Rhinophyma treatment using Versajet hydrosurgery

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A 78‐year‐old man presented with basal cell carcinomas (BCCs) at the nasal root and left cheek in the setting of severe rhinophyma (Fig. 1). His rhinophyma progressed over several years despite attempts at medical management with topical metronidazole. Due to the size and weight of the hypertrophic alar tissue, he experienced functional nasal obstruction bilaterally. Under general anaesthesia, the BCCs were excised and then the rhinophyma was tangentially excised using the Versajet hydrosurgery system. He was discharged home the next day with daily dressings. All wounds healed within 4 weeks. He reported significant improvement with his nasal breathing and was very happy with the outcome.
An 86‐year‐old man presented with severe rhinophyma (Fig. 2) causing nasal obstruction. His medical history is significant for atrial fibrillation, ischaemic heart disease and previous strokes for which he is maintained on warfarin. His anticoagulation was not withheld for Versajet excision (international normalized ratio was 2.0 at day of surgery) and his procedure was performed under sedation with local anaesthesia. After sampling some nasal tissue for histology, all nasal tissue was tangentially excised back to anatomical contour using the Versajet hydrosurgery system. The procedure took 32 min. He was discharged home the same day.
A 55‐year‐old Maori woman with past medical history of diabetes on oral hypoglycaemics and smoking presented with a 4‐year history of worsening rhinophyma despite topical metronidazole and oral doxycycline (Fig. 3). There were no symptoms of nasal obstruction from rhinophyma. The procedure was performed under general anaesthesia. She was discharged the following day. She was very happy with the outcome.
Several surgical techniques have been described for rhinophyma treatment, including cryosurgery, radiofrequency ablation, electrosurgery, radiowave surgery, heated scalpel, tangential excision, scissor sculpting, dermabrasion, fractional laser and conventional ablative laser.1 There are, however, limited publications describing the use of the Versajet in treating rhinophyma.3
Versajet is a Venturi effect‐based hydraulic instrument in which a stream of sterile saline is fired across the edge of an operative instrument at high velocities into an evacuation collector. The hydraulic jetstream allows for controlled tangential excision of tissue while simultaneously aspirating excisional debris away from the operation site and maintaining a clean operative field. Versajet has been most widely adopted in burn centres, where it has been shown to be safe, precise and to hasten burn excision.5
Compared with other surgical treatments, Versajet has several distinctive advantages in the setting of rhinophyma. As rhinophymatous tissue is highly vascular, bleeding can obscure the operative field, making accurate debridement difficult and haemostasis can be time consuming and can prolong operative time. With Versajet, the operative field is kept clear by the instrument facilitating precise sculpting of the nasal tissue. Moreover, because blood and debris are cleared during excision, and not fulgurated or aerosolized, there is a reduced risk of blood‐borne pathogen transmission.
Versajet utilizes sterile saline for debridement and hence produces little heat or smoke. This means that once the local anaesthetics are in effect, the rest of the surgery is relatively comfortable. Patients (and surgeons) will not need to endure smoke inhalation and can potentially avoid the need for prolonged sedation or general anaesthetics.
The power level of Versajet can be easily changed during the operation. This makes the operation safer and faster due to the ability of controlling the ablative power using a higher power during initial excision (when the skin is most thickened) and a lower power when ‘sculpting’ the final nasal contours.
There were two patients with follow‐up at 4 years post treatment with Versajet and the long‐term results were remarkable. The figures showed that there is little or no progression of the disease after treatment.
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