Category Archives: Mohs surgery

Mohs surgery, part IV: 6 weeks later.

I know that I have been absent, conspicuously or not, but I meant to give a final followup on the Mohs surgery. I had thought about that because FC commented that his brother was having same and he was sending him over here. The Mohs surgery posts consistently receive the most hits and I think that’s because lots of folks are worried/curious/concerned about what’s involved.

I will say that for the first weeks following, although I took you right through the procedure, I didn’t feel much like putting a photo of myself up. To me, the incision was as clear as the nose on my face- in fact, it felt as though it was the whole of the nose on my face. Now it’s sort of settling into becoming just another small battle scar in the course of day-to-day life. For me, these BC carcinomas crop up all together too often but there are certainly many worse things in life.

I’m heading up to Asheville later this week to see the house, start to plan for kitchen renovation next February and consider the garden. I may rototill it this autumn and throw a few things in as part of the happy anticipation. I’ll take some photos and try to get a few posts up. I’ll be away from the wool that’s clogging up the works around here so that might leave a bit of time for writing.

Here then is an unretouched- sans makeup, complete with bad haircut- photo. I still have a nose. Dr. Spencer said it could take up to a year to fully resolve and I’m busy applying something called Kelocote, a kind of silicone sticky mess that aids in healing and reduces scar formation. But, if you look closely, you can see the white scars from previous surgeries: one right in the middle of my forehead coming onto the bridge of my nose (that one was huge, a full inch diameter down to the bone, and one on my left upper lip (right side in the photo) that was also very deep. The point is, they heal. And I can get these all touched up surgically, if I’m so inclined, which I’m not. And so, if you’re getting ready for Mohs and worried about it, there you go. If you have a spot and you haven’t tended to it, get to the dermatologist. It will all be okay. FC, how’s your brother doing?vicki


Empty spaces

Yes, yes, there is one on my nose at the moment and no, I don’t care to show it to you even though I said I would. Trust me, it’s nothing more than an ugly dark bloody scab with black suture threads sticking out. It’s not so big but it’s a definite hole and I certainly hope that my nose can regenerate nose cells at the same rate I replicate hip and belly cells as opposed to brain cells. There’s some kind of inverse relationship with the net result being that my hips and brain have both narrowed their respective vocabularies to “food”, “time to eat”, “now.” McCloud and I speak the same language.cloudy 1As far as the nose goes, a petite little bobbed nose would be fine as long as it was that way on both sides but since you can never talk these surgeons into throwing in some cosmetic work on the side- well, I’m just hoping it grows back. One last complaint: I get to choose between wearing a bandage that then sticks my eyelashes together, gets part way up my nose and leaves that highly irritating adhesive residue or going without. In which case, my glasses slide down and bump the top two stitches and I have to be constantly mindful not to swipe at them. I woke myself twice during the night by itching it and then jumping into consciousness with “ouch! Ack!” and anxiously checking to make sure I hadn’t knocked anything loose. Or open. Really though, it’s all fine and a short couple weeks in the relative scheme of things and man, do I think the world of my dermatologist/surgeon. He’s everything a person could ask for when it comes to this BCC stuff and Mohs surgery. Assuming the hole fills in.

But this is all minor compared to what my friend, Larry, is dealing with. I just don’t know what to say about people who make crappy decisions about their lifestyle that then leads to misery, pain and poor health. I mean the lifestyle part about taking risks. Partly I want to say, “WTF? What were you thinking??!!?” The thing is, most of us spend some of our young adult lives not thinking at all and then the consequences can be really bad.

