Renaissance man: The grandson of a coal miner, Cook has interests that range from German opera to the history of philosophy to cultural notions of beauty. Credit: Chris Hildreth
Renaissance man: The grandson of a coal miner, Cook has interests that range from German opera to the history of philosophy to cultural notions of beauty. Credit: Chris Hildreth

Saving Face

Part oncologist, part sculptor, dermatological surgeon Jonathan Cook uses microscopic surgical techniques to eradicate skin cancer and minimize scarring on the part of the body that most strongly defines our identity.
June 1, 2010
 
On a typical Thursday afternoon in March, nearly every seat in the waiting room of the Duke Mohs Surgery Unit is full. Patients, most of them past the age of sixty, sport white gauze bandages on eyes, noses, cheeks, or foreheads. A septuagenarian in chinos, button-down shirt, and a cardigan sweater shuffles toward the multiple-option, self-serve coffeemaker and presses the button for a cup of dark roast, while a white-haired great-grandmother blazes through a crossword puzzle. The tables are stacked with a library’s worth of current publications—from The Economist and BusinessWeek to InStyle and National Geographic. Classical music plays softly, and a light scent of lavender wafts through the room from a discreetly located aromatherapy machine.

Conversations spring up between strangers. A returning patient asks a first-timer to guess where on her face she had surgery. He can’t tell—even though a few months before her top lip was cleaved nearly in two to remove a basal cell carcinoma.  Every patient here has been diagnosed with some form of skin cancer. Most patients are accompanied by a spouse or friend and will spend all day at the clinic. Referred here by personal physicians, they will have cancers removed and surgical repairs completed by Jonathan Cook, director of the Mohs clinic and of dermatological surgery at Duke.

 

Before and After: Mohs surgeon Jonathan Cook performed a forehead flap procedure to repair and reconstruct Jennifer Steele’s nose, a portion of which was removed to eradicate an aggressive squamous cell cancer. Here’s how Steele looked after her initial surgery, and several months post-op. Caution: The "before" picture below contains a graphic image of pre-nasal reconstruction. Viewer discretion advised before clicking to view the "before" image.

Cook is among the most accomplished Mohs surgeons in the country. A specialized subset of dermatology surgery, Mohs is a microscopic surgical procedure that removes every last cell of cancerous tissue while minimizing harm to surrounding, healthy skin and uses precise reconstruction to minimize scarring and provide a pleasing aesthetic outcome. Developed in the late 1930s by Frederic Mohs, a surgeon at the University of Wisconsin medical school, the approach has the highest success rate of any skin-cancer protocol—for new basal cell cancers, the five-year cure rate is nearly 100 percent; for recurrent cancers, it’s about 95 percent.

“I got interested in Mohs when I saw cancers just being scooped out,” says Cook, as he checks the printout of the day’s schedule to see what’s next on his docket. “Even though the tumors had been successfully treated clinically, they left devastating wounds. I was confident that it was possible to remove the cancer while performing rehabilitative and reconstructive surgery. My goal is not just to get rid of cancer, but to do it so that the casual observer can’t tell that the person has had skin cancer.”

Dressed in his daily uniform of surgical scrubs, Cook is an omnipresent force in the bustling clinic, barely standing still for more than a moment. In the course of fifteen minutes, he will enter an exam room to consult with a first-time patient, stop by the on-site pathology lab to examine a tissue sample from another patient, and head into the clinic’s operating room to slice a crescent-shaped wedge from a third patient’s ear. Twelve-hour workdays are standard. Six nurses, two pathology assistants, and three front-office staff members help Cook maintain the persistent pace of the clinic. He rarely takes more than ten minutes to eat lunch—dermatology residents who rotate through are warned in advance they’ll be challenged to keep up—and takes only one week of vacation a year.

Today, Cook will see forty-five patients and perform fourteen surgical procedures. Some of these will be fairly straightforward; others, more complex. In each instance, Cook excises the cancerous growth and an area of skin surrounding and underneath it and then analyzes the tissue sample in the lab to see whether there are any remaining cancerous cells. If there are, he removes more tissue, until the slide shows no remaining cancer cells. At that point, Cook stitches up the gaping holes and deep divots that the surgery has left behind. Like other Mohs surgeons, Cook uses the intricate architecture of the human face to hide scars in the natural folds and shadows of the skin—where the cheek and nose come together, for example, or the brow area around the eye. When the tumor removal site is large, he performs additional rounds of surgery to ensure symmetry and balance.

