Basal cell carcinoma (BCC) is the most common skin cancer and often not taken as seriously as squamous cell carcinoma (SCC) or, of course, melanoma. Here’s why this is a mistake.
The pic above is of my left leg. It was taken in September this year, a few days after surgery to remove two skin cancers, both diagnosed as basal cell carcinoma (BCC for short). The surgeon had to go wide and deep – almost to the bone – to be sure of clearing the margins. Bit gruesome, huh?
Here – have a close-up. You’re welcome.
Post-surgery BCC excision wounds before skin grafts failed
There’s more to my little BCC tale than soft-core surgical porn. I have to admit to some discomfort at going public with something like this, but I feel compelled to do so for two reasons:
- To caution others not to make my mistake of ignoring skin features deviating from the norm. Thing is, I’m generally well informed on skin cancer, but until recently my main focus was melanoma. I knew about the other types – squamous cell carcinoma (SCC) and BCC – and was aware that the former can be just as dangerous as melanoma IF not treated in time. But I thought BCCs were pretty trivial as skin cancers go, and nothing much to worry about. Skin cancer lite, if you like. I suspect I’m not the only one to have arrived at that misunderstanding. The experience I’m about to relate hammered home just how wrong I was. My hope is that this post might serve as a wake-up call, prompting others who have noticed something unusual about an area of skin, however small or seemingly insignificant, to consult the doc a lot sooner than I did.
- To provide some detailed information for people diagnosed with one or more BCCs on the lower leg requiring surgical excision and skin grafting. I couldn’t find a lot online on exactly what to expect after such surgery, particularly should the skin grafts fail. Hopefully, my experience as reported here will fill in some gaps for others facing similar treatment and rehab.
I should state from the outset that as unprepared as I was for what I went through post-surgery, others have suffered far more from BCCs left untreated for too long.
For example: the news came through just before my leg was operated on that John Blackman (the voice of Dicky Knee on Hey Hey It’s Saturday) was to have his lower jaw removed due to the bone being infiltrated by a BCC, which started as a spot on his face he’d assumed to be a pimple. If he’d checked with his GP when he noticed that the “pimple” was not going away, it could so easily have been biopsied and diagnosed as a BCC, then removed in the surgery under local anaesthetic in a few minutes, with minimal scarring and discomfort.
I well understand John Blackman’s apparently cavalier attitude. For years, I ignored the two patches of dry scaly skin on my shin that turned out to be BCCs. Like Blackman, I had no idea of their pathology. Like Blackman, I assumed they were nothing worth troubling my GP with. They didn’t hurt, itch or bleed. They did spread over the years, one more than the other, but so slowly that I barely registered the change.
I wrote them off as some sort of varicose eczema or, more likely, “sunspots” (solar keratoses) – areas of benign sun damage like those on my scalp my GP has periodically blitzed with liquid nitrogen for, oh, must be a couple of decades now. I wear trousers most of the time, and these two small areas on my leg didn’t look all that bad anyway, so why rush to get them zapped? I knew legs take notoriously longer to heal than other parts of the body, so my decision to put off having treatment seemed reasonable.
The Earlier You Check ANY Abnormal-looking Skin With Your Doctor, The Better!
Like Blackman, if only I’d checked with the doc way earlier when the lesions were small, they could have been excised in the surgery under local anaesthetic, the stitches removed in a few days and that would have been it. End of story.
Instead, with the BCCs developing slowly over years due to my neglect, this is what happened when I finally showed them to my GP:
Biopsies were taken that showed both lesions to be BCCs. I was referred to Plastics at Sir Charles Gairdner Hospital, and operated on a few weeks later by a plastic surgeon. As you can see from the pics, the wounds were too substantial to stitch, requiring skin grafts. The leg was dressed and wrapped in heavy compression bandaging and I was instructed to keep it elevated day and night. No walking, except to the toilet and back, no sitting except with the leg elevated, no standing, no driving, no showering.
The grafts failed and the anticipated 2 week healing period blew out to months. During this time my activity remained extremely limited. The compression bandaging required changing several times weekly, once at the hospital Plastics Dressings clinic (massive wait times, inconsistent quality of nursing), the rest at home by Silver Chain nurses (wonderful service from wound-care specialist nurses).
