Large Rhinophyma Treated by Surgical Excision and Electrocautery

Abstract

Rhinophyma is a benign condition characterized by a large, bulbous nose with prominent pores. It is commonly associated with untreated cases of rosacea. The disease can carry a substantial psychological impact that causes patients to seek advice about how to improve their physical appearance. Many treatment options are available for rhinophyma, but there is no standard treatment protocol. Here, we describe the case of a 65-year-old man with a large rhinophyma that caused him cosmetic and psychosocial embarrassment. The condition was treated by surgical excision and bipolar electrocautery. No complications occurred after the procedures, and healing was completed 2 weeks later by secondary intention and reepithelialization. A simple surgical removal using a scalpel to shave off the abnormal tissue with electrocauterization of the bleeding points can be considered as a good treatment option for rhinophyma, as it results in an excellent cosmetic outcome and has short recovery time.

Full text

Case Report
Large Rhinophyma Treated by Surgical Excision
and Electrocautery
Nabeel K. Al Hamzawi
1
and Salih M. Al Baaj
2
1
Department of Dermatology, Diwaniyah Teaching Hospital, Diwaniyah, Iraq
2
Department of Plastic Surgery, Diwaniyah Teaching Hospital, Diwaniyah, Iraq
Correspondence should be addressed to Salih M. Al Baaj; salih_albaaj60@yahoo.com
Received 5 December 2018; Accepted 20 May 2019; Published 25 July 2019
Academic Editor: Yueh-Bih Tang
Copyright © 2019 Nabeel K. Al Hamzawi and Salih M. Al Baaj. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Rhinophyma is a benign condition characterized by a large, bulbous nose with prominent pores. It is commonly associated with
untreated cases of rosacea. The disease can carry a substantial psychological impact that causes patients to seek advice about
how to improve their physical appearance. Many treatment options are available for rhinophyma, but there is no standard
treatment protocol. Here, we describe the case of a 65-year-old man with a large rhinophyma that caused him cosmetic and
psychosocial embarrassment. The condition was treated by surgical excision and bipolar electrocautery. No complications
occurred after the procedures, and healing was completed 2 weeks later by secondary intention and reepithelialization. A simple
surgical removal using a scalpel to shave offthe abnormal tissue with electrocauterization of the bleeding points can be
considered as a good treatment option for rhinophyma, as it results in an excellent cosmetic outcome and has short recovery time.
1. Introduction
Rhinophyma is a benign skin lesion characterized by a large,
bulbous, and erythematous-appearing nose. It is considered
to be an advanced stage of phymatous rosacea [1]. However,
some people have rhinophyma without having rosacea. The
diagnosis of rhinophyma is usually based on the clinical
appearance of the nose and the history of rosacea. Several
treatment options are available such as surgery, dermabra-
sion, and laser therapy. Here, we describe the case of a large
rhinophyma treated successfully by surgical excision and
bipolar electrocautery with an excellent cosmetic result.
2. Case Report
A 65-year-old man presented to the outpatient dermatology
clinic with a large bulbous nose for the past 5 years. The
physical examination showed three hypertrophied lobules
covering the tip of the nose with deep pores and fine telangi-
ectasia (Figures 1 and 2). The patient had been complaining
of rosacea for years without receiving treatment.
Surgical excision was performed under local anesthesia
using 2% lidocaine, which was injected into the nose. After
the local anesthetic was infiltrated, the hypertrophied tissue
was debulked using a number 10 scalpel. The excess tissue
was removed layer by layer, with attention to preserve part
of the basal appendages overlying the perichondrium to
avoid the possibility of scarring. Hemostasis was achieved
using bipolar electrocautery to reduce bleeding from the
denuded area at a setting of 10-12 watts. Topical mupirocin
ointment was applied to the wound, and the area was secured
with a tie-over dressing.
The dressing was removed after 72 hours, and the wound
was left exposed to heal by secondary intention. The excised
tissue was sent for histopathological study, and the diagnosis
of rhinophyma was confirmed. Follow-up was continued
with weekly visits until healing was completed by the fourth
week (Figure 3).
Hindawi
Case Reports in Surgery
Volume 2019, Article ID 2395619, 3 pages
https://doi.org/10.1155/2019/2395619

