Retrospective Study Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jul 16, 2024; 12(20): 4180-4190
Published online Jul 16, 2024. doi: 10.12998/wjcc.v12.i20.4180
Five-blade scratcher for treating severe rhinophyma: A retrospective study
Yu-Ping Zheng, Xu-Feng He, Yan-Feng Zhang, Lan-Xin Geng, Hui-Min Zhang, Xiang He, Department of Dermatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
Hua Wan, Department of Galactophore, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
ORCID number: Yu-Ping Zheng (0009-0004-2283-7562); Hua Wan (0000-0002-7595-8016); Xiang He (0000-0002-1141-8598).
Co-first authors: Yu-Ping Zheng and Xu-Feng He.
Co-corresponding authors: Hua Wan and Xiang He.
Author contributions: Zheng YP and He XF contributed to this work as co-first authors, especially in data collection, analysis, and drafting of the initial manuscript; Zhang HM conceived the study; Zhang YF and Geng LX helped to revise the manuscript; He X, Wan H were responsible for the idea, funding, and paper revision; He X and Wan H are designated as the co-corresponding authors for the following reasons. The designation of co-corresponding authors on this study accurately reflects the allocation of responsibility and burden associated with the time and effort required to complete the study and final thesis. In addition, He X and Wan H made equally important contributions throughout the entire research process. Choosing them co-corresponding authors is a recognition and respect for their equal contributions, as well as recognition of the teamwork spirit of this study. In summary, we believe that it is appropriate to designate He X and Wan H as co-corresponding authors for our manuscript; all authors contributed to interpret data; all authors have read and approve the final manuscript.
Supported by Shanghai Science and Technology Commission, No. 21ZR1464000.
Institutional review board statement: The study was approved by Institutional Review Board of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. All the study subjects provided informed consent.
Informed consent statement: The study was approved by Institutional Review Board of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. All the study subjects provided informed consent.
Conflict-of-interest statement: Dr. He has nothing to disclose.
Data sharing statement: The data in this study can be obtained from the corresponding author upon reasonable request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xiang He, MD, Associate Chief Physician, Department of Dermatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Pudong New Area, Shanghai 201203, China. heroxiang2020@126.com
Received: April 22, 2024
Revised: May 21, 2024
Accepted: May 23, 2024
Published online: July 16, 2024
Processing time: 69 Days and 20.7 Hours

Abstract
BACKGROUND

Rhinophyma, a late-stage subtype of rosacea, is characterized by excessive sebaceous glands and connective tissue proliferation. Patients may experience respiratory disturbances and psychological distress that significantly affect their quality of life when excessive nasal hyperplasia obstructs the external nasal valves. Surgery is the treatment of choice for rhinophyma. However, excessive bleeding, scarring, pigmentation, and high recurrence rates frequently characterize current surgical methods.

AIM

To evaluate the clinical effectiveness and recurrence rates after treating severe rhinophyma with the five-blade scratcher.

METHODS

This study retrospectively analyzed the clinical records of 28 patients with severe rhinophyma rosacea. The Global Flushing Severity Score (GFSS), Clinician Erythema Assessment (CEA), Rhinophyma Severity Index (RHISI), Glasgow Benefit Inventory (GBI), and satisfaction scores were used to assess the recovery of patients at 6 months and 5 years, with the recurrence rate calculated at 5 years postoperatively. In addition, the levels of pro-inflammatory factors (TNF-α, IL-1β, and IL-6) in the serum of patients before and after surgery were detected by ELISA.

RESULTS

The GFSS, CEA, and RHISI scores at 6 months and 5 years postoperatively were significantly lower than those preoperatively (P < 0.001 for both periods). Five-blade scratcher treatment greatly benefits patients as demonstrated by the GBI and patient satisfaction. A small number of patients (7/28, 25%) reported recurrence after surgical treatment for rhinophyma in our department that was not more serious than before treatment. The expression of pro-inflammatory factors (TNF-α, IL-1β, and IL-6) in the patient's serum was significantly reduced after surgery of five-blade scratcher.

CONCLUSION

The five-blade scratcher treatment demonstrates notable advantages, including simplicity, safety, efficacy, and cost-effectiveness, coupled with reduced bleeding, minimized scarring, lower recurrence rates, reduced the level of pro-inflammatory factors and improved patient satisfaction. Consequently, this therapeutic modality exhibits a viable option for individuals afflicted with severe rhinophyma.

