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CME

Rhinophyma: Review and UpdateRod J. Rohrich, M.D., John R. Griffin, M.D., and William P. Adams, Jr., M.D.Dallas, Texas

Learning Objectives: After studying this article, the participant should be able to discuss: 1. Clinical features andanatomy of rhinophyma. 2. The etiology and epidemiology of rhinophyma. 3. Associated diagnosis that can complicaterhinophyma. 4. Common nonsurgical and surgical therapies for rhinophyma. 5. A safe and integrated treatment plan forthe patient with rhinophyma.

Rhinophyma may have been first recognizedin ancient Greece and Arabia.1,2 Elliott et al.and Matton et al. credit Hebra with naming thedisease in the mid-nineteenth century.3,4 Thename is derived from the Greek rhis, for nose,and phyma, meaning growth.

Many imaginative terms have been used todescribe the erythematous, hypertrophied, andinflamed nose that typifies rhinophyma. In thepast, the deformity has been compared withtuberous vegetables as well as to animal snouts.The terms “rum blossom” and “whiskey nose”have permeated our society. These terms, andtheir association with famous persons such asW. C. Fields, have helped to perpetuate thecommon association of rhinophyma with alco-holism. Although the facial flushing caused byvasoactive substances such as caffeine and alco-hol may exacerbate the condition, rhinophymais more likely a severe form of acne rosacea.

Virchow is credited by Wiemer as havingcorrectly associated rhinophyma with acne ro-sacea in 1846.1 Over the last 40 years, numer-ous reports have supported the progression ofrosacea to acne rosacea and the final manifes-tation of rhinophyma.1,5–7 As a result, medi-cines that have been helpful in the treatmentof rosacea are now being used to augment thepredominantly surgical approach torhinophyma.

In this article, we present a discussion on thepathology, clinical manifestations, and de-scribed treatment options for rhinophyma. Wealso discuss the differential diagnosis with em-

phasis on conditions that can mimic rhino-phyma. We offer our preferred approach torhinophyma that incorporates medical man-agement and a surgical plan guided by preop-erative standardized aesthetic facial and nasalanalysis.

CLINICAL FEATURES AND HISTOPATHOLOGY

Rebora describes four stages of rosacea thatculminate in rhinophyma.6 The first stage isfrequent facial flushing. Wilkin notes that ro-sacea “is essentially a cutaneous vascular disor-der.”8 This increased vascularity is postulatedto lead to a second stage characterized by thick-ened skin, telangiectasias, and persistent facialerythema, or erythrosis.1,6 A subset of thesepatients will progress to a third stage: acnerosacea. Acne rosacea is characterized by ery-thematous papules and pustules of the fore-head, glabella, malar region, nose, and chin.Pustules can sometimes be seen in other areas,including the chest, back, and the scalp ofbalding men.6,9 Wilkin classifies these firstthree stages as prerosacea, vascular rosacea,and inflammatory rosacea.8

Rhinophyma is the fourth stage of evolvingrosacea.6,8 The group that develops rhino-phyma is smaller again than the papular-pustular group. The nose is usually the onlystructure affected, but mentophyma, oto-phyma, and zygophyma have been de-scribed.6,10,11 Grossly, the nasal skin is erythem-atous with telangiectasias, sometimes purple incolor. In severe cases, the skin can have pits,

From the University of Texas Southwestern Medical Center at Dallas. Received for publication October 10, 2001.

DOI: 10.1097/01.PRS.0000019919.70133.BF

860

fissures, and scarring.1 Inspissated sebum andbacteria result in chronically infected skin and,often, an unpleasant odor. The nasal tip ispreferentially enlarged. The nasal dorsum andside walls are involved, but to a lesser degree.As the nasal skin hypertrophies, the aestheticsubunits of the nose are distorted, merged, andobliterated. Patients often suffer from second-ary nasal airway obstruction.1,12 Tumorousgrowths can develop in late, nodular forms ofthe disease, resulting in dramatic cosmetic de-formity.1,13 In the vast majority of cases, thebony and cartilaginous frameworks areunaffected.

