Understanding Forehead Lesion Removal: A Closer Look at Nerve Blocks and Integrative Care

Abstract

This educational post explores the clinical procedure for a regional nerve block of the forehead, a critical step in preparing for minor surgical procedures such as lesion removal. We will get into the anatomical landmarks, the specific nerves targeted—the supraorbital and supratrochlear nerves—and the precise injection technique used to ensure effective local anesthesia. Additionally, my goal is to demystify this common procedure. I will explain the rationale behind each step to maximize patient comfort and procedural success. This post will also discuss how this procedure fits within the broader context of our integrative, multidisciplinary practice at Injury Medical Clinic. We will also highlight the collaborative model among me, Dr. Alex Jimenez, and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD. In doing so, we will show how we merge medical oversight with chiropractic and functional medicine principles to provide comprehensive, patient-centered care.

Introduction to Our Collaborative Care Model

Welcome to our practice. I’m Dr. Alex Jimenez, and I am deeply committed to a holistic and integrative approach to health and wellness. My background spans several disciplines, including being a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN), and a Family Nurse Practitioner (FNP-BC), and holding advanced certifications in Functional Medicine (CFMP, IFMCP). This diverse training allows me to view patient health through multiple lenses.

A cornerstone of our clinic’s philosophy is our multidisciplinary team approach. I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD, our Medical Director and Collaborative Physician. Dr. Cardenas is a highly respected, board-certified Internist with over four decades of clinical experience in Texas. Her extensive medical expertise provides invaluable oversight and guidance for the medical procedures performed at our clinic. As a result, we ensure we adhere to the highest standards of safety and efficacy.

This collaborative structure is common in advanced injury and integrative care settings. It allows us to seamlessly blend the diagnostic and procedural strengths of allopathic medicine with the holistic, function-focused principles of chiropractic and functional medicine. Whether a patient presents with a musculoskeletal injury from a car accident, a chronic metabolic condition, or the need for a minor dermatological procedure, our team works in concert. Dr. Cardenas’s medical direction ensures that all treatments, including those I perform as a Nurse Practitioner, are medically sound and appropriate. In addition, my chiropractic and functional medicine expertise helps address the underlying biomechanical and physiological imbalances contributing to a patient’s condition. This integrated model ensures you receive comprehensive, well-rounded care tailored to your unique needs.

A Clinical Case: Preparing for Forehead Lesion Removal

Recently, a patient came to our clinic to have a small lesion removed from her left forehead. To ensure the procedure is painless and comfortable, my first step is to perform a regional nerve block. Moreover, this technique is far more effective and comfortable than injecting anesthetic directly into the lesion area, which can be sensitive and can distort the tissue. The goal is to anesthetize the entire region by targeting the nerves that supply sensation to that part of the forehead.

The primary nerves responsible for sensation in the forehead are branches of the trigeminal nerve (Cranial Nerve V). Specifically, we are targeting:

• The Supraorbital Nerve: This nerve provides sensation to the majority of the forehead, extending up to the hairline and the upper eyelid.
• The Supratrochlear Nerve: This nerve covers the medial (inner) part of the forehead, near the bridge of the nose and the inner corner of the eye.

By blocking these two nerves, we can achieve profound anesthesia across the entire surgical field. As a result, subsequent lesion removal becomes a smooth, pain-free experience for the patient.

The Anatomy of a Forehead Nerve Block

Performing a successful nerve block requires precision and a thorough understanding of facial anatomy. The key is to locate the exact points where these nerves exit the skull.

Identifying the Landmarks:

1. The Orbital Rim: The first and most crucial landmark is the supraorbital rim, which is the bony ridge of the eye socket located just below the eyebrow. I can easily palpate this structure with my thumb and forefinger. This bony ridge serves as our primary guide and a safety backstop, ensuring the needle does not go deeper than intended toward the eye itself.
2. The Supraorbital Foramen/Notch: The supraorbital nerve emerges from the skull through a small opening in the orbital rim called the supraorbital foramen (a hole) or notch (a groove). This landmark is consistently located in a vertical line directly above the center of the patient’s pupil when they are looking straight ahead. My technique involves placing my thumb firmly on the orbital rim to both stabilize the area and protect the globe of the eye.
3. The Supratrochlear Nerve Exit Point: The supratrochlear nerve exits more medially (closer to the nose). It is found along the same supraorbital rim, but positioned vertically above the inner canthus—the inner corner of the eye.

