Rhinophyma: Prevalence, Severity, Impact and Management

Figures & data

Figure 1 Flow chart of inclusion and exclusion criteria and final selection of rhinophyma.

Table 1 Classification and Grading of Rhinophyma

Clark et al^Citation34
Group	Description
1	Involvement of nasal tip only – “lobular” nose
2	Involvement of distal half of nose, nasal tip, and ala
3	Involvement of distal half of nose, nasal tip, and alar nodules
4	Generalized involvement of the nose, including the nasal bridge and nasofacial sulci
Freeman^Citation35
Early Vascular Type
Diffuse Enlargement – Moderate
Localized Tumor – Early
Diffuse Enlargement – Extensive
Diffuse Enlargement – Extensive with Localized Tumor
el-Azhary et al^Citation33
Group	Description
Minor	Telangiectasias and mild thickening or texture change on nose.
Moderate	Thickening of the nose and early formation of lobules.
Major	Both nasal hypertrophy and lobules.
Rhinophyma Severity Scale (RHISI)^Citation36
Score*	Description
0	No evidence of rhinophyma
1	Mild skin thickening
2	Moderate skin thickening
3	Strong skin thickening, small lobules
4	Lobules with fissures
6	Giant Rhinophyma
Maximum one extra point	Presence of strong asymmetry, multiple cysts or strong vessels
*Maximum score: 6 points

Table 2 Variants of Rhinophyma

Jansen and Plewig^Citation15
Group	Description
Glandular	Prominent hyperplasia of sebaceous glands Presence of Demodex mites Dense distribution of VIP-R-positive cells Presence of intermediate filaments and neuroglandular antigen
Fibrous	Diffuse hyperplasia of the connective tissue Variable sebaceous gland hyperplasia Massive deposits of actinically damaged elastotic material, vascular enlargement Absence of pilosebaceous structures Positive Factor XIII staining
Fibroangiomatous	Nose is copper-red to dark-red, enlarged, edematous, with presence of ectatic veins Presence of pustules Presence of fibrosis, telangiectasias, inflammatory lesions Less prominent sebaceous hyperplasia
Actinic	Nodular masses of elastic tissue Proliferation of sebaceous glands Dilated ducts Expression of inspissated sebum Presence of gram-positive coryneform bacteria and Demodex folliculorum Sparse distribution of yeast-like organisms

Abbreviation: VIP-R-positive, vasoactive intestinal peptide receptor.

Table 3 Post-Operative Outcome Scales

Author	Scale
Har-El et al^Citation55	Excellent Result: Patient was satisfied Almost no evidence of previous disease No evidence the patient had surgery Very Good Result: No minor complication With evidence the patient had surgery Good Result: Patient was satisfied One minor complication
Clark and Hanke^Citation34	Excellent Result: Normal nasal contour without scarring Good Result: Acceptable nasal contour with some scar formation
Lazzeri et al^Citation57	On a scale of 0 (disappointed) to 10 (very satisfied), how satisfied are you with the treatment? Are the required effects of the procedure still maintained? What is your self-impression about the outcome? How long did it take for you to be socially presentable after the procedure? Would you recommend this treatment to other patients?

