Temporary or permanent weakness of the surgical area. 4th ed. Mohs surgery lets you keep as much healthy skin as possible the surgeon only removes skin with cancer cells. Mohs surgery (also known as Mohs micrographic surgery) is a specialized type of surgery commonly used to remove facial skin cancers, such as those from the lips. To do this he uses a customized, bespoke approach to each patient employing the most minimally invasive, innovative, and cutting-edge technology. 2023 Advanced Dermatology & Skin Cancer Center, PLLC 2023 Revive Medical Spa, LLC, About Our Dermatology & Skin Cancer Center, Patient Forms & Policies Advanced Dermatology & Skin Cancer Center, PLLC, Forms & Financing Revive Medical Spa, LLC. WebWhile it is impossible for a surgeon to cut the skin without leaving a scar, we will perform your reconstruction very meticulously to help ensure you have the best result possible. Authored by recognised experts from The shot might hurt for a few seconds, and then the medicine numbs the skin. It develops in the squamous cells that line certain oral and facial structures such as the lips, tongue, cheeks and throat. Eyelid Defect Reconstruction. Advertising revenue supports our not-for-profit mission. skin tone and radiance on after photos. Comparison of outcomes of early vs delayed graft reconstruction of Mohs micrographic surgery defects. There are a few reasons why this can happen, including an infection or bleeding/hematoma under the skin. After surgery to removeskin cancer, you may have many concerns, one of which may be how you will look. The initial tumour size was 228 mm, with an average maximum diameter of 8 mm. Read our. Saturdays by appointment only. You should be able to go home right after the procedure. Reddening of skin is common around areas that have undergone abrasion (which happens during Mohs surgery). Patient underwent an O to T advancement flap, borrowing along the hairline. SCC can also spread if not treated early. You usually don't leave your appointment until all of the skin cancer has been removed. Ear Defect Reconstruction. Heres What You Need To Know. Be sure to follow all post-op precautions from your doctor such as avoiding direct sunlight or extreme temperatures, not rubbing or touching the site of removal, reducing physical activity for at least one week, not drinking alcohol for at least 48 hours after your surgery, applying ice packs over gauze pads if needed for swelling relief, etc. #am-social-unique-id-3183 .am-social-svg {width:48px; height:48px}. WebMohs surgery, also known as Mohs micrographic surgery, is a multi-step, minimally invasive procedure. WebReconstruction of the Upper Lip after MOHS Surgery. The surgeon or a technician cuts the tissue sample into sections and looks at them with a microscope. Mohs micrographic surgery is a highly effective treatment for the removal of certain types of skin cancer lesions. Upper-lip reconstruction after Mohs micrographic surgery is challenging for dermatologic surgeons. The older lower lip wedge techniques resect a much larger portion of the lower lip than is necessary. I treated the scar using VBeam and CO2. See This is why he has gone on over twenty plastic surgery missions to poor countries around the world and provided free cleft lip and surgery for birth defects to over 500 children. The surgeon also takes a thin layer of tissue underneath and around the cancer. Healthline Media does not provide medical advice, diagnosis, or treatment. It requires microscopic analysis of tissue cells while the surgery is taking place. The skin was brought together and rearranged above the brow so that the brow itself would not be interrupted or unnaturally elevated. Petrungaro Plastic Surgery About Reviews. One of the advantages of Mohs surgery is that you know your results right away. Infection is extremely rare after Mohs surgery and Mohs surgery can be used to treat both lower lip and upper lip cancers, as well as other forms of skin cancer such as basal cell carcinoma and squamous cell carcinoma. Mohs meets these objectives successfully. Goals: MOHS reconstruction with an island pedicle flap to the upper lip was performed in order to repair this defect. Squamous cell carcinoma is a non-melanoma skin cancer, yes, but the chance of recurrence remains relatively high, up to 35%. What procedures can I look into to fixing my mouth by getting back symmetry and plumping up my lips so they're sexy? Following this surgery, there may be a large amount of skin and tissue that had to be removed. It is advised to refrain from vigorous exercising for 3 weeks, though walking at