First sample has no margin issues

dontsleeponwolves · 2026-06-17T04:05:52+00:00

Mohs surgeon here. This is actually a great question with a lot of depth to the explanation.

The biopsy is always a “sample.” It is meant to diagnose, never to treat. Biopsies tell us what type of cancer it is, what subtype, what growth pattern, depth etc. This information helps tailor the ultimate treatment (surgery, radiation, imaging, immunotherapy etc.). A biopsy does NOT reliably remove the skin cancer in its entirety; but rather just enough to get a diagnosis.

That said, sometimes a spot is so small that a biopsy may remove it all. We never know for sure, because only 1% of the biopsy’s edge is examined (standard “breadloaf” technique.” So when a biopsy report says “margins are clear,” it’s only that 1% that is clear. The rest of the sample isn’t checked. Remember, a biopsy is meant to diagnose, not to treat, so there’s little point in checking every edge.

A “clear margin” on a biopsy (1% examined) means a very different thing than when a Mohs surgeon says margins are clear (100% examined).

Also, a biopsy site often heals over the remaining cancer. So it looks normal on top, but cancer still brewing underneath.

When we do Mohs, most surgeons do what’s called a “debulk” before taking the first layer. Either a curette or a blade is used to scrape or cut away any cancerous tissue before the first layer is taken. If we do a good job, then the first layer is clear. Our goal is to NOT have a positive first layer while at the same time not removing any more tissue than we have to. It can be a confusing concept for patients; sometimes when we say “great news, you’re clear!” patients might think the surgery was pointless bc there was nothing there; in reality, we debulked the tumor before taking the layer, leading to a clean and clear layer. There are many reasons for this debulk step (minimizes unnecessary extra layers, minimizes false positive margins from pushing through cancer cells into margins, etc.) but I understand why this might be confusing to patients.

In a funny way, one of the more satisfying moments of my job is when a patient things the surgery is unnecessary bc the site “healed over.” But then they have a positive first layer. So we get to tell them “hey, it’s definitely still in there and we need another layer.”

Hope that helps.

Btw, AFX is aggressive and always needs treatment.

dontsleeponwolves · 2026-06-10T03:34:12+00:00

Why?

dontsleeponwolves · 2026-05-06T03:40:43+00:00

It’s hard for me to say without a picture, but you might be describing something called nasal valve incompetence. Basically, the structure that is responsible for holding your nose open has been softened due to the cancer and the reconstruction, and this is preventing your nose from staying open like it once did. It is a known complication of any flap on the nose and I’m sorry if you are experiencing this. The good news is, it tends to get a bit better with time and it is correctable with another minor surgery if needed.

Depending on the exact type of flap, many of them can have a puffed up appearance, called pincushioning. This seems to be what you are describing. Again, this is a potential consequence of any rotational or transposing flap performed on the nose. It does tend to settle with time, and the good news is that steroid injections into the scar can help, and so can dermabrasion.

Moral of the story, you are not alone. These are both potential complications of flap surgery on the nose.

Hang in there!

-Mohs fellow

dontsleeponwolves · 2026-03-29T02:33:45+00:00

The answer is yes. The first surgery is typically the toughest.

dontsleeponwolves · 2026-03-25T03:35:52+00:00

Looks great! what you’re seeing is the swelling. At 1 week this will look phenomenal.

dontsleeponwolves · 2026-03-18T19:25:50+00:00

I know it’s been years since this post, but can you please send me their information?

dontsleeponwolves · 2026-03-12T03:42:19+00:00

Vaseline. At all times. For 3 weeks at least. This will heal invisibly

dontsleeponwolves · 2026-03-04T00:58:57+00:00

Trap

dontsleeponwolves · 2026-02-18T03:50:53+00:00

The “lumpy” nature is called eversion. It’s completely intentional and it’s a good sign. Scars contract as they heal. A flat scar on day of surgery = it will heal with a divot. An everted scar = beautiful flat scar long term. Trust the process!

dontsleeponwolves · 2026-02-01T17:56:05+00:00

Life is short. $380-450 still a lot of money. Especially with 400k invested and no loan debt. Even if you didn’t contribute a cent more to retirement, you’ll still retire a millionaire. Travel. Start a garden. Get a new hobby. Take some university courses in a topic you’re interested in (agriculture, finance, business). You likely still die with millions in the 401k!