Key Words: Rhinophyma, Five-blade scratcher, Retrospective study, Efficacy, Recurrence rate

Core Tip: Rhinophyma is known as a late-stage subtype of rosacea. This study aims to observe the clinical effectiveness and recurrence of severe rhinophyma with Xia’s surgical five-blade scratcher treatment. We assessed the Global Flushing Severity Score, Clinician Erythema Assessment, Rhinophyma Severity Index, Glasgow Benefit Inventory, and satisfaction and recurrence of Xia’s surgical five-blade scratcher treatment preoperatively and 6 months and 5 years postoperatively. Five-blade scratcher treatment was safe, effective, and economical, with less bleeding, less scar, low recurrence rates, and high patient satisfaction. It offers an alternative to conventional surgery for severe rhinophyma.



INTRODUCTION

Rhinophyma, a chronic and progressive nasal disease, is characterized by benign skin thickening, surface irregularities, and telangiectasias with inflammatory infiltration, connective tissue hypertrophy, and sebaceous gland hyperplasia, causing a tumor-like growth of nasal tissues. Hypertrophic rhinophyma may cause nasal congestion and nocturnal apnea and affect the appearance of patients, resulting in functional, aesthetic, and psychosocial problems[1]. Chronic inflammation and fibrosis significantly influenced the development of rhinophyma, a condition whose precise etiology and pathogenesis remain elusive[2]. Additionally, Demodex folliculorum infection has attracted increasing attention from researchers. Histopathologic examination of rhinophyma has occasionally observed air follicle infection of Demodex. Furthermore, inflammation is increased in Demodex-infected rhinophyma, but the innate immune cells producing IL-4 and IL-13 are decreased[3]. Furthermore, Gether et al[4] revealed that rhinophyma occurred almost exclusively in males. Rhinophyma affects people aged 50–70 years in Caucasians and is very rare in African Americans and Asians[2].

The treatment goal of rhinophyma is to remove hypertrophic, hyperplastic tissue to restore normal contour, avoid scarring, and prevent nasal cancer development. No substantial evidence indicates rhinophyma as an independent risk factor for skin cancer, but basal cell carcinoma demonstrated an incidence of 3%–10% in rhinophymatous tissue[5]. Therefore, active early treatment is particularly important. The guidelines for rosacea published in the New England Journal in 2017[6] indicate a lack of rigorous randomized controlled trials for treating rhinophyma. The use of topical retinoids, oral doxycycline, oral tetracycline, or oral isotretinoin is recommended for treatment based on clinical experience. The choice of treatment, either laser therapy or surgical intervention, primarily targets aesthetic improvement in cases of rhinophyma where inflammation and fibrosis are not present. However, patients may experience discomfort or encounter scarring as a consequence[6]. Oral isotretinoin has improved rhinophyma, but the disease may recur within 1 year[7]. Tamoxifen has enhanced rhinophyma by down-regulating TGF-β2 to reduce fibrosis[8]. No standardized and comprehensive clinical study has confirmed its effectiveness and safety. Surgery is the best method to treat severe rhinophyma, considering the limited effect of oral rhinophyma treatment, the low possibility of spontaneous disease regression, and the difficulty in removing the rhinophymatous tissue. Many surgical options have been reported. The predominant methods are full-thickness resection + flap/skin graft, cold/hot blade excision or rhinoshave, electrosurgery, monopolar diathermy knife or cosmetic subunit method[9,10]. However, no controlled trials compared different surgical treatments. Most of the published literature were case reports, and the number of patients is limited. Additionally, no current randomized prospective controlled study focused on other treatments, making it difficult to recommend one treatment rather than the other[11]. Still, scarring and pigmentation are most prevalent near the nose postoperatively. Most of the surgical treatments cause a large trauma area, more bleeding, easily formed scars, and a high recurrence rate[9]. In the last few decades, a new ameliorated scarification approach has emerged for treating patients with severe rhinophyma. The late Professor Shi Guang-Hai pioneered this technique, also known as the five-blade scratcher treatment. This treatment modality boasts advantages, including simplicity, safety, effectiveness, and cost-efficiency, alongside benefits such as minimal bleeding, reduced scarring, lower recurrence rates, and enhanced patient satisfaction. The present study conducted a 5-year follow-up on rhinophyma treatment by a five-blade scratcher, and the clinical effect and recurrence rate were summarized and evaluated.

