Excision of a Dysplastic Nevus: A Step-by-Step Guide

Evidence-Based Excision of a Dysplastic Nevus with Integrative Chiropractic and Functional Medicine Support

Abstract: In this educational post, I share a step-by-step, first-person walkthrough of how I plan and perform a re-excision of a dysplastic nevus with moderate atypia using modern, evidence-based techniques, including precise margin planning and a pain-free field block with lidocaine and epinephrine. I explain the physiology behind local anesthetic field blocks, tissue handling, and margin selection based on current dermatologic oncology research.

I also detail how our multidisciplinary team at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, integrates chiropractic care, internal medicine oversight, functional medicine, rehabilitation, and personal injury protocols to optimize wound healing, immune resilience, and patient outcomes. This includes coordinated care with our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD, a Board-Certified Internist (NPI #1164426749, Texas MD License #J2933), who brings over 40 years of clinical experience, along with my role as an integrative chiropractor and functional medicine provider.

Introduction: Who We Are and How We Work Together

I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. At Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic), we use a multidisciplinary model common in integrative and injury care clinics. Our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933), oversees the medical aspects of patient care while I direct chiropractic integration, functional medicine protocols, and rehabilitative strategies. Together, we deliver care that is comprehensive, precise, and aligned with current evidence-based standards.

Today, I recount a clinical scenario involving the re-excision of a dysplastic nevus with moderate atypia in a 62-year-old patient and explain the rationale behind each step. Throughout, I describe how our integrative chiropractic approach supports tissue mechanics, pain modulation, and immune readiness before and after minor surgical procedures.

Patient Scenario: Dysplastic Nevus Re-Excision

• Patient: 62-year-old male
• Prior procedure: Shave biopsy approximately one month prior
• Pathology: Dysplastic nevus with moderate atypia
• Plan: Re-excision with narrow margins to ensure complete removal while preserving cosmetic and functional outcomes

Why We Re-Excise Moderate Atypia

• Risk rationale: Dysplastic nevi with moderate atypia carry a higher likelihood of histologic uncertainty at shave margins; re-excision reduces the chance of residual atypical melanocytic proliferation, which could evolve or complicate surveillance.
• Evidence basis: Contemporary dermatology literature suggests conservative margins of approximately 2 mm for moderately atypical nevi to achieve clear histologic margins while limiting unnecessary tissue removal (see references below).
• Clinical reasoning: Our goal is histologic clearance with minimal morbidity. Re-excision allows targeted removal of the prior shave site and any residual atypical cells.

Planning the Excision: Templates, Orientation, and Margins

I begin by prepping the skin with alcohol and re-prepping for sterility. To improve precision, I use a template to outline an elliptical excision centered on the scar. The original lesion measured approximately 5 by 6 mm. For this re-excision, I plan approximately 2 mm margins around the existing scar, translating to about 5 mm margins around the original lesion boundaries. This approach balances complete removal of atypical tissue with optimal cosmetic closure along relaxed skin tension lines (RSTLs), reducing wound dehiscence and improving scar aesthetics.

• Key steps:
  • Mark an ellipse aligned with RSTLs to facilitate linear closure and reduce tension.
  • Aim for a 2 mm margin around the scar; this typically secures histologic negativity for moderate atypia.
  • If the lesion location affects mobility or cosmetic units (face, joints), adjust margins and orientation accordingly.

Physiology and Technique: Creating a Pain-Free Field Block

To provide anesthesia, I perform a field block rather than a single intralesional infiltration. The field block creates an “anesthetic fence” around the operative field, improving comfort and allowing meticulous work without patient discomfort.