Marks proposes a mechanism for rhino-phyma evolution that begins with vascular in-stability in the skin.14 Loss of fluid into thedermal interstitium and matrix is postulated toinitiate inflammation and fibrosis.12,14 The na-sal skin thickens concurrently with dermal andsebaceous gland hyperplasia. Dilated seba-ceous ducts become cystic and plugged withsebum. Fibrosis and acanthosis are prominent.A lymphocytic infiltrate is seen as well. All ofthese histologic features are seen in acne rosa-cea as well, further supporting the link be-tween the precursor condition and rhino-phyma (Fig. 1).3,7,15,16

Several authors have observed differentforms and stages of progression of rhinophy-ma.1,12,13,16,17 Based on a study of 17 patientswith rhinophyma, Aloi et al. observed two dis-tinct forms of the disease.16 The first groupclinically appeared consistent with commonrhinophyma. The second group had more se-vere clinical features and different histology.The common form showed the usual his-topathologic changes described above. In con-trast, the severe form displayed less prominentinflammation, a more thickened dermis, thin-

ner epidermis, actual loss of recognizable seba-ceous units, and more diffuse dermal telangi-ectasias. Aloi et al. propose that in severerhinophyma, the sebaceous units may be oblit-erated by persistent edema and fibrosis. Theauthors remarked that the histopathologicfindings in severe rhinophyma were similar tolymphedema and elephantiasis.16 Interestingly,there appeared to be no correlation betweendisease severity and duration in Aloi et al.’sseries.

In an excellent review of this subject, Free-man reviewed 55 patients with rhinophyma,and devised a five-part classification based onseverity of deformity.13 We have found this clas-sification system useful in describing the vari-ability of deformity in patients with rhino-phyma (Fig. 2).

EPIDEMIOLOGY AND ETIOLOGY

Rosacea is common, with a reported preva-lence between 0.5 and 10 percent.6,9,18,19 Rosa-cea is thought to be more common in women;however, this may be inaccurate if it is true thatwomen with rosacea seek medical attentionearlier in their course than similarly affectedmen.6

In contrast, the progression to facial skinthickening and rhinophyma is more commonin men.1,3,13 The ratio of male to female pa-tients with rhinophyma ranges from 5:1 to 30:1.1,3 The increased incidence in men may bedue to androgenic influence. Thiboutot et al.note that 5-alpha reductase activity is higher inacne-prone sebaceous units relative to seba-ceous units in non–acne-prone skin.20,21 Theydo not specifically relate this finding to rosaceaor rhinophyma, however. Acne rosacea andrhinophyma are seen more often in persons ofEnglish and Irish descent than in those of Af-rican descent.1,12 Rhinophyma may be rare inAsians, with only 20 reported cases in the Jap-anese literature.22

The early form of rosacea, characterized byincreased facial vascularity, begins in the sec-ond and third decades.6 Patients with chronicerythrosis and acne rosacea are generally intheir fourth to fifth decade. In both Fisher’sand Matton et al.’s series and at our institution,the average age of patients operated on forrhinophyma was greater than 50 years.4,12 Nev-ertheless, cases of rhinophyma in patientsyounger than 30 years have been reported.1,23,24

There appears to be a significant familialcomponent to rosacea.6 However, the influ-

FIG. 1. Histology of rhinophyma. This is characterized bysebaceous hyperplasia, inflammation, and acanthosis.

Vol. 110, No. 3 / RHINOPHYMA 861

ence of heredity on rhinophyma remains un-clear. In Freeman’s series of 55 patients withrhinophyma, 12 patients reported close familymembers with the disease.13 Matton et al. re-ported two brothers who were similarly af-flicted.3,4 Still, few papers exist that explore thepossibility of a familial or hereditary compo-nent in rhinophyma.