I had a setback when the large wound developed hypergranulation, which resolved after a couple of weeks of treatment with silver nitrate. I had my first shower 3 months after the surgery. A couple of weeks later, just before Christmas, my Silver Chain nurse declared the wounds healed and discharged me from care.
Things could have been worse. Much worse. Wounds like mine that don’t heal as they should are classified as “chronic” (chronic wound = ulcer); some chronic wounds don’t heal for many months, years, or ever, requiring ongoing professional assessment and bandage changing several times weekly. And as with any open wound, there is a risk of infection. In rare cases, when unable to be controlled, infection can result in amputation of the affected limb, or even death. So, as incapacitated and inconvenienced as I was for way longer than expected, I count myself lucky. And boy, was the lesson punched home that BCCs are no trifling matter!
As problematic as the legs can be with healing, though, BCCs (or any skin cancer) have most serious potential repercussions when on the head or upper body. IF LEFT UNTREATED, the surgery required to remove the BCC can result in serious disfigurement. And that’s not all…
There are lots of sites out there claiming that BCCs rarely spread. You get the impression that “rarely” means hardly ever. This is not correct. BCCs on the head are potentially lethal because they can spread to the brain. Further, as John Blackman’s case demonstrates, those on the face can infiltrate other facial structures or features, including the eye. Skin cancers on the upper body, including BCCs, can spread to the lymphatic system, then to the major organs or elsewhere. As with any skin cancer, a BCC that metastasizes (ie: spreads) is bad news. The prognosis can be poor indeed – as in, death within months.
Please, if you have any concerns about any feature of your skin, anywhere, check in with your GP. Caught early, most BCCs can be easily treated, with minimal scarring or discomfort. Ignore, and the outcome can be grim indeed. Forget about BCCs metastasizing being “rare”. Remember, rather, that BCCs are malignant tumours, like SCCs and melanoma. They can and do spread. Get them checked early, and you minimise the risk of spreading, and/or disfigurement.
- The path report of the biopsy taken from my leg by my GP indicated that the larger of the lesions was an “infiltrative” BCC (ie: more aggressive). Who knew there were different varieties? Not me. Despite medical assurances that it was extremely unlikely, I began to worry that the bastard had gone through to the bone, as poor John Blackman’s had done.
- On referral to Sir Charles Gairdner Hospital, I was examined by a plastic surgeon who categorised me Class 1, and placed me in the high priority surgery queue. 3 weeks later, the BCCs were excised under “twilight” sedation (my choice, although it might as well have been GA – I can recall nothing of the operation). I was allotted a bed in the recovery ward and allowed to go home that evening, my leg trussed up as below.
- As previously mentioned, the excision wounds were too large for direct closure. That might not have been the case had the BCCs been on stretchier areas of the body, but there’s not much flesh for the surgeon to work with on the shin. I needed two skin grafts. Initially, the skin graft site was more painful than the excision wounds, stinging like a bad graze. As well it might – it’s basically raw meat.
- There was pain from the graft and wounds on standing and walking, but not so severe as to require pain killers. People have different pain thresholds, and mine is not particularly high, but I didn’t even need paracetamol. The pain when at rest with the leg elevated was negligible.
- Post-op, my expectation based on briefing by the hospital nurses was that I would have to lie around with the heavily bandaged leg elevated virtually all day, and raised on two pillows in bed at night (not a recipe for sound sleep, I can tell you that!). Walking would need to be restricted to toilet visits and the like. Showering was not a possibility. Ditto cooking, sitting in normal position, or standing. This regime was to continue until the grafts healed, which I was told would take around 2 weeks.
- In fact, the grafts failed (not all that uncommon, it seems, especially for those like me with venous insufficiency – although none of the hospital staff warned me of the possibility). Suddenly, the rehab period had blown out to weeks if not months.
- The wounds had now become “chronic” (chronic wound = ulcer), which meant the healing period could be indefinite. This raised all sorts of other nasty possibilities (see “On Reflection” above). By this stage I was plenty worried.
- With the grafts having failed, it took 3 months+ for my wounds to heal naturally. That’s 3 months of severely restricted activity, with the leg under constant compression.
