A modified deep tangential excision may prevent recurrent rhinophyma in patients whose disease persists following prior surgical treatment, according to a case report.
Researchers reported that the approach removed hyperplastic psilosebaceous tissue to a deep dermal plane while preserving adnexal structures necessary for re-epithelialization and healing by secondary intention.
In the case report, the researchers described a 66-year-old male patient with a third recurrence of rhinophyma following two cold-steel tangential debulking procedures performed 4 years earlier. The patient presented with progressive nasal enlargement and disfigurement, predominantly affecting the left nasal ala. Preoperative magnetic resonance imaging showed heterogeneous soft tissue enlargement without invasion into the nasal cartilage or bone. Histopathologic analysis of the excised specimen demonstrated sebaceous gland hypertrophy, stratified squamous epithelium, acanthosis, and mild perifollicular inflammatory infiltrates rich in plasma cells in the dermis without evidence of malignancy.
The researchers performed a modified deep tangential excision under general anesthesia using a sharp scalpel to debulk tissue within the reticular dermis until most hyperplastic glands were removed. The excision approached, but did not violate, the nasal perichondrium to preserve deep adnexal remnants intended to support re-epithelialization. Pinpoint electrocautery was used for hemostasis and contouring, and most of the wound was managed by secondary-intention healing with selective tension-free suture re-approximation of the wound edges.
The patient experienced no postoperative infection, hypertrophic scarring, or functional compromise. At 18 months of follow-up, clinical examination showed stable restoration of nasal contour without recurrence or contracture. The patient also reported a high degree of satisfaction with the cosmetic and functional outcomes.
The researchers suggested that the patient’s repeated relapses likely reflected an insufficiency in the depth of the prior excisions and incomplete eradication of the hyperplastic pilosebaceous units characteristic of rhinophyma. They noted that recurrence following adequate primary intervention is generally uncommon. Previous findings have indicated that patients treated with fully ablative carbon dioxide laser therapy reported a 4% recurrence rate, primarily among older male patients with advanced disease.
The researchers also explained that cold-steel excision was selected instead of carbon dioxide laser resurfacing to obtain a larger specimen for definitive histopathologic evaluation without thermal artifact. They described this as particularly important in recurrent disease because rhinophyma can coexist with or mimic malignancy. The researchers additionally noted that electrocautery introduced some thermal injury despite efforts to preserve viable adnexal tissue, representing what they described as a necessary trade-off for hemostasis and contouring.
The report was limited by its single-patient design, lack of a comparison group, and follow-up restricted to 18 months. The findings therefore cannot establish comparative efficacy or recurrence rates for broader patient populations or alternative surgical approaches.
“Superficial debulking is insufficient and predisposes to relapse,” wrote lead study author Bilal Aslam, of the University of Lahore in Pakistan, and colleagues. "Our experience demonstrates that for recalcitrant cases, a modified deep tangential excision—aggressively removing pathologic tissue down to a deep dermal plane that preserves the deepest adnexal structures for re-epithelialization—offers a definitive solution,” they concluded.
The study authors reported no conflicts of interest and no external funding.
Source: Clinical Case Reports