Maybe you remember me writing about Larry, actually it’s pronounced “Laawwwrry”, who is our gay Tennessee gardener. He periodically comes over to work in the yard here in Florida, especially when it’s SO DAMN HOT. Larry, by his own admission, has made “every bad move ah could make. But ah sure did move pretty.” He used to be a “part time tranny” and listening to descriptions of some of his high fashion days, I’m sorry I didn’t know him then. He hasn’t had anybody special in his life for quite a long time and he’s not looking but it doesn’t stop him from saying loudly, “Oh, Boo, lookie thar. That’s mah next husband.” This is usually when we’re  picking up mulch at Lowe’s or “Homo Depot”- both places he likes to go because there are so many construction guys hanging around.  Really, he talks like that but when he does it’s funny and outrageous and I can’t help but laugh. The thing is he’s a sweetheart and kind and generous. He’s very smart with no formal education past high school. He reads the paper and watches the news every day and he’s right on top of current events and politics. (Except he’s convinced that Michael Jackson is not really dead but merely transforming himself fully into a woman someplace in France. So he can finally be “his own true self and live in peace.”) He’s one of those people with vast amounts of random knowledge and if I ever want to know where to find something in St. Petersburg I ask Larry. He loves plants and he has an amazing green thumb and when his ADD hasn’t got the better of him, Larry is a super gardener. Larry loves animals and he always talks to the cats like they’re people.  Sophie’s a narrow minded bigot but McCloud adores Larry and always rolls around and purrs in whatever part of the garden Larry is cultivating. He’ll buy dog food for his little (gak) chihuahua, Cowboy, before he buys food for himself. At Halloween, Larry puts Cowboy in some ridiculous costume and decorates like mad and then he gets dressed up in a sweltering hot, very scary ghoulish outfit and hands out candy and he’s the hit of the neighborhood.

Larry likes the heat and hates the cold so last year I knit him a hat so he could still work in the yard when the temperature fell below 65. Up until then he was walking around covering an ear with one hand and pulling weeds with the other, muttering about how he was “freezing his white queer ass off.” He switched hands every 5 minutes but it was taking him twice as long as it should have. He put on the hat, came in the house three different times to check out his appearance in the mirror and then cornered, Bill, our back alley neighbor. Bill is well into his 80s, a former minor league pitcher and a life long Floridian and conservative. He and Larry get along quite well. So, Bill is finishing up a walk with Newton, his little goofy dachshund when Larry calls out, “Hey, Bill! Do you thank this hat makes me look gay?” Bill paused and then said he thought the hat looked fine but he didn’t rightly know a whole lot about gay fashion let alone gay anything. Larry called out, “Wall, Bill, be careful cuz ah got mah eyes on you!” Bill looked briefly confused and answered, “Okay, then, you do that and have a lovely afternoon. I’m going to take my nap.”

Larry was also the one who told me I had the “wrong kind of hurricane shutters.” We had just gotten new shutters for the whole house and I was showing Larry where they were stored because he has a side business where he goes around and puts up shutters as necessary for “all mah girls.” “Wha, Boo, you got yourself the wrong kinda shutters!”

“What’s wrong with them, Larry?”

“Wha, Boo, you can’t see out them! The hurricane be over and all your neighbors be out in the street having a paatty and you all won’t even know ’bout it.”

Larry’s been living on the margins for most of the last 20 years and now, no surprise, he’s in pretty dire straits. He was supposed to start taking some meds a few years ago but he tried and the first go around landed him in the hospital with terrible side effects. Larry and social services mix like oil and water but it’s a Sisyphus-ian nightmare in any case, trying to get through that system to find a regular doctor, get appointments, get medications- all without a phone number or a car. For as long as I’ve known him he’s been trying, with the help of his more organized friends like me, to get settled into a treatment plan. Partly he’s terribly distractible and inconsistent and partly the system just jerks people around until they’re hopeless. So now, he’s really sick. This morning he came by, ostensibly to work in the yard for a bit, but really to talk and get some moral support. He had an appointment last week and an all new and new to the States doctor (so, imagine Larry, who doesn’t really speak English trying to communicate with someone from Pakistan who doesn’t really speak English) tell him that his white blood count was so low that he could die “veddy soon.”  Larry said, “Boo, ah know ah have you and the other girls but ah really need mah mammaw now.” He does, indeed.  I know it, but I’m so sad he’s going back to Tennessee, feeling all sick and defeated.  All I can do is hope his mammaw takes really good care of him and pray for him, cuz you know, we don’t pass judgment around here if we can help it. It’s hard not to. I’m really really pissed at him for not taking better care of himself.stones

(A random non sequitur photo. I’m bored with these stones now, so I’ve moved on to vegetable-like vessels. Pumpkins, what have you. And, oh, yes! Wasn’t it wonderful to have Bonnie visit the ‘hood? I miss that woman.)