The importance of increased skin vascularityand chronic inflammation in the progressionfrom rosacea to rhinophyma is generally ac-cepted. The nature of irritants that may incitethis progression is less clear. Although the as-sociation of alcoholism and rhinophyma re-sults in unfair stigmatization of persons withthe disease, some authors support this link.6,7,13

Eighteen of Freeman’s 55 patients with rhino-phyma reported an alcoholic history.13 In con-trast, Wiemer suggests that facial flushing sec-ondary to vasoactive foods and drink,including alcohol, is a coincidental phenome-non seen in most people, and may have noinfluence on the evolution of rhinophyma.1Rebora states that the facial flushing seen inpatients with rosacea secondary to certainfoods, drink, and emotional stress is more pro-nounced and longer lasting than the flushingseen in persons without rosacea.6 Ayers andAnderson proposed a link between the skinmite Demodex folliculorum and acne rosacea in1932.25 Bacterial colonization within pluggedsebaceous glands is a consistent finding in rhi-nophyma; but it is unclear whether this is pri-mary or secondary in the disease process.

Investigators began to study a possible asso-ciation of rosacea with Helicobacter pylori when itwas observed that many patients with the skindisorder also complained of gastrointestinal

symptoms. The hypothesis that H. pylori couldbe an infectious etiology of rosacea has notbeen supported by recent studies.26–28 Articlesby Jones et al. and Sharma et al. showed nodifference in rates of H. pylori seropositivitybetween patients with rosacea and controls.26,27

In a randomized prospective trial, Bamford etal. showed that empiric treatment of H. pyloridid not improve outcome in patients withrosacea.28

DIFFERENTIAL DIAGNOSIS AND PITFALLS

The distinctive hypertrophied, erythema-tous, and nodular nose of rhinophyma is gen-erally an easy diagnosis upon inspection. How-ever, there are numerous reports in theliterature of patients who were diagnosed withrhinophyma, only to receive a different diag-nosis on the pathology report.

The deformity of rhinophyma can compli-cate accurate examination of the nasal skin. Asa result, malignancies can go unnoticed withinthe hypertrophied skin. Acker and Helwig sug-gest a 3 to 10 percent incidence of occult basalcell carcinoma in patients with rhinophyma.15

In their series of 47 patients, they also foundone adenoid squamous cell carcinoma and onesebaceous adenoma. Broadbent and Cort re-port two elderly patients with longstanding rhi-nophyma complicated by high-grade squa-mous cell cancer.29 Sebaceous carcinoma andangiosarcoma have also been found in the rhi-nophymatous nose.30,31

Not only can additional pathology hidewithin the rhinophymatous nose, but cancerand other disorders can also actually mimic thedisease. Keefe et al. reported a case of excisedrhinophyma in an elderly man that was foundon pathologic examination to be entirely com-posed of basal cell cancer.32 Nesi and Lynfieldreported a case of metastatic lung cancer to thenose which was thought initially to be rhino-phyma.33 Granuloma eosinophilicum, sarcoid-osis, and lymphoma have been found to mimicrhinophyma as well.32,34–36

TREATMENT

Nonsurgical Therapy

Today, based on proven efficacy, topical andoral antibiotics and retinoids are the mainstayin the treatment of rosacea.1,6,9,18,37,38 Goldsteinet al. showed in their study that patients withsevere acne treated with isotretinoin (Accu-tane, Hoffman-LaRoche, Nutley, N. J.) showed

FIG. 2. Clinical classification of rhinophyma based on se-verity of deformity. From Freeman, B. S. Reconstructive rhi-noplasty for rhinophyma. Plast. Reconstr. Surg. 46: 265, 1970.Used with permission.

862 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002

significant clinical improvement, as well as de-creased sebum production and sebaceousgland size that persisted well beyond the cessa-tion of therapy.37 Based on the observed seba-ceous changes in rosacea, others have studiedthe effects of retinoids on this disease.9,18,38 Ertlet al.’s study demonstrated the individual effi-cacy of topical tretinoin (Retin-A, Ortho Phar-maceuticals, Raritan, N. J.) and low-dose oralisotretinoin in the treatment of severe rosa-cea.18 While acknowledging the efficacy ofRetin-A, Wilkin cautions that the sensitive, er-ythematous skin of rosacea is easily irritated byRetin-A.8 He notes that this medicine may ac-tually worsen the erythema and the diseaseitself by stimulating angiogenesis.8 Rebora ad-vocates oral Flagyl (Pharmacia, Chicago, Ill.) asa first-line agent with tetracycline and Accu-tane (oral) as second-line agents.6 A potentialadvantage of Accutane over Retin-A is theavoidance of skin irritation.

