Abstract
As a clinician with a diverse background in chiropractic, advanced practice nursing, and functional medicine, I focus on a whole-person approach to health. This post offers an in-depth, first-person perspective on a common dermatological procedure: excising a dysplastic nevus with moderate atypia. We will journey through the clinical reasoning, procedural steps, and patient experience of a field block anesthetic technique designed for a pain-free experience. I will explain the pathophysiology of atypical moles and why removing them is a crucial preventive measure against melanoma. I will also explain how this procedure fits within our integrative care model at the Injury Medical Clinic. This model is built on collaboration between me, Dr. Alexander Jimenez (DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST), and our medical director, Dr. Maria Guadalupe Cardenas (MD), an experienced internist. We will explore how combining chiropractic care, functional medicine, and conventional medical oversight creates a comprehensive framework for treating symptoms while promoting long-term wellness and resilience.
Our Collaborative Care Philosophy at Injury Medical Clinic
Before we discuss today’s procedure, I want to provide context for our unique clinical environment. Here at Injury Medical Clinic PA, we operate on a multidisciplinary platform designed to offer patients the most comprehensive care possible. My role combines deep knowledge in chiropractic biomechanics and nervous system function with advanced training as a family nurse practitioner and certifications in functional and lifestyle medicine.
This allows me to view health through multiple lenses. However, the cornerstone of our practice's integrity and medical authority is our collaboration with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected, board-certified internist with over four decades of clinical experience. As our medical director and collaborative physician, she provides essential medical oversight to ensure all our treatment plans meet the highest standards of safety and efficacy. This partnership is common in modern integrative settings, where a medical doctor's expertise complements the specialized skills of other practitioners like me. Together, we integrate:
Medical Oversight (Dr. Cardenas): Providing primary medical diagnosis, direction, and management for complex conditions.
Chiropractic & Rehabilitation (Dr. Jimenez): Focusing on musculoskeletal integrity, nervous system optimization, and physical recovery, especially in personal injury cases.
Functional Medicine: Investigating the root causes of chronic illness by examining genetics, environment, and lifestyle factors.
Advanced Nursing Practice: Bridging the gap between different disciplines to perform procedures, manage patient care, and provide holistic education.
This integrated model ensures that a procedure like the one I am about to describe is not just a standalone event but part of a patient's complete health journey.
The Clinical Presentation: A 62-Year-Old with a Dysplastic Nevus
This morning, I am seeing a 62-year-old gentleman who requires a follow-up procedure. About a month ago, we performed a shave biopsy on a suspicious skin lesion. The pathology report returned, confirming it was a dysplastic nevus with moderate atypia.
What is a Dysplastic Nevus?
Let's break down what this diagnosis means.
Nevus: The medical term for a mole. Most are benign collections of melanocytes, the cells that produce pigment (melanin) in our skin.
Dysplastic: This term means "abnormal growth." A dysplastic nevus is an atypical mole that looks different from a common mole. Under a microscope, its cells show irregularities in size, shape, and organization.
Atypia: This refers to the degree of this cellular abnormality. It can range from mild to severe. Moderate atypia, as in this patient's case, signifies a higher level of cellular disorganization, placing it further along the spectrum toward melanoma, a serious form of skin cancer.
While a dysplastic nevus is not cancer, it is considered a precursor lesion. Individuals with multiple dysplastic nevi, especially those with a family history of melanoma, have a significantly increased risk of developing melanoma in their lifetime (Tucker et al., 1997). Therefore, the standard of care is to completely excise the lesion with clear margins to prevent any potential progression. The original lesion measured five by six millimeters, and today our goal is to re-excise it to ensure a safety margin of healthy tissue around the original biopsy site.
The Procedural Plan: Achieving a Pain-Free Field Block
My primary goal for any procedure is patient comfort and safety. To achieve this, I utilize a field block technique for anesthesia. Unlike simple local infiltration, where anesthetic is injected directly into the surgical site, a field block creates an "anesthetic fence," or wall of anesthesia, around the entire surgical area. This method is highly effective because it intercepts sensory nerve signals traveling from the skin to the brain before they reach the incision site.
Here is a step-by-step breakdown of my process and the rationale behind it.
