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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “You take care of a woman who has very light skin and sun exposure, and because of the current condition, she's delayed having this nodule removed. You can see it's characterized as being papular, that is, it's raised. It's not really pigmented, but there is injection, in other words, we can see the small blood vessels that are more generous than the surrounding skin. And there is not any central ulceration, it's all epithelialized. When we look on the inside of the nose, here we can see, I've got it, thank you, we can see that the skin is intact, and it's hard to tell by looking, but I can feel that there's no evidence of penetration all the way through both layers of the alar skin. So, this part of the nose is a wing that comes off, and the word for wing is ala, A-L-A. So, this is a papular nodule on the ala. Here's a smaller version of the same thing right here, it's a little harder to see, but it's papular and very well circumscribed. It doesn't have as much vascular injection as the larger one, but both of these are going to be skin cancers, and we're going to remove them today. So, stay tuned, and I'll show you how we do it. So, here's our lesion, I've anesthetized it, and what I want to do is take the lesion itself, and about two millimeters of normal skin around the circumference, and at the alar margin here, I don't want to take any more than I have to either, and I'm going to put a little mark on my lesion so I don't lose orientation for the 12 o'clock position. So now when I excise it, I'll put a marking suture on, and I'll be able to submit it to the pathologist for margins, and then we'll address the reconstruction. And there's a little bleeding at this stage because of two reasons, one, I'm holding tension and two, is because I've injected lidocaine with epi, and I've given it several minutes, it needs about eight minutes for the lidocaine to fully take effect. Nathan, if you will pick up a skin hook and just elevate that gently with one of the hooks, maybe use your other hand. Nathan, if I'd known how deft of hand you were, I wonder how you trained as a scrub tech. Originally? Come back the other way. There we go. Now do you want to show off what you've got there? And here is the defect in the nose, and as soon as I release pressure, you'll see where it's oozing from. Now Nathan, could I have the caudery please? Caudery looks like this.”
Nathan: “It's on 40-40 dark red.”
Dr. Joel Aronowitz: “There we go. Okay. Now we will mark that and send it off to pathology. But before we do that, let's go ahead and get the second lesion.”
Nathan: “Okay. Okay.”
Dr. Joel Aronowitz: “There we go. Now, yeah, that one I'm not going to. All right. So now we've taken our two lesions off. While we wait for the pathologist to tell us if the margins are clear or not, both around the periphery and the base, we're going to figure out what our options are for the reconstruction. Okay. Okay. So now we've partially closed this defect, and what I've done is undermined both the dorsum of the nose and the lateral sidewall all the way up, and I have not undermined the ala so as to keep that intact. And then if you come around this way, you can see I've actually, in the process of removing excess tissue from the inside, because there's redundant tissue on the inside now that I've made the ala smaller on the outside. So, we'll finish removing that tissue. I'll take a scissor, please. And we'll get that closed up and be all done. And this was, we just got the pathology report back that shows that all of our margins were clear, which is great. So, we'll be all done.”
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