Historically, dietary changes, combinationsof vitamins, herbs, salves, mercury vapor, injec-tion of fibrolysin, and steroids have all beenused to treat rhinophyma.1,3,12 X-ray therapywas felt to be promising in the 1920s, when itwas shown to decrease the size of sebaceousglands.1,3 But the use of x-ray therapy in thetreatment of skin disorders was discreditedwhen it was associated with secondary skin ma-lignancies.1,3 Recently, the role of x-ray therapyin select cases of rhinophyma has been sepa-rately reassessed by Keefe et al. and Plenk.32,39

Plenk reported two cases of rhinophyma com-plicated by basal cell cancers that were success-fully treated by punch biopsy and radiation.The author reports that both patients are freefrom cancer years after therapy.39 Photographsof these two patients seem to confirm thatsome aesthetic improvement is possible withbiopsy and radiation alone.

No antibiotic or retinoid has been shownconclusively to halt the progression from rosa-cea to rhinophyma or cause regression of ex-isting rhinophyma. Therefore, despite the ad-vances in medical therapy for the treatment ofrosacea, the mainstay of treatment for rhino-phyma remains surgical.

Surgical Therapy

Fisher reviews how Dieffenbach excised rhi-nophymatous skin and closed the nose primar-ily in 1845. Later, in 1851, von Langenbeckperformed full-thickness excision of nasal skinand allowed the surface to heal secondarily. In

1864, Stromeyer performed partial thicknessexcision of involved skin, allowing reepithelial-ization from retained sebaceous glands. Woodintroduced skin grafting to the treatment ofrhinophyma in 1912.12

Today, a myriad of effective surgical optionsare available. Dermaplaning and dermabrasionhave been used with impressive results formany years.1,40,41 Cryosurgery and heatedknives and loops also have their advocates.1,42,43

The CO2 laser was reported by Shapshay et al.in 1980 in the treatment of rhinophyma.44 In1983, Henning and van Gemert reported theuse of the argon laser for this disease.45 Sincethat time laser techniques have become verypopular in the treatment of rhinophyma.Greenbaum et al. reported three patients withrhinophyma who were each treated with CO2laser on one side of their nose and with elec-trosurgery on the other side. The authorsnoted comparable results between the twomodalities.46

Baker acknowledges the efficacy of the CO2laser in the treatment of facial rhytids andrhinophyma. However, he remarks, “despitethe continued demand for space age laser tech-nology, the dermabrader remains a safe andefficacious modality for the treatment of rhyt-ids and scars.”40 Har-El et al. retrospectivelystudied 23 patients who were treated with ei-ther laser or blade excision of rhinophyma.The authors found no difference in operativetime, pain, postoperative bleeding, overallcomplications, or subjectively graded aestheticoutcome.47 The authors did prefer the laser forimproved intraoperative hemostasis.

Toward the goal of incorporating the preci-sion of sharp dissection with improved hemo-stasis, Dufresne et al. recently used an ultra-sonic scalpel to treat rhinophyma. The authorsreported good hemostasis intraoperatively, aswell as improved tactile control that they com-pared with the “sculpting of clay.”48 In addi-tion, the authors report minimal tissue dam-age, comparable to samples of skin excised bya scalpel.

Algorithm for Management of Rhinophyma

Several authors have proposed treatmentregimens for rosacea and rhinophyma in thedermatologic literature.6,18,20,49 Despite theirdifferences, all seem to support a graduatedapproach, with appropriate preventative, topi-cal, and oral therapies for each stage of thedisease. On the basis of a literature review and


our clinical experience with rhinophyma, wepropose an algorithm to help guide decision-making when assessing the patient with in-creased facial vascularity (Fig. 3).

When evaluating the rhinophyma patient,we begin with a detailed dermatologic historyand examination. Prior or coexisting skin le-sions are noted. The use of medicines such assteroids, antibiotics, and retinoids is specificallyelicited from the patient.