a slower pace on the treadmill is fine. Link JL (expert opinion). This gallery contains before and after photos that may be graphic and/or unsettling. Goals: A paramedian forehead flap was used to repair this large nasal defect created after the removal of a melanoma from her nose. The problem is that I can't get traditional bandages or gauze to stick. The most common symptom experienced by those who undergo Mohs surgery is moderate pain in the lip. It also includes melanoma and other less-common skin cancers. The doctor who performs your Mohs surgery, also called Mohs micrographic surgery, to treat skin cancer may be able to complete your reconstruction when your lesion is removed, or you may be referred to a plastic surgeon for reconstructive surgery. WebMost reconstructive surgery can be performed on the same day as your Mohs surgery. For more surgeries, please visitMohs Surgery Book, Basal Cell skin cancer above lip Mohs surgery, 2023 Advanced Dermatology & Skin Cancer Center, PLLC 2023 Revive Medical Spa, LLC, About Our Dermatology & Skin Cancer Center, Patient Forms & Policies Advanced Dermatology & Skin Cancer Center, PLLC, Forms & Financing Revive Medical Spa, LLC, Fellowship-trained American College of Mohs Surgery surgeons. Nasal Defect Reconstruction with Multiple Staged Repair. This photo contains content that some people may find graphic or disturbing. A local flap was performed to repair the eyebrow, while maintianing the shape and contour of the brow. First lady Jill Biden is undergoing Mohs surgery to remove a skin lesion above her eye. Surgical removal involves injecting a local anesthetic and removing the tumor from the skin along with a safety margin to ensure that all of the cancer cells have been removed. He practices in Boca Raton and Delray Beach, Florida treating patients from Palm Beach, Ft. Lauderdale, Miami, as well as patients from all over the US and from around the world. Used skin routine with retinol and silicon scar strips until I found out I was pregnant in January. Oncology Certified Nurse Practitioner and freelance healthcare writer with over a decade of medical oncology and hematology experience. By understanding this specialized procedure, you can make an informed decision about having lip surgery. It was scaly, itchy, and not healing properly. Severe pain after surgery is not common. A vermillion lip advancement flap was utilized to reconstruct this defect of the lip. Mohs surgery is an outpatient procedure thats usually done in the span of a single day. Note improvement in scar 6 weeks after 1 session. The good, The purpose of massage after a Mohs surgery is to reduce discomfort, encourage circulation in, Dermatology & Skin Health Med Spa specializes in Mohs micrographic surgery, a highly specialized and, While Mohs surgery can be successful in eliminating skin cancer, it can leave a wound, Mohs surgery is a specialized procedure used to treat skin cancer on the scalp. A nasal cresenteric lip advancement flap was utilized to reconstruct this full thickness The surgeon takes care to remove tissue that contains cancer and leave as much healthy tissue as possible. Mohs surgery is becoming increasingly popular for treating skin cancer due to its high success rates. The after pictures show results after reconstructive surgery to repair the defects left behind after the cancer was removed. This is because it begins with numbing the area so that patients don't experience any discomfort during treatment. A bilobed flap procedure was performed. Procedures. Mohs surgery. You may have some mild pain and soreness after your surgery. February 24, 2014 Answer: Mohs to upper lip I would assume you will be swollen and even bruised for up to a week. WebMohs Surgery Photos. Etzkorn JR, et al. The after photos show the patient immediately following surgery and again six months postoperative with no distortion of the nasal anatomy. Mohs surgery is usually an outpatient procedure that can be done while youre awake. One simple trick that is often overlooked? (516) 773-4646 | Fax (516) 773-1360. WebMohs Surgery Mohs surgery has the highest cure rate of all therapies for squamous cell carcinomas. Tolkachjov SN, Brodland DG, Coldiron BM, et al. By Julie Scott, MSN, ANP-BC, AOCNP Accessed July 11, 2022. Jill Bidens Mohs Surgery: What Is It and When Is It Needed? document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); This field is for validation purposes and should be left unchanged. Bolognia JL, et al, eds. For smaller surgical wounds, your surgeon may be able to leave the area open to heal on its own in time. It, 784 Central