Round 1. April 2006.
I guess my experience with acral lentiginous melanoma began in late 2005 when I noticed a thin line than ran straight down my right index finger nail from cuticle to tip. The line was very faint at first, almost as if someone had drawn it with a pencil. I assumed it was due to wearing acrylic nails or possibly a fungus from a manicure, ew. The next time I saw my dermatologist, I happened to show him my finger since the line seemed to have gotten thicker and darker. He recommended I see a specialist -- a plastic surgeon that specialized in hands and fingers. The dermatologist suspected that I had a mole growing inside my nail bed (under the finger nail itself) which was causing discoloration of the finger nail. I went to see the plastic surgeon and he agreed with the dermatologist, it was likely a new mole that would need to be biopsied. In April 2006, I had my finger nail removed along with a sliver of my nail bed. To ensure the shape of my nail bed remained intact, they inserted a piece of aluminum into my finger as a temporary finger nail. The nail was stitched down and stayed on for about 4 weeks until my finger nail began growing back. The biopsy results came back negative (benign), and at that time my doctor mentioned that if the mole or line came back, there was no cause for concern since it was already found to be non-malignant. Unfortunately I do not have any photos of my nail prior to the first biopsy or any during the healing phase. I do not remember the healing process being very difficult or painful and within about 6 months my nail had grown back and looked almost exactly the same as before!
Round 2. April 2011.
Fast forward 4 years from the time of my first biopsy... In mid 2010 I began to notice discoloration in my right index finger nail again. It was different this time, however, because the line was spotted and grew very quickly. I remembered what my doctor had said, that it was nothing to worry about if the line came back. Since I had moved out of the area, making a follow up appointment with him was not very convenient so I just kept an eye on my nail assuming it was nothing to be concerned with. In August 2010, I noticed that the discoloration was getting significantly darker and my nail began to lift from my nail bed so I went to see my new dermatologist. I explained to him the history and had him take a look at the current state of my finger nail. He felt there was no cause for concern but took a photo for my medical records anyway.
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| August 2010 |
After a random conversation with a co-worker one day about my finger nail debacle, he referred me to a local plastic surgeon that was a hand specialist. I set up a consultation and met with the doctor at the end of March 2011. He agreed with the previous doctors, there did not seem to be cause for concern, HOWEVER, he left the decision up to me and offered to perform the biopsy again if it was something I wanted. I can't say I had a "feeling" or any profound emotions... I think ultimately it came down to aesthetics. I like my hands to be manicured at all times and I did not like the appearance of my finger nail. BUT I also didn't understand how three doctors could find this "normal."
I had the biopsy done on April 11, 2011. While I don't remember many details from the previous biopsy, I think I would have remembered if it had been as painful as the second one. I was awake for the procedure, the finger nail was removed, a piece of the nail bed was excised and, like before, an aluminum nail was inserted into my nail bed. The procedure took approximately 45 minutes and I was sent home... without pain medication. That was the first complication of many!!
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| 1 hour post-op |
The lidocaine began wearing off around 2am and I woke up in terrible pain. I ended up calling the doctor and driving to the pharmacy at 3am for Vicodin. It turned out that the Vicodin was not offering much relief and I was only sleeping in 45 minute intervals and the pain and throbbing were outrageous. The following day I asked the doctor for something stronger and was prescribed Tylenol with Codeine. This had the same effect on the pain (none) as the Vicodin, but allowed me to sleep for longer periods of time. It wasn't until I was allowed to remove the bandage on day 4 that I finally had relief. In retrospect, I believe the bandage had been wrapped too tight, causing more pain than necessary.
