ABSTRACT
Rhinophyma is an end-stage disease process of rosacea. These patients will usually present to dermatologic and cosmetic surgery offices for treatment.
Materials and methods: A review is presented of the pathophysiology and treatment of rhinophyma in a cosmetic surgery practice.
Results: Rhinophyma can be successfully treated by surgeons already familiar with common skin resurfacing and ablation modalities.
Conclusions: Rhinophyma represents hyperplastic tissue growth from the late stages of rosacea and causes social and functional problems for patients. Although it can become extremely disfiguring, treatment of mild-to-moderate cases is safe and predictable using common resurfacing modalities, such as CO2 laser and radiosurgery.

The term ‘rhinophyma’ is derived from the Greek rhis (‘nose’) and phyma (‘growth’). Rhinophyma is a pathologic process characterised by enlarged pores and thickening of the fibrous tissue of the nose. It is one of the end processes of severe rosacea and can be a debilitating, functional and psychosocial problem for patients. The most severe cases can affect breathing and even vision. Excessive alcohol consumption does not cause the disease, but can aggravate the condition and process — as it can with all phases of rosacea. Rhinophyma is a slowly progressive condition that worsens, with hypertrophy of the sebaceous glands. It manifests as single or multiple pink, bulbous, lobulated masses of the nasal tissue, especially on the dorsum and tip, may be associated with advanced telangiectasia, and may be pustular in advanced cases.

Rosacea is classified as types 1–41:

• Type 1 is erythematotelangiectatic rosacea, which presents with flushing and telangiectasia, and is usually seen as the primary state in younger patients
• Type 2 is papulopustular rosacea, and appears as bumps (papules) and pimples (pustules) on the skin
• Type 3 is phymatous rosacea, with enlargement of the nose and thickening of the skin owing to bump-like lesions
• Type 4 is ocular rosacea with burning, redness, irritation and watering of the eyes.

More women experience rosacea symptoms on the cheeks and chin, while the enlargement of the nose is usually seen in men past middle age1.

Figure 1 (A) The Ellman 4.0 MHz radiowave generator (B) with specialised rhinophyma electrodes

Diagnosis

The diagnosis of rhinophyma is visual, but can be confirmed with a biopsy. Phyma is the result of hyperplasia and fibrosis of the sebaceous glands in the presence of rosacea. Although rhinophyma is by far the most common pattern in cases of phyma, metophyma (swelling of the forehead), otophyma (swelling of the ear), and gnathophyma (swelling of the chin) may also be seen2. The lesions can become large, causing significant social stigmatisation and pose a challenge in the management of patient care.

Minor or early cases of rhinophyma may manifest as a ‘roughened’ patch of large pores and thickened tissue, which may remain static or progress to a grossly and advanced state. By using a range of rosacea medications, such as topical creams (Metrogel®; Galderma Laboratories, L.P., Ft. Worth, TX, USA), sulfur-based washes, antibiotics, Retin-A, light-based treatments (intense pulsed light), photodynamic therapy, and avoiding the triggers that can aggravate the condition, treatment of minor rhinophyma may be an option before permanent skin and sebaceous changes occur.

Figure 2 The Ellman Rhinophyma electrode in action

Medical or drug treatment is futile in moderate to advanced cases, and the definitive treatment is surgical. A number of modalities have been used to treat rhinophyma, including cryosurgery, radiofrequency ablation, electrosurgery, radiowave surgery, heated scalpel, tangential excision, scissor sculpting, skin grafting, dermabrasion, fractional laser, and conventional ablative lasers4-13. Simple resurfacing may be effective in minor cases, while aggressive ablative laser treatment is required in more advanced or disfiguring cases.

Surgical treatment

Figure 3 The Lumenis Encore laser (A) with the 3.0 mm spot handpiece (B) ablating nasal tissue

In a non-dermatology, cosmetic surgery office, moderate to severe rhinophyma is not a commonly seen condition and this author’s experience is based on approximately 20 procedures seen over the past decade. Most of these cases were in male patients, who are not usually motivated to seek, nor candidates for, medical treatment. They usually present for surgical treatment.

Although the author has experimented with different means of treating rhinophyma, he favours a combination of 4.0 MHz radiowave surgery (Figures 1 and 2) and fully ablative CO2 laser (Figure 3). Although either of these treatment modalities may be used alone, they team-up well to more easily and comprehensively treat rhinophyma. It is rare that the author uses cold steel for significant surgery, as incision with simultaneous coagulation is preferred. The nasal skin is quite vascular and using dermabrasion or scalpel to debulk presents a number of problems, such as a bloody and hard to visualise surgical field, and increased exposure of the surgeon and staff to blood (especially with dermabrasion). The ability to reduce, trim, and otherwise ‘pare’ the hypertrophic nasal skin with virtually no blood loss is a tremendous asset. Most commonly, both laser and radiosurgery (or electorsurgery) are used in conjunction, although either modality can be used as a sole therapy and is dependent on the instrumentation available to the surgeon and his/her specific preferences. The Ellman Ball Electrode (Ellman International, Inc., Hicksville, NY, USA) is also valuable for haemostasis if no laser device is available (Figure 4).

Figure 4 The Ellman Ball electrode is shown being used to cauterise and reduce hyperplastic tissue in rhinophyma surgery

The author uses the same treatment modalities for mild, moderate, and severe rhinophyma, but tempers the depth and power to the extent of the lesion. This is similar to treating acne scars, as light acne may be treated with laser devices at lower settings, while moderate and severe acne scars are treated using the same modality with the power and depth appropriately adjusted.