Pressure alopecia has been compared with comablisters that are seen in patients after a drug over-dose. In both, it is believed that the skin changes arecaused by ischemia because of immobilization andconstant local pressure. During surgery, other factorscan complicate this picture, particularly peripheralcirculatory failure as a result of hypovolemia ordehydration, Trendelenburg positioning, or, in thenewborn, prolonged labor with compression of thebaby’s head against the mother’s bony pelvis. In thispatient, the clamping of the scalp during surgery wasthe cause of the ischemic changes.

Postoperative pressure-induced alopecia mani-fests as an area of swelling and tenderness of theaffected area, on the days after the intervention. Thehair loss occurs quite soon, within the first 2 weekspostsurgery. The histopathologic examination of theaffected area will show pigment casts, catagen folli-cles, and melanophages. These features, once con-sidered typical of trichotillomania, are in fact seen inany condition where there is rapid termination of theanagen phase of the hair cycle, and has beendescribed in alopecia areata.

The differential diagnosis includes triangular alo-pecia, a condition that is seen on the temples ofchildren, where vellus hairs can still be identified.The absence of involvement of other skin sites,mucosas, and other hairy areas or nails; the triangularshape of the area of alopecia; and the negativeimmunofluorescence findings permit us to excludelichen planus and discoid lupus erythematosus.Alopecia areata produces rounded areas of hairloss; there were no exclamation-point hairs in thispatient, and no periappendageal inflammation wasseen histopathologically. He denied manipulation ofhis scalp. Telogen effluvium may follow a longneurosurgical procedure, but it would be morewidespread.

The prognosis regarding hair regrowth variesaccording to the extent of the ischemia. In severecases, full necrosis of the scalp can be seen. Possibly,the best treatment is observation only. In this patientthere was no further regrowth, and he accepted anoffer of surgical excision of the alopecic area. Preven-tion of this complication can be achieved withpositioning of the head on an elastic support, avoid-ing cardiocirculatory insufficiency and using skinhooks instead of clamps for the fixation of the scalp.

For this series, the recommended choices are: 7, b;8, d; 9, a; 10, d; and 11, e.

BIBLIOGRAPHY

Bruce JA, Simmons MA, Hampal S. Horseshoe-shaped post-

operative alopecia following lengthy head and neck surgery.

J Laryngol Otol 2002;116:230-2.

Hanly AJ, Jorda M, Badiavas E, Valencia I, Elgart GW. Postoperative

pressure-induced alopecia: report of a case and discussion of

the role of apoptosis in non-scarring alopecia. J Cutan Pathol

1999;26:357-61.

Tomioka T, Hayashida M, Hanaoka K. Pressure alopecia in living

donors for liver transplantation. Can J Anesthesia 2004;51:

186-7.

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A man with changes on nose

Nasir Aziz, MSIII, MA,a and Amor Khachemoune,MD, CWSb

Washington, District of Columbia a and New York,New Yorkb

A 63-year-old white man presents with thesechanges on his nose (Fig 5).

12. The differential diagnosis includes all of thefollowing excepta. sarcoidosisb. adenoid squamous cell carcinomac. leprosyd. angiosarcomae. basal cell carcinoma

13. Phymatous lesions have been known to occurin all of the following areas excepta. foreheadb. chinc. eyelidsd. mucous membranese. ears

14. The pathogenesis of rhinophyma involvesa. sebaceous gland hyperplasiab. increase in connective tissuec. chronic inflammationd. vascular ectasiae. all of the above

15. Recent studies have implicated dysregulationof the following cytokine as an important fac-tor in the excessive fibrosis associated withrhinophyma.a. Transforming growth factor-bb. Interleukin 8c. Tumor necrosis factor-ad. Erythropoietine. Interferon-g

16. Which of the following is not a form ofrhinophyma?a. Glandularb. Fibrousc. Fibroangiomatousd. Infundibulofolliculare. Actinic

