What do I need to ask about skin cancer surgery?
July 17, 2012 2:36 PM   Subscribe

Mohs surgery, end of next month. What should I be asking the surgeon in the meantime?

I'm 38. I've had this mole on my nose for at least 4 years. A GP two years ago looked at it and dismissed it as "just a mole," so when I went to a dermatologist a couple weeks ago it was just because I'm sick of looking at it and want it gone, even if it was just for cosmetic reasons and they'd have to charge me for it. But they biopsied it and found basal cell carcinoma.

My Dad has been having cancerous lesions (including one melanoma) removed and/or frozen off of his face, arms, legs and back for over 20 years. He's had Mohs surgery twice, both on his face, but both were caught early and were relatively minor.

After biopsy results they scheduled my surgery in 5 weeks and they're mailing me some info. That's it. No pre-surgery meeting, nothing. I've been doing all sorts of research, reading accounts and horror stories, looking at photos online, etc. And now I'm freaking. This is my face/head we're talking about!

Is there any way to know how long this mole has been cancerous, how big it is, or how extensive surgery will be? (The dermatologist said it didn't look too deep when he was doing the biopsy, but I don't know how much that can be trusted. Research I've read said basal cell is generally "slow growing" at something like 2-3mm every 6 months or so. That sounds like it could be huge to me.) Is the fact that the surgery is a month away a cause for concern? Why is Mohs done under local instead of general anesthetic?

These are all questions I intend to email to my surgeon, with a request for an interim appointment or at least a phone call. Any other questions I should be asking?

If you have any experiences, advice, suggestions, insight, questions, etc on the general topic, I'd appreciate those too.
posted by thrasher to Health & Fitness (16 answers total) 2 users marked this as a favorite
My Mom had a squamous cell taken off of her upper lip with a Mohs procedure about 6 years ago. It was in a weird, awkward place.....the resulting scar was kind of bad at first but you don't even notice it now. The most important thing is to get the cancer gone..... Any scars can be fixed later. I don't remember her having a terribly hard time with the surgery.... Lots of protein, that helps you heal faster. Good luck and good health.
posted by pearlybob at 2:45 PM on July 17, 2012 [1 favorite]

Probably the reason they're doing Mohs for a basal cell is because it's on your face; if you had a similar basal cell carcinoma on your arm, leg or torso they'd just slice it off in like two minutes and be done with it. Doing it using Mohs surgery means they don't leave as much of a scar or take as much tissue from a prominent area of your face. Try to relax; this is actually a pretty routine thing, and is very much routine for your surgeon.

The dermatologist said it didn't look too deep when he was doing the biopsy, but I don't know how much that can be trusted.

He looked at your lesion specifically; you should trust him more than you should trust information dealing in generalities.

Why is Mohs done under local instead of general anesthetic?

Because it's really minor surgery in terms of actual trauma to your body; it just takes a while because they slice really tiny pieces off and then examine each one under the microscope before doing the next slice. If this were on a less prominent part of your body, they'd probably just snip it off right there in the office after giving you a shot of lidocaine.
posted by infinitywaltz at 2:48 PM on July 17, 2012 [2 favorites]

Best answer: I had a "mole" on my face that my dermatologist dismissed year after year as "just a mole." Finally I went to a different dermatologist, where it was biopsied and found to be a BCC. It had been there for at least 20 years, so it seriously does grow slowly. I don't think you need to worry about the date of your surgery.

Mohs, as I'm sure you know by now, is tissue-sparing surgery. They remove tiny bits at a time, look at it under a microscope to see if the margins are clean, and if not, remove another tiny bit. My surgery required three or four rounds of removal, I can't remember anymore. What I do remember is asking to see the wound before they closed it. It was a giant hole in my face, and required a flap repair to close, using something like 40 stitches (tiny stitches, but still!). The repair took a lot longer than the Mohs, and I was silently freaking out the whole time. I walked out of the office in a state of shock, and once my husband got me down to the parking garage, I burst into tears.

Okay, why am I telling you this? Because within a few months, that huge wound was INVISIBLE. Today, if I try to show someone where it was, they literally cannot see it. They squint and peer at where I'm pointing but have a look of total incomprehension. It's truly amazing.