Doing the happy dance (Mohs surgery, part III)

You can find the history of this in Part I and Part II but today, with part III, I have weathered the surgery quite well and I’m doing the happy dance. Make that shuffle. I’ve just now shuffled into bed after sleeping on the sofa all afternoon. I highly recommend sleep as the best way to spend your first hours post surgery.mohsunk(The unkindest cut: Rich takes a picture of me sleeping, with my mouth hanging open and the dewlap in full repose…)

As you know, I was dreading this procedure and in retrospect, I think it was because the first time I had surgery on my face it was just so extensive. This biopsy was also BCC of the infiltrative  type so I was expecting the worst- a full blown forest of roots growing beneath the relatively small spot on the surface. It wasn’t so bad. (The moral of that is, “Don’t put off going to your dermatologist. The sooner you catch it, the less extensive it’s likely to be.”) Because I now scrutinize my skin constantly and go every 4-6 months for appointments, I think I’m doing a pretty good job of staying on top of it.

So, here’s a quick photo review of the day, with brief comments. I’ll follow up tomorrow with more (when I’ll probably feel worse because, if memory serves, the second day sucks) but tonight I’m going to watch 30 Rock and then read myself to sleep. If I last that long.

mohs1Waiting room, not smiling, not even sitting up straight. Xanax is starting to take effect. I like that it’s all done in Dr. Spencer’s comfortable and attractive office. It doesn’t smell like a hospital and I now know all the staff. Never wait for more than a few minutes. Today I met the perky woman who called with my biopsy results and I appreciated her happy and friendly manner. So now I apologize for being snappish about her overly cheerful initial report.mohs2La-la-la-la. A little pre-op discussion. I could care less. 1 mg of  Xanax is working nicely. Kind Dr. Spencer is optimistic with the proviso that he won’t know for sure without path results. I should mention that we had earlier discussed radiation as an option, one that apparently has a good success rate. The downside? Every day for 30 days and it can dry up-permanently- the mucus membrane on the inside of your nose. Sounds a little too buckshot to me so I opt for the Mohs.mohs3Hand comes up in defensive move. What Xanax? You take the cap off that needle and I might pop you one…mohs5owowowowowow! Although he’s fast, smooth, gets down to business when it comes to shots. owowowowo. Times 12 total today.mohs7Here we go. If you watched that video I posted in Part II you remember that during Mohs surgery they start small, read the path report while you wait in a nice waiting room with snacks, and go back again as necessary until the margins are clear of cancer cells. It can take hours but it means the smallest possible excision with a high cure rate. Because we told Dr. Spencer that I was going to be posting about this and Rich was taking pictures, he was especially good about talking us through the details as he worked. Rich found it pretty fascinating and said it wasn’t nearly as harsh as that first one 6 years ago.

mohs8Nasty, but not really. He’s cauterized the edges. He does this by putting his instrument on the exact spot and then his assistant touches the other end and sends the electrical impulse through it. Makes for extreme precision. We like precision. Now it’s off to the waiting room. Dr. Spencer had three of us going at once but it all seems to move smoothly, in order and on schedule. I think I napped a bit while Rich watched CNN.mohs9Oh, crap. Not this again.mohs10Dr. Spencer’s cheat sheet from the path report so he knows where to make the second excision.mohs13Yippee. More shots and then it’s time to close. This, as he described it and Rich went over it later, is pretty interesting. He lifts the skin away from the underlying tissue and removes bits of underneath tissue, skin and what have you that might make for little lumps. In the process of doing that, the round hole sort of reshapes itself into a more natural oblong hole. Dr. Spencer described it as sort of ‘finding it’s own shape’ which then guides him in his repair stitching. I figure this is where the art part of this procedure comes in. We shall see.mohs14As delicate as this work is, it feels like he’s doing upholstery repair. Tug, pull, jerk, tug. Skin must be thick and tough.mohs15That’s it for today. All stitched up and ready to go home. Tomorrow, probably more swelling and bruising.

Hey. Thank you for all the encouragement and support. And the pot roast. Rich says it was delish. I haven’t tried it yet. I think 2 Advil and a glass of  Chiefland Pure Florida Noble wine are just what the doctor ordered. Sleep well. I know I will.