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17. Which of the following variants is marked bythe greatest degree of sebum production?a. Glandularb. Fibrousc. Fibroangiomatousd. Actinice. None of the above

18. In which of the following individuals wouldrhinophyma most likely be encountered?a. 25-year-old Asian manb. 49-year-old Caucasian manc. 6-year-old African American girld. 73-year-old Caucasian womane. 39-year-old Hispanic man

19. Rhinophyma is often described as an end-stagevariant ofa. acne vulgarisb. atopic dermatitisc. systemic lupus erythematosusd. dermatomyositise. rosacea

20. The following constitutes an acceptable medi-cal treatment during the early course ofrhinophyma.a. Chronic corticosteroid treatmentb. Clonidinec. Atenolold. Topical clindamycine. None of the above

21. The following is an effective surgical treatmentfor rhinophyma.a. Laser surgeryb. Harmonic scalpelc. Dermabrasiond. Surgical scalpele. All of the above

22. The following is true regarding the treatment ofrhinophyma.a. Dermabrasion is an ineffective and outdated

resurfacing option

b. Electrocautery may damage the underlyingnasal cartilage

c. Laser surgery has a higher efficacy comparedwith dermabrasion

d. Argon laser treatment is optimal in the treat-ment of large rhinophymas

e. Only one surgical modality should be used inthe treatment of rhinophyma

23. All of the following are advantages of usingcarbon-dioxide laser treatment excepta. improved hemostasisb. thinner removal of sebaceous glandsc. lower risk of cartilage exposured. superior visualization of tissuese. detailed shaping of resection edges

24. The Shaw knife has been particularly useful ina. making fine contoursb. debulking large tumorsc. reducing healing timed. improving hemostasise. all of the above

DiscussionThe diagnosis of rhinophyma can trace its origins

as far back as ancient Greece and Arabia. It hasevoked interest not only among doctors but amongpoets and artists throughout the ages. The erythem-atous, hypertrophied fibrous tissue that replaces thenormal contours of the nose has often led to a varietyof pejorative terms, such as ‘‘whiskey nose’’ and‘‘rum blossom.’’

Phymatous rosacea is a subtype of rosacea thatinvolves thickened skin, irregular surface nodular-ities, and generalized hypertrophy. Although phym-atous lesions can be present on the chin, forehead,ears, and eyelids, it most commonly presents on thenose as rhinophyma. Rhinophyma is a result ofprogressive increase in connective tissue, sebaceousgland hyperplasia, vascular ectasia, and chronicdeep inflammation. Although the nasal tip is prefer-entially hypertrophied, the back and side of the nosecan also be involved, albeit to a lesser degree. As thenasal skin hypertrophies, the structure of the nosebecomes distorted, causing cosmetic deformity andpotential airway obstruction.

Moreover, 4 variants of rhinophyma have beendescribed. The glandular form is characterized bylobules of sebaceous gland hyperplasia and a pittedsurface with irregular follicular orifices. Sebumproduction is increased and may combine withbacteria, keratinocytes, and mites to form a white,pasty substance. The fibrous variant of rhinophymais typified by diffuse hyperplasia of connective

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tissue with a varying degree of sebaceous glandhyperplasia. The fibroangiomatous form is distin-guished by a dark-red appearance resulting fromlarge, ectatic veins that can be accompanied bypustules. Lastly, the actinic form is marked bynodules of elastic tissue that distort the nose andmainly occurs in fair-skinned individuals of Celticbackground.

Although relatively uncommon, rhinophyma oc-curs far more frequently in men, with a ratio as highas 20:1. The incidence of rhinophyma in the UnitedStates has been increasing because of the aging ofbaby boomers, the majority of who fall into the agerange highest at risk for the condition.

Although hypertrophy of the nasal skin and pro-liferation of sebaceous glands is considered to be themain mechanism in the pathology of rhinophyma,recent evidence suggests that fibrosis plays a prom-inent role as well. Specifically, overexpression ordysregulation of transforming growth factor-b hasbeen associated with the increased collagen produc-tion and proliferative scarring seen in rhinophyma.