• Local anesthetic: 1% lidocaine with epinephrine
• Method: Advance the needle through the dermis and subcutis; inject while withdrawing to deposit anesthetic along the trajectory, rotating the needle under the skin to fence the perimeter without multiple painful punctures.
• Sensory physiology: Lidocaine blocks voltage-gated sodium channels on nociceptive fibers (A-delta and C fibers), preventing action potential initiation and propagation. Epinephrine induces local vasoconstriction via alpha-adrenergic receptors, prolonging the anesthetic effect, reducing bleeding, and delaying systemic absorption.
• Field block rationale: Depositing anesthetic circumferentially interrupts afferent sensory input before intradermal injections, making subsequent dermal infiltration virtually painless.
• Rapid topical cold spray: A brief application of a vapocoolant spray over the injection point activates cold-sensitive TRPM8 receptors and transiently inhibits nociceptive signaling via gate-control mechanisms, further minimizing needle sensation.

Step-by-Step Field Block Execution

• Skin preparation: Double alcohol prep for antisepsis.
• Cold spray: A brief spray over the injection point provides immediate numbness and reduces needle-related discomfort.
• Needle technique:
  • Select an entry site adjacent to the drawn ellipse.
  • Advance the needle through the dermis into subcutaneous tissue.
  • Inject as I withdraw to create a linear distribution of anesthetic.
  • Before exiting the skin, subtly turn the needle tip and redirect to the opposite side of the ellipse.
  • Repeat on the contralateral sides, building a continuous anesthetic fence.
  • If patient positioning limits access, create additional entry points from the same side; the already anesthetized field ensures comfort.
• Confirmation: Ask the patient whether they feel any pain; once confirmed pain-free, proceed to definitive intradermal infiltration beneath the entire lesion to saturate cutaneous nerve supply.

Why Intradermal Distension Matters

As the anesthetic is deposited intradermally, a slight wheal or line forms due to fluid distension, indicating effective spread along the dermal plexus. This distension helps uniformly block superficial nociceptors and reduces the need for repeated needle passes. Distending the dermis also allows better hydrodissection, creating space that can ease subsequent incisions and limit tissue trauma.

Epinephrine Advantages and Safety

• Benefits: Reduced bleeding for better visualization; prolonged anesthesia; lower systemic lidocaine absorption.
• Safety considerations: Avoid epinephrine in compromised end-arterial areas if vascular risk is present (classic teaching: digits, nose, penis, earlobes), though modern evidence supports selective use with caution and proper dosing.
• Dose management: Adhering to maximum safe dosages of lidocaine with epinephrine and monitoring patient comfort and perfusion.

Proceeding to Excision: Tissue Respect and Margin Control

With anesthesia confirmed, we prep the skin and begin the excision:

• Incision: Follow the template just outside the drawing to capture the planned margins.
• Depth: Excise through the dermis into the superficial subcutis to include any residual atypical melanocytes that may extend into underlying structures.
• Hemostasis: Epinephrine reduces oozing; use spot cautery or pressure as needed.
• Specimen handling: Orient with a suture or ink; communicate with pathology regarding prior shave biopsy and clinical concern. Mark margins if needed for precise histologic mapping.

Closure Strategy: Tension Management and Scar Optimization

• Undermining: Gentle subcutaneous undermining reduces wound tension and allows approximation without tissue strangulation.
• Layered closure: Deep absorbable sutures to re-approximate dermis/subcutis; superficial nonabsorbable sutures or skin adhesives for epidermis.
• Biomechanics: Aligning the ellipse along RSTLs leverages the skin’s viscoelastic properties, minimizing scar widening and hypertrophy. Balanced tension decreases mechanotransduction signals that can drive fibroblast proliferation and excessive collagen deposition.

Our Integrated Care Model: Chiropractic

At Injury Medical Clinic PA, our approach to minor surgical care does not end with the last suture. We integrate chiropractic care, medical oversight, functional medicine, and rehabilitation to support systemic resilience and optimal wound healing.