MATERIALS AND METHODS
Study design and patients

Our study retrospectively analyzed 28 patients aged 30–75 years in the outpatient or inpatient department of dermatology in our hospital from October 2016 to August 2018. All patients provided informed consent before enrollment. Each patient was diagnosed with severe rhinophyma according to the grading system of minor, moderate, and severe rhinophyma proposed by El-Azhary et al[12]. Severe rhinophyma manifested as both nasal hypertrophy and lobules. This study excluded patients with hematological diseases, severe heart disease, infectious diseases, scar constitution, and patients with high expectations for efficacy. Patient demographic and follow-up data were collected.

Operative procedure

Our study used a modified five-blade scratcher as the surgical instrument. The five-blade scratcher is composed of a handle, a grooved cutting edge, a fixing bolt, a fixing sleeve, and a blade. The bottommost of the five surgical blades is cast on the same plane to ensure that the tip of the blade is at the same level. The blade is fixed on the handle by screws, and the height of the blade exposed to the tool holder was changed by adjusting the screws.

Sterile gauze is used to cover the nostrils to prevent blood from flowing into the nasal cavity, followed by routine iodophor disinfection of the skin area. Local anesthesia was administered with a 1% or 2% lidocaine solution containing epinephrine of 1:200000. We used a preoperative photograph of the patient to guide the determination of the patient’s nose contour according to the preoperative evaluation. The blade was then used to remove the hypertrophic nasal tip and nasal alar tissue, and electrocoagulation was utilized to assist resection and hemostasis. A five-blade scratcher was then used to decussate the lesions until a normal nasal profile appeared, and the final wound surface resembled that of a strawberry. Compression hemostasis was applied, followed by a cold compress placement with 5–6 pieces of gauze soaked in saline, and finally, the wound was covered with petrolatum gauze. Figure 1 shows the operative process.

Figure 1
Figure 1 Surgical procedure. A: Dry cotton balls were used to plug the nostrils to prevent blood from flowing into them; B and C: Performing criss-cross scratching using a five-blade scratcher; D: The final wound surface resembled that of a strawberry; E: Ice saline coverage; F: Covering the wound with petrolatum gauze.

Postoperative nursing consisted of a dressing change on the first postoperative day. The dressing was changed except for the petrolatum gauze, and this care was followed once a day for 5–7 days. Approximately 10 days postoperatively, the petrolatum gauze typically fell off by itself, revealing a new red and tender wound. The petrolatum gauze was removed the next day if there was more discharge, and daily dressing changes continued until the wound was dry. Postoperative wound pigmentation gradually appeared. This condition required no treatment, and a return to normal pigmentation generally occurred after 2–6 months.

Global Flushing Severity Score

The Global Flushing Severity Score (GFSS) was used to determine the severity of flushing in patients with rhinophyma[13]. The severity was recorded in a 0–10 score system, with higher numbers indicating more serious symptoms; GFSS of 0, 1–3, 4–6, 7–9, and 10 indicated no, mild, moderate, severe, and extremely severe flushing, respectively. GFSS scores were completed by telephone interviews with a non-medical staff at 6 months and 5 years postoperatively. The authors completed the statistical calculations.

Clinician Erythema assessment

We used the Clinician Erythema assessment (CEA) score to evaluate erythema improvement in patients[14]. CEA scores were recorded using a 5-point scale and defined as 0 (clearance), 1 (almost cleared), 2 (mild), 3 (moderate), and 4 (severe). We evaluated the improvement of CEA scores at 6 months and 5 years postoperatively compared with baseline. Two blinded dermatologists assessed the CEA score, and the average score was analyzed.

Rhinophyma severity index

Wetzi proposed the Rhinophyma severity index (RHISI) for further assessment preoperatively and at 6 months and 5 years for rhinophyma[15]. The index measures rhinophyma digitally based on the degree of skin thickening, the presence of lobules and fissures, and the presence of strong asymmetry, cysts, or vessels. Three blinded, experienced dermatologists randomly graded the severity of rhinophyma based on standard photographs during the two follow-ups postoperatively as well as on a presurgical photograph.

Glasgow benefit inventory

Objective tools to assess patient satisfaction and quality of life are very important in facial plastic surgery. The Glasgow benefit inventory (GBI) is a specific scale proposed by Robinson et al[16], which is used to assess patient benefits postoperatively or other medical interventions. This scale is used to evaluate postoperative rhinophyma, which includes 18 items categorized into three dimensions: general, social, and physical health[11]. The questionnaire was completed by a telephone interview conducted by non-medical staff at 6 months and 5 years postoperatively. The interview process generally took 5–10 minutes. The authors completed statistical calculations.

