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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
CASE REPORT Table of Contents   
Year : 2007  |  Volume : 11  |  Issue : 2  |  Page : 60-62
 

Do we really need high technology for excision of rhinophyma?


Department of Otolaryngology, Head and Neck Surgery, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey

Correspondence Address:
Mahmut Ozkiris
Yenimahalle Tayyareci Sadik, Sok. Sabir Apt. No:46/6, 34720 Bakirköy, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-029X.37383

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   Abstract 

Rhinophyma is a rare disease that primarily affects Caucasian men in the fifth to seventh decades of life, characterized by a progressive thickening of nasal skin, which produces a disfiguring soft-tissue hypertrophy of the nose. Severe cosmetic deformity and impairment of breathing may coexist, making surgical treatment necessary. A 64-year-old patient who had diagnosis of rhinophyma is discussed, along with the surgical modalities.


Keywords: Acne rosacea, rhinophyma, tangential excision


How to cite this article:
Ozkiris M, Kubilay U, Unver S. Do we really need high technology for excision of rhinophyma?. J Oral Maxillofac Pathol 2007;11:60-2

How to cite this URL:
Ozkiris M, Kubilay U, Unver S. Do we really need high technology for excision of rhinophyma?. J Oral Maxillofac Pathol [serial online] 2007 [cited 2019 Aug 22];11:60-2. Available from: http://www.jomfp.in/text.asp?2007/11/2/60/37383



   Introduction Top


Rhinophyma is a rare, disfiguring disease characterized by progressive hypertrophy of the soft tissue of the nose with its increased volume, mainly in the lower half, and often associated with an end-stage of severe acne rosacea. Clinically the lower two-thirds of the nose becomes enlarged and hypervascular, developing a reddish-purple discoloration and a lobular, nodular appearance. [1]


   Case Report Top


A 64-year-old man presented with a 5-year history of progressive hypertrophy of his nose. Despite appropriate antibiotic therapy, the patient developed disfiguring rhinophyma and complained of nasal obstruction and a foul odor from his nose. Physical examination revealed significant nasal sebaceous hypertrophy and skin abscesses. Purulent and keratinous material could easily be expressed. No other pathologies were found during otorhinolaryngological examination. Chest X-ray and neck ultrasound evaluations were found to be normal. The whole blood count, peripheral smear and biochemical values of the patient were normal.

Surgical excision of rhinophyma was performed under general anesthesia, and tissues were infiltrated locally with lidocaine 1% and epinephrine 1:100000 to reduce postoperative pain and bleeding during the surgical treatment. We adopted stepwise surgical approach consisting of tangential excision, sculping with scissors and finally contouring with dermarasio. At the end of the treatment, a Vaseline occlusive dressing with antibiotic (Nitrofurazone 0.2%) ointment was placed. Re-epithelialization occurred spontaneously from retained glandular elements in two weeks. Postoperative follow-up was continued up to six months [Figure - 1].


   Discussion Top


Rhinophyma may have been first recognized in ancient Greece and Arabia. [2],[3] The name is derived from the Greek 'rhis,' meaning nose; and phyma, meaning growth. [4],[5]

White people between the age of 45 and 60 years, [6],[7],[8] with a male-female ratio of 12:1, [9] are more frequently affected by this disease, while it is slightly present in the black race. [7]

Rhinophyma is most likely a severe manifestation of advanced rosacea. Common and early characteristic in the etiology of acne rosacea is a recurrent and fleeting vasodilatation of the face that, according to Marsili and Cockerell, [9] would cause a soft-tissue nasal hypertrophy, gradually giving rise to rhinophyma. In the past rhinophyma was considered a clinical sign of alcoholism, but this relationship has never been demonstrated. [6],[8],[10] In the same way, it is unclear that there is a correlation between a steroid hormone's excessive effect and the hypertrophy of sebaceous glands, which is peculiar of rhinophyma; or between rhinophyma and some microorganisms, like the Demodex Folliculorum, often isolated in this disease. Irritants, such as alcohol and sunlight, may contribute to the progression of the disease. The increased incidence in men may be due to androgenic influence. Thiboutot et al. note that 5-alpha reductase activity is higher in acne-prone sebaceous units relative to that in sebaceous units in non­-acne-prone skin. [11],[12] These epidemiological studies underline the importance of genetic factors not yet identified but do not help to understand the real etiology of this disease, which remains unknown.

In fact, the peculiar morphologic characteristics of rhinophyma are teleangiectasia, hypervascularity, a thick nasal cutaneous layer and nodularity covered by atrophic skin with expanded pores. [6],[8],[10],[13]

Histopathologically, two forms of rhinophyma are described in literature by Tope and Sangueza. [15] The most common one is characterized by histological lesions, which are peculiar of rosacea. The other is the 'fibrous variant.' In the first case, we can observe massive hyperplasia of sebaceous glands, elastosis in the derma, moderate fibrousness with collagen fibers plunged in a myxoid edematous stroma, many follicular cysts and lympho-histocyte infiltration around expanded blood vessels. In the fibrous variant, we can observe severe fibrotic alterations in the derma, decrease or lack of sebaceous glands and dermal annexes. [15] Not only can additional pathology hide within the rhinophymatous nose, but cancer and other disorders can also actually mimic the disease.