I'm sure surgeons do vary in their ability to do skillful repairs, so I would focus my worrying on that. Ask your surgeon if he has any before-and-after photos you can see, but bear in mind that the "after" shots will probably have been taken early in the healing process. Other than that, I wouldn't worry about it. Good luck!
posted by HotToddy at 3:00 PM on July 17, 2012 [3 favorites]

Response by poster: HotToddy, I take it the flap repair was done in the same visit as the Mohs? Did you bruise? (my dad said he had two black eyes after nose Mohs.) Did you go to work and go about your daily business bandaged for those interim months?

The photo galleries at basalcellmohs.com, especially of the forehead flap repair, are what I expect are worst case scenario.
posted by thrasher at 3:06 PM on July 17, 2012

Best answer: My husband had Mohs surgery here at the actual clinic where Dr. Mohs developed it. He says it's like taking an ice cream scoop -- they take a scalpel and scoop it out, more deeply at the center.

We had a power outage and crap that made them hurry at the end of the day, such that the nurse said, "HERE'S WHAT YOU'RE GONNA CLEAN, LADY" and it was a quarter-sized open wound. And then we had to come back the next day!

Where is it on your nose? The doctor was really good about tucking the scar into his laugh line. I was initially horrified that they left a jellybean-sized part open to heal on its own, but it healed very quickly and left a scar barely more noticeable than the original mole.

As far as I know, there was no way to tell how long it had been growing. My husband had had it for close to 10 years.

You can probably drive, but it's helpful to have someone there for support. There's a lot of sitting around; also, a lot of people there will be older and have pretty giant bandages that kind of seem frightening when you can't stop yourself from thinking about the worst-case scenario.

Bandaging was easy. Take square nonstick pads (you'll probably need to fold and trim). Get some surgical ointment -- no Neosporin -- and keep it clean and moist, getting the crusties off but not pulling off the healing surface.

We had lots of fun writing "Knife Fight" and "Bear Attack" on the bandages :P

I can't find it right now, but the best tape was this clear 3M stuff. It was nice and flexible but pretty strong, but it didn't pull too badly.

He had some pain for a few days. If you've ever wanted to get some opiates, now's your chance!

He did go to work with bandages, but eventually he just progressed to a band-aid, pretty much when the stitches came out. I think that was maybe 10 days. Things looked much less scary and more manageable then.

Please feel free to MeMail us; I've got not-scary pictures if you'd like.
posted by Madamina at 3:42 PM on July 17, 2012 [1 favorite]

Also, no real plastic surgery repair; also, no bruising (but I dunno, ymmv).
posted by Madamina at 3:45 PM on July 17, 2012

Response by poster: It's right on the top of my nose, towards the tip, directly over the cartilage near the end of my nose, nothing they can really tuck it into (my nose has always been larger and fleshier than I'd really like, maybe I'll get a more petite nose out of this whole deal.) I'll memail you Madamina. Thank you all for your input, it is helping a lot.
posted by thrasher at 3:56 PM on July 17, 2012

My mom has had different things frozen/zapped/Mohs'ed off her face and back over the last couple of decades. None of those lesions has ever morphed into anything really serious, and she probably has more candidates that will need to be removed eventually.

On a related note, I assume your doctor has talked to you about how to recognize a melanoma. If not, try to get some advice on that for future reference; you might also want an annual screening by a good dermatologist from here on out. I suddenly developed a small "beauty spot" on my big toe about a year ago and was worried about it till I saw a well-recommended dermatologist who told me what to watch for. The beauty spot remains where it was a year ago, unchanged; I've even learned to like it.
posted by Currer Belfry at 4:39 PM on July 17, 2012

Best answer: HotToddy, I take it the flap repair was done in the same visit as the Mohs? Did you bruise? (my dad said he had two black eyes after nose Mohs.) Did you go to work and go about your daily business bandaged for those interim months?

Yes, they did the flap repair right then and there. I was there for many hours--I think I probably came in at 8, or maybe even 7, and I know I didn't leave until 2 or 3. I think a good chunk of that time was spent waiting while he examined things under the microscope. Anyway, consequently, my blood sugar was totally tanking by the time I got out of there and I'm sure that contributed to my meltdown in the parking garage.

No, I didn't bruise, and the repair was just under my right eye--like, on my cheek, right under the socket.