Patient satisfaction

Lazeri created a patient questionnaire to evaluate patient satisfaction[17]. This questionnaire is also widely used for postoperative assessment of patients with rhinophyma. Further, we conducted a telephone interview at 6 months and 5 years postoperatively for a questionnaire survey on patient satisfaction.

Recurrence

During the telephone interview 5 years postoperatively, the patient was asked for the presence of recurrence and reduction or aggravation compared with the preoperative period, as well as the severity of the recurrence (the collected data included recurrence within 5 years postoperatively).

ELISA

To assess the concentrations of IL-6, IL-1β, and TNF-α in each group, the serum was collected and assayed using ELISA kits (Beyotime, China) according to the manufacturers’ instructions. The OD value was measured at the wavelength of 450 nm, and the concentrations of IL-6, IL-1β, and TNF-α were calculated based on a standard curve.

Statistical analysis

Statistical tests (the Wilcoxon 2-sample paired test in dependent groups) to evaluate differences in the scores of disease severity in the first, second, and third visits were performed following the data distribution analyses. A P-value of < 0.05 was considered to represent a statistically significant difference. IBM Statistical Package for the Social Sciences Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, United States) was used for data analysis.

RESULTS
Baseline demographics

Table 1 shows the demographic analysis. This study included 28 patients composed of 26 females and 2 males (male: female ratio of 13:1). The mean age of the patients was 52 years (range: 33–65 years), and the mean disease duration was 11.6 years (range: 5–20 years). No adverse events, such as postoperative bleeding, pain, or infection, occurred postoperatively.

Table 1 Patient characteristics.
Patient
Sex
Age at presentation (years)
Duration of rhinophyma (years)
1M5312
2F478
3M5010
4M548
5M466
6M5614
7M5815
8M6520
9M5515
10M6020
11M5316
12M6218
13M6515
14M488
15M395
16F5210
17M498
18M456
19M508
20M436
21M386
22M478
23M5010
24M3310
25M6315
26M6020
27M5713
28M5815
GFSS and CEA scores

The clinical symptoms of all patients were significantly improved during postoperative recovery than preoperatively. The mean changes in GFSS and CEA scores were -3.1 and -1.7 during the 6-month follow-up session and -2.3 and -1.4 during the 5-year follow-up session, respectively, compared with the baseline (Figure 2). The differences were statistically significant (P < 0.001). These results indicate that the five-blade scratcher treatment improved the symptoms of flushing and erythema in patients with severe rhinophyma.

Figure 2
Figure 2 Evaluation of therapeutic effect. A: Changes in mean Global Flushing Severity Score (GFSS) scores before and after five-blade scratcher treatment; B: Changes in mean GFSS scores before and after five-blade scratcher treatment. GFSS and Clinician Erythema Assessment scores significantly decreased at 6 months and 5 years postoperatively. aP < 0.001, the difference was statistically significant. GFSS: Global Flushing Severity Score; CEA: Clinician Erythema Assessment.
RHISI

After the 6-month and 5-year follow-ups, 28 (100%) patients showed an improved RHISI. At 6 months postoperatively, RHISI scores were 100% improved in 25 patients. In particular, 3 patients demonstrated improved RHISI scores by 83.33%. RHISI scores were 100% improved in 18 patients at 5 years postoperatively. In particular, 3 patients improved their RHISI score by 83.33%, 2 patients by 75%, and the other 5 patients by 66.67% (Table 2). The median severity scores of the first visit [interquartile range (IQR): 2.00-4.00] were significantly higher than that of the second (IQR: 0-0.00) and third visits (IQR: 0-1.00; P < 0.001 and P < 0.001, respectively). A statistically significant difference was found between the median scores of the second and third visits (P = 0.002). The horizontal line in the boxes represents the median. The lower margin and the upper margin of the boxes indicate the greatest and least values, respectively (Figure 3A).

