Post-Surgery: Day 14

The doctor had told me that I was using the wrong type of gauze (not a huge deal), so she showed me what to look for.  Of course Walgreens and Longs did not have any (it is a very thin, hospital-style gauze, as opposed to the thick gauze for general first aid that drug stores carry)

I found a medical supply store in our town and they had not only the right gauze but tan tape!  This meant I no longer had to have the ugly white tape across my nose that shouted “bad nose job!”  Happy Day!  At this point, it's the little things that make my day....

Post-Surgery: Day 13

Well, to my eye (and my husband’s) there was no real change in the wound, except that it did feel like it was separating around the edges.  I was extremely worried about what the doctor would say when I went in to see her that day. My understanding was that the next line of defense would be to go into the hospital with IV antibiotics.  My anxiety level was at about a million.

I called the doctor who did the Moh’s procedure to schedule an appointment that day so she could see the wound and give me her opinion too.  I was very unsettled at this point that the plastics doctor did not have a firm handle on exactly what was going on, especially since I did not think it was looking as if it was responding to the antibiotics.

The only change I had noticed since my last visit was not in my wound, but in my energy level.  I felt great on Friday night, Saturday and Sunday (basically 24 hours after I started the new antibiotic).  I felt like I was back to my old self for the first time since the surgery instead of sitting on the couch all day.  I hung out with my closest friends and family, and cooked up a double batch of beef stew so we’d have something to eat over the weekend and on Halloween, which was Monday.   I had good energy and didn’t get tired even after cooking for 2 hours.

I was prepared (almost) for the worst when I saw the doctor on Monday.  She told us that the culture had indeed come back negative for MRSA, so that didn’t give us any clues. 

However, when she took off the bandages to examine it, we were shocked that she said it looked better!  She was able to cut off about 1/3^rd of the scab, and there was viable skin tissue underneath!!!  We had thought that the whole flap died from the infection, so this was wonderful news.  There is still at least 2/3rds of the wound that is still scabbed, but she is optimistic that it may heal similarly.  She wants to wait at least a month before doing any more surgery to give it a chance to heal on its own.

I practically jumped for joy when I saw the new skin.  I was sent home with instructions to continue the antibiotics, ointment, and wet-to-dry bandages.

I kept my appointment with the Moh’s doctor because I still wanted her opinion and I also wanted to make sure that she was fully in the loop about what was going on (especially if it turned out I had MRSA).  She was actually relieved when she saw the wound!  She said that when she heard I had a possible MRSA infection in my nose that she assumed the worst, and that this looked great in comparison.  I told her how we were treating it, and she said that it was the exact right thing to do, so that was reassuring.  She also said that my plastics doctor does amazing work and that she won’t give up until I am totally satisfied.  This was also super-reassuring.  She said she would call the plastics doctor to circle back with her on this.

I also told her about a fairly new study that had come out on Moh’s and MRSA (which I found when I googled “Moh’s MRSA”)

http://www.ncbi.nlm.nih.gov/pubmed/20698869

This study has shown that pre-operative screening for MRSA can drastically reduce post-surgical MRSA infections.  She asked me to forward it along to her.  It is not current protocol to screen 100% of patients for MRSA, and I was not in one of the high-risk groups that she would normally screen (I don’t work in an institutional setting like a hospital or school, am not elderly, etc).   I don’t blame anyone for my developing a post-surgical infection – the doctors did their jobs right and these things can still happen. And we still don't even know if it was MRSA or not.  But if there are ways to make improvements so that other patients can avoid it, I want to make that happen.  It’s all about continual improvement.

This is a picture before the doctor took some of the scab off.  

This is what she considers “great”!  So I guess I do too. 

Sorry for the color cast on the photo.  I am not jaundiced in real life.

This is a picture the day after she took some of the scab off.  There is still about half the scab left. 

Notice the notch in the rim of my nostril.  This was caused totally by the infection and was not from the Mohs surgery. 

(it is essentially the path that the bacteria traveled out of my nose and into my wound). 

The plastic surgeon will correct this once I am fully healed. 

