Plastic Surgeon

[yeoldesage]

I have recently been diagnosed with skin cancer around the facial area and will in due course need the services of a reputable Plastic Surgeon. As costs are an issue (aren't they always) I will be shopping around the Chiang Mai area (maybe even further afield if needs be) once the full diagnosis/surgical procedure is fully assessed by the Rajavej Hospital, to ascertain the costs involved. Can any of you fine and upstanding ladies and gents recommend the services of a particular Plastic Surgeon from who, either yourselves or your close associates, have had satisfactory results without devastating the bank balance?

I will be asking the Rajavej Plastic Surgeon next week what their charges will be, so before I meet him I would like to be aware of any alternative (recommended) services/costs that are available. In the light of the economic climate I was prepared to make cuts, alas this wasn't one cut(s) I had anticipated!

Your assistance, as always, will be much appreciated.

YOS

Edited January 16, 2011 by yeoldesage

[ThaiPauly]

You should really post this in the Health Forum, with an op as important as this, if it were me I would be going down to Bangkok as the surgeons are far more experienced than here IMHO.

There are a lot of threads about plastic surgery in the other forum and feedback from people that have had operations such as the one you are contemplating.

Good luck anyway

[yeoldesage]

Thanks Pauly, point taken, I have now posted in the Health Forum.

Cheers mate,

YOS

[jsflynn603]

see thread: http://www.thaivisa....ailable-in-bkk/

It's dated, but there is some good info there.

I would strongly suggest that you find an accredited Moh's microsurgeon. One of the hospitals listed there (Bumrumgrad (sp?)) had an accredited by American College of Mohs Micrographic Surgery,'and I don't believe there is another Moh's college that offers accreditation. I seem to remember last I looked that this surgeon was no longer there. You can find the institution mentioned on the internet and see if they list a practitioner in Thailand.

In Moh's microsurgery the surgeon extends a reasonable distance beyond the lesion and excises the lesion. Then the surgeon takes (imagine a 1cm circle) a very thin slice of tissue from the margin and if necessary from beneath (especially if it is one of a few odd types of Basal Cell Carcinoma (BCC) or squamous cell carcinoma) and immediately, under microscope, stains the slice of tissue and looks for cancer cells. Let's say, for instance, the surgeon finds that between 2 and 3pm on the circle (imagining it like the face of a clock) there are cancer cells, but the rest is clear. So the surgeon returns and excises a wider strip of tissue from about 1-4PM. The surgeon then excises another tiny strip at the outside margin and checks it under the microscope. Let's assume now that there are still cancer cells between 2:45 and 3pm--so a third procedure is done, and so on until the margin shows no cancer cells.

The norm generally is about 1.5 procedures which means that most BCC's are cleared within two procedures (so you lay there waiting for about 15 minutes to see if it is cleared, or if the surgeon will return to extend the excision). It is fairly uncommon to require more than two "rounds." Each round might take an hour, mostly consisting of waiting for the surgeon to return.

The five year clearance rate with Moh's is very high, over 97% I think. The five year clearance using surgery but without a Moh's microsurgeon (I'm struggling to remember, so I'm guessing: is about 85%) if this is the case then with Moh's only 3/100 people will have re-occurrence, with a general surgeon it's more like 15/100. In my opinion a Moh's surgeon is worth finding.

You don't say if you have a BCC or a SCC, nor where on the face, or extent. If it is close to the eye, or on the nose, or "large in area" then surgery is your only option.

However there ARE viable other options in certain cases. Imiquimod is an interesting medication. There is some confusion as to exactly how it works but most believe that it is taken up by cells that are replicating only, and those cells are destroyed by your own immune response. Since cancer cells replicate frequently, and non-cancer (normal) cells slowly, the cancer cells gobble up the Imiquimod and are, over a period of about 4-6 weeks are destroyed.

A few years ago I had a BCE on my right temple that was about 1cm. I had it removed by a Moh's microsurgeon in America at a cost of about $1200 (another surgeon quoted me $2200 and since he was at a teaching college I knew that the surgery would be done by an intern--I also knew that it was summer, and interns were "green," so I said "no thank you.") The surgeon who removed the lesion was quite wonderful, the procedure was essentially painless, non-traumatic and there is a small visible scar, but not objectionable. There have been no signs of re-occurrence.

A year later, on a routine "search and destroy" mission another BCC was discovered on my right shoulder a bit bigger than 1cm. Along with a pay cut at work I had lost my medical insurance totally so i looked into alternate routes and questioned my dermatologist about Imiquimod. She said "go for it," and I did.