We follow the skin evaluation with detailedrhinoplasty planning.50 The rhinophyma pa-tient deserves the same critical evaluation andstandardized approach as patients who un-dergo more traditional rhinoplasty. Therefore,we begin the nasal evaluation with the nasalhistory. This is followed by precise anatomicexamination, photographic analysis, and finalcomplete aesthetic analysis of the nose in rela-tion to the face.50,51 The results of the consul-tation are discussed with the patient, and anindividualized treatment plan is devised.

It is important to not be overly focused onthe rhinophymatous abnormality and therebyignore other contributing factors to the pa-tient’s deformity. Clearly, patients with rhino-phyma can have prior nasal trauma, bony andcartilaginous framework deformities, andother abnormalities that must be consideredwhen planning surgery. Rhinophyma causingnasal airway obstruction is well described.1,12

However, when evaluating these patients, un-derlying septal deviations and turbinate hyper-trophy must not be missed.

As extensive resection of skin is generallyneeded to reduce rhinophyma, it is prudent tostage the operation when correction of com-bined rhinophymatous and framework abnor-malities is planned. Skin slough secondary toischemia after rhinophyma surgery has beendescribed.1

Regarding the hypertrophy of rhinophyma,we prefer the combination of partial thicknessskin excision/dermaplaning with a scalpel fol-

FIG. 3. Algorithm for treatment of rosacea and rhinophyma.


lowed by dermabrasion for final contouring.These instruments allow fine control whilesculpting the tissue and therefore reproducibleresults. In most cases, hemostasis has not beena problem when using pressure and judiciouselectrocautery. We use the CO2 laser primarilyfor additional hemostasis when needed, not foradditional sculpting.

Based on the reported association of skincancer with rhinophyma and the possibility ofrare disorders that mimic the disease, we sendall excised rhinophymatous skin for pathologicanalysis. Despite the fact that the laser can cutand excise as well as ablate tissue, we questionwhether use of the laser as the primary treat-ment modality for rhinophyma allows ade-quate tissue sampling for pathology. Certainlypatients who report a recent change or rapidenlargement of a rhinophymatous nose shouldbe encouraged to have surgery regardless oftheir aesthetic concerns.

We consider full-thickness skin excision andgrafting only in the contexts of severe nodularrhinophyma and widespread underlying malig-nancy. After consultation with a dermato-pathologist, patients with small foci of tumorare referred to a dermatologist trained inMohs’ surgery. Mohs’ surgery for multiple fociof basal cell cancers in the context of rhino-phyma has been described.52

Immediately postoperatively, we dress theraw nasal surface with antibiotic ointment andXeroform (Sherwood-Davis & Geck, Mansfield,Mass.) gauze. We use bacitracin or Bactrobanointment (GlaxoSmithKline, Research Trian-gle Park, N. C.). We inform the patient toexpect minimal oozing for 1 day after surgery.Beginning on postoperative day 1, the patientis asked to begin changing the dressing twice aday for 3 days, with a thin film of ointment anda single layer of Xeroform. The patient alsotakes a 3-day prescription of a first generationcephalosporin or another oral antibiotic thatcovers skin flora. At postoperative day 4, we seethe patient in the office. The nasal surfaceshould look red, with intervening pink areas ofearly reepithelialization. We stop the ointmenton postoperative day 4 to prevent maceration.The patient is seen weekly in the office tofollow healing. We have not observed problemswith full-thickness skin loss or hypertrophicscarring, but patients should be followedclosely for these problems postoperatively. Wecontinue Xeroform gauze dressing changeswithout ointment until the nose is healed.

Reepithelialization is usually complete in 2 to 4weeks.

Although it has not been our experience,problems with wound healing and keloids havebeen reported when surgical therapy of rhino-phyma was superimposed with isotretinointherapy.53 A causal relationship between com-bined isotretinoin and surgical therapy andkeloid formation is not conclusively proven byZachariae’s article.

It has been shown that Accutane impairsreepitheliazation in patients undergoingchemical peels.54 Therefore, we do not adviseoperating on patients with rhinophyma whoare taking Accutane/tretinoin. Any patientwith rhinophyma who is taking Accutane mustwait at least a year after quitting the drug be-fore surgery is safe. Also, secondary to the der-matitis that occurs with topical tretinoin, wewait 3 to 4 weeks postoperatively to begin treat-ment with Retin-A. However, use of Retin-A,unlike Accutane, is not a contraindication tosurgery.

