A 79-year-old man was referred for evaluation of a lesion to the nose with growth over 10 years, recurrent infections, and resulting embarrassment (Figure 1a and 1b). He was diagnosed with rhinophyma with significant deformity of the left ala with a protruding mass measuring 4 x 3 cm that obstructed the left nare.
Preoperative images: (a) anteroposterior and (b) oblique views of the nose, demonstrating significant rhinophyma and left-sided alar mass.
Preoperative intravenous antibiotics were administered, and 1% lidocaine with 1:100,000 epinephrine was injected into the nose for a block and hemostasis. Excision of the diseased area was performed using loop electrocautery dermabrasion with Valleylab Tungsten Loop Electrodes (10 x 10 mm, 20 x 12 mm, and 20 x 15 mm) set at 15 on the Bovie. The alar mass was excised with a #15 blade followed by loop electrocautery for contouring (Figure 2a and 2b). Significant sebaceous material was encountered, and final pathology was consistent with an epidermal inclusion cyst. Postoperative care consisted of antibiotic ointment and xeroform multiple times daily to keep moist for 10 days followed by Vaseline twice daily. Pain management included alternating ibuprofen and Tylenol with narcotics for breakthrough. At 3 months' post operation, the patient had mild hypopigmentation (Figure 3a and 3b) but was very happy with the result and denied desiring any further aesthetic intervention.
Intraoperative images: (a) Anterior view of the nose post loop electrocautery dermabrasion. (b) Oblique view of the nose post sharp excision of left alar mass and subsequent contouring with loop electrocautery dermabrasion.
Postoperative images: (a) Anterior view of the nose, demonstrating well-healed tissue with mild scarring and pigment changes. (b) Oblique view of the nose, demonstrating a well-healed left ala following the excision of an epidermal inclusion cyst.
Q1. What is Rhinophyma?
Rhinophyma is a disfiguring condition of the nose generally thought to be caused by long-standing chronic acne rosacea, specifically a subtype known as phymatous rosacea. Chronic inflammation and the concurrent release of vasoactive substances are thought to play a role in the progressive hypertrophy and hyperplasia of sebaceous glands in affected nasal tissue. These cellular and molecular changes lead to the classically thickened bulbous appearance of rhinophyma. Although it is well-accepted that the leading precipitant of rhinophyma is long-standing acne rosacea, the underlying pathophysiology of this condition remains unclear. Substance P is a prominent vasoactive peptide found to be involved in the development of rhinophyma and has been implicated in several other dermatologic pathologies, including psoriasis and eczema.
Q2. Why Might an Individual Seek Treatment of Rhinophyma?
Though it is a benign condition in and of itself, rhinophyma can lead to significant psychosocial distress as well as secondary anatomical defects such as nasal obstruction. Additionally, recurrent infections may occur in more severe cases of rhinophyma as bacteria become trapped in fluid secreted by hyperplastic sebaceous glands. For these reasons, many patients with rhinophyma elect to undergo treatment.
Q3. Are surgical or Nonsurgical Methods Preferred When Treating Rhinophyma?
Several therapeutic modalities have been shown to treat rhinophyma effectively. It has been well-established that surgical methods are superior to noninvasive methods, and surgical techniques should aim to cover 4 steps: excision of hypertrophied tissue, recontouring of affected tissue, hemostasis, and adequate postoperative care. Surgical methods used in the treatment of rhinophyma include but are not limited to sharp excision, carbon dioxide (CO2) laser, and electrocautery dermabrasion. Each of the aforementioned techniques is accompanied by both advantages and disadvantages.
Q4. What are the Advantages and Disadvantages to Common Surgical Techniques in the Treatment of Rhinophyma?
Sharp excision technique for the removal of rhinophyma generally involves the use of dilute infiltrating epinephrine, a scalpel, and electrocautery for hemostasis. The advantages of this technique include the allowance of sharp margins, minimal collateral thermal damage, and cost-effectiveness. However, the primary use of sharp excision does not allow for simultaneous hemostasis during excision, nor does it allow for completely accurate contouring of nasal tissue. CO2 laser is a relatively new option in the treatment of rhinophyma and is used more frequently in mild cases. This method simultaneously vaporizes affected tissue and enables adequate hemostasis. Additionally, CO2 laser treatment may be selected due to its precision and efficiency. Limitations not only include an increased risk of thermal damage to healthy tissue but also an increased risk of postoperative scarring and hypopigmentation.[7,8] Lastly, electrocautery dermabrasion provides a quick and effective method for precision excision while simultaneously providing effective hemostasis. Disadvantages to the use of electrocautery dermabrasion are similar to those of the CO2 laser technique in that it may lead to thermal damage but may result in less collateral thermal damage as treatment remains confined to the bulk of the rhinophyma.
Following the debulking and reshaping of rhinophyma using electrocautery dermabrasion, a series of cellular and molecular events take place during the re-epithelialization of treated tissue. These events lead to the regeneration of nasal tissue and produce a cosmetically appealing outcome.
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