An open rhinoplasty incision was made, extending around theinner surface of both alar rims and across the columella. The skin was undermined to reveal a 2 ...
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
The 'Pinocchio' nasal deformity due to cavernous lymphangioma
Volume 88
September 1995
Figure 1 Preoperative photograph
Jonathan L Hobby FRCS BSc(Hons) Eunan Tiernan FRCSI Bryan J Mayou FRCS J R Soc Med 1995;88:535P-536P
CASE PRESENTED TO SECTION OF PLASTIC SURGERY, 14 APRIL 1994
Keywords: Pinocchio; Cyrano; nasal Jymphangioma
The 'Pinocchio' or 'Cyrano' nose is a rare condition in which deformity of the nasal tip is produced by an underlying soft tissue tumour. Previously reported cases1-3 have been due to either capillary or cavemous haemangiomas (angiolipomas). The deformity is the cause of much teasing in children. There has been debate as to whether surgical intervention is indicated, as a proportion of cases will regress spontaneously. We report a case of 'Pinocchio' nose with a lymphangioma of the nasal tip which is previously undescribed and review the options for management CASE HISTORY
A 3-year-old Caucasian girl was referred by her general practitioner with a 1 year history of an increasingly large bulbous deformity of her nose. The midline swelling involved the nasal tip and extended into the columella. It was soft but was adherent to the underlying cartilage. It was non-pulsatile and was covered with skin of normal texture and colour. The parents were concerned that the deformity was progressing, and that other children were starting to comment upon it. They were eager that it should be treated before she started school. Under general anaesthesia the nose was infiltrated with 1:200000 adrenaline solution. An open rhinoplasty incision was made, extending around the inner surface of both alar rims and across the columella. The skin was undermined to reveal a 2 cm x 1 cm x 1 cm lobulated soft tissue mass, lying between the medial crurae of the alar cartilages. It was adherent to the underlying perichondrium. The mass was removed by a combination of scissors and blunt dissection. A small part of the alar cartilages was included in the specimen. There was minimal bleeding and haemostasis was Department of Plastic Surgery, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, England, UK Correspondence to: Bryan J Mayou FRCS
achieved with bipolar diathermy. The domes of the lower lateral cartilages were apposed with a single 4/0 chromic catgut suture. The redundant skin was excised, and the wound was closed with 6/0 chromic catgut. The child was discharged from hospital the following day after an uneventful postoperative recovery. The parents were pleased with the cosmetic result and this was maintained at 6 month follow up. Histopathological examination of the specimen revealed a cavernous lymphangioma. DISCUSSION
Wynn1 described a technique for excision of the Pinocchio nose using an elliptical incision at the nasal tip. His article described the use of a soft intestinal clamp to achieve a bloodless operative field, we found this to be unnecessary. The use of an open rhinoplasty incision was suggested by Koopman2 and offers an aesthetically superior scar. A number of non-operative methods of ablation have been suggested in the past, including radiotherapy, cryotherapy and injection sclerotherapy. Radiotherapy is associated with a plethora of long-term complications and gives inferior results to surgical excision4. It is used in conjunction with surgical excision in the treatment of recurrent lesions. Injection with sclerosants may produce considerable scarring and is often unsuccessful4. Excision at a single operation with minimal scarring seems preferable. Previous authors have questioned the wisdom of surgical intervention in these cases, citing the tendency of most capillary haemangiomas to regress spontaneously by 7 years of age. Thompson and Lanigan3 published a series of 19 patients, of whom 11 were treated operatively and of these only three were felt to have had aesthetically acceptable Figure 2 Six weeks after surgery
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Volume 88
results. They also reported problems with wound healing in half of all patients, and a need for multiple surgical procedures. Against this they cited spontaneous improvement in all eight of eight patients treated conservatively, all of whom had an aesthetically acceptable result. Many of the cases described had cutaneous rather than subcutaneous lesions and required excision of a significant amount of nasal skin. All the children described in their series had haemangiomas, while this patient had a cavernous lymphangioma which has almost no tendency to regress spontaneously5. In the case reported above a single operation produced a good cosmetic result without complications.
REFERENCES
September 1 995
1 Wynn SK. Aesthetic reduction of Pinocchio nose haemangioma. Arch
Otolaryngol 1976; 102:416-19 2 Koopman CF. The Pinocchio nasal deformity-haemangioma versus angiolipoma: aesthetic correction and aetiology. J Otolaryngol
1988;17(4): 169-72
3 Thompson HG, Lanigan M. The Cyrano nose: a clinical reivew of
haemangiomas of the nasal tip. Plastic Reconstruct Surg 1979;63(2):155-60 4 Watson WL, McCarthy WD. Blood and lymph vessel tumours; report of
1056 cases. Sury Gynec Obst 1940;71:569-80 5 Enziger FM, Weiss SW. Soft Tissue Tumours, 2nd edn. London: Mosby,
1988 (Accepted 10 August 1994)
