A. Arnaout et al. / JPRAS Open 11 (2017) 14e19
19
Conflicts of interest None. Funding None. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Niamtu J. Treatment options for mild to moderate rhinophyma. prime-journal.com. 2013;(1). Halsbergen Henning JP, van Gemert MJ. Rhinophyma treated by argon laser. Lasers Surg Med. 1983;2(3):211e215. Orenstein A, Haik J, Tamir J, et al. Treatment of rhinophyma with Er: YAG laser. Lasers Surg Med. 2001;29(3):230e235. Ries WR, Speyer MT. Cutaneous applications of lasers. Otolaryngol Clin North Am. 1996;29(6):915e929. Campolmi P, Bonan P, Cannarozzo G, et al. Highlights of thirty-year experience of CO2 laser use at the Florence (Italy) department of dermatology. ScientificWorldJournal. 2012;2012:546528. Fogelman JP, Stevenson ML, Ashinoff R, Soter NA. Idiopathic flushing with dysesthesia: treatment with the 585 nm pulsed dye laser. J Clin Aesthet Dermatol. 2015;8(8):36e41. Kassir R, Gilbreath J, Sajjadian A. Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma. World J Plast Surg. 2012;1(1):36e40. Krupa Shankar D, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg. 2009;2(2):72e80. Madan V. Dermatological applications of carbon dioxide laser. J Cutan Aesthet Surg. 2013;6(4):175e177. Bogetti P, Boltri M, Spagnoli G, Dolcet M. Surgical treatment of rhinophyma: a comparison of techniques. Aesthetic Plast Surg. 2002;26(1):57e60. Laube S, Lanigan SW. Laser treatment of rosacea. J Cosmet Dermatol. 2002;1(4):188e195. Lazzeri D, Larcher L, Huemer GM, et al. Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience. J Craniomaxillofac Surg. 2013;41(5):429e436. Madan V, Ferguson JE, August PJ. Carbon dioxide laser treatment of rhinophyma: a review of 124 patients. Br J Dermatol. 2009;161(4):814e818.