Or maybe I’ll just get a nose ring to camouflage it ;0

Post-Surgery: Day 9

On our second visit to the doctor two days later, she was able to examine the scab now that the dried blood was gone, and she removed the stitches.   She was completely flummoxed – a scab is not what is supposed to be there.  It is supposed to be healthy skin with a scar from the stitches around the edges. I wasn’t a smoker, I have normal blood pressure, I was young and in good health – she never sees this kind of outcome in a patient like me. 

She said it presented as some sort of infection, and since there was yellow involved, it could be MRSA, the antibiotic-resistant staph bacteria.  This doubled the bad news about the failed flap, because now we had to figure out what was going on with that. The antibiotic that I had been on for 10 days (Keflex) was not effective against MRSA.  She took a swab to have it cultured, but warned that since I had been on antibiotics for 10 days, the results might be compromised.  Her theory is that I harbored MRSA in my nose, and that it contaminated the wound site since it was so close to the edge of my nose.

She told me to continue with the warm showers, wet-to-dry bandages, and ointment (including putting the ointment in my nostril), and put me on a MRSA-effective antibiotic called Septra.  She would see me back in 4 days, on Monday, and hope that there is some improvement in the wound.

She also gave me detailed instructions about how to limit the spread of MRSA (if indeed it is that) to my family and friends.  So everything in our house was washed (by my wonderful mother), the surfaces disinfected, and we redoubled our hand washing efforts (which were already pretty strong because I was so worried about getting another cold post-surgery that would interfere with the healing).

What a mess, right?  Isn’t this how you’d like to look post-surgery too?!  

Blue stitches are still in, but even without the stitches, it is not a pretty sight.  

The inability to wash my face and apply make-up certainly doesn’t help the overall look….

Post-Surgery: Day 7

Finally, it’s time for my post-op visit with the plastic surgeon!  I was a little anxious about what it was going to look like, but I was also looking forward to having that itchy tape off and get some fresh air on my nose.

But when the doctor took the bandage off my nose, she was shocked.  The whole surgery area was black.  There was a ton of dried blood covering the area, and she was unable to tell if there was viable skin underneath.  She feared that it failed to take, but there was just too much dried blood to tell.  It was terrible news.  We were all shell-shocked.

I was sent home with instructions to stand under a warm shower and let the water run over my nose to clean off the dried blood.  Out of the shower, I put antibiotic ointment on it and covered it with saline-soaked bandages plus a dry bandage on top. These dressings were changed a few times a day.  Fortunately, there was no pain.  I don’t know if it’s because the whole area is numb from nerve damage in surgery/Mohs, or if it is because that area is dead.  That’s ok – I like no pain.  Over the next 48 hours, the dried blood came off, and what was revealed underneath basically looked like a scab slightly larger than a pencil eraser.

Post-Surgery: Day 3

Pain is pretty much gone today (I was down to 1 pain pill every 6 hours the day before). But I still took 2 Tylenol PM (as I had since the second night) to help me sleep. 

The hardest part of the meds routine was that the antibiotic I was on had to be taken 4 times a day, which means you need to take one basically in the middle of the night.  I would stay up until midnight, take an antibiotic, then sleep until 6am and take another, and then go back to sleep until 8am.  Luckily, my kids are old enough to get themselves up and ready for school (with some gentle prodding by my husband).

My friends brought us dinner every night, carpooled and took care of our kids, and visited and called me to keep my spirits up.  I had so much help from family, friends, neighbors, and my wonderful husband that I felt truly blessed and loved.  The outpouring was deeply moving, and I was very grateful.

I was able to take the head/ear bandage off and put antibiotic ointment on it.  Some of the bandage was stuck to the stitches, so I left it in there to let the doctor deal with it.

Post-Surgery: Day 1

I was under strict orders from my doctor to do nothing but sit on the couch so the site could heal.   I slept on the couch, sitting up, the first night, but did not get great sleep (not surprisingly).  Subsequent nights I slept in the guest bed upright with a “Bed Buddy” pillow that a friend had lent me. I took 1 pain pill every 3 hours (I could take up to 2 every 4 hours, but this way I never let the pain reliever level dip).  My ear hurt like the devil the first night – I felt like a dog that had its ears clipped.