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| 4 days post-op |
After the original bandage was removed, the swelling went down very quickly. I kept it wrapped and covered for the first week, but washed it with soap once a day. On Day 7, the aluminum nail popped out of place so I went back to the doctor. The stitches and nail were supposed to stay in for another week so I went in to the office with the idea that he would have to re-insert the aluminum otherwise my nail would not grow back properly. I was not prepared for what I was about to hear -- I had acral lentiginous melanoma in-situ. This is a very rare form of melanoma that is found in finger and toenails that does not correlate with sun exposure. It is a matter of having the right (or wrong) DNA. This type of melanoma is typically found in people with darker skin tones and later in life, which explains why my doctor and several pathologists were shocked to find this is a 25 year old Caucasian. In-situ meant that it did not appear that the melanoma had traveled beyond the finger tip, however, it was unclear how much of my finger would have to be excised to ensure all of the melanoma was removed. At this point, the aluminum nail was pointless so it was removed along with the sutures.
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| 7 days post-op |
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| Infection, 10 days post-op |
I was told that I would have to wait a few weeks for my finger to heal before the next procedure would be performed. At first, I was told that my entire nail bed would be removed and a skin graft would be taken from my big toe and placed on my finger to ensure that I would still have a fingernail after the whole process was complete. I was referred to an oncologist to have blood work done and to rule out any other melanoma. The oncologist gave me a 50% percent chance of losing my entire fingertip at the joint, however, when he looked at my age, he lowered the chance to 30%. He also informed me that too much of my nail bed would have to be removed and therefore I would never have a fingernail again. This meant that my next procedure would not involve a skin graft - just the excision of my entire nail bed, in hopes that the melanoma had not traveled any further.
Round 3. May 2011.
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| Pre-op, May 2011 |
My second procedure was May 26, 2011. Again, I was awake, but I made sure to have prescriptions filled for Valium and Percocet ahead of time. My entire nail bed was removed from germinal matrix (the portion of the nail bed closer to the knuckle) to the tip and all the way down to the bone. Part of the bone was also taken to biopsy. Since so much tissue was removed, the wound was not stitched shut, it was left open, with two small sutures above the germinal matrix. To reduce the flow of blood, my finger was cauterized which was definitely the most unpleasant part -- particularly the smell! This procedure lasted a little longer, approximately 1 hour. The trauma was more severe, but my doctor was more conservative when wrapping the bandage and I think that significantly helped with the healing process. The Percocet was also very helpful because my pain was not nearly as bad as the first time around. (WARNING: GRAPHIC PHOTOS BELOW)
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| 1 hour post-op |
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| My nail bed. Yum. |
On day 3 I was able to remove the bandage and clean out the wound. This proved to be a very challenging task because I am not the best when it comes to blood and I really had no idea what to expect. I wasn't aware that my nail bed had been hollowed out BELOW the skin so I got a little light-headed when I was pulling the gauze out of my finger, not knowing where it would stop! There was also a lot of blood, needless to say, and I could see down to my bone which was very disturbing
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| Day 3, hollowed out down to the bone. |
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| Day 3 |
The swelling was much more significant this time, but the tissue grew back very quickly. I received the biopsy results one week later, and unfortunately, the margins still were not clear. The bad news was that I would need another procedure to remove the very tip of my finger including a piece of bone. The good news was that the margins were clear at the germinal matrix and therefore, the entire joint would NOT have to be amputated. Again, I would have to wait a few weeks to allow my finger to heal before they would be able to operate.
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| 1 week post-op |
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| 2 weeks post-op |
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3 weeks post-op
Round 4. June 2011.
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| Prior to surgery, June 20 |
My wound never fully healed between the second and third procedures, however, the swelling did go down significantly and it was healed enough to operate again on June 20th. This procedure was slightly different than the rest because after the skin was removed, the doctor left the wound open. The reason he did this was because the risk of spreading melanoma cells at the fingertip would increase if he had to re-open the tip after stitching it up. He wanted to ensure that the margins were clear prior to closing the wound. The plan was to operate and send the biopsy to pathology immediately. Assuming the margins were clear, I would go back 2 days later to have the wound stitched up.
The procedure was done on Monday morning and was similar to the previous three. It took approximately 45 minutes, but I left with a much larger and tighter bandage -- since I had an open wound, pressure was necessary to minimize bleeding. The risk of infection was also much higher this time around because of the open wound. I was put on a 2-week cycle of antibiotics to ensure I did not get an infection. The pain that day was about the same as the previous procedure. I was much more limited due to the size of the bandage, but the post-op didn't produce any new results.