Table 4 Surgical Outcomes by Study

Technique	Lead Author	Patients, No. (M, No./F, No.)	Mean Age, y	Severity of Rhinophyma	Sessions, Mean
Carbon Dioxide Laser
	Shapshay SM (1980)^Citation65	4 (4/0)	65	Moderately Extensive	1.0
	Wheeland (1987)^Citation66	12 (12/0)	—	Not Reported	1.0
	Greenbaum SS (1988)^Citation48	3 (3/0)	—	Not Reported	1.0
	Bohigian (1988)^Citation67	8 (8/0)	—	Not Reported	1.0
	El-Azhary (1991)^Citation33	30 (30/0)	63	Minor: 11 Moderate: 11 Major: 8	1.0
	Har-El G (1993)^Citation55	16 (16/0)	64	Moderate to Major	1.0
	Karim Ali M (1997)^Citation56	18 (18/0)	65	Not Reported	1.0
	Bogetti (2002)	2 (Not Reported)	63	Minor: 1 Moderate: 1	1.0
	Kilty S (2008)^Citation60	4 (4/0)	59	Moderate: 4	2.0
	Madan V (2009)^Citation2	124 (111/13)	61 (M, 63; F, 48)	Minor: 10 Moderate: 40 Major: 74	1.1
	Cravo M (2009)^Citation68	4 (4/0)	47–74	Moderate: 2 Major: 2	1.0
	Lazzeri (2013)^Citation57	22	61	Minor: 55* Moderate: 9 Major: 3	1.0
Combined Therapy
Electrocautery with Staged CO2 Laser Contouring	Kilty S (2008)^Citation60	3 (3/0)	59	Moderate: 1 Major: 2	2.0
Erbium:YAG Laser
Traditional	Orenstein A (2001)^Citation51	6 (5/1)	64 (M, 68; F, 46)	Moderate: 4 Major: 2	1.0
Combined with CO2 Laser	Goon P (2004)^Citation50	6 (6/0)	Not Reported	Moderate: 4 Major: 2	1.2
Dual Mode	Fincher E (2004)^Citation49	6 (5/1)	59 (M, 58; F, 64)	Minor: 1 Moderate: 4 Major: 1	1.0
Neodymium:YAG Laser	Wenig (1993)^Citation54	5 (3/2)	61 (M, 65; F, 55)	Not Reported	1.0
Cold Knife Excision	Karge HJ (1975)^Citation69	15 (15/0)	Not Reported	Not Reported	1.0
	Dolezal R (1983)^Citation70	9 (Not Reported)	Not Reported	Not Reported	1.0
Cold Knife and Dermabrasion	Har-El G (1993)^Citation55	7 (7/0)	64	Moderate to Major	1.0
	Bogetti (2002)^Citation71	3 (3/0)	63	Moderate: 1 Major: 2	1.0
TWA	Stucker FJ (2003)^Citation59	51 (44/7)	Not Reported	Not Reported	1.0
	Curnier A (2002)^Citation58	6 (Not Reported)		Not Reported	1.0
	Wetzig (2012)^Citation36	23 (22/1)	59	RHISI: 3.3 ± 1.1	1.0
	Lazzeri (2013)^Citation57	45 (45/0)	61	Minor: 55* Moderate: 9 Major: 3	1.0
Shaw Scalpel	Vural (2009)^Citation61	7 (7/0)	67	Not Reported	1.0
Subunit Method	Hassanein (2017)^Citation62,Citation63	8 (6/2)	63	Not Reported	1.0

Notes: *Total number of patients in Lazzeri et al with minor, moderate, and major disease undergoing either carbon dioxide laser or scalpel excision.

Abbreviations: M, male; F, female; TWA, tumescence, weck blade, and argon beam coagulator; RHISI, Rhinophyma Severity Index Scale.

Table 7 Summary of Outcomes by Treatment Type

Technique	Post-Operative Erythema, Range, wks	Re-Epithelialization, wks	Recurrence, No. (%)	Complication, No. (%)	Revision, No. (%)
Carbon Dioxide Laser	6–12	1.4–6	3 (1.2)	26 (10.5)	5 (2.0)
Combined Therapy	Not Reported	Not Reported	0 (0.0)	1 (33.3)	3 (100.0)
Erbium:YAG Laser	Not Reported	1–4 weeks	0 (0.0)	0 (0.0)	0 (0.0)
Neodymium:YAG Laser	< 1 (edema)	Not Reported	0 (0.0)	0 (0.0)	0 (0.0)
Cold Knife Excision	6–9	2–6	11 (10.2)	4 (3.7)	0 (0.0)
Shaw Scalpel	Not Reported	Not Reported	0 (0.0)	1 (14.3)	0 (0.0)
Subunit Method	Not Reported	—	0 (0.0)	6 (75.0)	6 (75.0)

Table 8 Summary of Complications by Treatment Type

Technique	Reported Complications/Post-Operative Outcomes, No.
Carbon Dioxide Laser	Dilated sebaceous pores Milia and pustules immediately post-operative, 9 Notching, 6 Noticeable scarring, 5 Hypopigmentation, long-term, 6 Hypertrophic scarring, 6 Infection, 1 Alar fistula, 1 Alar hemorrhage, 1
Erbium:YAG Laser	None
Neodymium:YAG Laser	None
Cold Knife Excision	Noticeable scarring at ala, dorsum of nose, nasal tip, 3 Depression at margin of resection, 1 Early hypopigmentation with resolution, 12*
Shaw Scalpel	Alar collapse, 1
Combined Therapies	Notching, 1
Subunit Method	Noticeable scarring, 4 Required additional debulking, 1 Non-healing wound, 1