The diagnosis of rhinophyma is usually a clinicalone, although biopsy may be necessary to distin-guish atypical or nodular rhinophyma from lupuspernio (sarcoidosis of the nose); basal cell, squa-mous cell, and sebaceous carcinomas; angiosar-coma; and possibly nasal lymphoma.

Although surgery is the principal method oftreating rhinophyma, vascular-specific laser therapymay be used in the early, predominantly vascularstages of the disease. This prevents further growthand may even reduce the nose to its original size.Advanced cases of rhinophyma require more ag-gressive surgical care.

In a broad sense, surgical treatment focuses onrestoring the normal architecture of the nose whileminimizing the formation of scar tissue. This isaccomplished by incomplete excision of hypertro-phied tissue followed by re-epithelialization from theremaining glandular epithelium.

There are many surgical techniques for managingrhinophyma and naming a gold standard of treat-ment is a contentious issue. Dermaplaning anddermabrasion have been used with good results formany years. Dermabrasion remains an effectiveresurfacing option for rhinophyma and neither re-quires specialized equipment nor presents a firehazard in the operating department. Proper patientselection and recognition of planing depth are bothessential to a successful outcome. Cryosurgery usesextremely low temperatures to destroy sebaceousglands. Liquid nitrogen is sprayed on the rhino-phyma and two freeze-thaw cycles eliminate theexcess tissue. Heat in the form of electrocautery may

also be used to destroy phymatous tissue, but intra-operative crusting, exudation, and damage to un-derlying cartilage are problems encountered withthis treatment.

Laser techniques have become popular since theirintroduction in the early 1980s, although they havenot been shown to be more effective than classicdermabrasion. One retrospective study on 23 pa-tients treated with either laser or blade excision ofrhinophyma showed no difference in operative time,pain, postoperative bleeding, complications, or out-come. Nevertheless, the carbon-dioxide laser hasbeen used by itself or in combination with othermethods to vaporize the rhinophyma. Advantages ofthe laser include improved hemostasis, superiorvisualization of tissues, thinner removal of the hy-perplastic sebaceous glands, and detailed shaping ofthe resection edges. Potential disadvantages includerisk of burns to the face and exaggerated removal oftissue with cartilage exposure.

Excessive removal of tissue can be averted byusing an argon laser, which affects tissue to a depthof only 0.5 mm with each application. This ensuresthe underlying cartilage is protected as long as thenumber of passes is not too high. The argon lasercan also treat telangiectasias, erythema, and surfacetexture. The low tissue depth makes it impracticalin treating larger rhinophymas because it wouldrequire multiple sessions. Larger rhinophymas arebetter treated with the use of a Shaw knife. Theheated scalpel provides sound hemostasis, making ita useful debulking agent. Because assessing thezone of injury is often difficult when using a Shawknife, it may not be the best agent to make finecontours.

Newer instruments such as harmonic scalpelshave recently come into use in the surgical treatmentof rhinophyma. The harmonic scalpel consists of asurgical blade with a longitudinal ultrasonic vibra-tion of 50,000 Hz that promotes coagulation whileallowing for fine tactile control. Although it has beenshown to minimize tissue injury, it remains quiteexpensive.

Early complications of rhinophyma surgery in-clude hemorrhage and wound infection. Exposureof cartilage can lead to chronic infection and necrosisresulting in deformity. If the cartilage is exposed, itshould be covered by grafting. Late complicationsinclude delayed healing that may lead to escharformation and cicatrix. Failure of wound to heal by3 to 4 weeks postoperatively requires placement ofa split-thickness skin graft.

For this series, the recommended choices are: 12,c; 13, d; 14, e; 15, a; 16, d; 17, a; 18, b; 19, e; 20, e; 21,e; 22, b; 23, c; and 24, b.

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Curnier A, Choudhary S. Triple approach to rhinophyma. Ann Plast

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Powell FC. Clinical practice: rosacea. N Engl J Med 2005;352:793-803.

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