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| Post-op, June 20 |
I received a phone call the following day informing me that the margins were clear!!!!! I had waited 2 months to hear those words and felt as much relief and joy as possible considering I was heavily medicated. This meant that the wound could be closed as planned the following day. The final procedure proved to be the most painful. I was very relaxed throughout, and even got to take a look at my bone! The tourniquet was already on my finger so there was no blood flow. I was amazed at how shiny and large the bone actually was. Because a significant amount of skin was removed, the bone had to be shortened to allow the skin to close around it, which was the primary cause of the pain. Towards the end of the surgery, I began feeling more pressure than usual but it wasn't until the bandage was applied and I was leaving the doctor's office that I realized I was in more pain than usual. Typically the lidocaine lasts for several hours but in this case I was on my way home and had to turn right around because the pain was unbearable. I received 5 more shots of lidocaine which gave me instant relief. I was warned that it would only last for 6 hours, and sure enough, it wore off exactly 6 hours later. I was taking Percocet every 2 hours and was icing my hand continuously, but the pain was still at an all-time high. That night and the following day were the lowest points throughout my entire recovery. I felt much better on day 3, and the actual wound healed very quickly.
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| Post-op, June 22 |
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| Day 3, June 25 |
I had 4 sutures in my finger, two were removed 1-week post-op, and the others were removed 2-weeks post-op. My right index finger is now slightly shorter than my left, but only by approximately 1 centimeter. It certainly is not noticeable unless I hold them next to one another. The way my finger tip was stitched up actually makes it look like I still have a nail bed -- quite the illusion!
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| Day 5 |
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| Day 8 |
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| 2 weeks post-op |
Recovery/Rehab. July & August 2011. In early July, after my final sutures were removed, I was informed that I had developed mallet finger -- I could not fully straighten my finger. I hadn't bent my knuckle in over 2 months so it is understandable that there was some damage.
I was referred to an occupational therapist who specializes in hand therapy. I began OT on July 11 and was fitted for a finger splint that I was told I would have to wear for 6 weeks. The splint prevents my knuckle from bending and has to be worn at all times. I go to therapy once a week and have exercises to do on my own 3 times each day. There is quite a bit of scar tissue and swelling in the entire finger. I am currently 3 weeks into therapy and have noticed a significant improvement in the swelling and range of motion, but there is still a lot of progress to be made. Chances are, I will not regain full mobility, but it will be pretty close. The splint was very uncomfortable for the first week -- my finger felt very stiff and it was particularly sore in the morning. I am happy to say that I have no more pain. I feel discomfort when I go to therapy but it is minimal. The splint is becoming an inconvenience and I am definitely looking forward to being done with it altogether. I have to wear the splint 24/7 for 3 more weeks and then I will slowly begin to wear it less and less.
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| One of my splints... |
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| This is currently what my finger looks like. |
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| Another splint... |
I get asked a lot about my lack of a finger nail. As a serial manicurist, I was upset by it at first. Now, I really don't care. After all I have gone through, it is such a small price to pay. Things really could have been so much worse. A fake nail is not an option at this point because nothing will adhere directly to skin, but I do joke that I will be the first recipient of a prosthetic finger nail! I truly would be open to the possibility, but it is not necessary. For now I am rocking the 9 finger nail look, thankful that I still have a finger at all! More Recovery. August 19, 2011.
Monday marked 5 weeks wearing the finger splint, with 6 weeks being our ultimate goal. I had hand therapy on Wednesday and it was the first time we did exercises with my splint OFF. My finger is healing well and my therapist is very pleased with the progress. My finger was completely straight (!) when we took the splint off but after about an hour it began to droop slightly. I am now allowed to take the splint off for an hour each morning and an hour each evening, unless I notice it drooping. I am still not supposed to bend my knuckle but at this point, it wouldn't bend even if I forced it (I know because I tried!) It has now been over 4 months since that joint has had any movement. I have seen significant improvement in my other two joints... I have close to full range of motion in one knuckle (on my fist) and about a 45 degree range in the middle knuckle. I also have a lot of hypersensitivity in my finger tip and I am not sure if the nerves will ever fully regenerate, but as the swelling continues to decrease, the nerves will continue to grow back.
