Read about the surgery here-

http://www.tbtam.com/2008/03/mohs-nose-woes-part-1.html

http://www.tbtam.com/2008/03/mohs-nose-woes-part-2.html

Well, it’s done.

The dermatologist did the Mohs procedure on Thursday morning. It took 3 passes to get all the cancer out, and I was left with a defect about the size of a dime on the lower left part of my nose. Sort of like this –

Despite what was being done to me, I had a good time at my Moh’s surgeon’s office. We talked kids, and schools and family and money – and then I hung around his little back Mohs waiting room for a few hours till my plastics appointment, returning patient calls and checking labs on my laptop (one of the curses and advantages of an EMR). I left feeling relieved and upbeat.

Until I saw the plastic surgeon.

The Closure

Where my dermatologist is an upbeat, everything is going to be fine kind of guy, Dr Plastics is an empathetic, caring, almost rabbinical kind of guy who really understands how women feel about their faces. So when he entered the room and saw the size of my defect, he looked at me with those dog-eyes of his, looking so sorry for me that I started to cry. He told me the defect was larger than he had expected, and that he would not close it in the office, but under anesthesia at the surgi-center the next morning.

I walked home crushed, sure that I was going to be deformed for the rest of my life. And the fact that I had to spend the night with this hole in my face did not help. What if something happened and I couldn’t get to the surgery tomorrow? Suppose there was a fire, or I got hit by a car, or one of my kids got sick? I’d have to decide between them and closing the hole in my face.

Somehow I got through the night, and next morning went to the surgi-center. What a place – an Upper East Side townhouse that, when you enter, looks for all intents and purposes like a private mansion. Until you head into the back, where the place looks just like any recovery room and OR suite you’ve ever been to. Runs like a well-oiled machine, wonderfully friendly staff and anesthesia, high quality care. A real New York kind of place.

I waited for several hours in a gown on a gurney, listening mostly to my neighbors letting go of gas after colonoscopies while I finished almost all of the Friday NY Times crossword, a feat worth mentioning in any post. My nurse had had two surgeries similar to mine in the past, a fact I did not notice until she pointed out the faint scars. This made me feel hopeful.

Then my surgeon appeared, apologizing profusely for keeping me waiting due to his previous case that had gone longer than expected. I felt oddly reassured by this, figuring that he would take as long as he needed to give me the best cosmetic result he could.

So to sleep I went, the Fentanyl and Versed doing their job quite nicely, and awoke some 30 minutes later, finally done. Dr Plastics had performed a bi-lobed flap and used about 20 tiny stitches to close. So I have an incision running from near my inner eye down the side of my nose that looks like a half of a flower. Sort of like this –

Nice, Huh?

Post-Op

In addition to the incision, I have a black eye and my nose is swollen and red. The pain isn’t too bad during the day, but has kept me up a bit at night, and my stomach is a bit upset from the antibiotics.

Now I just have to wait. Wait for the sutures to come out next week. Wait for the swelling to go down and the scar to fade. It will be sometime before I know how I am going to look, but at least this thing is done.

I find myself embarrassed thinking about having to see patients over the next few weeks with a big bandage on my nose. I wish I had taken off a little more time from work, but everyone said I could go back pretty much right away, so I’m going back on Tuesday. But I feel like it’s all going to be about the nose for sometime. And I am anxious for the point when I can cover the incision with some makeup until the scar starts to fade.

Most people I talk to are remarkably supportive and no one seems particularly worried about how I’m going to look. But somehow their comments haven’t helped. They only make me feel as if I am over-reacting.

And in some respects, I am. I think about Patrick Swayze and know that I am so, so lucky that this is all I have to deal with. And truth be told, I haven’t thought about my nose too, too much today, as we are now on the 7th episode of the first season on The Wire.

But then, I look at myself in the mirror, and get upset all over again. It makes no sense, I know, but this thing has really hit me hard. I think it was the combo of the big hole, the unexpected wait and and then the Frankenstein sutures, and I expect I’ll feel much better about things in a week or so. But right now I’m feeling pretty darned sorry for myself.

After all, it is my Nose.
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If you want to see photos, go here. I’ll be posting updates periodically as I heal. I warn you, it’s not pretty……

Part 3 here

It all started sometime this summer when the skin on the side of my nose bled spontaneously as I was drying off after a shower. I looked – nothing there, just a spot of blood. I figured I scratched myself and didn’t give it much more thought.