Figure 3
Figure 3 Evaluation of Rhinophyma Severity Index and Glasgow Benefit Inventory scores. A: Changes in Rhinophyma Severity Index (RHISI) scores after five-blade scratcher treatment; B: Changes in Glasgow Benefit Inventory scores after five-blade scratcher treatment. The RHISI scores at 6 months and 5 years postoperatively were significantly lower than before. Concurrently, five-blade scratcher treatment can benefit patients, and the benefit is more obvious 5 years postoperatively. RHISI: Rhinophyma Severity Index; GBI: Glasgow Benefit Inventory.
Table 2 Rhinophyma Severity Index pre- and postoperatively.
Patient
RHISI (before treatment)
RHISI (6 months after treatment)
RHISI (5 years after treatment)
RHISI improvement (6 months, %)
RHISI improvement (5 years, %)
160110083.33
2300100100
3400100100
440110075
5300100100
6400100100
7600100100
861283.3366.67
9400100100
1060210066.67
11400100100
1261283.3366.67
13600100100
1440110075
15600100100
16300100100
17400100100
18300100100
19400100100
2030110066.67
21400100100
22400100100
23600100100
2460110083.33
25600100100
2660110083.33
2761283.3366.67
28600100100
GBI score

The need for objective tools to assess patient satisfaction and quality of life cannot be overemphasized in facial plastic surgery. We combined the GBI score and satisfaction evaluation to assess the satisfaction of patients in all aspects postoperatively, as indicated in several published studies on the results of rhinophyma surgery. The total GBI results at 6 months and 5 years postoperatively were 74.31 and 87.60, respectively. Five-blade scratcher treatment can benefit patients, as demonstrated by the GBI outcome, and the benefit is more pronounced 5 years postoperatively. Patients reported that the questionnaire was easy to understand, with no difficulty in answering the questions (Figure 3B).

Satisfaction score

The patients were followed up for 5 years postoperatively. The patient’s medical records and treatment results were collected at 6 months and 5 years postoperatively, and the patient’s cognition was evaluated by questionnaires. The patient demonstrated a very high satisfaction score, and 89% and 93% of the patients were completely satisfied with the recovery at 6 months and 5 years, respectively, after rhinophyma surgery. The proportion of patients with good nasal appearance after 5 years was as high as 86% and that with positive self-image was as high as 89% at 6 months and 5 years postoperatively. The patient’s recommendation was 100%, indicating that the patient was very satisfied with the five-blade scratcher treatment for rhinophyma (Table 3).

Table 3 Results of patient satisfaction survey.
Question
6 months after treatment (%)
5 years after treatment (%)
Satisfaction
    0–30 (0)0 (0)
    4–60 (0)0 (0)
    7–93 (0.11)2 (0.07)
    1025 (0.89)26 (0.93)
Effects maintained
    Yes26 (0.93)24 (0.86)
    Not sure2 (0.07)4 (0.14)
    No0 (0)0 (0)
Self-impression
    Excellent25 (0.89)25 (0.89)
    Good2 (0.07)2 (0.07)
    Sufficient1 (0.04)1 (0.04)
    Disappointing0 (0)0 (0)
Back to social life
    Too long0 (0)0 (0)
    Long0 (0)0 (0)
    Sufficient4 (0.14)4 (0.14)
    Quick19 (0.68)19 (0.68)
    Very quick5 (0.18)5 (0.18)
Recommend
    Yes28 (1)28 (1)
    Not sure0 (0)0 (0)
    No0 (0)0 (0)
Recurrence assessment

A small number of patients (18%; 5/28) reported recurrence of rhinophyma postoperatively in our department. However, all patients with recurrent nasal tumors (100%; 5/5) reported that the appearance of the recurrent rhinophyma was less obvious than preoperatively. None of the patients considered that the recurrent rhinophyma after surgical treatment was comparable with or more severe than preoperatively (Table 4).

Table 4 Clinical manifestations of recurrent rhinophyma 5 years postoperatively.
Type
Percentage (%)
Recurrence of rhinophyma5/28 (18)
Improved postoperatively5/5 (100)
Same before/postoperatively0/5 (0)
Worse postoperatively0/5 (0)

We selected three of the participants with recurrent rhinophyma and provided their photos (Figures 4 and 5).

Figure 4
Figure 4 A 63-year-old male patient with severe rhinophyma with a 15-year course. A: Preoperative photograph, taken on October 13, 2016; B: April 15, 2017, which is 6 months postoperatively; C: October 8, 2021, with a significant improvement observed.
Figure 5
Figure 5 A 33-year-old male patient with severe rhinophyma with a 10-year course. A: Preoperative photograph, taken on December 20, 2016, B: June 18, 2017, which is 6 months postoperatively; C: December 20, 2021, with a marked improvement postoperatively.
The level of inflammatory factors

Next, we explored whether five-blade scratcher surgery affects the expression of pro-inflammatory factors in patients' serum. we compared inflammatory factors including IL-1β, IL-6, and TNF-α, between before and after surgery group. The results showed that the expression of TNF-α, IL-1β, and IL-6 were significantly decreased in the serum from after surgery group (Figure 6). Five-blade scratcher surgical treatment was able to alleviate inflammation levels in the patient's serum, indicating that Five-blade scratcher is an effective treatment for rhinophyma.

