Radiofrequency electrosurgery of severe, extensive rhinophyma: A case series.

Dear Editor, Rhinophyma is a severe form of acne rosacea that affects the nasal soft tissues.1-3 This dermatological condition most commonly affects Northern European males in their fifties to seventies.3 Rhinophyma presents clinically with sebaceous gland hypertrophy with erythematous changes and potential telangiectasias.2 In severe cases, patients can develop scars, fissures, pits, nasal distortion, and secondary airway obstruction.1, 2 Other associated complications include psychosocial morbidity, chronic infection, and neoplasm development in advanced nodular disease.4, 5 The exact etiology and pathophysiology of rhinophyma are unclear, but smoking, alcohol, hot beverages, mental stress, ultraviolet light, and Helicobacter pylori and Demodex Folliculorum infection may play a role.1 Though rhinophyma is benign, its associated stigmatization and functional limitations highlight the need for early detection and aesthetic treatment.4 Rhinophyma has a low likelihood of spontaneous regression.6 Nonsurgical interventions include radiation and oral and topical therapy, but their effects are limited.6 Surgical treatment is the accepted treatment modality of established rhinophyma and aims to excise hypertrophied tissue, recontour affected tissue, control intraoperative bleeding, and minimize postoperative complications.7 Surgical interventions include laser therapy, scalpel excisions, and electrosurgery.7 There is no gold-standard treatment.7 Surgeons perform procedures based on preference and considerations of operative time, tissue sample preservation, postoperative scarring, and achieving hemostasis.8-10 Herein, we describe three cases of radiofrequency electrosurgical excision of extensive rhinophyma under local anesthesia. Due to lack of consensus on preferred treatment, we seek to review the literature and outline the benefits and drawbacks of this technique compared to current treatment modalities of rhinophyma. Three male patients were referred to plastic surgery for rhinophyma excision and were identified (Table 1).11 On physical exam, all patients received a grade of 3 or 4 on the rhinophyma severity index and had attempted conservative treatment with topical and oral medical with no to minimal success (Figures 1-3). All patients were given bilateral infraorbital nerve blocks followed by a field block with diluted Xylocaine with 1% epinephrine. The entire mid face was prepped with Betadine and draped in a sterile fashion. The Elman Surgitron model FFPF and a loop hand piece were used for electrodesiccation and serial shave excisions. Hemostasis was achieved with a standard electrocautery unit. The procedure lasted 60 min, and all patients tolerated the procedure well (Figure 4). All three patients recovered without the use of analgesics and returned to work or normal activities within 3 weeks. One patient encountered mild postoperative bleeding, which required cauterization under local anesthesia. The bleeding was well-controlled and did not recur. Pathology analysis of all three specimens confirmed benign rhinophyma. Postoperative follow-ups ranged from 40 to 100 days (Figures 5-7). All patients were satisfied with the outcome and did not experience recurrence or post-operative complications at the latest post-operative follow up. This case series documents the cost-effective treatment with radiofrequency electrosurgery under local anesthesia with excellent post-operative results. Rhinophyma has significant aesthetic and psychosocial impacts on patients and does not respond well to oral and topical therapies.6 Multiple surgical approaches have been described, but there is no consensus on the mainstay management of this condition.6, 8-10 Our case series advocates using radiofrequency electrosurgery under local anesthesia as the preferred approach to severe rhinophyma, as it is a quick and precise method with effective hemostasis.6, 9 The Ellman Surgitron is a light and portable electrosurgical device suitable in an outpatient setting.9 Aferzon and Millman reported 2 patients treated with the Surgitron under general anesthesia with good outcome and recovery.9 However, patients with advanced age and multiple comorbidities, such as type 2 diabetes and obstructive sleep apnea, have increased risk of adverse effects during general anesthesia.12, 13 Performing electrosurgery under local anesthesia would provide excellent analgesia with improved side-effect profile, reduce medical costs, and allow for flexible scheduling.14 Electrosurgery has several advantages over the widely used CO2 laser.6, 8 The CO2 laser does not allow precise tissue ablation, is highly reliant on clinical experience, and does not yield a biopsy specimen.8 Electrosurgery has a lower risk of scarring and hypopigmentation and yields a biopsy specimen to rule out malignancy.1 Electrosurgery can also reduce the risk of uncontrolled bleeding and unfavorable scarring that may occur with the commonly used excisional approaches.6 The main disadvantage of electrosurgery is lateral heat accumulation in adjacent tissues and potential thermal injury.11 The Surgitron minimizes this disadvantage by outputting a frequency of 3.8–4 MHz, the optimal frequency for producing less lateral heat accumulation and tissue injury.11 This case series supports the use of radiofrequency electrosurgery performed under local anesthesia as an effective treatment of severe rhinophyma affecting the nose and cheeks. From our patients’ experience, the treatment was satisfactory, effective, efficient, low cost, and did not require the operating room. This report adds to the limited body of evidence for the preferred treatment of rhinophyma. Our postoperative follow-up at various time points comprehensively displays a painless and quick recovery. In our third case, the patient experienced postoperative bleeding, which warranted a reoperation with cauterization of the culprit vessel. While the patient may have been at risk for postoperative bleeding due to his history of hypertension, the importance of intraoperative hemorrhage control with Surgitron's coagulation mode or electrocautery, postoperative pressure dressings, and patient education should be emphasized in future procedures.15 Following re-operation, the patient recovered well and experienced no additional complications. The senior author has performed numerous procedures with this technique, and all patients had excellent outcomes and satisfaction rates. As a case series, the findings are not generalizable to patients with different severities of rhinophyma or medical histories. Future studies are needed to determine the definitive treatment of different stages of rhinophyma. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare that there is no conflict of interest. Consent for the publication of all patient photographs and medical information was provided by the authors at the time of letter submission to the journal stating that all patients gave consent for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available. Data sharing is not applicable to this article as no new data were created or analyzed in this study.