I was told to not take the nose bandage off at all until I saw the doctor a week later.  

I watched lots of daytime TV.

Same Day – Repair Surgery

Immediately following the Mohs procedure, my husband drove me directly to the ambulatory surgery center, which checked me in and got me into a bed.  Unfortunately, because of the possibility of using general anesthesia, I could not take any oral pain meds, so I was stuck with the nose pain.  It dulled down a bit but was still about a 4-5 out of 10.

Things seemed to be going along smoothly until the nurse came in and told me that my surgery was delayed by 1.5 hours.  Bummer!!!  It was almost noon at this point. I was so hungry, and in pain, but there was nothing I could do but wait.  I kept reminding myself that it was going to be just one day of hassle, and then I was home free. I was fairly patient and sent my wonderful husband out so he at least could get some lunch for himself.  No use with both of us being hungry and cranky!

I counted the minutes until the surgery, only to be visited by another nurse, who told me there would be another hour delay.  This time I was pissed.   But once again, it was out of my control, so the only thing I could do was lie on the bed and watch bad hospital TV.

Finally, at 2:30 the anesthesiologist and plastic surgeon came in and said it was time.  Thank God.  The anesthesiologist tried 3 times to get a needle into my wrist for the IV, as I begged him to use my arm instead.  I was in pain, hungry, cranky, and was in no position to be patient as he poked me looking for a vein.  He was very nice, but said that if I was this agitated with the IV portion of the process, then he wanted me under general anesthesia for the surgery – twilight was not an option.  I completely agreed at that point.  Knock me out and make this all end!!!

He gave me some Versed to calm me down, and wheeled me to the Operating Room. In the OR, I fell asleep to the tunes of Michael Jackson….no kidding….it’s what the doctors were playing on the speakers.

Here is a non-medical description of the repair that the doctor performed:  She took cartilage from my left ear (same side as my hose) and put it into the arch of my nostril to rebuild that rounded area.  She then cut a flap of skin from my nose in a butterfly-like shape (leaving it attached to the surrounding skin) and pulled it to cover the wound.  She then stitched it up and we were done.

I woke up in the post-op area at 4:30pm coughing, but felt ok other than that.  I could see the white bandage on my nose, but it took me about 30 minutes to realize that my whole head was wrapped in gauze.  This was to hold on the ear bandage.   But it had the effect of making me look like I had a major head injury.

I was able to leave at about 5:30pm.  The anesthesia had worn off and my nose was starting to hurt so they gave me Tylenol in the post-op, and sent me home with a prescription for Tylenol with Codeine (at my request since I do not tolerate Vicodin or Percoset), plus antibiotics.

Surgery Day – Mohs First

The night before the surgery, the anesthesiologist called to run through the no-eating rules, etc.  I told him that I was interested in twilight anesthesia rather than general anesthesia if it was at all possible, just because it is less hard on the system.  He said that once they knew how extensive the operation was going to be we could make that call.

It was very difficult not knowing how bad the reconstruction would be after the Mohs because it left so many variables open, but I had no choice.

My husband drove me to the Mohs doctor’s office at 8am to begin the procedure.  I bought a laptop computer, DVDs, magazines, books, my phone and iPod to keep me busy. 

I was taken to a private exam room, where the assistant prepped me, marked my nose, and took pictures.   My husband stayed in the room with me and watched the whole procedure (which was a surprise to him – he was expecting her to tell him to wait outside). She gently laid a cloth over my forehead and eyes – which was fine with me because I did not want to see what was going on – and then I got some shots of local anesthetics in my nose to numb it. The doctor did such a great job with the first shot of anesthesia in my nose that I hardly felt it.  This was going to be ok!