- Home visits from Silver Chain nurses for wound monitoring/treatment and changing of compression bandages were required every second day until healing started, then twice weekly. I also had to attend the Plastics Dressings clinic at the hospital for weekly assessment and dressing changing – a real pain in the arse, since the waiting time was between 2 and 4+ hours. It was also a pain for my partner, who had to taxi me to and fro (I had to keep the leg elevated at all times and minimise walking, so using public transport was not viable). She also had to do all the cooking, washing up, shopping etc. All I could do for the first few weeks was lie about with my leg up above heart level, every 30 minutes or so getting up to walk around for a short while to enhance blood circulation. Pretty frustrating for an active person. I could feel my fitness slipping away day by day, and tried to push the walking a bit, managing a few hundred metres to the local shops and back. My Silver Chain nurse chided me for overdoing it.
- A few weeks into the rehab period, I had a set-back when the larger wound developed hypergranulation (overgrowth of skin, which impedes the healing taking place beneath). It resolved with several applications of silver nitrate.
- With the wounds starting to look better, my Silver Chain nurse instructed me to increase my walking to get the blood pumping. This marked the beginning of real progress with my healing.
- 3 months after the op, my nurse gave me the go-ahead to have a shower. What a joy! A couple of weeks later, I was given the all clear. Healed at last!
- Healed doesn’t mean back to normal, however. It’s now 3.5 months since the surgery, and I’m still way down on condition despite a month of walking at some pace for about an hour 5 days per week. Stay prone for months, and I guess it’s not so surprising that it takes more than a few weeks of walking exercise to return to reasonable fitness.
Some facts about BCCs you might not know
- Once you’ve had a BCC, odds are you’ll get more. I’d never had any skin cancer diagnosed until 2018, when I had 4 removed. In order of detection, the first was on my upper right arm, the second in a nasty position near the corner of my right eye, and the next two on my lower left leg. I’d dismissed the one on my arm as an infected mosquito bite, but mentioned it to my GP when it hadn’t gone after a few months. He was suspicious of its pathology, and cut out more flesh than usual when performing a biopsy. Turned out it was a BCC, completely excised. Great call of the doc’s, then – nothing more to do. Fortunately, I discovered the one near the corner of my eye at a very early stage. A delicate operation was performed by a plastic surgeon at Sir Charles Gairdner Hospital, and now, around 7 months later, the scarring is virtually undetectable. I make no apology for repeating, yet again, that early detection and treatment makes all the difference. STAY VIGILANT.
- Here’s something sinister: BCCs can recur in the same place, even if completely excised. STAY VIGILANT!
- And something else. BCCs can infiltrate a nerve, and when they do they’re near-impossible to treat. STAY VIGILANT!
- BCCs (and other skin cancers) are not confined to sun-exposed areas. The one on my upper arm was on the underside, where the sun rarely reaches. And I have recently heard of a case of a BCC being excised from inside the ear, only to recur years later, having already metastasized when discovered. STAY VIGILANT!
- Statistically, 2 in 3 Australians are diagnosed with skin cancer by the age of 70. It’s not unusual for it to come on in the 40s, or younger. Since BCC is the most common form of skin cancer, odds are pretty high that YOU will be diagnosed with it at some time. The greater your sun exposure, the higher your risk, especially if you’re fair-skinned. STAY VIGILANT!
An Acknowledgement of Silver Chain
I was under the impression that Silver Chain is a geriatric home care service. I now know better. Their services extend to patients of all ages.
Silver Chain are indispensable in providing excellent home care, taking some of the pressure off the clearly over-burdened and under-budgeted hospital system, and freeing patients and carers from the inconvenience of time-consuming trips to and from hospital clinics. The Silver Chain nurses specialise in wound-care (among other things). I cannot sing their praises loudly enough. I am particularly indebted to my regular nurse, Gemma, for her unending positivity and terrific care (her obsessively neat compression bandages are works of art).
Please support Silver Chain in any way you can. You never know when you might need their services.