We advise shielding from the sun indefi-nitely and use of combined ultraviolet A andultraviolet B sunscreens. Our preferred formu-lation is micronized, clear zinc oxide, whicheffectively blocks both ultraviolet A and ultra-violet B. The association of skin irritation inpatients with rosacea with sunscreens contain-ing PABA and related compounds has beenreported.49 In addition, Nichols et al. advise theuse of PABA-free sunscreens that contain dime-thicone and cyclomethicone for patients withrosacea.49 The authors’ patients with rhino-phyma have reported no problems with skinirritation secondary to use of clear zinc oxide.

CASE STUDIES

Case 1A 54-year-old white man presented for evaluation of a

slowly enlarging nasal deformity with a longstanding historyof nasal airway obstruction. Facial and nasal analysis revealedadequate facial proportions. His overall complexion wasruddy, consistent with rosacea. On frontal view (Fig. 4, above),the nose was not significantly deviated; however, there wassome degree of asymmetry secondary to nasal skin hypertro-phy. Abnormal nasal skin nodularity contributed to the cos-metic deformity. The skin hypertrophy also created the illu-sion of wide bony and cartilaginous pyramids. The tip and alawere similarly widened by the thickened skin characteristic ofrhinophyma. The tip overprojected significantly, again sec-ondary to skin thickening (Fig. 4, center). The illusion of adeep supratip break was secondary to rhinophyma as well. Hisangle of tip projection and columellar-lobular angle werenormal. On basal view (Fig. 4, below), the patient was notedto have an abnormally long lobular portion of the tip relative


to the columellar portion. The external nasal valves werecompressed by the weight of the rhinophymatous mass. An-terior-caudal septal deviation was noted on the right. Bilateralinferior turbinate hypertrophy was noted as well. This patienthad more of a localized tumor than diffuse enlargement byFreeman’s classification.13

Operative goals were to reduce the rhinophyma, to re-create and contour the aesthetic subunits of the dorsum andtip, to restore a smooth skin surface, and to correct nasalairway obstruction. The surgical plan was as follows:

1. Bilateral anterior-inferior turbinates submucosalresections.

2. Right hemitransfixion incision and resection of quadran-gular cartilage and scar, preserving an adequate L-strut.

3. Partial-thickness dermaplaning of hypertrophied nasal tipand dorsal skin using a scalpel to reduce volume andrestore contour and tip projection.

4. Completion of restoration of aesthetic subunits andsmoothing of nodular skin with dermabrasion.

At 4 months postoperatively, our patient demonstratedcomplete healing of his nasal skin. The nasal skin nodularityand asymmetry were corrected. The dorsum, supratip area,lobule, and alae had restored smooth contour. The over-projecting tip was corrected on lateral views. Of note on basal

views, the external nasal valves were significantly more patentpostoperatively. Reduction of the rhinophymatous massalone is responsible for this change. Nasal airway obstructionwas corrected by the above, septal resection, and inferiorturbinates resection.

Case 2A 62-year-old white man presented with a severely deform-

ing rhinophyma. He clearly had diffuse enlargement withlocalized tumor.13 He demonstrated the illusion of nasalframework asymmetry secondary to asymmetric growth of therhinophyma (Fig. 5, above and center). The columellar-lobularangle was acute preoperatively because of the weight of thehypertrophied nasal skin. He also suffered from nasal airwayobstruction resulting from compression of the external nasalvalves (Fig. 5, below).

This patient underwent dermaplaning with a scalpel fol-lowed by dermabrasion. Postoperative views were taken 3months after surgery. He demonstrated a more normal nasalcontour, resolution of asymmetry, widening of the columel-lar-lobular angle, and correction of his nasal airwayobstruction.

FIG. 5. Preoperative and 3-month postoperative views.

FIG. 4. Preoperative and 4-month postoperative views.