Yes, I just went about my daily business. One thing I did that seemed helpful was to use those silicone scar sheets on the wound as soon as I could. I've also had a thyroidectomy (which involves a big horizontal incision across the throat) and used the scar sheets on that as well, and both scars healed amazingly well (and in general I scar really badly and bear the evidence of all scrapes, cuts, acne, etc. that I've ever had), so I highly recommend these things.
posted by HotToddy at 7:42 PM on July 17, 2012 [1 favorite]

Oh, and I also used Mederma, but I feel it was the scar sheets that did the most.
posted by HotToddy at 7:45 PM on July 17, 2012

Okay, I looked at the photos on that basalcellmohs site. I think that's a pretty bad worst-case scenario, certainly worse than mine was, and look how great that guy looks now. If I can give you some advice, don't do what I did and ask to see the wound before they repair it. It was unnecessarily traumatizing and didn't change anything about the course of treatment or outcome. All it did was freak me out.
posted by HotToddy at 7:58 PM on July 17, 2012 [1 favorite]

Best answer: I had mohs to remove a basal cell carcinoma on my face just about 5 weeks ago. It was my 5th bcc removal, but my first mohs. Like Hot Toddy, the actual removal site was really teeny--like less than 1/4 inch, but the repair is much larger. Mine is near my mouth, unfortunately a very mobile area. The scar is like an upside-down V, with one branch being slightly more than an inch long, and the other about half an inch, verging into the corner of my upper lip. The longer cut was done in my smile line so eventually it will be hidden by the natural crease. Right now, about 5 weeks after the surgery, I have a fairly large red patch just above and to the side of my mouth. The scar is raised and thick, and the whole area is numb. But I have been told that the redness will go away completely by 6 months, and the thickness and numbing by a year. I was quite dismayed by the long healing process, but I guess I have to accept it.

The day I had it done, they got all the diseased tissue in the first go, then repaired it. The repair took much longer than the actual removal of tissue. They used local, lidocaine, for both the mohs and the repair. I had many, many, many injections of lidocaine. Probably about 10 or so for the mohs, and then probably 15 or so for the repair. The first several injections each time hurt a little, the usual pinch and slight burn associated with lidocaine--just like when you have dental work done. Then I felt no pain or even real discomfort. But the repair surgery was kind of freaky: I experienced really strong tremors or shaking. The doc said it was a side effect of the lidocaine. I had been feeling fairly calm about the whole procedure, but when my whole body started shaking I freaked out a little. But then my body stopped shaking, even before the procedure was done, and I felt better.

I had a pretty impressive bandage on my face for a week following the procedure. I was told to leave it in place for the first 48 hours without changing it. Then I was told to remove it, clean the area gently, apply vaseline, and a non-stick (Telfa) bandage with paper tape. I would remove the dressing each day, and repeat the procedure. I returned one week later and had my stitches removed and was told to leave it uncovered. I had a slight infection. so I was told to apply antibiotic cream twice a day for the following week. I used a bandage at night just so I wouldn't get the antibiotic all over my pillow.

Aside from the actual procedure and healing process, basal cell carcinomas are really not that big a deal. They are very slow growing and well-contained. Also, research shows very little correlation between them and more virulent cancers, like melanoma. In other words, even if you have one or more basal cell carcinomas, you don't seem to be at much higher risk for melanoma.

Good luck!
posted by primate moon at 8:54 PM on July 17, 2012 [1 favorite]

Call the doctor's office; explain that you want more information. They'll send you lots of info.
posted by theora55 at 11:33 PM on July 17, 2012 [1 favorite]

Response by poster: Thanks all for the input, I really appreciate it.
posted by thrasher at 9:40 AM on July 18, 2012

(i have not had bcc or mohs, i edit derm/cancer books)

the mohs is not a big deal, the repair is for most people. if you're very concerned, or it's going to be a very wide and deep repair, try to have a plastic surgeon do the repair instead of the dermatologist/oncologist. some of them get very good at repair because they do it so often, but some of them don't, and some of them are new, etc.

yes, you can get bad repairs fixed usually (by a plastic surgeon), but it's better to do it right the first time.
posted by misanthropicsarah at 1:09 PM on July 18, 2012

Response by poster: Update: At the last minute the surgeon suggested radiation therapy instead. After meeting with the radiologist I decided to go with that. Surgery averted at least for now. Thanks for all the input in this thread.
posted by thrasher at 3:31 PM on August 29, 2012

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