Ready…set…complain (Mohs surgery, Part II)

I wish I had this one memorably lovely photo of myself as a tot but it’s packed away until we get to the mountain house next year. You would love it. It’s one of those early color photos, somewhat faded, of me at the beach. Diminutive, with reddish blond hair, big green eyes and a sweet green print bathing dress, I’m just standing there looking waif-like and fair.  I was really very cute. At three I was already wearing big Coke-bottle lensed glasses everywhere but the beach; there, I stumbled around blindly most Sundays as my family escaped the ticky-tacky postwar suburbs of Royal Oak to Detroit’s Metropolitan Beach. Five decades later, sitting on an exam table in University of Michigan’s cancer care center, I would see an almost identical poster size 1950s photo of a pretty little girl on a beach and the title, “This is when it all started.”

I met Rich when I was 51. I had one child in college and one in high school. a fulltime psychotherapy practice, a little weekend cottage on a small headwater lake. a blessedly wonderful posse of friends and very nice skin. We were married the next year in June and, although it is not visible in any of our wedding pictures I remember that I had noticed the tiniest pinprick of a spot on my forehead- a spot that bled slightly when I rubbed hard with a towel but never seemed to hurt, was never inflamed or irritated. I just noticed it a couple times a week.MVC-113F(Me and my face-in the sun-a few months before the first bout of basal cell cancer. Can’t see a thing.)

September has always been the month when I’ve gotten an annual physical and that year I mentioned it, almost as an afterthought, to my internist. She referred me to a dermatologist. In her office, I was more alarmed about getting a shot in the forehead so she could take a small biopsy than I was that anything was wrong.

So that was the first round of basal cell cancer and, typical of this type of skin cancer, it has recurred. Again and again. It’s as though a time bomb went off in my body and all of the things that collude to make a person prone to BCC came together at once. (Basal Cell, along with Squamous Cell are called NMSC or non-melanoma skin cancers. They rarely metastasize, frequently recur and are usually not life threatening, as opposed to melanoma, which is the very best reason for you to get checked regularly by a dermatologist.) These days, it seems as though everybody can put themselves and their children at risk for skin cancer through over exposure to the sun but here are the factors that are most likely to put you at risk:
-Early unprotected exposure to the sun or severe sunburns, often at a young age. My parents didn’t know about sunscreen. In fact, in the fifties people were busy trying to tan skin with oils that attracted damaging rays. In high school I had friends who would coat themselves with baby oil and bask on tin foil. Even today, the tanning booth business is a big industry with the rays from tanning booths being twice as damaging as the sun outdoors. I never did any of that but I did burn severely several times in my young life and during later trips to Central America I still didn’t know enough to BLOCK sun exposure as opposed to applying 15-30 spf sun screens. Today, I try to avoid much sun exposure and cover myself with hat, high level sunblock, protective clothing. Today, I sometimes have to be physically restrained from smearing glop all over random small children. It makes me sad that, when I’m focused on this BCC, the sun seems like my enemy, especially since I am a passionate gardener, love the ocean’s shore, crave the light. But I cope. My Tilley hat is my constant companion.
-Very fair skin. That includes most people of Irish descent, with the white skin, blue or green eyes, freckles, reddish hair. That’s because a high percentage of Irish people have a Skin Phototype of I or II. In our family I am definitely the one with the ‘always burns, never tans’ phototype skin. It seems as though skin pigmentation provides some screen from UV rays.
  • SPT I – Always burns, never tans
  • SPT II – Burns easily, tans minimally
  • SPT III – Burns moderately, tans gradually to light brown
  • SPT IV – Burns minimally, always tans well to moderately brown
  • SPT V – Rarely burns, tans profusely to dark
  • SPT VI – Never burns, deeply pigmented

-Certain medications make you more prone to burning.

a. Diuretics, Antibiotics, (Tetracycline drugs) skin care products
b. Microdermabrasion products and Retin A
c. Heart medications containing Amiodarone
d. Diabetes medicines containing Glipizide
e. Herbal ingredients Balsam of Peru used in after shaves and perfumes
f. Nonsteroidal anti-inflammatory pain drugs such as Advil, Aleve, Motrin and Celebrex

Certain medical conditions, particularly immune disorders.

Okay. Back to my specifics, complaint and whining. My dermatologist sent me over to the Mohs Clinic at U of M. Oh, wait, another digression from me. Mohs surgery is named after Frederick Mohs who started systematically whacking small chunks out of people as far back as the 1930s and today it’s a specialty area with many highly skilled surgeons and, if this stuff shows up on your face it’s most likely the best treatment option. Here is a brief video clip explaining the procedure, the benefits and it’s not at all gory. I’ll wait while you watch it.