She then did the excision, which lasted about 10 minutes.  I didn’t feel anything.  She cauterized it, which smelled horrible and felt like a light zap, but nothing bad.  The assistant covered the area with bandages and then it was time to wait while she processed it.   I watched a movie and texted with friends, but after about 45 minutes the anesthesia started to wear off and it was beginning to hurt. 

By the time they came in to tell me they got about 70% of it but needed to do a second pass, it was smarting pretty well.  I told them and they gave me more anesthesia, but this time the shots hurt like the devil!  I don’t know if it was because I already had pain in that area or it was because they had to put it up closer to the bridge of my nose, but it was no fun.   It did the trick, though, and she took her second slice.  I went back to the movie, but once again, the anesthesia started to wear off after 45 minutes.  It was really hurting this time.  It felt like my nose had been hit with a basketball going about 50 mph.  It smarted like the dickens and my eyes were constantly watering.

I called the nurse in to tell her and she said that the nose is really hard to keep anesthetized.   She said they could give me another shot, but I was not thrilled about that.    So we decided to wait and see if we had to do a 3^rd pass.  Luckily, the doctor came in about 15 minutes later and said we got the whole thing, so I decided against more shots since they weren’t lasting long anyways, and that I would just tough it out until my surgery in 2 hours.

The doctor measured the site (9mm x 7mm), took pictures and emailed them to my surgeon so she could start to plan the reconstruction.  This was great – it was not our worst case analysis (although it was also not out best case).  But still, I was comforted that I dodged a bullet on that.

We were done by 10:30am and out the door to proceed to our next stop for the repair.

A Delay

It turned out that a week before my scheduled surgery, I caught a cold.  I went on antibiotics immediately to prevent a sinus infection, but I was still congested the day before the surgery.  I called the plastic surgeon to get her recommendation, and we decided to postpone it.  Apparently, the sinus cavities run all throughout the face, and an infection in them can really ruin the healing process so it was better to wait til I was all clear. In addition, the anesthesiologist wanted to wait until I was completely clear as well. This pushed my operation back 3 weeks, which was a hassle but I figured worth it in the long run.

Choosing a Doctor

I was referred by my dermatologist to a doctor in her network who performs Mohs to remove the basal cell carcinoma.  My mother had used this doctor too. The doctor only did group consults, which was a little disappointing, but I figured that I’d just have to deal with it.

The day of the consult, I showed up to the conference room for the group consultation.  Here I was, a 43-year-old mother of a pre-teen and a teenager, surrounded by a dozen men aged at least 75 or older.  Needless to say, I felt slightly out of place.  (she did have us sign confidentiality statements to not discuss other’s cases, however)

She explained the procedure to us all, and then went around the room to examine each of our spots and tell us her plan.  I was about the 8^th person.  Everyone else before me was told “ok, you are going to have a small scar on your shoulder/back/leg etc.”  Then she got to me.  I figured I would be told I’d have a small scar too.  But what she said, was  “this is going to be bad.  You are going to need a skin graft, or a flap, or cartilage from your ear to repair it.” 

WTF? This is not what anyone wants to hear.

It tuned out that because of the location of my cancer (location, location, location!) my case was not an easy one.  Even though it was very small and we caught it very early, my cancer was located about 2 mm from the edge of my left nostril, about half way between the tip of my nose and where the nose meets the cheek.  There is not a lot of real estate there for them to work with, so they need to get material from elsewhere to rebuild it after taking out the cancer.  On top of that, my basal cell was micro-nodular, which meant that it sent down sneaky roots.  Bad news.

The good news is that mine was small, and that basal cell carcinomas are slow growing.  This was not a threat to anything other than my vanity, so I could wait a few months to have the Mohs surgery done.  In fact, the doctor told me, since this was June and we were heading into vacation season “Do everything that you want to look good for, and then we can do the procedure in September.”  I told her I was hoping to look good for the rest of my life.  Needless to say, I left fairly upset over the prospects of facing an involved reconstructive surgery when I had thought that all I would be dealing with is a few stitches. 

