Mohs Surgery and Reconstruction for Lentigo Maligna - Mount Sinai, NY

I had a small light brown area developing on my cheek for a few years, I tried over the counter bleaching compounds as it started getting bigger in size and more noticeable to no real effect.

I had a dermatologist look at it and she said it was probably just due to age and to keep an eye on it. After about 6 years I was becoming more uncomfortable as it had tripled in size and was becoming darker and variegated in colour in over just about a year.

I happened on a couple of clinics/spas while visiting in the US. Selecting a company called MediSpa in Atlanta to get it looked at as a second opinion. I dealt with a Dr. Atkins there who was very thorough & who immediately said with level of sun exposure and the general appearance of darkness she did not like the look of the mole/darkness and she suggested a biopsy which I had done. Unfortunately it came back positive as a Lentigo Maligna, a quite rare form of Melanoma. The positive news was that it was diagnosed as a Clark Level 1 , in situ lesion and as such I was very lucky.

Dr. Atkins recommended I find a Mohs Surgeon that also was a reconstructive plastic surgeon, again excellent advice.

This is where a lot of google searches and research commenced and we found an excellent Doctor based in Mount Sinai Hospital NY. by the name of Dr. Khorasani. He clearly had a lot of experience in both areas and when I went for a consultation he was very reassuring , obviously very skilled and at the forefront of Mohs procedures which would minimise the amount of tissue that would need to be removed. Sometimes no matter how much research you do its your gut feeling you have to rely on and when I met Dr. Khorasani I knew he and his team were going to give me the best result possible, they were all very caring , communicative and professional.

So after only 4 weeks I was booked in for the procedure, although just on the surface the nature of most melanomas is they can change quickly so better to have them removed as soon as possible. It was to be done just under locals (which I preferred). It was clear quite a bit of tissue would have to be removed even though it was on the surface to get all affected tissue. Which again is why Mohs is so effective as they progressively remove tissue , do tests and only remove the actual amount that is necessary.

As the day approached of course a lot of trepidation set in but I was sure I was in one of the best places to have this done. Very important to get the immune system in top notch as, infections are something u don't want to deal with as well in such times, so plenty of rest etc.
The day came and my general state of mind , which is very important was positive and calm although jittery.

Dr Khorasani went through the procedure once again very thoroughly with both my husband and I, and then with some sedation and multiple injections to the face the initial Mohs procedure was performed, they ended up doing a few passes to remove all affected tissue which isn't that unusual but in the end needed to take a 2 inch diameter circle of tissue. This is more than I had hoped for but the issue is you sometimes can't see the full extent on the surface, and I was glad they were being extra cautious. During the Mohs procedure the injections they put in the area and topical deadeners which worked well and the most I felt was a bit of pressure.

When they finally had the all clear from the lab after about 90 mins of procedure a cotton gause pressure bandage was put over the area, and I went out to the waiting room and had lunch with my husband.
My thoughts at this point were….Is that it?, really seemed like a lot less than I had been expecting , but of course the anaesthetics were still doing the job and the reconstruction to close the 2 inch hole had not started.

I was soon back in the chair given some heavier pain killers/sedatives and the reconstruction commenced. They would need to do a Bilobar rotation instead of just a usual rotation because of the amount of tissue involved. This was again the magic of going with a skilled plastic surgeon as they rotated forward the tissue from behind my ear and neck to close the area on my cheek something I would not have thought possible. Anyway this part was of course longer and took about 4-5 hours. I did start feeling some pain because of the length of this procedure but was given more Anaesthetics / sedatives which pretty much knocked me out.

I came too and my husband was there it was 6pm and New York had been hit by a large snow storm so getting back down to lower Manhattan was a bit of a task but it was over , the drugs kept me out of it for quite some time so definitely have someone with you for a procedure like this.
I was given a regimen of antibiotics and pain killers in a script to fill and also used some simple tylenol and we made our way back to the hotel, in the blizzard. I also had to have a drainage bag on side of face to deal with swelling /drainage and was to come back in 48 hours for a checkup. That night we ate Japanese something easy to deal with and then a lot of R&R for the next few days. The checkup was fine, drainage bag removed.

I experienced some leakage most probably from the salivary duct/gland for about 4 weeks but aside from this healing progressed slowly and steadily. I applied Aquafor to keep the wound moisturised and did nothing much else until stitches except used steristrips which are very important to keep on, if they peeled off I applied additional, as they keep the wound pulled together and add support these with stitches were removed at about the 1 week mark,2 weeks later I used silicone strips to help protect the wound and improve healing and at the 3 week mark used a product called Bicorneum which has an spf factor is silicon based to help healing of the scar and also forms a base for makeup which could then be applied. Great product felt a tightening sensation when I put on as it acts to pull the wound together and minimise scaring.
I also went in to Sephora and got some great assistance with a makeup system to use which I can highly recommend. The prescribed cleanser/Moisturiser products by Cetaphil from the hospital were very good. The other product worth seeing if is right for you is ScarGuard which is good I found but flakes a bit so only really used when at home later on as initially I found it slightly irritating.

I was so appreciative to find the real self site, as this site has helped me know what to expect from other people's experiences especially with the scar healing which was very accurate.

As can be seen from the photos you see a big improvement at about 6 weeks, and then 3 months and 7 months, with a gradual lessening of the redness of course the skill of the plastic surgeon is crucial here also.
Dr. Khorasani was great in explaining after treatments that could be used to improve the appearance of the scar, and at the 5 month mark I had a a Deep FX laser treatment and resurfacing of the scar area. The Deep FX can stimulate Collagen production and the resurfacing helps to flatten the scar area, it is recommended to have a second procedure of this for maximum results but I have found that after this first treatment although there is a ways to go I am happy with the result at this point.
When having the laser there is quite a bit of swelling and while not what I would say is pain..discomfort with this procedure so u need to plan down time. A fair bit of swelling followed and redness for about 3-4 weeks It can take over a year for the redness /flattening of the scar area to settle down and I am still in this process but am so happy considering the extent of what had to be done with the result so far.
I can't recommend Dr. Khorasani and his great team enough and was lucky to find them.

Aside from all this obviously one of the most important things is no sun for the first 3 months after the initial procedure or the Laser/resurfacing, and minimising sun exposure to the area afterwards , (to minimise darkening of the area / safety) and at least the use of a good spf 30 product , I recommend a metal based (not chemical) product such as the Australian cancer council sunscreens.
For those undergoing similar situations take heart, it is of course scary but if you are lucky enough to catch it early it can be dealt with effectively especially if you have a good Mohs/plastic surgery team such as I did.