Medical treatment may be used before, and in conjunction with, surgical treatment. [16] There is no agreement about the ideal treatment for rhinophyma; in literature there are various treatment modalities for the treatment of rhinophyma, such as the scalpel, the electrocautery, the dermabrader, ultrasonic scalpel and the carbon dioxide laser. [5],[6],[9],[14],[17]

Surgical treatment with cold knife includes total eradication (full thickness excision) or subtotal eradication (partial thickness excision, superficial decortication) of the diseased tissue. Total eradication (down to the loose areolar layer overlying the osteocartilaginous scaffolding) and the following covering with skin grafts or flaps needed for deeply infiltrating rhinophyma, rhinophyma with underlying neoplasia or rhinophyma fibrous variant where there is excessive fibrous tissue, which make a partial thickness excision difficult. Subtotal eradication by tangential excision of diseased tissue preserves the underlying sebaceous gland and allows spontaneous re-epithelialization and complete healing in two to three weeks. [6],[16],[18],[19]

Subtotal eradication and the following spontaneous re-epithelialization is not only a less complicated surgical procedure but it also guarantees better esthetic results, although a low risk of recurrence remains.

The profuse bleeding during the treatment of a hypervascularized disease like rhinophyma often does not allow an accurate resection of the damaged tissues. An increased rate of recurrence in case of incomplete removal, or a lesion of underlying sebaceous or cartilaginous tissues in case of excessive resection, may occur For this reason, it is important to examine pathological specimens. We prefer to use the scalpel to cut and local infiltration of dilute epinephrine and bipolar electrocautery for good hemostasis, with minimal thermal injury of the underlying surrounding tissues and a quick and spontaneous re-epithelialization.

 
   References Top

1.Hoasjoe DK, Stucker FJ. Rhinophyma review of pathophysiology and treatment. J Otolaryngol 1995;24:51-6.  Back to cited text no. 1  [PUBMED]  
2.Wiemer DR. Rhinophyma. Clin Plast Surg 1987;14:357-65.  Back to cited text no. 2  [PUBMED]  
3.Barton FE Jr, Byrd HS. Acquired deformities of the nose. In : McCarthy JG, editor. Plastic Surgery, Vol.3. Saunders: Philadelphia; 1990. p. 1987-90.  Back to cited text no. 3    
4.Elliott JG Jr, Hoehn JG, Stayman JW 3rd. Rhinophyma: Surgical refinements. Ann Plast Surg 1978;1:298-301.  Back to cited text no. 4    
5.Matton G, Pickrell K, Huger W, Pound E. The surgical treatment of rhinophyma. An analysis of fifty-seven cases. Plast Reconstr Surg Transplant Bull 1962;30:403-14.  Back to cited text no. 5    
6.Har-El G, Shapshay SM, Bohigian RK, Krespi YP, Lucente FE. The treatment of rhinophyma: Cold vs. laser techniques. Arch Otolaryngol Head Neck Surg 1993;119:628-3l.  Back to cited text no. 6    
7.Plenk HP. Rhinophyma, associated with carcinoma, treated successfully with radiation. Plast Reconstr Surg 1995;95:559-62.  Back to cited text no. 7  [PUBMED]  
8.Wiemer DR. Rhinophyma. Clin Plast Surg 1987;14:357-65.  Back to cited text no. 8  [PUBMED]  
9.Marsili M, Cockerell C, Lyde CB. Hemangioma associated with rhinophyma: Report of a case with successful treatment using carbon dioxide laser surgery. J Dermatol Surg Oncol 1993;19:206-l2.  Back to cited text no. 9    
10.Matton G, Pickrell K, Huger W. The surgical treatment of rhinophyma. Plast Reconstr Surg 1962;30:403-l3.  Back to cited text no. 10    
11.Thiboutot, DM. Acne and rosacea: New and emerging therapies. Dermatol Clin 2000;18:63-71.  Back to cited text no. 11    
12.Thiboutot, D, Harris G, Iles V, Cimis G, Gilliland K, Hagari S. Activity of the type 15-alpha-reductase exhibits regional differences in isolated sebaceous glands and whole skin. J Invest Dermatol 1995;105:209-14.  Back to cited text no. 12    
13.Hallock GG. Laser treatment of rhinophyma. Aesthetic Plast Surg 1988;12:171-4.  Back to cited text no. 13    
14.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.  Back to cited text no. 14  [PUBMED]  
15.Tope WD, Sangueza OP. Rhinophyma's fibrous variant. Am J Dermatopathol 1994;16:307-10.  Back to cited text no. 15  [PUBMED]  
16.Stucker FJ, Hoasjoe DK, Aarstad RF. Rhinophyma: A new approach to hemostasis. Ann Otol Rhinol Laryngol 1993;102:925-9.  Back to cited text no. 16  [PUBMED]  
17.Wenig BL, Weingarten RT. Excision of rhinophyma with Nd-Yag Laser: A new technique Laringoscope 1993;103:101-3.  Back to cited text no. 17    
18.Ersek RA, Denton DR. Rhinophyma: Treatment with electrocautery and silver-impregnated porcine xenograft. Plast Reconsr Surg 1984;74:269-73.  Back to cited text no. 18    
19.Furukawa M, Kanetou K, Hamada T. Rhinophyma in Japan. Int J Dermatol 1994;33:35-7.  Back to cited text no. 19  [PUBMED]  


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