Till it happened again a few months later in the exact same spot. Still nothing to see, but on careful palpation, I noticed the skin there felt just a little raised and irregular.

Now, I’m a girl with my Mom’s Irish skin and a baby oil adolescence who has had four basal cells on my back scraped off in the past 5 years. So I knew before I even saw the dermatologist that this was another basal cell.

But this is not just another basal cell. This one’s different.

This is my Nose.

And that means I need Mohs.

What is Mohs?

Mohs surgery is a special procedure designed to remove skin cancer with the least chance of recurrence and the least removal of healthy tissue.

Skin cancer can grow along the planes under the top layer of skin, so the cancer is often larger than it initially appears on the surface. So when the cancer is removed, the dermatologist will want to take a wide margin of healthy-appearing tissue around the edges of the visible lesion to be sure the cancer is all out.

But on the face, there is not the luxury of wide open space for big margins. And so the procedure of choice is Mohs surgery.

Here’s how Mohs works – The dermatologist shaves off what he thinks is all the cancer, then you go into the waiting room and he goes into the lab and looks at the specimen to see if all of it was removed. If the cancer is growing all the way to the edge of any part of the specimen, that means there’s probably some more still back there on your face. So back you go into surgery to have a little more removed – but just in the spots where the margins are positive. Then it’s back to the lab to see if that’s enough, and so one, till the whole lesion and every last bit of cancer is removed. Each subsequent specimen is smaller and smaller, leaving healthy tissue where it is and just going after the “legs” of the cancer, till finally it’s all out and you’ve got the smallest defect to repair that you can possible have.

But now you have a hole in your face, and it’s got to get closed up somehow.

Closing the skin after removal of skin cancer

After a skin cancer is removed, one can leave the defect to fill in itself. This is how the cancers on my back were treated – They were scraped off, then left to fill in on their own, and in a few weeks, I was left with red round scars that fade with time.

On the face, if the lesion is small, you can do the same thing.

But for the cancer on my nose, this method will not work. That’s because this kind of healing is accompanied by contraction of the skin, which in my case would lead to the nostril pulling up and out on one side.

So I need to have a flap, wherein the skin above the defect is rotated downward to cover it.

But it’s my Nose!

Mr TBAM had a similar surgery this past summer for a small cancer on the tip of his nose – a Mohs procedure followed by a flap. Now he has a sort of Raggedy Andy patch there that you don’t notice unless he points it out to you, at which point you can’t not see it, until you forget about it again.

Now that I am having to have the same procedure, all I can do is stare at Mr. TBTAM’s schnoz and worry about my own. I mean, he looks fine for a guy, but I’m sorry, I don’t want that scar on my nose.

So I asked my dermatologist if plastics could do my closure. He said of course, but that in fact he’s done many more of these than they have. His nurse confirmed that he does 90% of his own closures, and that other dermatologists send their difficult ones to him for that very reason. At that point, what I really wanted to say was “If I was Julia Roberts, would you do the closure or call in plastics?” but that seemed rather rude. So instead I just said that he could do the closure.

And then I spent the rest of the week silently freaking out. And staring at Mr TBAM”s nose.

Three days before my procedure, I happened to mention this to a nurse I work with, who was shocked that there was even a dilemma. Why wouldn’t I want plastics? She then regaled me with stories of deformed faces she’d seen on the subway, wondered how those poor people got through the day, and reminded me how in America appearance is everything. I then called a female colleague who I’d seen as a patient several times. “What, are you nuts? Of course, plastics is closing you! This is your nose, for gods sake! You’re seeing the best Mos dermatologist I know, but he’s a dermatologist, for god sakes! Of course he’s going to tell you you’ll look fine – He’s a guy, they don’t even notice when we get our hair cut half the time! End of discussion. Here’s the name of the plastic surgeon who’s going to do your closure…”

I made the call, dropped my name and I was in.

I have no idea if using plastics for the closure is going to make any real difference in how I look after my Mohs procedure. I adore my dermatologist, and he really is the go-to man for this surgery. But suddenly I’m calm. Not because I don’t think I’ll have a scar, but because I know I will have done everything I can to be sure it’s the best scar I can get.

After all, this is my Nose.
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Part 2 here