defects. We have observed significantly better aes-

thetic results and patient satisfaction. There are no

track marks (without sutures through the epider-

mis), and scars widen minimally or not at all.

References

1. Dixon AJ, Dixon MP, Dixon MB. Prospective study of long-term

patient perceptions of their skin cancer surgery. J Am Acad

Dermatol 2007;57:445–453.

2. Alam M, Posten W, Martini MC, Wrone DA, et al. Aesthetic

and functional efficacy of subcuticular running epidermal

closures of the trunk and extremity: a rater-blinded

randomized control trial. Arch Dermatol 2006;142:

1272–1278.

KATHARINE CORDOVA, MD, FAAD

Dermatology Professionals, Inc.

East Greenwich, Rhode Island

SUSAN SWEENEY, MD, FAAD, FACMS

Dermatology Professionals, Inc.

East Greenwich, Rhode Island

and Division of Dermatology

University of Massachusetts Medical School

Worcester, Massachusetts

NATHANIEL J. JELLINEK, MD, FAAD, FACMS

Dermatology Professionals, Inc.

East Greenwich, Rhode Island;

Division of Dermatology

University of Massachusetts Medical School

Worcester, Massachusetts;

and Department of Dermatology

Warren Alpert Medical School

Brown University

Providence, Rhode Island

All work was performed at DermatologyProfessionals, Inc., East Greenwich, Rhode Island.

Supplementary Material

Additional Supporting Information may be found

in the online version of this article:

Figure S1. (A and B) Excisions sutured with

running subcuticular poliglecaprone; note everted,

approximated epidermis at time of closure. (C)

Upper back closure 1 month after surgery.

Figure S2. (A) 2.6-cm excision of atypical nevus,

2.5-year follow-up. (B) 7.6-cm excision of Merkel

cell carcinoma; note minimal widening 1.5 years

later despite wide margins.

Treatment of Severe Rhinophyma Using Scalpel Excision and Wire Loop Tip Electrosurgery

Letters:

Rhinophyma (progressive hyperplasia of nasal

sebaceous glands and connective tissue of the lower

two-thirds of the nose) may cause nasal airway

obstruction and hide occult malignancies. We

present a case of severe rhinophyma treated

successfully using scalpel excision and wire loop

tip electrosurgery.

Case

A 55-year-old man presented with disfiguring

rhinophyma causing functional impairment and

emotional distress (Figure 1). After anesthesia with

local injection of buffered 1% lidocaine with

1:100,000 epinephrine, bulky areas of rhinophy-

matous tissue were excised using a no. 15 blade.

The remaining involved sebaceous tissue was

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removed using a wire loop tip electrosurgical

device in cutting mode (Surgistat, Valleylab, Boul-

der, CO). Finessing of the involved area was per-

formed using the wire loop to provide a normal

shape and contour of the nose. Because electrosur-

gery causes tissue destruction beyond the visual

operative field, care was taken to decrease the cur-

rent used with the wire loop from six on the nasal

sidewall and dorsum to four on the tip and ala to

minimize the risk of cartilage damage. Hemostasis

was obtained using electrocoagulation and alumi-

num chloride (Figure 2). At 4- and 40-week fol-

low-up, the patient had normal nasal contour,

resulting in markedly improved function and cos-

mesis (Figures 3 and 4). Although mild scarring

was noted, the patient was extremely pleased with

the results.

Discussion

The carbon dioxide laser is considered one of the

best treatment modalities for rhinophyma because

of its accuracy, hemostasis, and excellent wound

healing and esthetic results. Its cost, operating time,

and need for special training and safety precautions

are major disadvantages of this treatment.1

We have obtained excellent results in treatment of

rhinophyma with the combination of scalpel exci-

sion and electrosurgery. Scalpel excision alone

allows great control in sculpting the nose, removal

of large amounts of sebaceous tissue, and preserva-

tion of tissue for pathologic examination, if

necessary. It causes superficial decortication of the

hypertrophic tissue, leaving the base of sebaceous

Figure 4. Ten months after surgery.

Figure 1. Severe, disfiguring rhinophyma in a 55-year-oldman with long-standing history of rosacea.

Figure 2. Immediately after surgery.

Figure 3. Four weeks after surgery.

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follicles to aid in re-epithelization. Its limitations

include bleeding, with poor visualization of the

operating field, and difficulty performing fine

sculpting with a flat surgical blade. Electrosurgery

uses radiofrequency electricity to generate heat,

allowing excision of hypertrophic tissue in a blood-

less manner. The electrosurgical current can be

used for cutting and coagulation purposes. The use

of a wire-loop tip in the cutting mode allows fine

sculpting of the nose by removing small slivers of

hypertrophic tissue in a controlled manner after

the excessive amount of sebaceous skin is removed

with the scalpel blade. We find that using the wire

loop on the cutting setting allows for precise tissue

removal, with excellent hemostasis and minimal

collateral tissue damage. The combination of scal-

pel excision and electrosurgery in one procedure

overcomes each individual treatment’s limitation,

allowing excellent final results.

The amount of tissue removed using each modality

is individualized. In severe cases such as the one

presented, most of the sebaceous skin is removed

using the scalpel blade, and wire-loop tip electro-

surgery is reserved for fine tuning the nasal con-

tour. In milder cases, the wire-loop tip may be

used exclusively.

