Beth's Nose and Lip Mohs Microsurgery

**NOTE: graphic medical photos included **

 

I am sharing this little adventure for the curiosity of anyone who might be interested.  It contains medically graphic photos, so I didn't want to put it on Facebook and freak out any of my friends who might stumble upon it accidentally.  I also want to offer my personal experience to anyone who might be facing this procedure and might appreciate yet another viewpoint among the many that are out there.  My experience has been, what I would consider, the norm for this diagnosis and procedure.  There was nothing extreme or unique about it, other than the fact, perhaps, that I had two procedures done within five days of each other.  Beyond that, I believe my experience is indicative of what the average person might expect when facing Mohs microsurgery on the nose or lip. 

 

For over a year, I had this spot on my nose, like a hard little pimple-sized blister. As time went by, it began to bleed when I would wash my face. It would scab a little, flake a little, bleed again, and never fully heal. And the skin around the spot began to do the same. It wasn't highly visible to anyone but me, and I didn't have health insurance, so I delayed having it checked. Meanwhile, a small spot at the edge of my upper lip also caught my attention. This one wasn't pimple/blister shaped, but kind of a small nick that would bleed frequently and never fully heal. I was pretty sure they were skin cancers -- my mom had dealt with one on her nose several years ago, and I knew I was at risk from having a few serious sunburns when I was a child and in college.

Eventually, after more than a year of ignoring these spots, I went to the dermatologist. I had gotten married and found myself with insurance and a husband who supportively nudged me to take care of my health concerns. I suspected that the spots were "mildly cancerous" (my term) and that the doctor would advise taking action on them, but I hadn't researched or really thought about what that would involve at the initial appointment. It is unlike me to go into a situation uninformed, and so when the clinical checkup took this turn, I was startled by the relative trauma of the biopsy on my nose and lip.

The numbing shots for the biopsy were quite painful -- two shots in the nose and two in the lip -- and the tissue removal left me feeling like I'd slid face-first across a gravel road. If I had been prepared for this, I'm sure I would have taken it in stride just fine, but the discomfort and impression of violence to my face was really very surprising. I laughed about it with the "HOLY MOLY!" expression in the photo above but, as a very non-neurotic, non-dramatic, laid-back, yogic, Zen kind of person, I was uncharacteristically shaken.

A few days later, as the biopsy scabs were healing, the dermatologist's office called to say that both spots were basal cell carcinoma. By that point, I had scrambled to do research and was not at all surprised by the diagnosis or what I knew would inevitably follow. Skin cancer is the most common of all cancers. BCC (basal cell carcinoma) is the most common of all skin cancers. It is not life-threatening. Some doctors would rather not even call it "cancer" because of the dramatic connotations. Blah blah blah.  But a BCC left untreated for years can grow and cause deformation and other potential problems, depending on the area.  So, the preferred method for dealing with BCC is a procedure called Mohs microsurgery, a procedure at which my particular dermatolgist is basically an expert.  I knew what was coming, before we even had our next consultation.

 

Believing that "knowledge is power," I googled Mohs Microsurgery every day for about two weeks. And every day I ended up making myself nauseous with the information I read. Even the best case scenarios were disturbing. The plastic surgeons' proud, before-and-after photos freaked me out. It wasn't that I was worried about the outcome -- not from a health or a cosmetic standpoint. I knew that this was not a serious health issue, and I trusted that the scarring would be acceptable. I just could not wrap my mind around the procedure itself.

 

It goes like this: in a clinic, completely awake, you get lidocaine shots to numb the affected area, then a layer of tissue is cut out and examined to see if the "margins" (around the width and depth edges of the excised tissue) are clear of cancerous cells; you get to sit in a waiting room (with quite elderly people) for around 45 minutes while the lab work is done; then, if the margins are not clear, they inject more numbing medication and repeat the procedure as many times as it takes; then eventually they repair the area with internal and external stitches or skin grafts or whatever reconstruction is necessary. The prospect of having this done smack dab in the middle of my face while I was fully conscious seemed barbaric.