Case 3A 55-year-old white man presented with deforming rhino-

phyma. Again, here is an example of diffuse enlargement withan accompanying tumor.13 The rhinophyma distorted the tipand supratip areas more than the dorsum. Similar to theprevious cases, this patient underwent dermaplaning anddermabrasion. Photographs taken 1 year postoperativelydemonstrate normal nasal contour and unveiling of normalnasal tip anatomy (Fig. 6).

The pathology from all three operations re-vealed sebaceous hyperplasia consistent withrhinophyma.

DISCUSSION

Rhinophyma is most likely a severe manifes-tation of advanced rosacea. Irritants, such asalcohol and sunlight, may contribute to theprogression of the disease. Avoidance of theseand other irritants has been described for pa-tients with rhinophyma and is advocated in ourtreatment algorithm. Patients with all stages ofrosacea, including those with rhinophyma, can

benefit from varied topical and oral medicines.We favor clear zinc oxide, MetroGel (Gal-derma, Cranbury, N. J.), and Retin-A for ourrhinophyma patients.

Again, we caution against operating on rhi-nophyma patients who are taking Accutane. Ifsevere acne coexists with rhinophyma, the Ac-cutane can be supplanted by other drugs for ayear preoperatively. We would not restart Ac-cutane until healing from surgery is complete,including full resolution of postoperativeerythema.

Clearly, many surgical modalities are effec-tive. We prefer dermaplaning followed bydermabrasion because of their simplicity andreproducibility of results. The laser is em-ployed mainly for hemostasis when needed.We advocate complete nasal and facial aes-thetic analysis, as patients with rhinophymamay have other nasal problems that would ben-efit from correction. However, to prevent com-plications related to devascularization of thenasal tip, we recommend staging the proce-dures if both rhinophyma sculpting and formalrhinoplasty are planned. As rhinophyma canmask an underlying malignancy, the authorssend all excised tissue for pathologic analysis.

Having endured significant deformity foryears, most of our patients display some degreeof stoicism regarding their rhinophyma.Achieving a good result can therefore stimu-late a significant improvement in the rhino-phyma patient’s self-esteem.

Rod J. Rohrich, M.D.Department of Plastic and Reconstructive SurgeryUniversity of Texas Southwestern Medical Center5323 Harry Hines Boulevard, #E7.212Dallas, Texas 75390–[email protected]

ACKNOWLEDGMENTS

The authors would like to offer acknowledgment and spe-cial thanks for assistance in the preparation of this article toClay J. Cockerell, M.D., Simon Warren, M.D., and Sarah Weit-zul, M.D. from the Department of Dermatology, University ofTexas Southwestern Medical Center, Dallas, Texas.

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Self-Assessment Examination follows onthe next page.


Self-Assessment Examination

Rhinophyma: Review and Updateby Rod J. Rohrich, M.D., John R. Griffin, M.D., and William P. Adams, Jr., M.D.

1. WHICH OF THE FOLLOWING IS THE MOST LIKELY ETIOLOGY OF RHINOPHYMA?A) Increased facial vascularityB) Alcohol abuseC) Ultraviolet radiationD) Caffeine consumptionE) Acne rosacea

2. WHAT IS THE PREVALENCE OF ROSACEA?A) 0.1 to 0.5 percentB) 0.5 to 10 percentC) 15 to 20 percentD) 25 to 30 percentE) 35 to 45 percent

3. RHINOPHYMA IS MOST COMMON IN WHICH OF THE FOLLOWING ETHNIC GROUPS?A) African AmericanB) CelticC) AsianD) HispanicE) Eastern European

4. THE MAJOR HISTOLOGICAL DIFFERENCE BETWEEN ACNE ROSACEA WITH EARLY RHINOPHYMA ANDSEVERE ADVANCED RHINOPHYMA IS:A) Obliteration of sebaceous unitsB) Decreased dermal thickeningC) Increased epidermal thicknessD) Increased inflammationE) Decreased vascularity

5. EACH OF THE FOLLOWING HAS BEEN DESCRIBED AS AN EFFECTIVE INSTRUMENT FOR RHINOPHYMASURGERY, EXCEPT:A) CO2 laserB) CryosurgeryC) ElectrocauteryD) Ultrasonic scalpelE) Pulsed-dye laser

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