Rhinophyma
Considerations
Preparation
Carefully examine for aesthetic and functional deformity
Inspect and palpate the external nose
Examine the nasal vestibule and nasal cavity
Mark
The midline from the root the the base
The area of transition from normal to diseased skin
Procedure
Infiltrate with local anesthesia for a tumescent effect
Decorticate diseased skin - multiple techniques available
Be careful to avoid violating and destroying the underlying dermis
The key is to control your depth at the level of the "crater" without completely removing the crater
Maintaining the pilosebaceous units is critical for spontaneous re-epithelialization of the wound bed
Coblation
Start at low settings (Ablate 2 and Coag 1) and increase gradually to higher settings (Ablate 6 and Coag 3)
Use light brush type strokes
Avoid using Ablate in one location for too long - You will form a deep defect quickly
Work broadly and evenly
Feather edges lightly to create a smooth transition
Decorticate one side of the nose while preserving the contralateral side at the midline
Once one side is satisfactory, move to the contralateral side and create symmetry
As with all nasal procedures, avoid damage to the soft tissue triangle and alar rim
Sample operative report
Post-op
Immediately cover the wound with petroleum based ointment generously and overlay petroleum impregnated gauze
The keys for wound care are moisture and occlusion
Change the dressing daily
Expect re-epithelialization in 2-4 weeks
Maintain standard scar care for the first 12 months with strict sun-avoidance
Maintain dermatologic therapies as needed for other areas of disease
Medications
Ointment - Aquaphor or equivalent
Tylenol and Ibuprofen
Narcotics as needed for the first few days
Antibiotics are generally not needed