Scalpel excision allows tissue to be submitted for

pathologic examination. There are several reported

cases of carcinoma occurring in conjunction with

rhinophyma; whether this is a true association

remains unclear. Acker and colleagues have

reported an incidence of occult basal cell carci-

noma of 3–10% in patients with rhinophyma.2

Patients who report a recent change or rapid

enlargement of a rhinophymatous nose should be

encouraged to have surgery, and the removed tis-

sue should be sent for pathologic examination.3

The technique of scalpel excision and wire-loop tip

electrosurgery may result in some degree of scar-

ring, as noted in our case. Our patient’s scarring

was considered mild, and he was pleased with his

final functional and cosmetic outcome, but severe

scarring may occur if appropriate precautions are

not taken. Tissue should not be removed below the

depth of the pilosebaceous unit, which would

result in a smooth atrophic scar rather than normal

porous nasal skin. The thin nasal ala and the

supratip area are at particularly high risk for this

complication.

The nasal ala, tip, and supratip areas are also at

higher risk of cartilage damage during electrosur-

gery, which may result in scarring and retraction

of the free margin. Thermal damage can also injure

the sebaceous follicles. These complications are

attributed to the greater amount of tissue destruc-

tion beyond the operative field. The depth of tissue

destruction error beyond the visible surgical field

may be up to 1.0 mm with a Bovie cutting current

at a power setting of 20–30 W, as judged accord-

ing to histologic study.4 This is a major disadvan-

tage over laser surgery, in which tissue destruction

appears to be only 0.5 mm deeper than the visible

surgical field.5 Therefore, we recommend that

lower voltages be used in high-risk areas, such as

the nasal ala, tip, and supratip. Hemostasis of lar-

ger vessels should also be performed with care,

because the longer time required to cauterize them

may result in greater thermal damage to the under-

lying perichondrium and cartilage.

As with laser surgery, even when staying above the

pilosebaceous units, this combination therapy for

rhinophyma can result in a visible change in skin

texture on the nose. The treated nasal areas will

often heal with a smoother appearance with fewer

pores and greater light reflection than the sur-

rounding skin. This can be noticeable, as in our

patient, if the skin on the remainder of the face is

also highly sebaceous.

Conclusion

We present a case of severe rhinophyma treated

with scalpel excision and wire-loop tip electro-

surgery with excellent cosmetic results. This

combined treatment modality is a technically

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LETTERS/COMMUNICATIONS

simple procedure, which demonstrates outcomes

comparable with those of the carbon dioxide

laser, lower cost, and less time. It should be

considered the treatment of choice in patients

with recent change or rapid enlargement of a

rhinophymatous nose because it allows pathologic

examination of the removed tissue. It should be

considered an appropriate option in cases of

severe rhinophyma.

References

1. Madan V, Ferguson JE, August PJ. Carbon dioxide laser

treatment of rhinophyma: a review of 124 patients. Br J

Dermatol 2009;161:814–18.

2. Acker DW, Helwig EB. Rhinophyma with carcinoma. Arch

Dermatol 1967;95:250–4.

3. Rohrich RJ, Griffin JR, Adams WP Jr. Rhinophyma: review and

update. Plast Reconstr Surg 2002;110:860–9; quiz 70.

4. Linehan JW, Goode RL, Fajardo LF. Surgery versus

electrosurgery for rhinophyma. Arch Otolaryngol 1970;91:

444–8.

5. van Gemert MJ, Welch AJ, Tan OT, Parrish JA. Limitations of

carbon dioxide lasers for treatment of port-wine stains. Arch

Dermatol 1987;123:71–3.

RENATA PRADO, MD

Northeast Dermatology Associates

Andover, Massachusetts

ALISA FUNKE, MD

Ada West Dermatology

Meridian, Idaho

MARIAH BROWN, MD

JULIAN RAMSEY MELLETTE, MD

Department of Dermatology

University of Colorado Denver

Aurora, Colorado

A Study Comparing the Efficacy and Risk of Adverse Events Using Two Techniques of Electrocautery for the

Treatment of Seborrheic Keratoses

Letters:

Seborrheic keratoses are among the most common

skin tumors. They usually appear in the fifth

decade in temperate countries but may develop

earlier in tropical countries. Various theories exist

for the etiology of seborrheic keratoses, including

ultraviolet exposure. Also, a French working group

has shown that the somatic fibroblast growth

factor receptor 3 (FGFR3) mutation plays an

important role in the development of seborrheic

keratoses.1

There is little tendency to spontaneous disappear-

ance, and new lesions may continue to appear for

many years. Because this tumor is benign, treat-

ment is not mandatory, but multiple lesions on the

face and neck can often be cosmetically disturbing,

and many patients seek treatment for removal of

seborrheic keratoses. Despite some reports on topi-

cal and systemic vitamin D analogue therapy for

seborrheic keratoses, such approaches have gener-

ally proven unsuccessful. One study showed that

once-daily application of calcipotriene 0.005%

ointment, tazarotene 0.1% cream, imiquimod 5%,

and Vanicream did not result in clinical improve-

ment but that twice-daily application of tazarotene

0.1% cream caused clinical and histologic

improvement in seven of 15 patients.2 There are

many methods of removing seborrheic keratoses,

including curettage, cryotherapy, electrocautery,

and ablative lasers such as erbium-doped yttrium

aluminum garnet or carbon dioxide.3 Most involve

ablating the skin surface and can potentially cause

scarring and postinflammatory hyperpigmentation

(PIH), especially in the pigmented skin of the

Asian population.

Electrocautery or diathermy is a common and

effective method of removing seborrheic keratoses.

Physicians have varying techniques for removing

these lesions. One of the most significant decisions

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