Imiquimod costs about $30 per foil "packet." This relates to about $3720 per ounce--double the price of gold! You are supposed to apply it at night before bedtime and then throw the packet away. But the instructions clearly state that for the maximum lesion size, no more than 50 milligrams should be used, therefore you are throwing away 80%. My dermatologist said keep the unused material in a clean covered container (I used a shot glass with some aluminum foil) and use one packet for 5 days, for the duration of 4 weeks. Using pharmacychecker.com I tried a place called Pharmstore. Initially I had a problem with them as they seemed unable to receive a fax and on pharmacychecker there is a complaint by me (that pharmacychecker will not remove) though I later found that where I worked (which was closing) had locked out all 800#'s so the problem was on my end.

When I figured out that the fax issue was on my end, not theirs, my order for Imiquimod went though at about $5 per packet. What I received was Aldera 5% cream which is THE brand item, not the generic item. The packaging indicated that it had been shipped from Sweden. I ordered 8 packets which was enough for the duration and used it.

Imiquimod causes mild to severe inflammatory response. In my case it was moderate, and the area turned red and crusty, enough so that I returned to the MD who said "take a break for a week" and then start again for the last two weeks." It was still nasty looking at the end of two weeks but rapidly cleared and today (now about 6 months later) my dermatologist says there is no sign of cancer. There is no scarring or any visible indication that there was cancer--the skin looks absolutely the same as the rest of my skin. My real complaint was only that for some weeks it "itched," and though I was never quite sure, it seemed that I'd often get a "stiff neck" on that side. The re-occurrence rate varies depending upon which study you look at, and essentially relates to the duration of med use (6 weeks 3 times a week versus, 4 weeks, daily at bedtime) is between 80 and 100% cure rate.

If I developed the BCC on my temple today, there is no doubt that I would go the Imiquimod route and I have no doubt that it would be clear, and there would be zero scar, and cost would be less than $60 (excluding dermatologist visits). I would have a rather ugly inflamed 2cm area on my temple for about 4 weeks, so this option is not for everyone. (I was plant nurse at a factory--so who cares?) Further I would forgo the initial $200 pathology fee to "ID" the cancer. Why? Because the chances (in my opinion only) of it being an odd form of BCC are very low and $200 these days is very dear to me. Note: Imiquimod is available as a generic at an even lower price. For some with no insurance, and no job this may be the "only" option if the lesion is in an area where Imiquimod can be used.

But again, there are areas on the face where Imiquimod should not be used, especially on the nose--so if interested, run this by your dermatologist and if she can't discuss Imiquimod intelligently, find another dermatologist--again just my opinion.

If you have a BCC then you probably have a hundred or more Actinic keratoses (AK's) (precursors to BCC) on your face, arms, hands, back, etc. Your dermatologist (when this issue is resolved) ought to be addressing that and there are many options to resolve sun damaged tissue and knocking out (AK's) some of which are likely to turn into BCC's. Levulan, topical 5-fluorouracil (5-<deleted>), and other option are available which destroy only the aberrant tissue in the AK's. Like it or not, if you have one BCC it is more likely than not you will develop others later in life. I believe a pre-emptive approach is wise, but of course, this is something between you and your medical practitioner. Good luck.

Edited January 16, 2011 by jsflynn603

[yeoldesage]

see thread: http://www.thaivisa....ailable-in-bkk/

It's dated, but there is some good info there.

I would strongly suggest that you find an accredited Moh's microsurgeon. One of the hospitals listed there (Bumrumgrad (sp?)) had an accredited by American College of Mohs Micrographic Surgery,'and I don't believe there is another Moh's college that offers accreditation. I seem to remember last I looked that this surgeon was no longer there. You can find the institution mentioned on the internet and see if they list a practitioner in Thailand.

In Moh's microsurgery the surgeon extends a reasonable distance beyond the lesion and excises the lesion. Then the surgeon takes (imagine a 1cm circle) a very thin slice of tissue from the margin and if necessary from beneath (especially if it is one of a few odd types of Basal Cell Carcinoma (BCC) or squamous cell carcinoma) and immediately, under microscope, stains the slice of tissue and looks for cancer cells. Let's say, for instance, the surgeon finds that between 2 and 3pm on the circle (imagining it like the face of a clock) there are cancer cells, but the rest is clear. So the surgeon returns and excises a wider strip of tissue from about 1-4PM. The surgeon then excises another tiny strip at the outside margin and checks it under the microscope. Let's assume now that there are still cancer cells between 2:45 and 3pm--so a third procedure is done, and so on until the margin shows no cancer cells.

The norm generally is about 1.5 procedures which means that most BCC's are cleared within two procedures (so you lay there waiting for about 15 minutes to see if it is cleared, or if the surgeon will return to extend the excision). It is fairly uncommon to require more than two "rounds." Each round might take an hour, mostly consisting of waiting for the surgeon to return.

The five year clearance rate with Moh's is very high, over 97% I think. The five year clearance using surgery but without a Moh's microsurgeon (I'm struggling to remember, so I'm guessing: is about 85%) if this is the case then with Moh's only 3/100 people will have re-occurrence, with a general surgeon it's more like 15/100. In my opinion a Moh's surgeon is worth finding.

