Integrative Skin Lesion Treatment and Patient Experience

Integrative Skin Lesion Treatment and Pain Control

Abstract: An Integrative Approach to Cutaneous Lesion Management

In this educational overview, I will walk you through the procedural steps and clinical reasoning for excising a dysplastic nevus, a type of atypical mole. This procedure highlights the precision required to ensure complete removal while minimizing discomfort. We achieve this goal using a technique called a field block for local anesthesia. Furthermore, I will explain the physiological basis for this method and how it allows for a virtually painless patient experience. I will also place this procedure within the broader framework of our practice at Injury Medical Clinic. In addition, I’ll discuss how our multidisciplinary team, with crucial medical oversight from our Medical Director, Dr. Maria Guadalupe Cardenas, MD, collaborates to provide comprehensive, integrative care. This model combines chiropractic, functional medicine, rehabilitation, and conventional medical expertise. As a result, it addresses not just isolated symptoms but the patient’s overall health and well-being.

Introduction: A Collaborative Model for Patient-Centered Care

As a clinician with diverse certifications spanning chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP), my guiding philosophy has always been to view the patient as a whole. At Injury Medical Clinic, this philosophy is the cornerstone of our practice. Additionally, we have cultivated a unique, multidisciplinary environment where different fields of healthcare converge to provide superior patient outcomes.

A key element of our success is our collaboration with Dr. Maria Guadalupe Cardenas, MD, a highly respected, board-certified internist with over 40 years of experience. As our Medical Director and Collaborative Physician, Dr. Cardenas provides essential medical oversight to ensure our protocols meet the highest standards of care. Therefore, this integrative model allows us to blend the strengths of various disciplines:

• Chiropractic Care (Dr. Alex Jimenez): Focused on spinal health, nervous system function, and musculoskeletal integrity.
• Medical Oversight (Dr. Maria Cardenas): Provides diagnostic expertise, manages medical conditions, and ensures all treatments are safe and appropriate from an internal medicine perspective.
• Functional Medicine: A systems-based approach to uncover and address the root causes of chronic illness.
• Rehabilitation and Personal Injury Care: Specialized protocols to restore function and facilitate recovery after an injury.

This team-based approach allows us to manage a wide spectrum of health issues. We address both complex chronic conditions and straightforward procedures like the one I will detail today.

Preparing for the Excision: Pre-Procedural Planning

This morning, on September 1, 2026, I am preparing to see a 62-year-old gentleman who requires a re-excision of a skin lesion on his back. Approximately a month ago, a shave biopsy of this lesion revealed a dysplastic nevus with moderate atypia. A dysplastic nevus is an atypical mole that has abnormal cells and a higher potential to develop into melanoma, a serious form of skin cancer. The pathology report’s finding of “moderate atypia” signals a significant level of cellular abnormality. This finding necessitates a follow-up procedure to ensure all atypical cells are removed.

Our goal is to perform a complete excision with clear margins. This means removing the original biopsy scar along with a small, precise border of healthy tissue. Importantly, this “safety margin” is crucial to prevent recurrence and ensure the lesion is fully eradicated.

Mapping the Surgical Site

My first step is meticulous preparation of the surgical site. After cleansing the area with alcohol, I use a sterile surgical marker and a template to plan the excision.

• Defining the Margins: The original lesion was approximately 5 x 6 millimeters. Based on current guidelines for a dysplastic nevus with moderate atypia, I plan to secure about a five-millimeter margin around the original lesion site, which equates to about two millimeters around the visible scar.
• Creating the Ellipse: I draw an elliptical shape around the scar. This shape is not arbitrary; it’s designed to align with the natural skin tension lines (Langer’s lines). By orienting the excision this way, we can close the wound with minimal tension, which leads to better healing and a less noticeable scar.

Mastering Anesthesia: The Pain-Free Field Block Technique

Patient comfort is paramount. For a procedure like this, simply injecting anesthetic directly into the lesion site can be painful and less effective. Instead, I use a field block, a technique that creates an “anesthetic fence” around the entire surgical area. This approach numbs the nerves before they reach the target tissue, producing profound, widespread anesthesia.

The Physiological Rationale

The goal of a field block is to anesthetize the cutaneous nerves that supply sensation to the skin in a specific region. Instead of a single deep injection, we perform a series of interconnected, superficial injections in the subcutaneous tissue encircling the planned excision site. The anesthetic I am using is 1% lidocaine with epinephrine.