Figure 6
Figure 6 The level of inflammatory factors. The level of IL-1β, IL-6 and TNF-α were detected in serum from before and after surgery groups by ELISA. The difference was statistically significant. aP < 0.05, bP < 0.001.
DISCUSSION

Rhinophyma is an advanced stage of rosacea. The nasal architecture destruction, airway obstruction development, and nasal aesthetic unit disfigurement cause a serious social psychological burden to patients and seriously affect the quality of life[2]. Drug treatment can only delay the early development of rhinophyma once rosacea enters the rhinophyma period, and the likelihood of spontaneous regression of the disease is low. Fibrotic lesions can only be treated surgically.

At present, surgical treatment has no gold standard, but the two steps of “excision” and “reconstruction” are usually the cornerstone of surgical treatment. Nasal neoplasm usually only invades the superficial dermis; thus, rhinophyma resection is classified according to the layer it is cut. Carbon dioxide laser, erbium YAG laser, grinding, and cryotherapy can be selected for light rhinophyma[9]. However, the risk of hypertrophic scar formation, insufficient pigmentation, postoperative erythema, and infection can occur in clinical practice[1,18]. Scalpel excision is the best choice for severe rhinophyma. It is not only a more cost-effective treatment but demonstrates relatively few postoperative complications[2]. At present, the predominantly used methods in clinical practice are full-thickness resection + flap/skin graft, cold blade/hot blade, or cosmetic subunit method[19]. Full-thickness resection is the removal of rhinophyma tissue to the whole dermis. This method completely removes the lesion site with a scalpel, and the wound is covered with a flap or skin graft after complete resection to achieve secondary healing. However, this method has some disadvantages because of the heterogeneity of transplantation, such as skin color and texture mismatch between the donor site and transplantation site, flap/skin graft non-survival, postoperative contracture, and scar retention[10]. Cold and hot blades are selected for resection. The use of a “thermal blade” (“Shaw’s heated scalpel”) to change the temperature between 150°C and 200°C can produce good cosmetic results[20]. The main disadvantage of this technique is that it increases the risk of postoperative pain, scarring, and nasal collapse because of alar cartilage injury[21]. The cold blade causes no thermal damage, but more bleeding is observed intraoperatively, and the surgical field is unclear, which hinders the stratification intraoperatively and may cause lesion recurrence[17]. Attention is required to protect cosmetic subunits in nasal surgery. The cosmetic subunits should be reshaped according to the classification criteria of cosmetic subunits in the reconstruction. Concurrently, the scar should be hidden on the division line of cosmetic subunits, which can achieve a good postoperative aesthetic effect. The cosmetic subunit method is new based on this hidden scar. In the operation, the nose was incised with six flaps according to the cosmetic subunit, the rhinophyma tissue was cut to the perichondrium, the ineffective cavity was sutured, and the excess skin was excised to restore the nasal appearance and function, which provided a new method for nasal cartilage remodeling. However, this method has high technical requirements for the surgeon, warrants a strong foundation in facial cosmetic surgery, and with no ideal wound healing environment. The postoperative recovery time is long because of the bacterial load and diseased skin associated with rhinophyma, which easily causes wound infection[22].

We aimed to explore a surgical method without scarring in severe rhinophyma; therefore, we pursued an alternative approach. The five-blade scratcher is a patented method for treating severe rhinophyma. Our previous studies only focused on describing the operative process, immediate postoperative recovery, and adverse reaction evaluation[23,24]. We did not systematically evaluate the long-term recurrence rate, and we aimed to follow up on recurrence, patient satisfaction, and quality of life for a long period after treatment. Therefore, we designed this study to evaluate the RHISI score, GBI score, patient satisfaction, and recurrence 6 months and 5 years postoperatively to assess the therapeutic effect of scratch surgery more systematically and comprehensively.