You don't say if you have a BCC or a SCC, nor where on the face, or extent. If it is close to the eye, or on the nose, or "large in area" then surgery is your only option.

However there ARE viable other options in certain cases. Imiquimod is an interesting medication. There is some confusion as to exactly how it works but most believe that it is taken up by cells that are replicating only, and those cells are destroyed by your own immune response. Since cancer cells replicate frequently, and non-cancer (normal) cells slowly, the cancer cells gobble up the Imiquimod and are, over a period of about 4-6 weeks are destroyed.

A few years ago I had a BCE on my right temple that was about 1cm. I had it removed by a Moh's microsurgeon in America at a cost of about $1200 (another surgeon quoted me $2200 and since he was at a teaching college I knew that the surgery would be done by an intern--I also knew that it was summer, and interns were "green," so I said "no thank you.") The surgeon who removed the lesion was quite wonderful, the procedure was essentially painless, non-traumatic and there is a small visible scar, but not objectionable. There have been no signs of re-occurrence.

A year later, on a routine "search and destroy" mission another BCC was discovered on my right shoulder a bit bigger than 1cm. Along with a pay cut at work I had lost my medical insurance totally so i looked into alternate routes and questioned my dermatologist about Imiquimod. She said "go for it," and I did.

Imiquimod costs about $30 per foil "packet." This relates to about $3720 per ounce--double the price of gold! You are supposed to apply it at night before bedtime and then throw the packet away. But the instructions clearly state that for the maximum lesion size, no more than 50 milligrams should be used, therefore you are throwing away 80%. My dermatologist said keep the unused material in a clean covered container (I used a shot glass with some aluminum foil) and use one packet for 5 days, for the duration of 4 weeks. Using pharmacychecker.com I tried a place called Pharmstore. Initially I had a problem with them as they seemed unable to receive a fax and on pharmacychecker there is a complaint by me (that pharmacychecker will not remove) though I later found that where I worked (which was closing) had locked out all 800#'s so the problem was on my end.

When I figured out that the fax issue was on my end, not theirs, my order for Imiquimod went though at about $5 per packet. What I received was Aldera 5% cream which is THE brand item, not the generic item. The packaging indicated that it had been shipped from Sweden. I ordered 8 packets which was enough for the duration and used it.

Imiquimod causes mild to severe inflammatory response. In my case it was moderate, and the area turned red and crusty, enough so that I returned to the MD who said "take a break for a week" and then start again for the last two weeks." It was still nasty looking at the end of two weeks but rapidly cleared and today (now about 6 months later) my dermatologist says there is no sign of cancer. There is no scarring or any visible indication that there was cancer--the skin looks absolutely the same as the rest of my skin. My real complaint was only that for some weeks it "itched," and though I was never quite sure, it seemed that I'd often get a "stiff neck" on that side. The re-occurrence rate varies depending upon which study you look at, and essentially relates to the duration of med use (6 weeks 3 times a week versus, 4 weeks, daily at bedtime) is between 80 and 100% cure rate.

If I developed the BCC on my temple today, there is no doubt that I would go the Imiquimod route and I have no doubt that it would be clear, and there would be zero scar, and cost would be less than $60 (excluding dermatologist visits). I would have a rather ugly inflamed 2cm area on my temple for about 4 weeks, so this option is not for everyone. (I was plant nurse at a factory--so who cares?) Further I would forgo the initial $200 pathology fee to "ID" the cancer. Why? Because the chances (in my opinion only) of it being an odd form of BCC are very low and $200 these days is very dear to me. Note: Imiquimod is available as a generic at an even lower price. For some with no insurance, and no job this may be the "only" option if the lesion is in an area where Imiquimod can be used.

But again, there are areas on the face where Imiquimod should not be used, especially on the nose--so if interested, run this by your dermatologist and if she can't discuss Imiquimod intelligently, find another dermatologist--again just my opinion.

If you have a BCC then you probably have a hundred or more Actinic keratoses (AK's) (precursors to BCC) on your face, arms, hands, back, etc. Your dermatologist (when this issue is resolved) ought to be addressing that and there are many options to resolve sun damaged tissue and knocking out (AK's) some of which are likely to turn into BCC's. Levulan, topical 5-fluorouracil (5-<deleted>), and other option are available which destroy only the aberrant tissue in the AK's. Like it or not, if you have one BCC it is more likely than not you will develop others later in life. I believe a pre-emptive approach is wise, but of course, this is something between you and your medical practitioner. Good luck.

Many thanks for your detailed reply, it was most informative. Although I haven't had the biopsy results as yet, due on Thursday, I did have a small area of BCC removed from my nose several years ago, so this could be same. The lesion I have now is on my left temple area and is around 1 cm dia.

I read up on the Imiquimod and Aldara these seem to be for superficial BCC only.

I will pm you later.

Cheers,

YOS

PS Maybe this post could be combined with the ongoing Dermatologist post Mods can you fix it please.