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| As of today, 08/19/11 |
I am so excited to get a break from the splints, even if it is just an hour here and there! The splints have always been uncomfortable but recently the discomfort was not due to pain, it was due to irritation. I was originally given 3 different splints, but have only used two. One of them is plastic and therefore waterproof. This is the one I primarily wore at the beginning. The second splint is a plaster cast with velcro strips that is a better fit and provides more support for my finger. It is not waterproof, however, and does not allow me the same flexibility. It also irritates the skin on the underside of my finger because it does not "breathe" very well. At first, I wore this splint at night. As the weeks went by and the swelling began to decrease, the plastic splint got too big. It was very tight on my knuckle and did not offer as much support to my finger tip. I began wearing the casted splint more for the support but had to deal with the skin irritation and general "stiffness." I was told about 2 weeks ago that my finger will never fully straighten AND bend again, it was one or the other. I have come to find out, however, that it will never do EITHER again. I naturally have double jointed fingers so my right index finger already stands out from the rest. Add to that the fact that it is shorter, has no nail and is still swollen and purple around the knuckles. (I think the splints have actually hindered the swelling from going down.)
On a more positive note: I received a wonderful gift in the mail earlier this week from the VP at OPI. An elementary school friend had told her (his mother) about my blog and after seeing that I was a nail polish connoisseur, she sent me a box full of OPI products! It absolutely made my day, if not my week, and I was so excited that I had to give myself a manicure immediately!
I also received this snazzy gift from my brother...
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It conveniently fits over my splint and adds so much character. He pointed out that these are intended for a child's thumb but who's keeping track? When I showed this to my therapist, he assumed my brother was 10 or 11. Nope, he's 28.
My experience in hand therapy has been so comical. It is held at a normal physical therapy office and as a past PT patient I can empathize with patients who are there trying to recover from injuries. Hand therapy is a different world! I sit at a half-circle table with about 4 other people who are getting hand & arm massages, ultrasounds, paraffin wax, etc. We get to sit in chairs and read books and magazines while we get our hands worked on. It's like a manicure, without the nail polish! I do have to do exercises but they are not painful, they just stretch my hand and it feels good! Hand therapy patients are not well liked amongst the others because we get to relax (I almost fell asleep once). It is pretty comical... don't get me wrong, it is incredibly necessary and I have really recovered quickly because of it, but I have also been warned by other patients that hand therapy can be very addictive!
I finally feel like I am in the final stretch of recovery... The end is in sight... I can see the light at the end of the tunnel. Insert your own cliche catchphrase here. I still have a ways to go in therapy and the splints are not going in the trash (or the fireplace) anytime soon but the worst is definitely behind me. I have to admit I do have fears that the melanoma will come back or that they really didn't get it all out. I also have moments where I am disappointed in the appearance of my new finger. I feel like I went through so much pain that it should look normal. But when I put it all in perspective, it really isn't so bad, looking at my hand is now a reminder of my strength and the fact that I fought and I WON.
October 4, 2011
Yesterday marked Week 12 in hand therapy. Every week has shown improvement, however, yesterday marked a milestone. My finger finally reached zero degrees, which means it is officially straight without the assistance of my splint! The range of motion in my finger tip is now 54 degrees, with 70 being average for a mallet finger. When my therapist said I might not make it to 70, my response was, "oh yes I will!" I am determined to get the best possible outcome from all of this! There is still scar tissue and swelling that continues to heal very slowly. It is also painful to bend my finger, but I have daily exercises that are helping. Typing has also proven to be difficult recently. I began using my finger to type several weeks ago but began feeling discomfort last week. Chances are it is due to the lack of "cushioning" where my nail bed used to be. There is not much between the bone and skin which is most likely causing the discomfort. When this happens, I just revert to typing with 4 fingers until my index finger feels better. I continue to wear the splint a few hours a day -- typically at night.
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