The scratching surgical method is a typical product of the combination of traditional Chinese medicine with a surgical treatment concept and modern western medicine surgical methods. This technique can be traced back to ancient cutting therapy, as the treatment of blood stasis syndrome. The criss-cross scratching method cuts off the dilated capillaries, removes the hyperplastic sebaceous glands, repairs the epidermal cells remaining in the hair follicles on the wound surface, and leaves no scar after healing. It is a major innovation in treating rhinophyma. The thickened tissue of rhinophyma is mainly composed of epidermis and superficial dermis. The middle and lower layers of the dermis, which is equivalent to extra hyperplastic tissue on the normal nose, attained no great damage. Therefore, in rhinophyma surgery, most of the hyperplastic tissue is first removed with an ordinary scalpel to make the nasal shape close to normal size. Criss-cross scratching follows, using the five-blade scratcher on the residual wound. Postoperatively, the middle and lower layers of the dermis, including sebaceous glands and the stratified squamous epithelium of hair follicles, remained intact. After scratching, numerous filiform, papillae-like structures remain on the wound surface. Hence, the surgical wound is gradually repaired, with epithelial healing rather than scar formation. We have developed several cautionary notes through continuous summarization of our experience, including (1) Before-and-after pictures of the nasal hyperplasia should be repeatedly compared to guide the excision of the rhinophyma lesions step by step until the nose returns to a normal profile during the operation. The ala nasi is the most difficult site and should receive close attention; (2) during scarification, the surgeon should master the principle of cutting depth: Rather shallow than deep, the height of the blade should range from approximately 0.5–0.8 mm, and the depth can be increased by 1 mm (amount of the blade allowed out of the knife rest). Avoid cutting too deeply to avoid promoting scar formation. The sharpness of each knife is different, as is the hyperplasia of each patient. The surgeon adjusts the depth of scarification by observing the exudation rate and regulating the knife gradient and hand strength accordingly; and (3) each area requires repeated and uniform cutting during decussation and alternate nick cutting in different directions.

CONCLUSION

Our results reveal the feasibility of a five-blade scratcher for treating severe rhinophyma. This technique presents a viable alternative to traditional surgical approaches, providing potential benefits such as reduced trauma, improved prognoses, lower recurrence rates, and increased patient satisfaction. However, this study has limitations that should be addressed. First, the sample size is small, and subgroup analysis was not performed on patients of different ages or severities. Second, this is only a clinical study, and no experimental study confirmed that the surgical method improves rhinophyma. Third, this was a single-center study, which may have caused bias. Whether the reason for almost no scar formation after scratching is related to the large reduction of fibroblasts and the reduction of inflammation postoperatively warrants further study.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Medicine, research and experimental