Table 5 Surgical Outcomes by Study

Technique	Lead Author	Post-Operative Erythema, wks	Re-Epithelialization, wks	Recurrence, No. (%)	Complication, No. (%)	Revision, No. (%)	Results, No. nd Patient Satisfaction
Carbon Dioxide Laser
	Shapshay SM (1980)^Citation65	Not Reported	3–4	0 (0.0)	0 (0.0)	0 (0.0)	Good to Excellent, 3 Satisfactory, 1
	Wheeland (1987)^Citation66	Not Reported	2–4	0 (0.0)	1 (8.3)	0 (0.0)	Not Reported
	Greenbaum SS (1988)^Citation48	Not Reported	1.4–2.1	0 (0.0)	1 (25.0)	0 (0.0)	Not Reported
	Bohigian (1988)^Citation67	Several	4–6	0 (0.0)	0 (0.0)	0 (0.0)	Excellent, 8
	el-Azhary (1991)^Citation33	Several	3–4	2 (6.7)	3 (10.0)	0 (0.0)	Not Reported
	Har-El G (1993)^Citation55	Not Reported	3–5	0 (0.0)	2 (12.5)	0 (0.0)	^HVery Good to Excellent, 14 Good, 2
	Karim Ali M (1997)^Citation56	Not Reported	4–7	0 (0.0)	3 (16.6)	0 (0.0)	Improvement in cosmetic appearance, 18
	Bogetti (2002)	Not Reported	2–4	0 (0.0)	0 (0.0)	0 (0.0)	Satisfaction with either cosmetic appearance or functional outcome, 2
	Kilty S (2008)^Citation60	Not Reported	Not Reported	0 (0.0)	1 (25.0)	4 (100.0)	^HExcellent, 3 Good, 1
	Madan V (2009)^Citation2	8–12	3–4	0 (0.0)	12 (9.7)	0 (0.0)	^HGood to Excellent, 118 Poor, 6 77% 10/10 satisfaction 92% recommend surgery
	Cravo M (2009)^Citation68	Not Reported	3.5–4	1 (25.0)	0 (0.0)	1 (25.0)	Excellent, 2 Good, 2
	Lazzeri (2013)^Citation57	6–9	4	0 (0.0)	2 (9.1)	0 (0.0)	^HExcellent, 20 Unacceptable, 2 ^L84.1% 10/10 satisfaction 89.4% recommend
Combined Therapy
Electrocautery and Staged CO2 Laser Contouring	Kilty S (2008)^Citation60	Not Reported	Not Reported	0 (0.0)	1 (33.3)	3 (100.0)	^HExcellent, 1 Very Good, 1 Good, 1
Erbium:YAG Laser
Traditional	Orenstein A (2001)^Citation51	Not Reported	1–2	0 (0.0)	0 (0.0)	0 (0.0)	^CExcellent, 4 Good, 2
Combined with CO2 Laser	Goon P (2004)^Citation50	Not Reported	1–2	0 (0.0)	0 (0.0)	1 (16.7)	Good nasal contour, symmetry, minimal scarring, 6 Patients very pleased with results, 6
Dual Mode	Fincher E (2004)^Citation49	Not Reported	4	0 (0.0)	0 (0.0)	0 (0.0)	^HExcellent, 3 Very Good, 3
Neodymium:YAG Laser
	Wenig (1993)^Citation54	< 1 (edema)	Not Reported	0 (0.0)	0 (0.0)	0 (0.0)	Not Reported
Cold Knife Excision
	Karge HJ (1975)^Citation69	Not Reported	2–3	0 (0.0)	0 (0.0)	0 (0.0)	Good, 15
	Dolezal R (1983)^Citation70	Not Reported	3	0 (0.0)	0 (0.0)	0 (0.0)	Pleased with cosmetic and functional outcome, 9
Cold Knife & Dermabrasion	Har-El G (1993)^Citation55	Not Reported	3–5	0 (0.0)	1 (14.3)	0 (0.0)	^HVery Good to Excellent, 6 Good, 1
TWA	Bogetti (2002)^Citation71	Not Reported	3–4	0 (0.0)	0 (0.0)	0 (0.0)	Not reported
	Stucker FJ (2003)^Citation59	Not Reported	2–4	0 (0.0)	0 (0.0)	0 (0.0)	Satisfaction with either cosmetic appearance or functional outcome, 3
Dermabrasion for contouring	Curnier A (2002)^Citation58	Not Reported	5–6	0 (0.0)	0 (0.0)	0 (0.0)	Not Reported
	Wetzig (2012)^Citation36	Not Reported	Not Reported	11 (47.8)	0 (0.0)	0 (0.0)	78% excellent satisfaction 22% good satisfaction 100% recommend surgery
	Lazzeri (2013)^Citation57	6–9	4	0 (0.0)	3 (6.7)	0 (0.0)	^HExcellent, 42 Unacceptable, 3 ^L85% 10/10 satisfaction 92.5% recommend surgery
Shaw Scalpel	Vural (2009)^Citation61	Not Reported	Not Reported	0 (0.0)	1 (14.3)	0 (0.0)	Excellent, 5 Good, 2
Subunit Method	Hassanein (2017)^Citation62,Citation63	—	—	0 (0.0)	6 (75.0)	6 (75%)	Not reported

