rhino phy ma
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RHINOPHYMA
Rhinophyma consists of hypertrophic, hyperemic, large nodular masses centered
around the distal half of the nose. Rhinophyma is seen almost exclusively in men
over 40 years of age. The tip and wings of the nose are usually involved by large
lobulated masses, which may even be pendulous. The hugely dilated folliclescontain long vermicular plugs of sebum and keratin.
The cause of rhinophyma is unknown. It is usually associated with a long history
of rosacea.
The histologic features are epidermal epithelial hyperplasia and pilosebaceous
gland hyperplasia with fibrosis, inflammation, and telangiectasia.
Treatment of this disfigurement is simple and most effective. Isotretinoin, though
surprisingly helpful, is hardly worth giving because the benefit is so temporary.
Rhinophyma is best treated by surgical ablation, electrosurgery (surgical cuttingcurrent) laser surgery, or wire-brush surgery.
For anesthesia a bilateral infraorbital nerve block just below the notch in the
maxilla on both sides and a ring of 2 percent Xylocaine in the skin around the
nose produce complete anesthesia. Often the latter is sufficient. The needle is
introduced opposite each ala and the injection is made upward toward the bridge
of the nose. If a needle 11/2 inches long i$ used, the two injections will meet on
the bridge of the nose. If the needle is partially withdrawn and then reintroduced
along the upper lip horizontally, a complete ring of anesthesia is given through
the same puncture wound. In addition, it is advisable to withdraw the needle
partially again and then to make an injection downward toward the corner of the
mouth.
Surgical ablation of redundant grapelike masses and of the bulbous swollen tip of
the nose is easily done with a razor blade, though the invention of the Shaw
scalpel, a decade or so ago, has superseded it. This instrument has a copper-
and Teflon-coated standard scalpel blade with a thermostatically controlled
heating element that heats it to 110-270 C, which provides hemostasis.
Tromovitch et al reported on its use in 19B3, and Eisen et al in 1986. Stegman
still prefers it to the cutting loop. The excessive tissue is shaved off in successive
layers until the desired amount has been removed. Bleeding ceases after a fewminutes with application of pressure. If an artery is cut, a suture should be
passed around it and tied. When oozing persists, Oxycel gauze may be applied.
Wire-brush surgery (dermabrasion) is useful for mild cases. If there are
pendulous redundant masses, these should first be cut off with scalpel or with
surgical cutting current. Dermabrasion may then be used to remove any
objectionable remnants.
Although the bipolar electrical cutting current is perfectly satisfactory, "brushing"
with an electrode shaped like a small hockey stick is even better because it sears
the tissues just enough to stop all bleeding, which may be troublesome with the
bipolar cutting current and with plastic surgery. This brushing action is obtained
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by using a cutting current without the indifferent electrode, i.e., as if it were a
unipolar current. After the operation, the nose is dressed with a nonadherent
dressing such as a Telfa pad. This type of treatment produces the best results of
any of the treatment modalities mentioned above.