Rich went with me that first time (and most every time since) and I want to go on record as saying I didn’t find any humor in his musing, “Why this is just like the waiting area at the airport, except for all these lepers.” They had taken a first piece out of my forehead, I was lightly bandaged and sent to wait with all the other diced up patients. Just like at the airport, you try to find a seat where you can be as far from the next person as possible and stare mindlessly up at the television screens running CNN (and old Mayberry RFD reruns. I liked that touch.) About 45 minutes later they called me back and said they found more in the margins of what they had removed and needed to take more. Back to wait, back for a THIRD pass, back to wait and then they said they were ready to close the wound. U of M is a teaching hospital so I had a full cadre of residents and interns and students-I didn’t like that so much. On the other hand, everybody has to learn their trade and the Mohs Clinic at U of M is state of the art. I wasn’t thrilled when the surgeon let the resident in plastic surgery do the close, either, but in fact, the resident did a very nice job and no one really sees that scar today unless I show them. At the time, you could have fooled me about this outcome, given my first look 2 days after I got home.  They offered, incidentally, to let me look at the open incision but I declined because Rich had looked and was turning green and retreating to the corner as he choked out, “Well. That’s not too bad. I guess.”IMG_6264(No, I was not a happy camper. No, that was not my hair color at age 52. It turned bright silver at 32 years of age, as though all the pigment decided to leave my hair as well as my skin…they had also taken a small biopsy beneath my left eye, which I KNEW wasn’t the same thing because I’d had funky backed up tear ducts there since childhood. An intern did this despite my protest. Today I would ask for a higher power before letting someone nick me, because that also left a mark that I still see today. Be a good patient and advocate for yourself.)

Here are the worst things about that first experience:
This is all done under local anesthesia. Shots in the face kind of hurt, although my current dermatologist is smooth, very smooth.
I didn’t have anything to relax me before hand. This is a mistake for most people, I think. I mean, they drape your face, which is pretty claustrophobic, turn on really bright lights, clank scalpels and sometimes you can feel warm liquid running down into your ears if they don’t wipe it up fast enough. Today, I wouldn’t have this procedure without some kind of sedative or anti-anxiety medication beforehand- Valium, Xanax, etc. I have to say I don’t remember great pain afterwards- but that could be one of those things I’ve sort of blocked out. We’ll see this time. I DO remember itching as it healed. Serious, annoying, want-to-scratch-my-eyes-out-itching. You have no idea how many times you touch your face in the course of a day, let alone an hour. So itching and keeping my hands off was hard for me.

They did another small one on my upper lip, too- that one I never could see before the fact. Because I was short on extra skin to pull together (lots of blotches, not so many wrinkles yet) they decided to let this one heal from the inside out. Much smaller, it was far more irritating over the next couple months and today leaves a more noticeable scar.
Since those first two on my face, it’s been fairly steadily showing up on other parts of my body. Usually, every 6 month check up results in 3-4 “burns” where they freeze off spots and I’ve had 4 additional surgical bouts with it. By far the largest was one on my upper back that I never would have found on my own. That one was a little rough because (as FC knows) it’s hard to keep still and every movement of my arm and shoulder pulled on it for a while. Having the stitches removed was a relief.
I’m not a BIG complainer but I tend to complain out loud when I do. Next week’s procedure (sounds better than surgery) will be back on my face and I’m dreading it. I have leftover twitchiness from multiple eye surgeries as a child- anybody but a loved one gets too close in my personal space and I want to swat at them. Not rational, but I can’t seem to help it. However, this BCC is not the end of the world and probably not even the end of my nose so I’m going to try and keep this in perspective. Lots of people, including some of you, have gone through this or will go through it. Each year more than 1 million cases of skin cancer are diagnosed in the United States, one in five adults over 50 will have it and WHO says it’s on the rise. (Jeez! What’s it going to take for us to protect the ozone layer?) I’ll probably post about every day life between now and then but I’m going to ask if Dr. Spencer minds if Rich takes photos so you can picture the before, during and after-if you care too. Maybe if you go through it with me you won’t be quite so freaked at the possibility if you need to do it. Because, you know, it’s probably a really good idea to get that annoying sore on your face looked at…

Oh. Here are the results, photo from 2006 taken two years after surgery. Not so bad, really.after(What the hell? I’m out in the sun again…)