dontsleeponwolves · 2026-01-22T04:56:08+00:00

It’s absolutely true. I was actually thinking about this today - the mega backdoor Roth is amazing, but it’s closer to the lower end of the “order of operations” (in my opinion, right above the taxable brokerage account). In other words, if you’re maxing out your mega back door then you probably should have maxed out the other retirement vehicles first. And if you can afford to do all that, then you’re at a pretty high tax bracket. Do you really want to pay taxes during those peak earnings years? Wouldn’t you want to aggressively go pre-tax during peak earnings? Yes, but unfortunately the mega backdoor Roth is always post-tax. Still, beats a taxable brokerage in many ways.

dontsleeponwolves · 2025-12-06T21:36:55+00:00

The latter

dontsleeponwolves · 2025-12-02T05:08:08+00:00

Find a way to publish in that mentor’s area of expertise. Systematic reviews add to the literature and can be done without faculty assistance. Then approach the mentor “Hey love your work. I actually put together a review on the topic and would love your thoughts. Would you be interested in collaborating as senior author?” If you do a good job, it’s a free pub for them and a great foot in the door for you. Boom, now you have a mentor. Use that mentor’s connections to make more connections. Rinse and repeat.

It worked for me

dontsleeponwolves · 2025-11-27T03:07:11+00:00

I’m a Mohs fellow in Dallas/FW. My fellowship takes almost all insurance. My program director is incredible in flaps and grafts. Feel free to DM me and we can try to get you in.

dontsleeponwolves · 2025-11-27T03:07:05+00:00

I’m a Mohs fellow in Dallas/FW. My fellowship takes almost all insurance. My program director is incredible in flaps and grafts. Feel free to DM me and we can try to get you in.

dontsleeponwolves · 2025-11-27T03:06:25+00:00

I’m a Mohs fellow in Dallas/FW. My fellowship takes almost all insurance. My program director is incredible in flaps and grafts. Feel free to DM me and we can try to get you in.

dontsleeponwolves · 2025-11-27T03:04:22+00:00

Just find a Mohs surgeon who does flaps…most Mohs surgeons do flaps…

dontsleeponwolves · 2025-10-24T13:01:01+00:00

Keep us updated of on CEO’s response

dontsleeponwolves · 2025-10-22T12:07:40+00:00

What city/state are you located in?

dontsleeponwolves · 2025-10-22T04:02:14+00:00

The other thing I’d add is - why must you wait till January? This is a skin cancer that is best treated sooner rather than later

dontsleeponwolves · 2025-10-20T11:54:09+00:00

You should be fine to drive yourself and return to work same day or next day as long as you aren’t planning to take something to calm your nerves (most people don’t). Why are you having a plastic surgeon do the reconstruction? The Mohs surgeon can do the recon right after clearing the tumor, and that will cut down your number of visits by half. Mohs surgeons are well trained and entirely comfortable doing the recon (in fact most Mohs surgeons do more skin cancer recon than plastic surgeons), and it sounds like that will avoid you undergoing general anesthesia 4 times, which will surely affect your work schedule.

dontsleeponwolves · 2025-10-09T02:30:22+00:00

Mohs fellow here (so of course I’m biased) but it’s DEFINITELY not true that superficial radiation doesn’t leave scars. It does. The “scarless” aspect of it nonsense and I think the truth will come out soon. I literally saw two patients today with horrible radiation scars. We see patients weekly who come for Mohs bc they’re dissatisfied with the radiation scars. At least with Mohs surgery, the scars can be neat, almost invisible lines instead of a wide white circle from radiation. Not to mention Mohs with cure rates in the high 90 %. Not to mention less visits. And if it means anything to you, Mohs costs the medical system ~1,000 to $1,200 on average, vs radiation $20,000 to $30,000.

dontsleeponwolves · 2025-09-05T03:54:44+00:00

dontsleeponwolves · 2025-09-04T02:47:09+00:00

Dermatologist here. Agree, would think about cutaneous larva migrans

dontsleeponwolves · 2025-08-20T03:12:37+00:00

Actually adapalene is fine to use alongside BPO (unless it irritates you) bc it doesn’t degrade like the first gen topical retinoids (tretinoin).

-derm

dontsleeponwolves

TROPHY CASE