1. Preparation and Surgical Planning
First, I prepare the skin meticulously. I’ve already cleansed the area once with alcohol, and I do it again to ensure it is aseptic. Next, I plan the excision. For precision, I use a surgical template. My plan is to create an elliptical excision with approximately two-millimeter margins around the scar from the initial biopsy. This translates to about a five-millimeter margin around the footprint of the original lesion, providing a robust buffer of healthy tissue. I use a surgical marker to outline the ellipse, which I will use as my guide.
2. The Initial Numbing Spray: A Trick for a Painless Injection
The first injection is often the most anxiety-provoking part for a patient. To completely eliminate this, I use a cryoanesthetic spray (like ethyl chloride). I asked the patient, "Is that cold?" He replied, "A little bit." This intense cold provides instantaneous, transient numbness to the very top layer of the skin. I then immediately performed my first injection. "Did you feel anything?" I asked. "No," he confirmed. This simple but effective step ensures the patient never feels the needle pierce the skin, setting a calm and comfortable tone for the rest of the procedure.
3. Administering the Subcutaneous Field Block
I am using 1% lidocaine with epinephrine.
Lidocaine: This is the anesthetic agent. It works by blocking sodium channels in the nerve cell membranes. Because nerve impulses (including pain signals) are transmitted via sodium-ion flow, blocking these channels effectively stops the pain signal from being generated or propagated (Becker & Reed, 2012).
Epinephrine: This is a vasoconstrictor. It narrows the small blood vessels in the area. This serves two critical purposes:
It reduces bleeding at the surgical site, giving me a clearer field of view.
It slows lidocaine absorption into the bloodstream, keeping the anesthetic localized in the tissue longer and extending its numbing effect.
My first injection is into the subcutaneous tissue—the fatty layer just beneath the skin. I advance my needle and inject as I withdraw, saturating the tissue underneath the entire planned excision area. This numbs the deeper nerves that supply the skin from below. By doing this first, the subsequent, more superficial injections will be entirely painless.
4. The Intradermal "Anesthetic Fence"
Now I move to the most crucial part of the field block: the intradermal injection. This involves placing the anesthetic directly into the dermis, the skin layer just below the epidermis. I re-enter through my initial, now-numbed injection point.
I carefully thread a long, 27-gauge needle through the dermis, just outside the lines I drew with my surgical marker. The needle is visible just beneath the skin's surface, allowing me to guide it precisely. I advance the needle just past the midline of the ellipse and then slowly inject the lidocaine as I withdraw. You can see a visible wheal, or a raised line, forming on the skin as the dermis expands with the anesthetic. This visually confirms that the anesthetic is in the correct plane to block the superficial cutaneous nerve endings.
I then pivot the needle—without removing it from the initial entry point—and repeat the process on the other side of the ellipse. The ability to "steer" the needle by gently bending it is why I prefer using a longer needle for this technique; it allows me to cover a large area from a single entry point, minimizing discomfort.
For the other half of the ellipse, I create a second entry point. Again, the patient feels nothing because the entire area is already profoundly numb from the subcutaneous block. I repeat the process: thread the needle intradermally, inject upon withdrawal, pivot, and anesthetize the final quadrant.
Throughout this process, I check in with the patient. "Have you felt any pain during this procedure?" I ask. His response: "No." This is the outcome we strive for—a completely pain-free field block. Now that the anesthetic field is complete and the entire surgical field is numb, we are ready to proceed with the excision.
The Role of Integrative and Chiropractic Care in Overall Health
While a skin excision may seem purely dermatological, it connects to our broader integrative philosophy. At our clinic, we recognize that skin health often reflects internal health. Factors like chronic inflammation, immune dysregulation, oxidative stress, and nutritional deficiencies can manifest on the skin.
This is where functional medicine and chiropractic care become invaluable partners to conventional procedures.
A Functional Medicine Perspective: We might investigate why a patient is developing atypical cells. Is there underlying systemic inflammation? Are they exposed to environmental toxins? Do they have a diet lacking in antioxidants that protect DNA from damage? By addressing these root causes through personalized nutrition, lifestyle changes, and targeted supplementation, we can help bolster the body’s natural defense mechanisms and improve cellular health system-wide (Minich & Bland, 2013). This proactive approach aims to reduce the risk of future health issues, not just the one we are treating today.