That was the case for Jennifer Steele, a Raleigh social worker who had an aggressive squamous cell cancer growing on the left side of her nose. Squamous cell cancers are the second-most common form of skin cancer. If left untreated, they can spread to lymph nodes and other organs; about 2,500 people die from squamous cell carcinomas in the U.S. every year.

Because Cook had to remove such a large section of Steele’s nose, he recommended that she undergo what’s called a forehead flap procedure to rebuild her proboscis using a section of her forehead. The technique, which originated in India more than 3,000 years ago when cutting off noses was a form of social punishment for thieves and adulterers, redirects a section of the patient’s forehead downward so that healthy skin and blood vessels grow into place. To help the new nose retain its shape, Cook takes a sliver of cartilage from the patient’s ear and positions it on the top perimeter of the nostril he’s repairing so that it doesn’t collapse as the nose heals.  The cartilage helps the nostril maintain a rounded shape, and prevents it from puckering into an unsightly scar. As with all Mohs procedures, from the simplest nip-and-stitch to extensive reconstruction, the forehead flap is performed on an outpatient basis using a local anaesthetic.

“When Dr. Cook first explained the procedure to me,” says Steele, “I was nodding but my heart was about thirty seconds behind my head. Then it hit me—I was going to be disfigured.” In the weeks following each of what would eventually be four steps of the procedure, Steele wore large bandages on her face. Children stared at her when she went out in public. A well-meaning friend told her she could never imagine leaving the house looking like that. It was emotionally exhausting, she tells Cook. She lies on a bed in the clinic’s small operating room, where he is about to begin the penultimate stage of her nose repair.Team effort: Cook and staff members discuss day’s schedule—forty-five patient visits

Team effort: Cook and staff members discuss day’s schedule—forty-five patient visits and fourteen surgical procedures. Credit: Chris Hildreth.
“Surgery on the face can have a profound effect on a patient’s psyche,” he tells her, adeptly trimming bits of flesh here and gently pulling skin together there. Opera music plays in the background, while nurses Kathleen Jagow and Ann Adcock anticipate almost intuitively Cook’s need for additional anaesthetic or surgical instruments. (All six Mohs nurses handle every aspect of patient care, from prepping patients for surgery to surgical assistance to counseling patients on follow-up care. They have a combined 163 years of experience.)

“Studies have shown that some areas of the face are more visually important than others when it comes to a person’s sense of identity,” Cook continues. “The eyes, nose, and lips form an inverted triangle, and when we look at someone’s face, our eyes are scanning that triangle more than any other part of the face. So we know that someone who has had a large tumor removed from her nose will be more psychologically affected than if that same tumor was removed from her cheek.”

Of the approximately 3,500 procedures that Cook performs annually, 95 percent are on the face—the part of the body most exposed to the sun. Although not all skin cancers can be directly linked to sun exposure, ultraviolet light is widely considered to be one of the key factors for causing skin cancer.

Returning patient Ralph Stroud, a retired operations manager for North Carolina’s Employment Security Commission, grew up on a tobacco and soybean farm.  Throughout his youth he headed to the coast with family and friends and routinely used a mixture of iodine and baby oil thought to help achieve a deep, dark tan. Once, on a college spring-break trip to the beach, he and his buddies forgot the baby oil, so they used motor oil instead.

Stroud, who is sixty-eight, has seen Cook twice already to have basal cell carcinomas removed, but today he’s here for treatment of a melanoma. Basal cell carcinomas spread on the surface of the skin if left untreated but are rarely fatal; melanomas can metastasize quickly into the bloodstream and are the deadliest form of skin cancer. According to the National Cancer Institute, there were more than 68,000 new cases of melanoma in the U.S. in 2009 and more than 8,000 deaths. Stroud is convinced he and his family have a genetic predisposition to skin cancer; his wife and nephew each have had three melanomas removed. Still, the experience of being diagnosed with one of his own has led him to don a broad-brimmed hat and sunscreen when he heads out to his garden to tend his corn, butterbeans, and watermelons.

