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Facial Asymmetry With Deviated Nasal Tip

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 40s presented to the dermatology clinic with a 10-year history of progressive skin thickening and subcutaneous enlargement of the right side of her nose and right cheek. She had been seen by several dermatologists and otolaryngologists and had undergone nondiagnostic skin biopsies. She underwent a septorhinoplasty 6 months prior to presentation because of collapse of her right nasal ala. During the surgical procedure, the surgeon noted a significant amount of submucosal tissue in the right nasal cavity, which was removed; histopathological analysis was performed, and the results were reported as fibroadipose tissue and vascular proliferation. A skin biopsy was performed at the time of the surgical procedure and was interpreted as sebaceous hyperplasia. The patient initially had improvement in her skin, but she again noticed enlargement of the soft tissue with thickening of the overlying skin on her right cheek and right side of her nose several months later.

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B. Spindle cell lipoma

Histologic examination showed a subcutaneous-based proliferation of spindle cells of varying density associated with thickened and fragmented collagen bundles and mature adipocytes, extending into skeletal tissue (Figure, B and C). The spindle cells had bland cytomorphology with tapered nuclei and ill-defined cytoplasm. No cellular pleomorphism was observed. Based on these findings, a diagnosis of spindle cell lipoma (SCL) with focal intramuscular involvement was made. Immunohistochemical evaluation was deemed unnecessary because this subcutaneous-based lesion showed the classical triad of ropey collagen, tapered spindle cells without atypia, and mature adipocytes.

Spindle cell lipoma is a benign tumor that typically occurs on the shoulders of middle-aged or elderly men.1 Histopathologic findings include a proliferation of spindle cells dispersed diffusely or in loose fascicles among ropey, fragmented collagen bundles and with a variable quantity of background mature adipocytes.1 Immunopositivity for CD34 is typically present within lesional cells, and these cells are immunonegative for S100 protein, although mature adiopocytes are positive.2 Although SCL is a common tumor, it is unusual for these tumors to be located outside of the back/shoulder region. There have been 17 case reports of SCL involving the nose and cheek, to our knowledge; of these, 5 occurred in female individuals.2 There has been a single case report of an SCL causing a nasal tip deformity, although it was located in the vestibule of the nose.3

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Article Information

Corresponding Author: Elizabeth Veasey, MD, Division of Dermatology, University of Louisville School of Medicine, 3810 Springhurst Blvd, Ste 200, Louisville, KY 40241 (ecveas01@louisville.edu).

Published Online: December 26, 2019. doi:10.1001/jamadermatol.2019.3890

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Bolognia  J, Lorizzo  L, Schaffer  JV, eds.  Dermatology. Philadelphia, PA: Elsevier Saunders; 2018.
2.
Cheah  A, Billings  S, Goldblum  J, Hornick  J, Uddin  N, Rubin  B.  Spindle cell/pleomorphic lipomas of the face: an under-recognized diagnosis.  Histopathology. 2015;66(3):430-437. doi:10.1111/his.12548PubMedGoogle ScholarCrossref
3.
Gulbinowicz-Gowkielewicz  MM, Kibiłda  B, Gugała  K.  Spindle cell lipoma of the vestibule of the nose.  Otolaryngol Head Neck Surg. 2008;139(2):325-326. doi:10.1016/j.otohns.2008.02.025PubMedGoogle ScholarCrossref
4.
James  W, Berger  T, Elston  D.  Andrews’ Diseases of the Skin: Clinical Dermatology. 12th ed. Philadelphia, PA: Elsevier Saunders; 2016.
5.
Siddiqui  S, Khan  ZA, Wahab  S, Akhtar  K, Ansari  FH, Lampung  N.  A rare case of diffuse neurofibroma masquerading as a hemangioma: a radiological perspective.  J Ultrasound. 2017;20(4):343-346. doi:10.1007/s40477-017-0268-zPubMedGoogle ScholarCrossref
6.
Machol  JA  IV, Cusic  JG, O’Connor  EA, Sanger  JR, Matloub  HS.  Spindle cell lipoma of the neck: review of the literature and case report.  Plast Reconstr Surg Glob Open. 2015;3(11):e550. doi:10.1097/GOX.0000000000000405PubMedGoogle Scholar
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