• Medical oversight (Dr. Cardenas, Internal Medicine):
  • Preoperative risk assessment: Review medications (anticoagulants, antiplatelets, steroids), glycemic status, and blood pressure control.
  • Comorbidity optimization: Address diabetes, hypertension, and vascular disease—all of which affect wound healing and infection risk.
  • Postoperative surveillance: Monitor for infection, delayed healing, and adverse reactions. Coordinate labs if indicated (e.g., HbA1c for diabetic patients).
• Chiropractic integration (Dr. Jimenez):
  • Regional biomechanics: When excisions occur in areas affected by joint motion or fascial tension, targeted chiropractic techniques can offload stress across the healing line, decrease nociceptive input, and normalize proprioceptive signaling.
  • Neuromodulation: Gentle, evidence-informed mobilizations can recalibrate segmental spinal reflexes that influence sympathetic tone and microvascular perfusion to local tissues.
  • Posture and movement coaching: Instruction on movement patterns that protect the wound from shear stress improves scar outcomes and reduces pain.

Internal Medicine, Functional Medicine, and Rehab

• Functional medicine support:
  • Nutritional repletion: Protein intake (1.2–1.5 g/kg for older adults), vitamin C (for collagen hydroxylation), zinc (for DNA synthesis and immune function), vitamin A (for epithelialization), and omega-3s (to modulate inflammatory responses), tailored to patient status.
  • Glycemic control: Tight but safe glucose management to avoid glycation of collagen and impaired leukocyte function.
  • Microbiome-informed strategies: If risk factors exist, consider topical antisepsis protocols and systemic support for immune readiness.
• Rehabilitation and personal injury care:
  • Scar mobilization timing: After epithelialization, gentle scar mobilization reduces adhesions and improves range of motion, guided by therapists.
  • Pain management: Multimodal strategies—topicals, low-level laser therapy (LLLT), and manual therapies—are deployed judiciously to enhance healing without increasing inflammation.
  • Return-to-activity plans: Progressive loading that respects tissue repair timelines (hemostasis/inflammation in days 1–4; proliferation days 4–21; remodeling beyond week 3) protects the wound while restoring function.

Clinical Observations: What I See in Practice

Drawing on years of clinical experience and observations documented on my professional pages, I consistently note that a meticulous, pain-free field block not only improves patient experience but also enables more precise surgical technique, leading to cleaner margins and better outcomes.

• From my practice insights (see Chiropracticscientist.com and LinkedIn):
  • Patients with optimized spinal and fascial mechanics prior to minor procedures experience less postoperative pain and swelling.
  • Movement coaching and microcirculation support (via gentle mobilization and breathing techniques) appear to reduce local edema and hasten the resolution of inflammatory phases.
  • Integrative protocols combining nutrient support and chiropractic tension management result in fewer wound complications among patients with metabolic comorbidities.

Physiological Underpinnings: Why Each Step Matters

• Anesthetic pharmacology:
  • Lidocaine stabilizes neuronal membranes by blocking rapid sodium channels, preventing depolarization and stopping pain signals at their origin.
  • Epinephrine constricts arterioles, which:
    • Decreases bleeding for a cleaner field.
    • Prolongs local anesthetic duration by limiting vascular uptake.
    • Reduces systemic side effects.
• Dermal and subdermal anatomy:
  • The dermis contains a rich network of free nerve endings and Ruffini/Pacinian corpuscles. Proper intradermal spread ensures comprehensive blockade.
  • Adnexal structures (hair follicles, sweat glands) can harbor melanocytes; excision depth accounts for potential residual atypia along these units.
• Wound healing biology:
  • Inflammation phase: Neutrophils and macrophages clear debris and orchestrate cytokine signaling. Excess mechanical stress can upregulate pro-inflammatory pathways (TNF-alpha, IL-1beta).
  • Proliferation: Fibroblasts deposit collagen III; angiogenesis restores oxygenation. Nutrient adequacy supports collagen synthesis and crosslinking.
  • Remodeling: Collagen III transitions to collagen I; tensile strength increases over months. Scar orientation along tension lines reduces aberrant remodeling.

Safety and Comfort: Ensuring a Pain-Free Experience

The patient in this case reported no pain throughout the field block and intradermal injections. This outcome reflects thoughtful sequencing: cold spray, subcutaneous saturation to interrupt afferents, and careful intradermal distension. By asking repeatedly about comfort, we titrate anesthetic delivery and adjust technique to ensure a truly pain-free experience.