• Lidocaine: This is the anesthetic agent. It works by blocking sodium channels in nerve cell membranes. Nerve impulses (including pain signals) are electrical signals that depend on sodium ion flow. By blocking these channels, lidocaine prevents the nerve from depolarizing and sending a pain signal to the brain.
• Epinephrine: This is a vasoconstrictor, meaning it narrows the blood vessels in the area. Its inclusion is strategic for two reasons:
  1. Prolongs Anesthesia: By reducing blood flow, it slows the rate at which the lidocaine is carried away from the injection site, extending the duration of the numbness.
  2. Reduces Bleeding: The vasoconstriction also minimizes bleeding during excision, giving me a clearer view of the surgical field and allowing more precise work.

Executing the Block: A Step-by-Step Guide

1. Initial Numbing Spray: To make the first needle stick completely painlessly, I use a vapocoolant spray (ethyl chloride). It rapidly cools the skin, creating an immediate, temporary numbing effect. As I asked the patient, “Is that cold?” he confirmed it was, and when I inserted the needle, he reported feeling nothing. This small step significantly enhances the patient experience.
2. Creating the Subcutaneous Reservoir: I insert the needle at one corner of my marked ellipse and inject the lidocaine solution into the deeper subcutaneous tissue beneath the entire lesion. This creates a foundational layer of anesthesia, numbing the larger nerve branches that feed the area.
3. The Intradermal Fence: This is the most critical part of the field block. Using the same entry point, I redirect the long, thin needle just under the skin’s surface (intradermally). I advance it along one side of the drawn ellipse and slowly inject the anesthetic as I withdraw the needle. This creates a visible wheal, or raised line, of anesthetic fluid. I then pivot the needle at the entry point and repeat the process on the other half of that side.
4. Completing the Perimeter: I then move to the opposite corner of the ellipse and repeat the process, creating two more lines of intradermal anesthetic that connect with the first set. This completes the “fence,” ensuring the entire elliptical area is enclosed within a wall of numbness.

By the end of this process, the patient confirmed he felt no pain whatsoever. This is the power of a well-executed field block. It transforms what could be an uncomfortable procedure into a pain-free experience.

The Role of Integrative Chiropractic Care in Overall Wellness

While a skin lesion excision may seem purely medical, it’s an opportunity to consider the patient’s holistic health. In our practice, even when a patient comes in for a specific medical or minor surgical procedure, we see it through an integrative lens.

From a chiropractic and functional medicine perspective, skin health often mirrors internal health. Chronic inflammation, poor gut health, hormonal imbalances, and nutritional deficiencies can all manifest in the skin. Additionally, as a chiropractor, I am trained to assess the neuro-musculoskeletal system and understand that nerve function is critical for regulating all bodily processes, including tissue repair and immune surveillance.

If this patient were also seeing me for chiropractic care, my focus would be on:

• Optimizing Nervous System Function: Through chiropractic adjustments, we can reduce nerve interference along the spine. Proper nerve supply is essential for healthy cellular communication, immune function, and the body’s ability to heal efficiently post-procedure.
• Supporting the Body’s Healing Response: We would discuss anti-inflammatory nutrition, stress management techniques, and targeted supplementation (like Zinc and Vitamin C) to support wound healing and bolster the immune system.
• Addressing Systemic Inflammation: A dysplastic nevus, while localized, can be influenced by systemic factors. A functional medicine workup could explore inflammatory markers, gut health, and toxin exposure to reduce the body’s overall inflammatory load, potentially lowering the risk for other health issues down the line.

This is the essence of our integrative model: we manage the immediate concern with precision and care. At the same time, we use it as a gateway to improve the patient’s foundational health and resilience. The collaboration between Dr. Cardenas and me ensures this comprehensive approach is both holistic and medically sound. Once the anesthesia has taken full effect, we are ready to proceed with the excision. We do so confident that the patient is comfortable and that we have a clear, well-prepared surgical field.

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References

• Kouba, D. J., LoPiccolo, M. C., & Alam, M. (2012). Guidelines for the use of local anesthesia in office-based dermatologic surgery. Journal of the American Academy of Dermatology, 66(3), 477-493. https://doi.org/10.1016/j.jaad.2011.08.012
• Robinson, J. K., Hanke, C. W., Siegel, D. M., & Fratila, A. (Eds.). (2018). Surgery of the skin: Procedural dermatology (3rd ed.). Elsevier.
• Tzarnas, S., & Jelinek, J. E. (2017). Local anesthetics. In StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534859/