Inside the Little Plastic Castle

In October I was diagnosed with squamous cell carcinoma on my nose. Last week I learned I also had basal cell carcinoma, while I was having it surgically removed. Good news! That’s it — don’t need drugs or chemo.

Back in 2020, I wore 3M Aura N9205+ masks I had on hand. Its interior nose wire is cushioned by gray foam. After a couple days I saw a little spot on my nose when I took the mask off: I assumed my twitchily-sensitive skin was reacting to the foam.

I switched masks and thought nothing more of it. That little red spot stayed the same size, approx 6 by 7mm. It didn’t ooze and it didn’t scab. I basically forgot about it. After my annual doc visit this year, MyGuy mentioned "Hey, maybe you should get that sore checked out. It’s been there a long time."

Hooray for electronic medical records. I uploaded this picture and asked my primary doc, "Should I be worried about this sore?"

He replied, "you should check it out with a dermatologist." First appointment was 4 months later. I escalated it by saying, "It’s been there two years without healing." Saw dermatologist 11 days later. She biopsied it (like peeling the skin from a carrot). "Yep! This is a squamous cell cancer and you need Mohs surgery."

Frederick Mohs was a doctor here at UW-Madison. His smart idea was to remove skin cancers in one visit, by repeated excision and testing until the skin is cancer-free.

1. Use local anesthetic
2. Cut away likely cancerous tissue
3. Analyze tissue to ensure clear margins via frozen section
4. Any remaining cancer on step 2? Return to step 1.
5. No cancer on step 2? Close the wound.

The Mohs surgery this past Thursday was the least traumatic I’ve ever had. Taking 0.5mg clonazepam 15 minutes before the start was a great idea. The surgeon and nurse were sweet and encouraging, ushering me and MyGuy into the biggest suite they had so there was room for my powerchair as well as the surgical chair-bed contraption. They seemed happy to have me and MyGuy experimenting with various props and pillows so I could be comfortable. "You’re doing great! Just a few more minutes!" At one point I was bellowing like a cranky goat to release tension. "We like hearing goats!" I was particularly struck by the surgeon’s opinion that I had a pretty nose, and she wouldn’t change its tip at all. (I've always regretted my tiny WASPy nose, so unlike my family of origin.)

Closing the wound required carving a flap of unaffected skin from the side of my nose and cheek then rotating it to cover the excision. Thanks to the 21st Century Cures Act requirement giving patients access to their entire medical records, I was able to read the details documented by the surgeon-nurse team.

I love the precision in their description of the final flap:

The defect and surrounding area was infiltrated with 2% lidocaine without epinephrine, mixed 1:2 with saline for better hemostasis. The defect was then cleansed and prepped with chlorhexidine and draped with sterile drapes. The wound edges were debeveled and the wound was undermined bluntly in all directions. The rotation flap was incised sharply to the level of subnasalis. The flap was undermined from all surrounding tissue. Hemostatis was obtained using electrodessication. The flap was then rotated into the primary defect secured with buried vertical mattress sutures. A cone of redundant skin was excised opposite the leading edge of the flap and careful attention was given to maintaining the pedicle to the flap. The epidermis was then carefully approximated using 6-0 prolene sutures throughout the length of the flap. Careful attention was given to even approximation of the wound edges. Flap size measured 3 x 5 = 15 sq cm.

That a 7mm sore needed a 30 by 50mm flap surprised me. They did a thorough job bandaging me up: the 2 inch wide bandage starts mid forehead, covers my nose, and then splits to anchor on both cheeks — an upside-down Y:

For curious readers, detailed pictures at each step of surgery documented elsewhere in my journal