 

The consultation was brief and matter-of-fact, and we scheduled two separate procedures -- the nose first, and then the lip, which doctor expected to be smaller and simpler.  After about two weeks of feeling sick and anxious about the procedure, I came to peace with it.  It helped to see small scars on friends who had dealt with similar things.  It helped to receive sympathetic words and encouragement from friends.  It helped to stop looking at the pictures and stories online.  After a certain amount information, I believe you have to let go and move forward with acceptance.  One thing that brought a shift in my feelings about all this was recognizing the importance of not resisting it in any way.  Friends suggested listening to soothing music or self-hypnosis or bringing some physical object to hold for comfort.  And definitely asking for valium or whatever sedative I could get.  I planned to do all of that, but the night before the first procedure, I had a kind of epiphany.  I am not the type of person to shy away from experiences.  I tend to be courageous and adventurous and bold.  So I realized that "escaping" was a kind of "resisting" for me. I suddenly felt relieved in simply being curious about my own experience.  I found the path to do it my way, and it felt right.  I would go into the procedure as awake as I could be, and I would endeavor to experience it with great interest.  For me, I believe this was a tremendously helpful key in changing my whole experience to be much more positive and peaceful.

We arrived at the clinic at 7:30 on Thursday morning, October 24, for Mohs on my nose.  Because he is an awesome husband, Brian came with me for support, for entertainment, and for documenting the procedure on camera so that I could look at the pictures later if I wanted to.  (Eight days later, I finally had the stomach to view them, and I found them fascinating.) 

After checking in and paying the enormous bill (even with insurance), the doctor came in to consult with me and to mark my nose where the incision would go.  The nurse took pictures of each step.  And Brian took pictures of her taking pictures.  I was feeling eager to get started.  A little adrenaline, but not really "nervous," per se.

 

 

Ahhh, the numbing injections.  Shudder.  But obviously, they beat the alternative.

 

 

The very proficient nurse gave me multiple injections around the site, and I practiced diligent yoga relaxation techniques.  It is truly helpful if you can relax peripheral areas of your body when under localized duress.  I like to believe this is analogous to life stress, too.  The shots hurt.  The medication stings so much that tears will spontaneously stream down your face.  And the injection process lasts for a minute or two.  But it's very effective, and I didn't feel any sharp, outright pain for the rest of the day.

 

 

 The only thing I wish I'd done differently was to bring an eye pillow.  It would have been nice to shield my eyes from the really bright lights used during the excision stage.   

 

 

The doctor came in and got to work immediately. It did not hurt, but I could tell what he was doing by the feeling of his movements and the slight pressure in my face. There is the sensation of miniature sawing, then tugging to loosen the tissue, then lifting the plug.  I stayed calm and present by relaxing my arms, my legs, my chest.  Over and over, I kept reminding myself to relax my body.  It was very effective for me, and I noted that it felt oddly similar to being in a beauty salon for a hair shampoo and cut.

 

 

The photo above is the first plug removed.  Brian says it was the size of a Smartie, in diameter and depth. 

 

Below, the nurse cauterizes the wound to stop the bleeding.  That part is odd -- you can feel warmth, though it doesn't burn; you can feel stinging sparks, though it doesn't hurt.  But it does smell like burning skin.  It's over quickly, though.

 

 

 

** warning **

 

 

** potentially disturbing photo coming up! **

 

 

 

 

 

And this is what the hole in my nose looked like after the first round of Mohs microsurgery.  I did not see this picture until over a week later.  It probably would have bothered me earlier.  Now, I just find it extremely interesting.  And you can tell by my little smile that I was not in pain.

 

 

 

So they put a bandage over the hole and sent us out into the waiting room, while they examined the bit of removed tissue to see if the margins were clear.  Leading up to the day of the procedure, I had been really bothered by the idea of having to go sit in a waiting room, but it was not a problem at all.  It is a semi-private waiting room, only for patients who are undergoing Mohs (and their supportive family members), so almost everyone in the room has some sort of gauze pad strapped to their bodies.  I'm pretty sure I was the only patient under the age of 75.  It was sweet to have Brian's company through all of this.

After a short time, we were called back into the procedure room, and the doctor came in to tell me that there was still a little bit left on the edge, so we'd have to do a second stage of excision.  I was not surprised, based on what I'd learned about the procedure.  He seemed pretty confident it would take only two stages, so he went ahead and drew on my nose to indicate where he would cut to repair the hole.  They added a little more numbing medication (which stung slightly) and then removed a little more tissue from the area. 

 

 

** warning **

** another potentially disturbing photo coming up! **

 

 

This picture blows my mind a little.  Despite the gaping hole in my nose and the lines indicating where more incisions would be made, I look so peaceful and non-traumatized.  In my weeks of worrying about the procedure, I didn't imagine I could feel the way I look here.  And, if you're reading this with anxiety about your own procedure, I don't imagine this makes you feel a lot better.  None of the pictures of holes in noses helped me feel better; they only freaked me out more.  But the obvious lack of pain and stress that is visible on my face here is really indicative of what my experience was like.  I believe I took the time I needed to arrive at my own clear understanding of how I could best move through this -- for me, with curiosity and interest and very focused relaxation techniques -- and it served me well.  I believe that I found my way to accept and trust the circumstances, my body, my mind and my healthcare providers.  And it worked well for me. 