Country of origin: China

Peer-review report’s classification

Scientific Quality: Grade C

Novelty: Grade C

Creativity or Innovation: Grade B

Scientific Significance: Grade B

P-Reviewer: de Moraes F, Canada S-Editor: Lin C L-Editor: A P-Editor: Wang WB

References
1.  Kassirer SS, Gotkin RH, Sarnoff DS. Treatment of Rhinophyma With Fractional CO2 Laser Resurfacing in a Woman of Color: Case Report and Review of the Literature. J Drugs Dermatol. 2021;20:772-775.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
2.  Chauhan R, Loewenstein SN, Hassanein AH. Rhinophyma: Prevalence, Severity, Impact and Management. Clin Cosmet Investig Dermatol. 2020;13:537-551.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 4]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
3.  Ricardo-Gonzalez RR, Kotas ME, O'Leary CE, Singh K, Damsky W, Liao C, Arouge E, Tenvooren I, Marquez DM, Schroeder AW, Cohen JN, Fassett MS, Lee J, Daniel SG, Bittinger K, Díaz RE, Fraser JS, Ali N, Ansel KM, Spitzer MH, Liang HE, Locksley RM. Innate type 2 immunity controls hair follicle commensalism by Demodex mites. Immunity. 2022;55:1891-1908.e12.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
4.  Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018;179:282-289.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 70]  [Cited by in F6Publishing: 120]  [Article Influence: 20.0]  [Reference Citation Analysis (0)]
5.  Fink C, Lackey J, Grande DJ. Rhinophyma: A Treatment Review. Dermatol Surg. 2018;44:275-282.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 18]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
6.  van Zuuren EJ. Rosacea. N Engl J Med. 2017;377:1754-1764.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 107]  [Cited by in F6Publishing: 118]  [Article Influence: 16.9]  [Reference Citation Analysis (0)]
7.  Schaller M, Almeida LM, Bewley A, Cribier B, Dlova NC, Kautz G, Mannis M, Oon HH, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren E, Tan J. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:465-471.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 81]  [Cited by in F6Publishing: 75]  [Article Influence: 10.7]  [Reference Citation Analysis (0)]
8.  Payne WG, Ko F, Anspaugh S, Wheeler CK, Wright TE, Robson MC. Down-regulating causes of fibrosis with tamoxifen: a possible cellular/molecular approach to treat rhinophyma. Ann Plast Surg. 2006;56:301-305.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 31]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
9.  Dugourd PM, Guillot P, Beylot-Barry M, Cogrel O. Surgical treatment of rhinophyma: Retrospective monocentric study and literature review. Ann Dermatol Venereol. 2021;148:172-176.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
10.  Ramsdell WM. Two Alternative Approaches to "Treating Severe Rhinophyma: A Stepwise Approach". Dermatol Surg. 2023;49:208-209.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
11.  Daoud M, Ullas G, Kumar R, Raghavan U. Rhinophyma: Combined Surgical Treatment and Quality of Life. Facial Plast Surg. 2021;37:122-131.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
12.  el-Azhary RA, Roenigk RK, Wang TD. Spectrum of results after treatment of rhinophyma with the carbon dioxide laser. Mayo Clin Proc. 1991;66:899-905.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 57]  [Cited by in F6Publishing: 58]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
13.  Tong Y, Luo W, Gao Y, Liu L, Tang Q, Wa Q. A randomized, controlled, split-face study of botulinum toxin and broadband light for the treatment of erythematotelangiectatic rosacea. Dermatol Ther. 2022;35:e15395.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 9]  [Article Influence: 4.5]  [Reference Citation Analysis (0)]
14.  Suggs AK, Macri A, Richmond H, Munavalli G, Friedman PM. Treatment of Erythematotelangiectatic Rosacea With Pulsed-Dye Laser and Oxymetazoline 1.0% Cream: A Retrospective Study. Lasers Surg Med. 2020;52:38-43.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 13]  [Article Influence: 2.6]  [Reference Citation Analysis (0)]
15.  Wetzig T, Averbeck M, Simon JC, Kendler M. New rhinophyma severity index and mid-term results following shave excision of rhinophyma. Dermatology. 2013;227:31-36.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 14]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
16.  Robinson K, Gatehouse S, Browning GG. Measuring patient benefit from otorhinolaryngological surgery and therapy. Ann Otol Rhinol Laryngol. 1996;105:415-422.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 456]  [Cited by in F6Publishing: 458]  [Article Influence: 16.4]  [Reference Citation Analysis (0)]
17.  Lazzeri D, Larcher L, Huemer GM, Riml S, Grassetti L, Pantaloni M, Li Q, Zhang YX, Spinelli G, Agostini T. Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience. J Craniomaxillofac Surg. 2013;41:429-436.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 23]  [Cited by in F6Publishing: 24]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
18.  Badawi A, Osman M, Kassab A. Novel Management of Rhinophyma by Patterned Ablative 2940nm Erbium:YAG Laser. Clin Cosmet Investig Dermatol. 2020;13:949-955.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
19.  Benyo S, Saadi RA, Walen S, Lighthall JG. A Systematic Review of Surgical Techniques for Management of Severe Rhinophyma. Craniomaxillofac Trauma Reconstr. 2021;14:299-307.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
20.  Seiverling EV, Neuhaus IM. Nare obstruction due to massive rhinophyma treated using the Shaw scalpel. Dermatol Surg. 2011;37:876-879.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
21.  Vural E, Royer MC, Kokoska MS. Sculpting resection of rhinophyma using the Shaw scalpel. Arch Facial Plast Surg. 2009;11:263-266.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
22.  Hassanein AH, Vyas RM, Erdmann-Sager J, Caterson EJ, Pribaz JJ. Management of Rhinophyma: Outcomes Study of the Subunit Method. J Craniofac Surg. 2017;28:e247-e250.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
23.  Wang DM, He XF, He X, Zhang HM. A Surgical Management for Severe Rhinophyma With Five-Blade Scratcher. J Craniofac Surg. 2021;32:2821-2822.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
24.  Li W, He X, Chen W, Ding P, Zhang H. A Novel Surgical Approach for Rhinophyma: Experience From a Cohort of Thirty Patients. J Craniofac Surg. 2022;33:233-235.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]