Mission: Save My Nose

By Sue Eisenfeld
Special to The Washington Post
Tuesday, April 25, 2006

There's nothing like spending a vacation worrying that you might have to get your nose removed. But that was my situation during the weeks leading up to my skin cancer surgery last summer.

Sure, total nose loss was a worst-case scenario, but it was a possibility. My husband's uncle had his nose removed. Several dermatologists told me they'd seen or operated on dozens of people who waited too long to deal with their skin cancer and wound up having their nose, ears, cheeks, eyes or lips removed. And my doc warned that even the "least worrisome" and most common kind of skin cancer -- basal cell carcinoma, my variety -- can spread to the muscle, cartilage or bone.

I was first diagnosed with a basal cell carcinoma, on my chest, at age 29. What started out as an itchy bump (that I scratched and picked) turned into a scabby wound that never healed. Because of the prominent location -- around the "plunging neckline" area -- my dermatologist recommended it be removed with liquid nitrogen, to minimize scarring, instead of cutting it out and sewing it up. A white mark the size of a pencil eraser remains.

Though I was gently warned that I would probably have other skin cancers in my life, I didn't really change my behaviors. I admit I had a bit of that "it won't happen to me" attitude back then.

Five years later, a pearly bump appeared on the tip of my nose. I thought it was a zit, but Clearasil and several months' time didn't seem to help. Once diagnosed with my second basal cell carcinoma, I needed a specialized procedure called Mohs surgery, a technique often used on the face, to minimize tissue removed and leave the smallest scar.

My surgeon sat me down just before vacation, and gave me a stern talking-to about my future.

"You're very likely to have other cancer surgeries on your face," he explained. Worse, he warned, "basal cell carcinoma and melanoma like to keep the same company," referring to the sometimes metastasizing, sometimes fatal form of skin cancer that kills 7,300 Americans each year.

I went home and promptly bought a stylish wide-brimmed hat, three bottles of SPF 45 sunscreen, and two pairs of UV-A/UV-B sunglasses for my August vacation in New Mexico.

'It's Nothing'

When I first mentioned my skin cancer to friends and family, several people gave me an "Oh, it's nothing" or "Everyone in Florida has that." And while the majority of basal cell carcinoma cases amount to nothing more than a nuisance -- dermatologists all over the world routinely remove them from all over the body -- skin cancers of the middle of the face can be tricky to remove with a cosmetically pleasing result. My surgeon explained that the visible cancer can be like the tip of an iceberg, with most of the dangerous cells lying beneath the surface. He also described cancers of the middle of the face as having a "root system"; both scenarios make it difficult to know how much of a mark surgical removal will leave on the face.

Glenn H. Fuchs, a dermatologist and dermatological surgeon who practices in Arlington and the District, recounts a patient who had a golf-ball-size basal cell carcinoma in the cheek.

"I've seen three cases where the cancer led into the brain, and other cases where basal cell carcinoma destroyed the entire center of the face," recounts Martin Braun III, a dermatologist and Mohs surgeon in the District.

Just the day before I chatted with Braun, he said, he had seen a patient with an "ulcerating, cauliflower squamous cell carcinoma" on his shin that had been removed three times but had grown back each time. "I don't know if I'm going to be able to help him," Braun lamented. "He might need an amputation."

Better Sick Than Pale

The Washington City Paper, which publishes people's secrets, ran one last fall that read, "I'd rather get skin cancer than be pale."

Among some of the younger adults I know, the same attitude prevails: "People always say that if you're pale, you look like death, but if you're tan, you look healthy," said a 29-year-old girlfriend of mine who lives in Arlington. (Her mother has a 12-inch scar from her hairline to her neck, the result of skin cancer removal.)

Changing the skin's natural color can come back to haunt you later. You can end up with dark patches, leathery skin, premature wrinkles and other skin problems that probably look a lot worse than your pale skin did. "People are very short-sighted in terms of what makes them look good at the moment versus what will be harmful down the road -- especially young people," notes Fuchs.

Jennifer Core of Athol, Mass., already had had one basal cell carcinoma removed when she was diagnosed with melanoma at 29. She had spent several years in equatorial regions of the world and had many "awful blistering sunburns" throughout childhood -- a factor that increases risk for the disease. (Experts say that even one or two blistering sunburns as a child can double your chance of getting melanoma.) Though her melanoma was caught early and had not spread to her lymph system, she came away with a 10-inch-long, half-inch-wide scar on her back after having what seemed like just a small mole.

I trace my sun exposure back to the days of carefree ignorance when I spent many a week at the Jersey shore in the 1970s and '80s. Once, my face was so badly burned it puffed up like a blowfish. Another time, the backs of my legs burned so badly I couldn't bend my knees. Though I abandoned my sun-baking mentality after reaching my twenties, I didn't protect myself well enough on other outdoor trips to prevent a few additional burns, mostly on my face and chest, which -- voilà -- both wound up getting cancer.

Under the Knife

So after having applied sunscreen 10 times a day while hiking in sun-blasted places in the Southwest -- and still fretting each night that I seemed a tad pink -- I showed up for my surgery white as a snow angel. And thank God for Frederic Mohs. He's the guy ultimately responsible for saving my nose. In the 1930s, this Madison, Wis., doctor developed a technique for removing skin cancer that saves healthy skin and minimizes scarring.

The Mohs surgery goes something like this:

The surgeon injects you with a fast-acting local anesthetic and tells you to keep your eyes shut. He then removes all visible areas of the tumor with a scalpel, while cheerfully talking about what a nice day it is outside.

Next, he removes a thin layer of skin -- approximately 1.5 to 2 millimeters thick and shaped like a saucer. Next he goes off into a corner and divides that layer into tiny specimens, and draws a map interpreting the divisions. The nurse bandages up your nose -- or whatever you've had worked on -- and sends you out into the waiting room.

While you wait, the surgeon -- who is also the pathologist in this case -- reads the slides and determines whether there is any cancer left in your face. If so, you are called back in for another round. The surgeon uses his map to home in on just the area with remaining cancer, rather than taking a full slice again, which would contain some good skin as well.

My Mohs surgeon, Braun, reports taking two slices on most patients, but has also had his share of "fours, fives, sixes and sevens, and we had a 15-layer surgery the other day." Once all the cancer is removed, the wound is stitched up, grafted, flapped or -- in a best-case scenario, like mine -- simply left to heal on its own, which requires vigilant daily care to prevent scarring.

Ultimately, my pre-vacation worry turned out to be overkill for what wound up being a simple surgery leaving a negligible scar.

But my story isn't over.

Within a month of the biopsy of the growth on my nose, another growth emerged, only a centimeter away -- this one white and barely noticeable but growing fast. My surgeon said it didn't strike him as looking like any basal cell carcinoma he'd seen before. I pressed for a biopsy because it was new and it had changed.

Two months later, I found myself lying on a table again with a scalpel at my face. I was told to think calming thoughts, like how I felt on my favorite vacation -- not those searing cliffs in New Mexico, where I was too worried about my surgery to enjoy myself, but lying on a white sand beach on a Caribbean island, swimming in turquoise water . . . slathered in sunscreen, of course. ยท

Sue Eisenfeld is a Washington area freelance writer. Comments: health@washpost.com.

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