“Even though my cancer was small, Dr. Cook ended up taking out a hole about the size of a quarter,” says Stroud, whose many moles put him at higher risk of melanoma. “I’d tell anybody who has moles to see a dermatologist because moles can change to melanomas.”

Chances are Stroud and most of the other patients in the waiting room today will be back again. Having just one basal cell cancer increases the risk of having a second within five years by 40 percent. And while basal cell cancers can’t become melanomas, having multiple basal cell or squamous cell cancers increases the risk of melanomas.

Damage from sun exposure, whether cumulatively over decades or intermittently in the form of sunburns, takes its toll as people age. People who spent years of their lives in the sun before SPF lotions were invented are at increased risk. Unfortunately, says Cook, he is starting to see more and more patients in their twenties—mostly women—who have done irreparable damage to their skin by baking in tanning beds to achieve an oxymoronic “healthy glow."

As a boy growing up in Bristol, Tennessee, Cook knew he wanted to be a doctor like his older half brother, Patrick Rash. (Rash is a general dermatologist in Kingsport, Tennessee, and Cook’s twin brother, Joel, is also a Mohs surgeon, in Charleston, South Carolina.) An emergency medical services volunteer during high school, Cook estimates he logged twenty to forty hours a week learning hands-on emergency medicine on top of his academic workload. At the time, he thought he might want to be an emergency-room physician.

But he also had a passion for the arts—in the sixth grade, he fell under the spell of opera and attempted to teach himself German so he could appreciate Tristan und Isolde and Die Fledermaus as Richard Wagner and Johann Strauss had intended. In high school he received a bagpipe for Christmas and went on to become a competitive Scottish bagpiper throughout his medical training.

In the spring of 1985, during his freshman year at the College of Charleston, Cook was accepted into the Medical University of South Carolina through an experimental program-administered in conjunction with the Johns Hopkins University-to see whether early acceptance to medical school alleviated the competitive pressure to focus solely on a premed curriculum. “It allowed me complete intellectual freedom,” he says. “By the time I finished college, I had taken only those [premed] classes that were on the MCATs—biology, organic chemistry, inorganic chemistry, and physics. My other courses were everything from the history of warfare to the age of Goethe to the history of philosophy. It allowed me to really think about things rather than just digesting information.”

After graduating at the top of his medical-school class and completing an internship in internal medicine at Harvard Medical School’s New England Deaconess Hospital, Cook decided to specialize in dermatology and did his residency at Emory University. While there, he says, “I realized that I was slightly less interested in the science of medicine and slightly more interested in the craftsmanship of surgery. I am visually oriented, so I became fascinated by what our faces mean to us and the emotional impact of having cancer, and cancer surgery, on one’s face.”

Cook signed up for a brief post-residency stint with a Los Angeles cosmetic surgeon to learn more about procedures such as brow lifts and rhinoplasty. A returning patient, back for an eyelid tuck consultation, mentioned how much she liked the way the surgeon had removed a minor blemish using laser treatment. He gave her a pen and told her to mark any additional spots she wanted removed, while he checked on another patient.  

“This woman was drop-dead gorgeous,” recalls Cook. “But when we came back into the consult room, she had drawn circles all over her body. It made me realize that treating medical diseases would be far more gratifying for me than performing surgery on real or perceived physical imperfections.”

It’s a point that Cook underscores during presentations he makes to fellow dermatological surgeons at national and international conferences. While not for the squeamish, his before, during, and after slides of successfully treated Mohs patients are remarkable. In most cases, the after photo looks better than the pretreatment shot. Gone is the telltale red scab of a basal cell cancer or the scaly growth of a squamous cell carcinoma. In their place is healthy, healing skin; surgical scars are imperceptible to all but an experienced eye. (Jennifer Steele says she was “stunned” at the results once her skin healed and that even her own family couldn’t tell that she’d had surgery.) Comparison photos of non-Mohs patients who have had similar cancers removed show men and women so mutilated by the traditional cut-and-suture approach that it’s painful to look at their faces.