Avenue, Dover, New Hampshire(603) 742-5556, 2299 Woodbury Ave, Suite 3 The Beane Farm, Newington, NH(603) 742-5556, 23 Centennial Drive, Peabody, MA(978) 525-0100, 50 Michels Way, Suite 202 Londonderry, NH(603) 742-5556, 160 South River Road, Suite 2400, Bedford, NH(603) 742-5556, If your desired appointment type or preferred provider is unavailable online, kindly call (978) 525-0100 for Peabody, MA and (603) 742-5556 for all New Hampshire locations. See Photo Photos Douglas S. Steinbrech, MD, FACS The 28-year-old patient Dr. O.J. Webthe book concludes with a section on reconstructive surgery including Mohs surgery, local flaps and grafts, cleft lip and palate, and craniomaxillofacial trauma. WebPatient 4. Sometimes a larger area may need to be removed, which requires more extensive surgery to repair. (2017). Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. The room has a lab nearby. This is an 89-year-old patient was referred for a biopsied skin cancer, a basal cell carcinoma. Last medically reviewed on January 18, 2023. Pain medicines you can buy without a prescription may help. My lip is 4 or 5 times normal size & I still have a day or so to go for max swelling (according to my instruction sheet). WebMohs surgery is a procedure used to treat skin cancer. WebView 954 before and after Mohs Surgery photos, submitted by real doctors, to get an idea of the results patients have seen. Accessed July 11, 2022. Our website services, content, and products are for informational purposes only. National Comprehensive Cancer Network. Thank you, {{form.email}}, for signing up. Each I see nothing for me to do as far as swelling. WebMohs Surgery Lip Area Procedure. WebResults: Six hundred fifteen patients underwent lip reconstruction. Thanks very much for your response. Covid-19s Secondary Skin Effects - Maskne Face Skin Breakouts, 5 Key Steps To Provide Safe Medical and Surgical Care During COVID-19 (and beyond), Dr. Steiger One of the First US Physicians to Offer Sofwave Ultrasound, the Latest Non-Invasive Technology in Wrinkle Treatment, Smile & Laugh Lines Be Gone! A full thickness skin graft was also required. Here are activities that you should avoid: Knowing what to avoid and following all postoperative instructions from their doctor are essential steps in ensuring your wound heals properly and quickly post Mohs surgery. You'll wait about an hour in a waiting room. WebSurgery Surgery is often recommended to remove squamous cell lesions, particularly those classified as high risk. The tissue was removed and oriented for further processing. Mohs micrographic surgery. A specialized flap called a tenzel flap was used to reconstruct the eyelid, and the lacrimal (tear duct) apparatus was reconstructed. A lip lift shortens the space between the top of the lips and the bottom of the nose through a bullhorn-shaped strip of skin below the nostrils. There are only 1,500 world-wide Fellowship-trained Mohs surgeons worldwide. Before and after pictures of Mohs surgery for basal cell carcinoma. This 76-year-old had an extensive defect involving the lower lip following the removal of squamous cell carcinoma. WebHave a dermatologist check it out! In our plastic surgery practice serving Beverly Hills and Sacramento, we have done thousands of rhinoplasties. Frozen section analysis showed: No residual tumor existed. Mohs surgery is a procedure used to treat skin cancer. Thinking of Getting Mohs Surgery In Long Beach, CA? A question bank of more than 1000 questions and answers is included to assist revision and exam preparation. Did something happen in healing process and is reconstructive surgery ever covered by insurance after removing skin cancer and not healing properly!? One of the objectives in treating high-risk cancers, as well as highly-visible skin cancers, is to do so as conservatively as possible. This is especially true if the surgery wasperformed ona prominent and important area like your face. The coldness can help to reduce inflammation and swelling while numbing the nerve endings of any pain you may be feeling. The healing process on the lips can take 7-14 days depending on the size of the area treated. The second stage involved sectioning (separating) the flap attachment. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Only very thin layers of skin and tissue are removed at a time during Mohs surgery, but multiple layers removed could add up to a sizeable wound. The post-op photo was taken at seven days, in the early stages of healing. Eyelid Defect Reconstruction. What is Mohs surgery? Patient underwent a neck transposition flap, and forehead and cheek rotation flap to close this large defect. This precise procedure requires a special kind of doctor one who is both a dermatologist and a surgeon or two separate doctors working together in coordinated surgical teams. If this itching becomes unbearable, talk to your doctor about using an emollient cream designed specifically for use on skin irritations (available over the counter). Pt was given an anti anxiety medication to help her relax before the procedure and was treated with Mohs micrographic surgery in the treatment of skin cancer. WebMohs micrographic surgery is the preferred method of treatment for nonmelanoma skin cancers of the lip, as it has the lowest recurrence rates and allows for the maximum preservation of healthy tissue. He is committed to providing his surgical expertise in a caring, supportive environment with a professional staff that has you as their focus and concern. Mohs surgery is also called Mohs micrographic surgery. There are several reasons why Mohs surgery is perceived as the ideal surgical treatment for skin cancer and lip cancer. You may get another shot of local anesthetic if necessary. Nasal Alar Defect Reconstruction. Rustad has performed well over 7,000 Mohs surgeries, including their necessary reconstructions. Depending on how many levels were done for the procedure, this can lead to more bruising and swelling too, particularly in the lips where the skin is very thin and delicate. (Photo) I had Moh's surgery on upper lip a few years ago and the WebSkin Cancer Patient 1. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Avoid alcohol and vitamin E a few days before as well. Worrying about how your skin may look after the procedure is normal. Reconstruction was achieved using a forehead advancement flap procedure. Cost-effective Mohs surgery serves as your key to unlocking the door of confidence again. Wearing SPF lip balm. This defect required a two staged surgery using a pedicled (stays attached to the donor site) paramedian forehead flap. WebLip cancer is a type of oral cancer. The first stage was performed to transfer skin and soft tissue from the forehead to the nose. Goals: This patient presented with a through and through defect of the nostril margin. May 5, 2022. Then, he underwent MOHs resection to remove another basal cell carcinoma of the right ala. An important feature that makes this method so effective is that it allows for both cancer removal and reconstruction in the same surgical setting. Avoid direct sun exposure near the affected area until advised otherwise by an attending physician. A single staged meloabial (cheek skin) transposition flap was used for reconstruction. It is dependent upon how much tissue was removed during the Mohs surgery, and if any other reconstructive surgery is needed. Using a scalpel, the surgeon will remove a layer of the target zone and its surrounding area. Nasal Defect Reconstruction with Multiple Staged Repair. It was at that moment that Doctor Jacono knew he wanted to fix peoples faces and change their lives. Our decades of experience in this procedure has given us a wealth of knowledge in terms of advising patients about what to expect during the The goal of Mohs surgery is to completely remove all cancerous tissue and to acquire diagnostic information from the tissue being removed. Accessed July 11, 2022. It is important to ask a lot of questions and pay close attention to what your healthcare provider has to say about your options. The specimen was oriented, mapped and divided into 2 blocks. The procedure is done in an operating room or procedure room. The tissue is taken immediately to a nearby laboratory for analysis, and the surgeon examines the tissues under slides. I had MOHs surgery done on my upper lip under my left nostril. Eyelid Defect Reconstruction. WebRhinoplasty is a common but complex procedure that heals in stages, within a generally predictable timeline. WebThe upper lip is composed of the philtrum and tubercle centrally, the paired philtral columns laterally, and the white roll of the vermiliocutaneous junction. How Flap Techniques Are Used in Reconstructive Plastic Surgery, What Happens During Post-Mohs Reconstructive Surgery. This usually occurs within five to seven days after surgery and may be decreased by the use of an ice pack during the first 24-48 hours. Accessed July 11, 2022. Accessed July 11, 2022. After surgery, the remaining lip defect often requires reconstruction with skin grafts or a local cutaneous or myocutaneous flap. Next, the suspected tumor and a small area of tissue surrounding the area are removed. They may feel