3. Discussion
Rhinophyma is a slow-growing and disfiguring enlargement
of the nose that primarily occurs in men aged 50-70 years.
Established rhinophyma is characterized by a large bulbous
nose, wide pores, thick skin, and telangiectasia [2]. It is
considered to be a characteristic of an advanced stage of
phymatous rosacea. Phymatous rosacea can also affect the
forehead (metophyma), chin (gnathophyma), ears (oto-
phyma), and eyelids (blepharophyma) [3]. The exact cause
of rhinophyma is not understood. It is thought to be multi-
factorial in origin with a primary etiology of unregulated
superficial vasodilatation [4, 5]. Several hypotheses include
potential roles for environmental factors and microorgan-
isms such as Demodex folliculorum and Helicobacter pylori
[6]. There is a misguided belief that it is related to alcohol
consumption, with a nickname of the condition “whiskey
nose.”There is no link between rhinophyma and alcohol
[7]. Rhinophyma can be classified into three clinical varieties:
glandular (nasal enlargement due to hyperplasia of the
sebaceous glands), fibrous (increased density of the nasal
connective tissue with variable sebaceous hyperplasia), and
fibroangiomatous (nasal enlargement due to edematous con-
nective tissue with enlarged veins) [8]. A histopathological
evaluation can help to exclude disorders that mimic rhino-
phyma, such as squamous cell carcinoma and angiomatous
tumors. Histopathological features of rhinophyma include
sebaceous hyperplasia, connective tissue hyperplasia, and
signs of chronic inflammation [8].
Treatment of rhinophyma can be very challenging and
involve a combination of different treatment options. Medi-
cal therapies include oral isotretinoin and antibiotics, such
Figure 1: A 65-year-old man with the mid and apical areas of the
nose covered with a large lobulated rhinophyma. Figure 2: Rhinophyma manifested by three lobules two at the side
and one at the apex of the nose with prominent pores and
telangiectasia.
Figure 3: Complete healing by reepithelialization one month after
the surgical procedure.
2 Case Reports in Surgery

as tetracycline, erythromycin, and topical metronidazole,
which may have a positive effect in the early stages of the
disease. Oral medications are not usually effective in
established rhinophyma; therefore, surgery is often neces-
sary. Surgical treatments are aimed at removing the excess
tissue and restoring the natural appearance of the nose; it is
considered the standard gold treatment. Surgery, dermabra-
sion, and debulking and sculpting the tissue using a sinus
microdebrider, ablative carbon dioxide laser therapy, electro-
surgery, and electrocautery were all considered as treatment
options [9, 10]. However, there is no standard protocol to
manage rhinophyma. In our case, we used a combined tech-
nique of simple surgical excision and bipolar electrocautery
as an alternative option to treat large rhinophyma. This
procedure is less aggressive, is easy to perform, and leads to
a significant result. Furthermore, no complications such as
scarring or hyperpigmentation were recorded following this
operation after long-term follow-up. In some degree, a
similar technique has been reported in the literature. Silva
et al. have described two patients with rhinophyma that
underwent tangential excision associated with electrocoagu-
lation with good long-term results [11]. The extent of tissue
growth and the severity of the condition can help determine
the preferred treatment method. The modality of treatment
selected and expert skill result in a better outcome.
4. Conclusion
Because there is no cure with procedures that are aimed only
at removing the overgrowth of rhinophyma and reshaping
the nose, surgeons should select the option with the least
complications. A simple surgical excision using a scalpel to
shave offthe abnormal tissue with electrocauterization of
the bleeding points can be considered as a good treatment
option for rhinophyma, as it results in an excellent cosmetic
outcome and has short recovery time.
Consent
A written consent was obtained from the patient to publish
his photos.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
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3Case Reports in Surgery