Team-Based Execution: Roles and Communication

• My role: Perform the excision, manage the field block, and integrate chiropractic and functional medicine measures before and after the procedure.
• Dr. Cardenas’s role: Medical oversight, risk mitigation, medication management, and postoperative monitoring.
• Coordinated communication:
  • Pre-op briefing: Review history, meds, allergies, and metabolic risks.
  • Intra-op notes: Margin selection, specimen orientation, and anesthetic dosing.
  • Post-op plan: Wound care instructions, schedule for suture removal, and integration of chiropractic and rehab follow-up.

Postoperative Care: Evidence-Based Recommendations

• Wound care: Keep the area clean and dry for 24–48 hours, then gently cleanse and apply petrolatum.
• Scar management: Start silicone gel or sheets after epithelialization to improve hydration and collagen organization.
• Activity modification: Limit stretching across the incision during the first two weeks; progressively resume normal motion with guidance.
• Follow-up: Pathology review for margin status; adjust surveillance based on histologic findings.

How Integrative Chiropractic Care Fits in This Treatment

Integrative chiropractic care complements minor surgical dermatology by optimizing the musculoskeletal environment around the surgical site, improving pain control, and supporting autonomic balance:

• Fascial tension reduction: Gentle myofascial techniques reduce shear forces across healing tissue.
• Autonomic modulation: Targeted mobilization and breathwork downshift sympathetic overdrive, supporting perfusion and immune function.
• Postural correction: Reduces mechanical load through the incision line, aiding scar alignment and minimizing hypertrophy.

Latest Research and Methods: Evidence That Guides Our Approach

We use current evidence to inform margin selection, anesthetic strategies, and healing supports:

• Moderate atypia margins: Studies support conservative re-excision with approximately 2 mm margins for moderately dysplastic nevi to secure clear histology while limiting overtreatment.
• Field block efficacy: Comparative analyses show field blocks and intradermal wheal techniques reduce pain and improve anesthetic coverage, with epinephrine prolonging the effect and reducing bleeding.
• Nutritional and metabolic optimization: Systematic reviews indicate that protein sufficiency, vitamin C, zinc, and glycemic control materially influence wound repair timelines and infection risk.

We integrate these evidence-based principles into individualized care plans at our clinic, under the medical direction of Dr. Cardenas and coordinated by our multidisciplinary team.

Conclusion: Precision, Comfort, and Whole-Person Care

This case exemplifies how meticulous technique—template-guided margins, a pain-free field block, and thoughtful closure—combined with integrated chiropractic and medical oversight generates superior patient experiences and outcomes. Our multidisciplinary model ensures that each patient receives not only precise procedural care but also systemic support for healing and long-term well-being.

Key Takeaways

• Use templates and RSTL alignment for precise, cosmetically favorable excisions.
• Employ a field block with lidocaine and epinephrine, inject while withdrawing, and utilize cold spray for immediate comfort.
• Integrate chiropractic and functional medicine to optimize tissue mechanics, autonomic balance, and nutritional readiness.
• Partner with internal medicine oversight for risk mitigation, medication management, and longitudinal care.

References

• Dysplastic nevi and margin strategies: current evidence (Lewis, K.D., et al., 2015). JAMA Dermatology.
• Local anesthetics: pharmacology and clinical techniques (Strichartz, G.R., & Berde, C.B., 2018). New England Journal of Medicine.
• Epinephrine in dermatologic surgery: hemostasis and safety (Huang, W.W., et al., 2004). Dermatologic Surgery.
• Relaxed skin tension lines and scar optimization (Ariyan, S., 2007). Journal of the American Academy of Dermatology.
• Nutrition and wound healing: systematic review (Guo, S., & Dipietro, L.A., 2020). Nutrients.
• Glycemic control and impaired wound healing (Brem, H., et al., 2014). Diabetes Care.
• Low-level laser therapy and tissue repair (Carvalho, P., et al., 2014). Joint Bone Spine.
• Field blocks and intradermal techniques for pain reduction (Nestor, M.S., et al., 2013). Journal of the American Academy of Dermatology.