Eletrocirurgia no tratamento de rinofima gigante : relato de um caso Electrosurgery in the treatment of giant rhinophyma : a case report

Rhinophyma is characterized by the hyperplasia of sebaceous glands in the nasal region, associated with a nodular thickening of the skin, enlargement of the pores, and fibrosis in the later stages. It occurs most commonly in male patients bearing rosacea, and may be associated with phymas in the region of the mentum (gnatophyma), ears (otophyma) and forehead (metophyma). The present article describes a case of giant rhinophyma with significant impact on the patient’s quality of life, hampering breathing, sleeping, and eating. The lesion was successfully treated with electrosurgery.


Introduction
Rosacea is a common condition in adults and is characterized by a variety of clinical manifestations.Its pathogenesis is multifactorial, nevertheless it is clearly related to vascular hyperactivity. 1,2 hinophyma is a late manifestation stage of rosacea and presents with hyperplasia of the sebaceous glands and the connective tissue of the nasal region in its progressive pathophysiology. 3It is possible to clinically observe swelling and subsequent lobulation, dilation of the pores, and unevenness in the surface of the nose, which may also increase in size over time.Patients with large-dimension rhinophyma can present with nasal obstruction accompanied by respiratory distress and feeding difficulty, as well as a disfiguring appearance and social isolation. 1,4 ere are different treatment modalities described in the literature, such as electrosurgery, carbon dioxide laser, cryosurgery and dermabrasion.There is no consensus in the literature regarding the best technique, and all have advantages and disadvantages. 4,5 rg Cosmet Dermatol 2015;7(3 Suppl 1):S50-2.

Case report
A 60-year-old male patient with a history of progressive modification of the nasal contour over the previous 10 years and with a worsening of the condition during the last three years and a significant enlargement of the nose.(Figure 1) Electrosurgery was chosen as a therapy to approach the lesion.After asepsis and antisepsis were carried out with povidone-iodine, a bilateral anesthetic block was performed in the infraorbital nerve, with additional injection in the surface of the nasal skin.
The procedure was performed with a monopolar electrocautery (model SS500, Wem Equipamentos Eletrônicos ® , Rio de Janeiro, Brazil), set at Cut Blend 1 mode, 2W potency, using the small round handle tip (0.3 mm thick and 1.2 cm in diameter).Due to profuse bleeding that occurred during the first surgery, two similar surgical steps were necessary at intervals of three months.An occlusive dressing with an ointment containing 0.6U/g collagenase and 0.01g/g chloramphenicol was applied, with daily changes for ten days.The total epithelization of the surface of the nose took place over 15 days.
The result was very satisfactory from an aesthetic and functional point of view (Figure 2), and the patient had a significant improvement in his quality of life.

DISCUSSION
Rhinophyma is a part of late-stage rosacea.The invasive approach to treatment -either by conventional surgery, electrosurgery, carbon dioxide laser, or cryosurgery--is mandatory in the treatment and cure of the lesion. 5,6 ant rhinophyma is not a common presentation, but is one that causes significant impact on a patient's quality of life, interfering with vital functions such as breathing and eating.A compromise of self-esteem and the entailed social isolation can also occur due to the grotesque appearance that it causes, or due to the myth of association with alcoholism. 6There is no consensus in the literature regarding the best therapeutic approach to rhinophyma. 4,5 ny therapeutic technique adopted should preserve the normal tissue, sparing the hair follicles of the dermis underlying the lesion, in order that reepithelialization can start with these follicles, lessening the risk of unsightly scars. 4n the present case, electrosurgery has proved to be a safe, effective, fast, and low cost therapeutic modality.
In addition to providing a satisfactory cosmetic result, the patient experienced a relief of respiratory distress in the immediate post-operative period.In addition to functional improvement, there was also a significant improvement in the patient's self-esteem and hence social life.l l

Figure 1 :Figure 2 :
Figure 1: Giant rhinophyma: the presence of phymatous tissue can also be noticed in the malar region, in addition to nasal and oral obstruction