I got home and proceeded to talk with everyone about it – my husband, friends, neighbors and family.  Many of them recommended that I have a plastic surgeon close the wound rather than the dermatologist.   The thought had never occurred to me, nor had the Mohs doctor mentioned it as an option.  I called her office to ask whether or not she worked with a cosmetic surgeon, and did not hear back.  I called again a second time and was told that there were two in the network that she recommended, so I made an appointment with one for a consult.

The plastic surgeon told me he thought that there was an 80% chance I would not need his services, that the Moh’s doctor did an excellent job closing her own work.  Not knowing how big my wound would be until they actually do the Mohs procedure, however, all we could do was guess at what would need to be done. While this gave me some comfort knowing that a plastics doc was available if need be, I was still unsettled by the whole process, especially that the Mohs doctor never mentioned using a plastic surgeon to do the close.

As I continued to talk with friends about the situation, I got the recommendation for a different Mohs doctor from two of my friends who had used her and were very happy with their outcomes.  I decided to do a consult with this second doctor to see what she thought. 

Immediately after our consult, which was in a private appointment lasting about 30 minutes, I was reassured that she was the doctor for me.  She was warm, empathetic, and positive. The very first thing she said when she examined the site of my basal cell, was that I should undoubtedly have it closed by a plastic surgeon.  She said there was a tiny chance that the site would end up being small enough for her to close it herself, but that I should have someone who specializes in the contours of the nose take care of it.  This made a whole lot of sense to me, and I immediately booked my appointment with her for the Mohs procedure.   Her Mohs Coordinator took care of scheduling consults with 2 plastic surgeons so I would have a choice.  What a difference from the first doctor!

There were two options for the “close” with the plastic surgeon: (1) I could have it done the same day as the Mohs procedure, which meant that there was only one day of medical procedures but that I would not be able to eat all day due to the general anesthesia required for the repair, or (2) I could do the repair the day after the Mohs procedure.  I opted for the former, figuring that I’d rather have it done all at once.  In retrospect, I might do it differently next time (details later).

Diagnosis

I've had annual mole checks for over 20 years.  I've had lots of "atypical" moles removed, and one that was considered pre-cancerous, but that's all.

A month after my annual mole check with my dermatologist, I found a tiny bump – 2mm - on my left nostril that bled ever so slightly after I washed my face (we’re talking one or two drops of blood).  Other than that, the area was totally unremarkable.  I thought perhaps my skin was dry, so I used extra moisturizer, but it didn’t go away.

After a month or so I found myself in my dermatologist’s office with my daughter for her regular visit, and I mentioned it to the doctor as I was leaving. She had always said if I find anything suspicious in between our annual visits to let her know.  She took one look and said that it needed to be biopsied for sure.  It just so happened that her next appointment cancelled, so she was able to biopsy it right then.  She was fairly certain that it was a basal cell carcinoma.  So when the pathology came back a week later positive for basal cell, I was not surprised.

Both my mom and and sister have had basal cells removed from their faces, and I know there is a genetic component to this as well (not to mention that we are fair-skinned, blond-haired and blue-eyed Californians – all major risk factors) so I knew my turn would come one day.  They both had the Mohs procedure, and had great outcomes, so I knew that that was what I would do too.  

This picture is the day before surgery (3 months after biopsy).  

You can’t even tell where the basal cell is – it’s that small. 

Prior to biopsy, it looked like a slightly raised pore, kind of pearly color. 

The biopsy took off the raised portion.

Introduction

I’m writing this account of my Moh’s surgery and reconstruction surgery in hopes that it will be of help and reassurance to people who are facing the same procedures.  I know that when I was facing this procedure, and especially when I was developed complications afterwards, it was extremely helpful to me to hear from other people with similar experiences so that I could know what to expect, know what to ask the doctor, and be reassured that the outcome would be ok.

It goes without saying that every case is different, and that you must follow the medical advice of your own doctor.  I AM NOT A DOCTOR; THIS IS SIMPLY MY STORY, AND IT IS NOT INTENDED TO BE MEDICAL ADVICE.  And I caution you, there are post-surgical pictures here, some of them not-so-pleasant, so be forewarned.

This is me, the day before my Mohs Surgery.