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 follicles contain 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 cutting current) 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 If the needle is partially withdrawn and then reintroduced along the upper lip horizontally, a complete ring of anesthesia is given through the same puncture wound.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tip of the nose is easily done with a razor blade, though the invention of the Shaw scalpel, a decade or so ago, has superseded it.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 copperand 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 few minutes 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

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.