some slight pressure when a sample of tissue is removed, but this is usually minor. As easy as it is to minimize the risk of skin cancer, it seems to be equally effortless to neglect the care that is needed to do so. He and his staff enjoy providing this service for Its is Doctor Jaconos passion to help his patients achieve their facial aesthetic goals, creating natural appearing results to either enhance their beauty and proportion or rejuvenate their aging appearance. The gallery below provides before and after pictures of Mohs surgery for basal cell carcinoma. Robinson JK, et al., eds. How long should I stay away from exercising? Another operation might be needed to repair the wound, though this is rare. Patient had a scar after Mohs surgery for basal cell carcinoma. In addition to taking prescribed medications, you should also consider the following: Following Mohs surgery, it is important to take the right steps after to ensure that your wound heals properly and quickly. Mohs Reconstruction Surgery Patient 1: This patients Mohs surgery left her without an upper lip. Although all of these have some side. The mask is the pillow type which fits into each nostril but also covers the area just below my nose. Full Thickness Upper Lip Defect Reconstruction. When needed, reconstruction may happen anywhere from the day after your Mohs surgery to a month later. By removing the smallest amount of healthy tissue, it also offers superior cosmetic results. Additional tissue may be removed until the surgeon is satisfied that the remaining tissue around the tumor site is free of cancer cells. Is reconstruction surgery necessary after Mohs surgery? In this article, we'll provide an in-depth look at Mohs surgery for the lips and discuss its benefits, risks, and tips for post-surgery. Due to its extremely precise nature, Mohs surgery can provide more successful outcomes than many alternative methods, such as wide local excision (which involves simply cutting out a larger portion of tissue), radiation therapy, chemotherapy or cryosurgery (freezing). Post-surgery lip swelling is normal and expected after Mohs surgery. All rights reserved. WebAbstract. Lip cancer has a high survival rate because the condition is often diagnosed in the early stages. View More Images . Thus, wedge excisions for carcinoma have become less common with the availability of Mohs surgery. Saunders Elsevier; 2015. https://www.clinicalkey.com. Goals: A local flap to the lower eyelid was performed to repair this defect created after skin cancer removal from MOHS surgery. Mohs surgery is a procedure that can successfully treat and cure various forms of skin cancers, including basal cell carcinoma. A specialized flap called a tenzel flap was used to reconstruct the eyelid, and the lacrimal (tear duct) apparatus was reconstructed. My question is after surgery will I have to stop using the CPAP machine? Its best to clear your schedule the day of your Mohs procedure, as the process can take time. Are you considering Mohs micrographic surgery to treat a lesion on your lips? WebProcedure Details. The scar is hard and super puffy. His approach is to maintain your uniqueness and facial identity; it is still you just better. Whats the Difference Between Seborrheic Keratosis and Actinic Keratosis? MOHS surgery is reserved for early stage lesions that are thin (less than 2. A thorough consultation and examination provide valuable data from which treatment may be planned. If there is more cancer, your Mohs surgery continues. Expansion to nearby lymph nodes decreases a patients five-year survival rate to approximately 50%. Mayo Clinic does not endorse companies or products. So health care providers often recommend planning for the procedure to take the whole day. 2017;92(8):1261-1271. doi:10.1016/j.mayocp.2017.04.009, David AP, Miller MQ, Park SS, Christophel JJ. I had Mohs Surgery 2 days ago on my upper lip area. Boca Raton, FL 33432. It reduces the need for other treatments or more surgery. Tel. But you won't be able to leave until the procedure is done. The nostril (nasal ala) was repaired with a 2 staged interpolated cheek flap (nasolabial flap) procedure. We describe a series of 15 patients (7 men and 8 women; mean age, 65.6 years) with skin cancer on the upper lip treated with Mohs surgery: 10 basal cell carcinomas, 2 melanomas, and 3 squamous cell carcinomas. Warning- Some of the pictures below are graphic in nature! I was expecting some swelling but not what I see this morning. The information on RealSelf is intended for educational purposes only. Dr. Jacono has been a Castle Connolly Top Doctor