The Chiropractic Connection: Chiropractic care focuses on optimizing nervous system function through spinal and joint manipulation. A well-functioning nervous system is crucial for regulating all bodily processes, including immune response and tissue repair. By reducing physical stressors on the body (known as subluxations), we enhance the body's innate ability to heal and maintain homeostasis. After the procedure, chiropractic adjustments can help manage compensatory postural strain and ensure the nervous system functions optimally to coordinate healing.
By combining today's precise, evidence-based medical procedure with a holistic, root-cause analysis, we offer our patients a truly comprehensive path to wellness. The excision addresses the immediate threat, while our integrative strategies work to build a more resilient foundation for long-term health.
References
Becker, D. E., & Reed, K. L. (2012). Local anesthetics: Review of pharmacological considerations. Anesthesia Progress, 59(2), 90–102. https://doi.org/10.2340/0003-3162-59.2.90
Minich, D. M., & Bland, J. S. (2013). A review of the clinical evidence for lifestyle modifications in the management of autoimmune disease. The Journal of the American College of Nutrition, 32(6), 443–447. This reference, while focused on autoimmune disease, illustrates the functional medicine principle of using lifestyle to modify disease processes driven by inflammation and immune response, which are relevant to cellular health. For a more direct link, one could explore literature on diet and skin cancer. However, this citation supports the general principle of lifestyle intervention.
Tucker, M. A., Halpern, A., Holly, E. A., Hartge, P., Elder, D. E., Sagebiel, R. W., Guerry, D., & Clark, W. H. (1997). Clinically recognized dysplastic nevi: A central risk factor for cutaneous melanoma. JAMA, 277(18), 1439–1444. https://doi.org/10.1001/jama.1997.03540420045030
Zaidi, Z., & Asad, F. (2024). Dysplastic Nevus. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441864/
The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, and physical medicine, as well as wellness, sensitive health issues, and functional medicine articles, topics, and discussions. We provide and facilitate clinical collaboration with specialists across disciplines. Each specialist follows their professional scope of practice and the jurisdiction in which they are licensed. We utilize functional health and wellness protocols to treat and support care for musculoskeletal injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters and issues that directly or indirectly support our clinical scope of practice. Our office has made a reasonable effort to provide supportive citations and identify relevant research studies for our posts. We provide copies of supporting research studies upon request to regulatory boards and the public.
We are here to help you and your family.
Blessings
Dr. Alex Jimenez, DC, MSACP, APRN, FNP-BC*, CCST, IFMCP, CFMP, ATN
Email: coach@elpasofunctionalmedicine.com
Multidisciplinary Licensing & Board Certifications:
Licensed as a Doctor of Chiropractic (DC) in Texas & New Mexico*
Texas DC License #: TX5807, Verified: TX5807
New Mexico DC License #: NM-DC2182, Verified: NM-DC2182
Multi-State Advanced Practice Registered Nurse (APRN*) in Texas & Multi-States
Multi-State Compact APRN License by Endorsement (42 States)
Texas APRN License #: 1191402, Verified: 1191402 *
Florida APRN License #: 11043890, Verified: APRN11043890 *
New York APRN License #: N25929, Verified: APRN-N25929*
License Verification Link: Nursys License Verifier
* Prescriptive Authority Authorized
ANCC FNP-BC: Board Certified Nurse Practitioner*
Compact Status: Multi-State License: Authorized to Practice in 40 States*
Graduate with Honors: ICHS: MSN-FNP (Family Nurse Practitioner Program)
Degree Granted. Master's in Family Practice MSN Diploma (Cum Laude)
Dr. Alex Jimenez, DC, APRN, FNP-BC*, CFMP, IFMCP, ATN, CCST
My Digital Business Card
Dr. Maria Cardenas, MD
(Board Certified in Internal Medicine)
Medical Director & Collaborative Physician
NPI # 1164426749
MD License #: J2933
Dr. Maria Cardenas, MD
(Board Certified in Internal Medicine)
Medical Director & Collaborative Physician
NPI # 1164426749
MD License #: J2933