Notes: Post-operative outcomes measured per Har-El, Lazzeri, Clark and Hanke scales, or per study author if otherwise not indicated.

Abbreviations: H, Har-El Post-Operative Outcome Scale; C, Clark and Hanke Scale; L, Lazzeri Scale.

Table 6 Summary of Outcomes by Treatment Type

Technique	Patients, No. (M, No./F, No.)	Mean Age, y	Severity of Rhinophyma, No.	Sessions, Mean
Carbon Dioxide Laser	247	61	Minor, 67 Moderate, 64 Major, 87	1.1
Combined Therapy	3	59	Moderate, 1 Major, 2	2.0
Erbium:YAG Laser	18	62	Minor, 1 Moderate, 12 Major, 5	1.1
Neodymium:YAG Laser	5	61	Not Reported	1.0
Cold Knife Excision	108	61	Minor to Moderate	1.0
Shaw Scalpel	7	67	Not Reported	1.0
Subunit Method	8	63	Not Reported	1.0

Figure 2 Subunit approach for refractory rhinophyma. (A) Intra-operative markings with six subunit based flaps (dorsum, two sidewalls, two alae, tip). (B) Subunit flaps are raised to provide exposure for removal of the phymatous tissue and facilitate correction of nasal support with cartilage grafts. (C) Extensive debulking of phymatous tissue to perichondrium. (D) Excess skin that has been “expanded” by sebaceous growth is trimmed.

Figure 3 (A) Pre-operative photo of patient with rhinophyma refractory to laser and tangential excision. (B) Intra-operative result after undergoing subunit method. Note incisions are planned at the subunit junctions. (C) Post-operative image with improvement in rhinophyma and nasal definition.

Table 9 Summary of Treatment Advantages and Disadvantages

Technique	Advantages	Disadvantages
Ablative
CO2 Laser	Precise decortication Controlled hemostasis Bloodless surgical field Deep tissue penetration	Higher cost Longer operative time Thermal injury relative to Er:YAG Deep tissue penetration No surgical specimen
Er:YAG Laser	Precise ablation Precise depth of tissue penetration	Poor hemostasis No surgical specimen Higher cost
Nd:YAG Laser	Precise ablation Precise depth of tissue penetration	Risk of thermal injury
Excisional
Cold Knife Excision	Precise decortication Low cost Less operative time Surgical specimen	Poor hemostasis Poor visualization of surgical field Thermal injury from electrocautery Unfavorable scarring along aesthetic subunits
Shaw Scalpel	Precise decortication Low cost Less operative time Hemostasis Surgical specimen	Thermal injury Unfavorable scarring along aesthetic subunits
Subunit method	Scars hidden in aesthetic units Enhancement of nasal tip Framework restoration Maximal debulking of tissue	Requires two stages Technically demanding Relatively prolonged healing time

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