Dermatology Online Journal

Giant rhinophyma in a bronchial asthma patient treated by excision and full thickness skin grafting
Rüştü Köse MD¹, M Ihsan Okur MD², M Emin Güldür MD³
Dermatology Online Journal 14 (9): 9

1. Department of Plastic and Reconstructive Surgery, Harran University Hospital, Sanliurfa, Turkey. rkose@harran.edu.tr
2. Department of Plastic and Reconstructive Surgery, Firat University Hospital, Elazig, Turkey
3. Department of Pathology, Harran University Hospital, Sanliurfa, Turkey

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Abstract

A 72-year-old man presented with an unusually severe case of rhinophyma. The pedunculated mass was widely excised and a skin graft from the medial upper arm was applied. A very satisfactory cosmetic result was obtained.

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Figure 1
Figure 1. The preoperative appearance of giant rhinophyma involving the distal half of the nose, alae, and nasal tip

A 72-year-old man presented with a seven-year history of a progressively growing mass on the nose with a history of nasal obstruction (Fig. 1). The patient had perceived rapid growth of the mass over the last year. He had been known as a bronchial asthma patient for the last eight years for which he was using tiotropium bromide and salmeterol xinafoate medications. His history revealed neither alcoholism nor episodes of facial flushing nor redness suggestive of any dermatological illness. Personal details revealed that he was confined to his home and had become a social recluse.

Figure 2
Figure 2. The postoperative appearance at 2 months following surgical treatment with full-thickness graft

On examination, there was a large pedunculated mass measuring 15x10x8cm arising from the tip to the dorsum of the nose. The mass was excised completely with a 1cm margin with a scalpel, preserving the perichondrium and periosteum of the nasal osteo-cartilaginous framework, resulting in a 10x7cm defect involving full-thickness skin loss of the dorsum and tip of the nose. Electrocautery was used for hemostasis. Reconstruction was immediately performed with a full thickness skin graft from the less hairy medial aspect of the upper arm (Fig. 2). Graft take was complete and the cosmetic result satisfied the patient.

Figure 3
Figure 3. Acantosis, dermal inflammatory infiltration, and dermal follicular structures that are cystic and filled with keratin (Hematoxylin and eosin x40)

On histopathological examination of the biopsy specimens, acanthosis, dermal vascular and lymphatic dilatation, perivascular and perifollicular inflammation and dermal fibrosis was seen. Sebaceous gland hyperplasia was prominent; follicular and sebaceous ducts were dilated and filled with keratin (Fig. 3). There was no granulomatous inflammation. The diseased tissues examined by the histopathologist did not reveal the presence of neoplastic cells.

Rhinophyma is a rare, disfiguring disease characterized by a progressive hypertrophy of the soft-tissues of the nose with its increased volume, mainly in the lower half and often associated with an end-stage of severe acne rosacea. Surgical reduction is the mainstay treatment of an established rhinophyma [1].

Severe rhinophyma is a disfiguring and socially stigmatizing condition, characterized by lay terms such as "whisky" or "rum" nose and "grog blossom" [2]. Although many patients with a severe degree of rhinophyma had nasal obstruction, their primary concern was usually to treat the severe cosmetic deformity [3]. Our patient hardly went out of his home because of his embarrassment caused by the appearance of his nose. In the past, rhinophyma was considered a clinical sign of alcoholism, but this relationship was never demonstrated [4].

Although some have reported that the incidence of simultaneous carcinoma in the setting of rhinophyma varies from 15 to 30 percent [5, 6], others suggest that the risk of cutaneous malignancy in rhinophyma may be much lower than previously thought [4]. In our case too, no neoplastic cells were detected.

Although in the related literature an association between the use of phenytoin and development of recurrent rhinophyma is reported [7], no association between the use of tiotropium bromide or salmeterol xinafoate and development of rhinophyma is reported.

Treatment depends on the severity and extension of affected skin. Even though medical therapy may be an option for very early rhinophyma before scarring and fibrosis has occurred, surgical modalities are the accepted treatment of established rhinophyma [7, 8]. Surgical reduction can be performed in two forms, either partial-thickness excision or full-thickness excision. In the most commonly used method, partial excision, the rhinophyma is shaved off tangentially and the residual deep pilosebaceous appendages produce re-epithelization [1, 3]. The reasons for full-thickness excision include deeply infiltrating rhinophyma, rhinophyma with underlying cancer, or the presence of excess scar tissue making partial thickness excision difficult. Full-thickness excision requires covering the defect with a skin graft or local flap [7, 8].

Excision of the affected skin preserving perichondrium and reconstruction with a full thickness graft provided a technically simple one-stage reconstruction with an acceptable cosmetic result and good definition of nasal features. Because we used this method successfully in our patient, we strongly recommend this method to be used for giant rhinophyma.

References

1. Rex J, Ribera M, Bielsa I, Paradelo C, Ferrándiz C. Surgical management of rhinophyma: report of eight patients treated with electrosection. Dermatol Surg. 2002 Apr;28(4):347-9. PubMed

2. Redett RJ, Manson PN, Goldberg N, Girotto J, Spence RJ. Methods and results of rhinophyma treatment. Plast Reconstr Surg. 2001 Apr 15;107(5):1115-23. PubMed

3. Bogetti P, Boltri M, Spagnoli G, Dolcet M. Surgical treatment of rhinophyma: a comparison of techniques. Aesthetic Plast Surg. 2002 Jan-Feb;26(1):57-60. PubMed

4. Curnier A, Choudhary S. Rhinophyma: dispelling the myths. Plast Reconstr Surg. 2004 Aug;114(2):351-4. PubMed

5. Acker DW, Helwig EB. Rhinophyma with carcinoma. Arch Dermatol. 1967 Mar;95(3):250-4. PubMed

6. Ress TD. Basal cell carcinoma in the setting of rhinophyma. Plast Reconstr Surg. 1955 Oct;16(4):283-7. PubMed

7. Jaramillo MJ, Stewart KJ, Kolhe PS. Phenytoin induced rhinophyma treated by excision and full thickness skin grafting. Br J Plast Surg. 2000 Sep;53(6):521-3. PubMed

8. Sharma R, Ramana YV, Makkar S, Nanda V. Giant rhinophyma: managing a social recluse. Plast Reconstr Surg. 2005 Jun;115(7):2146-8. PubMed

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