 

 

They let me hang out in the procedure room while they examined the second stage of tissue, and it was nice to just stay put and realize that this experience was not turning out to be as difficult as I'd been concerned it might.

Sure enough, the second stage was clear, and the doctor was able to stitch me up.  I hadn't understood how the repair would be done -- short of a skin graft patch or just pulling two pieces of skin back together, the artistic creativity required was beyond my imagination.  But he referred to the process as a skin rotation.  If you look at the markings he drew -- which looks a little like an "M" -- he cut on those lines to loosen the skin, so he could rotate the one "hump of the M" down to cover the hole.  (The hole was 1.2 cm x .9 cm)  Brian said it looked like the way you'd loosen the sheets on a bed in order to re-tuck them and make the bed up neatly. 

 

 

The doctor put a layer of sutures internally and then closed the incision with a delicate, looping, external stitch (which I counted 19).  The next picture is the only unbandaged glimpse I took of the whole procedure that day.  It did not startle or disturb me.  I was actually impressed at how tidy it looked.

 

My last picture from the appointment was to document Brian's presence.  He sat nearby, took pictures, joked around, held my hand, kept me company, tucked in the covers.  It was wonderful to have him with me.

We were in and out of the clinic in two hours.  They sent me home with a secure bandage, and I rested and iced my nose for the rest of the day.  I took some Tylenol for what I would classify as discomfort but not pain.  The picture below was taken later that afternoon.

I slept very well Thursday night -- carefully nested on the couch with pillows supporting me on all sides -- and was eager to take a look under the bandages on Friday morning.  This picture is immediately after I took the bandages off, before I cleaned it up at all.  Kinda gooey, but not that bad.



So I took a shower and washed the area gently with soap and water.  Next step was to dab it with peroxide to clean any ooze away so it wouldn't crust and scab, apply a coating of neosporin to keep it moist, and then re-bandage it for protection.  I was impressed with how neat and clean it looked, though I did get a little bit queasy by the time I was finished and ready to go lie down again.

All day on Friday, I rested and applied ice to the area.  It was a bit uncomfortable but not bad.

The next picture is on Saturday, two days after the procedure.  There was minimal swelling, no redness, only a little discomfort -- mostly from stiffness, swelling, and mostly in my jaw and the muscles across cheeks.  It was all still very numb.  I counted 19 visible stitches.  In addition to cleaning with water and peroxide, I began applying frankincense oil and vitamin E before I bandaged it up each day.

 

It continued to heal and feel better on days 3-4.  A little discomfort, residual numbness.  I kept it bandaged most of the time and was fortunate to be able to take things easy and rest a lot.  After the first couple of days, though, it was no problem to get out and about.

 

 

On Tuesday, October 29 -- five days after my nose procedure, we were back again for the lip. 

 

 

 

Same thing.  Consultation and mark the area.  Doc said my nose was healing so well, he'd take the stitches out (after only five days!).  I asked them to wait until after my lip was finished so I could take a picture of stitches in both, since by removing the stitches he was foiling my plans for a wicked Halloween costume. 

 

Then came the lidocaine shots to numb. Those shots really hurt, there's no getting around it. Your eyes tear up, your toes curl, and in the lip, you get instant Botox-style swelling.

 

 

This area seemed smaller, though, and the doc assured me that it is much easier to repair a lip than a nose, because there is plenty of flexible tissue to work with.  This appointment was at 9 a.m. rather than 7:30, and we could tell it was a busy morning that was already beginning to get backed up.

 

 

The absolute highlight of my entire Mohs experience came while I was buried under all that sheeting and just as the doctor was making the incision above my lip.  I hadn't noticed that the Pandora station (which I'd chosen) was playing my beloved Bruce Springsteen's "I'm On Fire", until this lyric line rose to the surface loud and clear and exquisitely timed: "Sometimes it's like someone took a knife, baby, edgy and dull, and cut a six inch valley through the middle of my skull."

It was all I could do not to fall on the floor, laughing. Yeah, sometimes it's Exactly. Like. That.