 Cellular precision: Mohs procedure includes microscopic analysis to isolate cancer from healthy skin.
Cellular precision: Mohs procedure includes microscopic analysis to isolate cancer from healthy skin. Credit: Chris Hildreth.
“Symmetry is everything,” says Cook, citing studies that show animals tend to choose mates with symmetrical features. Humans, he notes, are even choosier. Infants as young as two months prefer an attractive face to an unattractive one. “We know that beauty is perceived at a glance and that attractiveness matters. I see no reason why we can’t move beyond the perception that treating skin cancers necessarily means disfigurement. The challenge of reconstructive surgery on the face should be not only to restore function—so that the patient can breathe through their nose or blink both eyes at the same time—but also to ensure that they are left with a pleasing appearance.”

In 1996, he went to the University of Pennsylvania’s School of Medicine to complete a year of Mohs training with Leonard Dzubow, one of the preeminent Mohs surgeons in the world. Dzubow became a mentor, and Cook continued working with him for another two years. But when Duke approached him in 1999 to head a Mohs unit in Durham, Cook knew it was time to strike out on his own.

“It was a little like playing football for your father,” Cook says. “The day comes when you realize you are good enough to keep up, and it’s time to spread your wings.”

As he confers with patients and clinic staff during the day, Cook’s rich and varied background is on display. With his Appalachian roots, artistic and intellectual curiosity, and specialized medical training, Cook can talk to just about anybody. A composer and New York native getting an ear repair recognizes “The Toreador Song” from Carmen playing on the operating-room CD player. He and Cook launch into a discussion about Broadway musicals, Liza Minnelli, and the high cost of New York hotels. A few minutes later, Cook is dropping his “g’s” as he finds common ground with a Southern good ol’ boy who likes to fish.

Cook, the grandson of a coal miner, is unfailingly polite to his patients, whom he addresses formally: Ms. Steele, Mr. Stroud. When he says he considers it a privilege to practice medicine, you believe him. “Our practice is run the way I would want it to be if I were a patient,” he says. That includes making sure that patients don’t try to be stoic if they are experiencing any discomfort. “Life is too short for pain,” he says repeatedly throughout the day. (The clinic uses between eighty and 100 syringes of lidocaine a day.) His concern for his patients’ well-being extends beyond the work day and the clinic walls. He gives every surgery patient his home phone number and urges them to call if they experience any problems.

He can also be stern. During a procedure to remove a basal cell from a woman’s cheek, he is soothing and reassuring. “You’re doing great,” he tells her. “We’re in the home stretch.” Once she’s bandaged and ready to go, he adopts a firmer tone, urging her to quit smoking. “Smoking makes it really hard for your body to heal,” he says. “Can you try to quit?” She nods, but then in a quiet voice says that she sure could use a cigarette right now.

Back in the waiting room, Mark Davis sits in a soft reclining chair, waiting to be escorted to the back for removal of his stitches. He had a flap procedure to repair his nose; in his case, Cook used part of Davis’ cheek and a section of his right ear. “I’m deaf in my left ear, so I was tellin’ a girl at church the other day that even though I still can’t hear out of my left ear, maybe now I can hear through my nose,” he jokes. Davis, who is seventy, has had a number of medical problems. Last year, he had a heart attack during post-op recovery for a knee repair and spent nearly a month in the hospital.

It might seem counterintuitive that a heavy smoker or a frail man like Davis would be a suitable candidate for invasive facial surgery. But Cook says that Mohs, which is done on an outpatient basis using local anaesthesia, is actually safer than procedures requiring hospitalization and general anaesthesia. In a 2003 issue of Archives of Dermatology, Cook reported the results of a study that looked at outcomes for 1,343 Mohs patients at Duke. Only twenty-two patients—1.64 percent—experienced any complications, usually in the form of excess bleeding. None required hospitalization.

 “We are able to treat really large, aggressive tumors that used to be treated exclusively in a hospital setting,” says Cook. “That means that it is more cost-effective, and it creates much less anxiety for patients. But we have also shown that it is safer. Mohs is gaining popularity as the first choice of treatment because it works so well.”

Even though Cook has performed tens of thousands of Mohs surgeries, he says he never gets bored by the challenges of reconstructive surgery for cancer patients. “I’ve never done the same surgery twice,” he says. “Every face is different.”