Some Observations on Sir Charles Gairdner Hospital
First, the positive. I am a believer in the public hospital system, and in the past have had uniformly excellent service as a public patient. That standard of excellence was maintained by the plastic surgeons who operated on me to excise the BCC close to the corner of my eye in mid-2018, and the two BCCs on my lower leg in September 2018.
However – and it pains me to say this – in the latter case, the post-op follow-up at the Plastics Dressings clinic fell short of acceptable standards in several respects. For example:
- Lack of supervision of obviously inexperienced young nurses, one of whom tended to me on two visits. Both times it was evident that this nurse was struggling. Both times errors were made, one of which so concerned my Silver Chain nurse that she complained to Plastics management. The blame lay with the lack of supervision, not the young nurse.
- Unavailability of compression bandages and tubing that according to Silver Chain were essential in my wound care and basic requirements in a dressings clinic.
- Even some of the experienced nurses seemed to lack training in wound management and/or appropriate bandaging. Early in my rehab, one decided I didn’t need a compression bandage. My pain levels increased and we sought advice from Silver Chain, who advised that compression bandaging was essential until the wounds healed, and sent out a nurse to remedy the situation first thing next day.
- During one visit, after being tended by a nurse I was left sitting on the bed, uncovered open wounds pooling with blood, for around 40 minutes before the doctor came.
- Nursing issues aside, the doctors seemed to be on constant rotation – I rarely had the same one twice, so there was no sense of continuity of assessment or treatment. There was never a follow-up appointment with the operating surgeon (eye or leg). One doctor was so rushed he didn’t consult my medical file notes pre-examination. On seeing my wounds he asked me what I’d done to myself.
- There is a sign in the Plastics Dressings clinic warning patients that wait times can be up to 2 hours. I rarely got out of there inside 2.5 hours. The last time I attended, I had to wait over 4 hours. That was the final straw. I elected not to go again. I had far more confidence in my Silver Chain nurse, not to mention the convenience of her home visits.
- I do not know whether the problems I describe apply to other sections of the hospital. I suspect the Plastics Dressings clinic is understaffed and unable to cope with patient demand. This may be down to budgetary restrictions. I also suspect there is a systemic problem. Whatever, the shortcomings I noted are significant and need to be promptly addressed. I am submitting feedback on my experience to the hospital. I’ll report back here on the response I receive.
The Upsides of My Long Rehab
Yes, there were some.
Such as being forced to stay away from the computer (no laptop, too uncomfortable to sit at the PC with my leg elevated – and too painful for the first 2 weeks post-surgery). I was especially glad to be free of Facebook and its toxic milieu, which I discovered on going cold turkey that I detest even more than I’d thought. How good it was to be absent for months from that world of bigheads and sycophants and rampaging tribalism and all the nastiness and sniping and shaming and self-righteous virtue signalling bullshit that goes with it.
Such as getting back into reading after years of immersion in screens. I read for hours per day – old novels, new novels, non-fiction (I even got around to reading Germaine Greer’s The Female Eunuch all these years too late). I just couldn’t get enough. It was like waking up from years of somnambulism.
Such as watching some classic old westerns I’d been promising myself to catch up on since forever. That said, I surprised myself by not bothering too much with film. Reading was physically easier, and devouring novels more enjoyable and stimulating.
The break from routines enforced by my extended rehab has given me new perspective on a number of things. I’m grateful for that.
For example, I found I did not miss attending media film screenings. Regular screenings and reviewing films have been a major part of my life for 10+ years now, but I find myself dispirited for a few reasons, and not looking forward to resuming reviewing. I may elaborate in another post. And things may change. But for now, I feel disinclined to continue to devote so many hours and so much effort to my reviews for so little return. That is not to say I will cease reviewing, but I do intend to make some modifications, and to prioritize other personal writing projects that mean more to me.
A Parting Plea
SEE YOUR DOCTOR SOONER RATHER THAN LATER IF YOU NOTICE OR ALREADY HAVE ANY UNUSUAL SKIN FEATURE(S) ANYWHERE. Early detection and treatment of BCCs (or any skin cancer) makes all the difference.
If you think anyone you know might be at risk of developing BCC or other skin cancers (and if you live in Australia, that’s just about everyone) please point them to this post. I’m happy to answer any questions in the Comments thread, or privately.