 

 

And so he cut a hole above my lip -- same sensations as before, and I used the same relaxation technique of consciously softening my whole body over and over again.  Then they sealed it with the little welding torch, covered my lip with a bandage and sent me out to the waiting room.  It took much longer this time.  The waiting room was crowded and filled with overly-loud conversations about politics.  When they finally brought us back into the procedure room, he said that there was a little bit more to go, and that we'd have to do a second round of excision.

 

 

So there was a little bit more numbing medication.  A little more cutting and tugging.  Then he stitched the internal layer and allowed me to stay in the chair in the procedure room while he went to deal with other patients and read the results of the tissue examination.

 

 

I was a little surprised and slightly disappointed that this had required a second round.  I think we'd all expected this one would be a piece of cake.  But I was still taking it all in stride... until the next round of shots.  The doctor came back and said the results were clear, and that he'd be back soon to finish the repair.  But the minutes ticked by and, because the wait time was so long in between all of this, I began to feel some sensation in my lip again and asked the nurse to check it.  She gave me a HUGE boost of lidocaine around the edges of where it had been deadened before, and it hurt like crazy. 

 

 

She was also a little sloppy -- she was new and was nervous and doing her best, I'm sure -- but she released some of the liquid from the syringe onto my face and into my mouth. My tongue went slightly numb for a bit. She also didn't initially cover the wound, so it began bleeding, and I could feel blood running down my cheek and taste blood in my mouth.  Up until that point, I had felt completely secure and well-tended to by all of the staff.  But the carelessness and the pain combined to challenge my remaining reserves of calm, peaceful coping.   

 

 

By the time the doctor finally arrived to finish up the stitches, I was really ready to be done with the whole thing.  My lip was swollen and completely numb, but I could feel him pulling and stretching the skin as he sewed it back up.

 

 

There were several internal stitches to stabilize the area -- he warned that it would be fragile because the mouth is such a dynamic, mobile area -- and he put about 9 stitches on the outside.  The 1.1 cm x .8 cm area of tissue removed was nearly identical in size to the nose procedure.

 

 

So I got my picture of the stitches in both my nose and lip, then the nurse removed the sutures from my nose.  And that also hurt a lot as she was doing it, and I needed to hold Brian's hand for the first time.

 

 

It took about three hours total, but everything looked good.  Brian drove me home so I could rest, ice and take Tylenol. 

 

 

It was a challenge to figure out how to ice the upper lip and still breathe out of either the nose or the mouth.  And my face was numb, so I couldn't really tell where the ice/pea pack was. 

 

 

I played with the humor of the frozen pea pack, but it was a really uncomfortable afternoon. There were a few hours when the pain was seriously distracting, then it waned to just pain. It was impossible to eat. Very difficult to sip -- more like gently pouring something into an only slightly-opened mouth.  The few hours between when the nurse overdid my last round of numbing shots and the time the intense pain diminished around 3 p.m. were really the only horrible parts of the experience.

 

 

 

 The next day, my lip was very swollen and extremely fragile.  (That's the best word I can come up with to describe the lip recovery:  "fragile")  You can't smile, you can barely talk, you can't wrinkle your nose or make any expression that involves muscles that connect to your lip.  It feels stiff and awkward, and it hurts.  But I could tell that the doctor had done a good job and that it would heal just fine.  So the picture below is Day 1 of my lip. (one day after surgery)

 

 

 

Day 6: nose... feels awesome in comparison to lip

 

 

Day 1 lip; Day 6 nose

 

 

Day 2 lip... still really swollen and awkward.  I was very grateful to have another full day to be very still and quiet.  I wish I could smile or make some expression.

 

 

 

Day 7 nose... one week after surgery

 

 

Day 3 lip... swelling is about halfway down, but still very vulnerable feeling... I could finally run my tongue over my front teeth and verrrrrry gently slide a toothbrush over them. Ahhhhh!

 

 

Day 8 nose... looking better and better

 

 

I began using silicone strips on my nose on the 8th day after surgery (3 days after stitches removed).  I heard they work wonders for minimizing scars.

 

 

Day 3 lip; Day 8 nose... not too shabby looking... Just eager for the lip to get stronger.  A silver lining is that even with creamy soups and ice cream, a limited liquid diet is still a great way to lose a few pounds!

 

I will add more pictures of the healing process, as I go.  All in all, I was well-prepared from an informational as well as mental/emotional standpoint.  The lip was more impactful than I expected, but the nose was definitely less.  And in general, it was not nearly as traumatic an experience overall as I thought it might be.  It's only 9 days after my nose surgery and 4 days after my lip, so things are going well.  Very well!