since 2012. For a better experience, please enable JavaScript. This method lets the doctor continue removing and examining suspected tissue until all the cancerous areas have been removed. Nick Blackmer is a librarian, fact-checker, and researcher with more than 20 years experience in consumer-oriented health and wellness content. French, now 50, worried that the spot kept returning, so she showed it to her dermatologist, Dr. Shirley Chi in Arcadia, California, during her annual skin exam. In the second stage of the procedure, 2 weeks later, the connection was detached to restore the forehead into position. National Comprehensive Cancer Network. If the thought of work leaves you with feelings of nervousness and dread, you could be dealing with workplace anxiety. The tumor was first debulked with a curette to remove clinically apparent tumor, tumor visible to the naked eye. In: Dermatology. Browse Mohs Surgery before & after photos shared by doctors on RealSelf. WebIn addition, multiple adjacent facial subunits (i.e., the cheek, the nose, the upper lip, the upper eyelid, etc. We describe a series of 15 patients (7 men and 8 women; mean Mohs surgery follows this procedure: Apply a local anesthetic to the treatment area. Mohs surgery is a proven treatment for skin cancer, with an impressive success rate of, Nerve damage is a serious consideration when undergoing Mohs surgery, a technique used to remove, Mohs forehead flap is a reconstructive surgery that helps restore skin to areas of the, Basal cell carcinoma is a type of skin cancer that can recur after undergoing Mohs, Uneven nostrils after Mohs surgery can be a frustrating experience for some people. For basal cell carcinoma, the cure rate is around 99%. Dr DeLuca - Patient #3 Reconstructive surgery performed by Louis DeLuca, MD, FACS, of Boca Raton, FL. Design and Development by. Consult with a doctor virtually or in person. Dr Jacono - Patient #1 Reconstructive surgery performed by New York board certified facial plastic and reconstructive surgeon, Andrew Jacono, MD, FACS. Doctor Jaconos desire to become a facial plastic surgeon was solidified in grade school. Research suggests that the large majority of lip cancers begin in the squamous cells. This content does not have an English version. The BCC is on my upper lip slightly left of my nostril. After the anesthetic takes effect, the surgeon uses a knife called a scalpel to remove the visible portion of the cancer. View More Photos of this Patient. WebTwenty-seven patients underwent upper-lip reconstruction following Mohs' surgery from 1993 to 1997. Reconstruction and full healing can take up to a year after the procedure. Pictures attached. Choose a Gallery: BOTOX CosmeticCellfinaChemical PeelsCoolSculpting EliteEMSCULPTFiller - ChinFiller - HandsFiller - LipsFiller - Tear TroughKybellaLaser - Pico GenesisLaser - YAGLaser GenesisLaser Hair RemovalLimelightMelasmaMohs Surgery - Above LipMohs Surgery - EarMohs Surgery - EyebrowMohs Surgery - EyelidMohs Surgery - NoseMohs Surgery - TempleRhinophymaSculptra AestheticSkinPen MicroneedlingSpider VeinsUltherapy. She underwent a bilateral transposition flap procedure. Not just skin cancer; allcancers. Home; About Us; Cosmetic Plastic Surgery; Non-Surgical Cosmetic Treatments; MOHs; Skin Conditions. To prevent scarring and promote healing, it is important to keep the area covered and moist with Vaseline. Does insurance cover reconstruction after Mohs surgery? All Photos Videos Practice Photos. The final section of the book covers post-operative management in detail, including procedures for scar refinement. He is shown here 3 months after the MOHS procedure and reconstruction was performed. Here's how to tell them apart. Can I use liquid bandage over the stitches & Vaseline? Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Increase drainage/bleeding (which can often happen with open wounds) etcetera - those typically require prompt medical attention so don't hesitate to reach out. Treatment options include surgery, chemotherapy and radiation therapy. Her treatment is a reminder of the importance of regular skin, Basal cell carcinoma is the most common and treatable type of skin cancer. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Available Sun Protection Products at Mayo Clinic Store, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, Mayo Clinic Minute: Treating skin cancer with Mohs surgery, Mayo Clinic Q&A podcast: Mohs surgery for melanoma.
Pros And Cons Of Having A Vague Constitution, Purple Reign Strain Indica Or Sativa, Directions To Greyhound Bus Station St Louis Missouri, Articles P