INTERNATIONAL JOURNAL OF SURGICAL PROCEDURES (ISSN:2517-7354)

Rhinophyma is a relative uncommon condition affecting the lower nasal region which causes severe disfigurement and in many instances, nasal blockage. As a result, patients with rhinophyma often require treatment. This condition is thought to be most severe form of the final stage of acne rosacea, which is characterized by a progressive painless hyperplasia of the sebaceous glands and connective tissue of the nose [1]. The typical clinical feature of rhinophyma is of a large, hypervascular mass in the lower two-thirds of the nose which has reddish-purplish discoloration and a lobular, nodular appearance.² Occasionally, it can also involve the chin and the forehead [1]. This condition most commonly affects middle-aged to elderly white males. Incidences in Asia are relatively rare where only 20 cases reported in Japan and only 3 of such cases in Africa [2-4]. Histologically, rhinophymas feature a chronic inflammatory process and hypertrophy of the subcutaneous and sebaceous tissues with dilated ducts occluded with debris, bacteria and sebum [2].

Definitive treatment for rhinophyma remains surgical although in cases of acne rosacea and very early non-established rhinophyma, medical therapy may be an option where retinoids and topical and oral antibiotics appear to be the treatment mainstay [3]. Over the years, various surgical techniques have been developed and refined. These procedures include cryosurgery, dermabrasion, scalpel and razor blade excision, CO₂ laser surgery and argon laser.

Good cosmetic results are often achieved by paring of the excess hypertrophied nasal tissue and leaving the area to re-epithelialize. This process occurs rapidly as the remnants of the hypertrophied sebaceous glands act as multiple foci for re-epithelialization. However, one of the problems with paring technique is that the operative field is often quickly covered with blood which makes accurate nasal sculpting difficult. Electrosurgery has been introduced to produce a relatively bloodless operating field and to make removing excess tissue technically more favourable. 

An eighty-two year old Chinese man was referred to the Plastic Surgery department with a long- standing history of gradually enlarging nasal growth and nasal airway obstruction. Facial and nasal analysis showed adequate facial and nasal proportion. His overall complexion was ruddy, consistent with acne rosacea. On frontal view, the nasal framework was asymmetrical due to the nasal mass with overlying skin hypertrophy. The abnormal nasal skin nodularity contributed to the cosmetic deformity. The presence of skin hypertrophy created an illusion of wide bony and cartilaginous nasal pyramids. Similarly, the nasal tip and alae were widened by hypertrophied skin. The columellar-lobular angle was acute because of the weight of the hypertrophied nasal skin and caused compression the external nasal valves resulting nasal airway obstruction.  

The procedure was done under general anaesthesia. The operative field was cleaned with povidone iodine solution and draped. Local infiltration of the nose is done with bupivacaine (marcain) 0.5% with adrenaline solution. The instrument used for excision was a half inch round electrosurgery loop with a regular wire size measuring 1/16 inch. This electrosurgery loop was set at 4 on combined mode (coagulation and cutting).

Shaving of any excess tissues of the nose proceeded with one subunit of the nose at a time in a cephalad to caudal manner. The procedure began with gradual shaving of the excess tissue at the dorsum of the nose until normal tissue is visualized. Shaving must be done cautiously as over shaving will result in poor contouring. Once the bulky tissue at the nasal dorsum is excised, contour and shape of supratip, alae and columella regions can be sculptured accordingly to the desired shape. Finally, any surface irregularities can be further resurfaced by electroshaving. Throughout the surgery, the treated surfaces were cleaned with moist gauze soaked with adrenaline 1:100,000 to clear all superficial charred tissues and to achieve haemostasis. Finally, the nose was dressed with a layer of calcium alginate dressing. The dressing was allowed to separate spontaneously.

Early re-epithelialization was seen at the tenth postoperative day and complete re-epithelialization was achieved by the third postoperative week. At three months postoperatively, there was a complete healing of the nasal skin. Nodularity of the nasal skin and asymmetry appearance were corrected. The smooth contour of dorsum, supratip area, lobule and alae were restored. The columellalobular angle and nasal airway obstruction were also corrected.

Various terminology in the literature including electrosurgery, eletrocautery, radiosurgery, diathermy and radiofrequency heating have been used interchangeably but there is a fundamental difference between electrosurgery and electrocautery. Electrosurgery uses radiofrequency electricity to generate heat in the tissue itself when the tissue produces resistance to the passage of a radiofrequency wave. This results in cutting without pressure. On the other hand, electrocautery uses heat from an outside source [2].

The electrosurgical devise provides an alternating current at a base frequency. This base frequency is sinusoidal and can be “dampened” into several waveforms. The “cutting” mode is the continuous sinusoidal output of the base frequency which, together with the thin electrode loop used, produces a smooth-edged incision. The “coagulation” mode is when there are short bursts of high amplitude waveforms which results in intermittent heating and coagulation of denatured proteins. The combination of the cutting and coagulation modes allows a synergistic effect during the surgical procedure [2].

Treatment of rhinophyma by electroshaving method using electrosurgery has several advantages over the traditional paring of excess nasal tissue with a scalpel. Perhaps the main advantage is the relatively bloodless operative field which greatly facilitates assessment of depth and sculpturing of the nasal tissue. This technique is relatively quick, simple and easy to master. The usage of a fine electrode wire loop also enables the surgeon to precisely shave and sculpture the nasal tissue for superior cosmetic results. Another advantage of this technique is that the cutting diathermy does not alter the tissue [5]. Hence, the shaved tissue can be sent for histological analysis if required.

In summary, the treatment of rhinophyma by the electroshaving technique with an electrosurgery wire loop restores the aesthetic subunits of the nose and produces satisfactory cosmetic results.

1. Sadick H, Goepel B, Bersch C, Goessler U, Hoermann K, et al.Rhinophyma: Diagnosis and Treatment Options for a DisfiguringTumor of the Nose. Ann Plast Surg. 2008 Jul;61(2):114-120.
2. Aferzon M, Millman B. Excision of rhinophyma with highfrequency electrosurgery. Dermatol Surg. 2002 Aug;28(8):735-738.
3. Wiemer DR. Rhinophyma. Clin Plast Surg. 1987;14(2):357-365.
4. Furukawa M, Kanetou K, Hamada T. Rhinophyma in Japan. Int JDermatol. 1994 Jan;33(1):35-37.
5. Acker DW, Helwig EB. Rhinophyma with carcinoma. ArchDermatol. 1967 Mar;95:250-254.