Before beginning, the patient’s skin is meticulously prepped with an alcohol swab to sterilize the injection sites. As an extra precaution, we also minimize any risk of infection.

Step-by-Step Procedural Walkthrough

Step 1: Blocking the Supraorbital Nerve

With the landmarks identified, I proceed with the first injection. My goal is to deposit the anesthetic—in this case, Lidocaine—precisely where the supraorbital nerve emerges.

1. Positioning and Preparation: I ask the patient to look directly ahead. I locate the midpoint of her pupil and trace a line upward to the supraorbital rim. I’ve already cleaned the area.
2. The Injection: I pinch the skin just above my thumb, which is resting firmly on the orbital rim. This accomplishes two things: it distracts the patient from the needle poke and slightly lifts the skin away from the more sensitive periosteum (the tissue covering the bone). I calmly inform the patient, “One, two, three,” and insert the needle. While the initial poke can cause a brief, sharp sting, it subsides quickly as the anesthetic takes effect.
3. Depth and Placement: I advance the needle until I feel its tip gently touch the orbital rim bone. This tactile feedback confirms I am at the correct depth. It’s crucial that the injection remains superior (above) the rim to avoid any risk to the structures within the eye socket. My thumb, placed on the rim, acts as a physical barrier and a sensory guide.
4. Administering the Anesthetic: While maintaining this position, I slowly inject approximately 0.5 mL of Lidocaine. As I inject, I can physically feel the fluid creating a small bulge, or bleb, under the skin, pressing against my thumb. This confirms that the anesthetic is being deposited into the correct tissue plane surrounding the nerve. I then withdraw the needle.

Step 2: Blocking the Supratrochlear Nerve

Next, I move to the second injection site to anesthetize the medial forehead.

1. Locating the Site: I shift my focus to the area directly above the inner canthus of the eye, again using the supraorbital rim as my guide.
2. The Second Injection: I repeat the process. I inform the patient, “One, two, three,” and insert the needle at this new site until it touches bone. This consistency in technique ensures safety and predictability.
3. Anesthetic Delivery: I inject another 0.5 mL of Lidocaine at this location. Again, I feel the anesthetic solution pooling against my thumb, confirming proper placement around the supratrochlear nerve.

After completing both injections, I apply gentle pressure to the sites with a sterile gauze pad. This helps to disperse the anesthetic fluid throughout the tissues. Additionally, it encourages the anesthetic to bathe the nerves more thoroughly. It also helps to minimize any potential bruising or swelling at the injection sites.

Within a few minutes, the entire left side of her forehead will become numb. To ensure complete anesthesia right at the lesion’s edge, I may administer a tiny, supplemental amount of Lidocaine directly around the lesion itself. Therefore, the patient is now fully prepared for lesion removal and will not feel any pain during the procedure.

The Role of Integrative Chiropractic Care in Overall Wellness

While a minor surgical procedure like this might seem purely medical, it fits perfectly within our integrative care framework. At Injury Medical Clinic, we don’t just treat symptoms or isolated problems; we look at the whole person. Many patients who come to us for personal injury rehabilitation, chronic pain management, or functional medicine consultations may also have other health needs, such as a dermatological issue. Our model allows us to address these needs conveniently and comprehensively under one roof.

Here’s how chiropractic care integrates into this holistic picture:

• Stress and the Nervous System: Any medical procedure, no matter how minor, can cause stress and anxiety. Chiropractic care, particularly adjustments to the cervical and thoracic spine, can modulate the autonomic nervous system. By promoting a shift from a “fight-or-flight” (sympathetic) state to a “rest-and-digest” (parasympathetic) state, chiropractic care can help patients feel more relaxed and at ease before, during, and after medical procedures (Wirth, Gassner, & Helt, 2020). This can lead to better procedural outcomes and an improved patient experience.
• Pain Perception and Management: Chiropractic adjustments influence the way the central nervous system processes pain signals. By restoring proper joint motion and reducing nerve interference, we can help lower a patient’s baseline pain perception and improve their overall pain tolerance. For a patient undergoing a procedure, this can mean less post-procedural discomfort and a reduced need for pain medication.
• Addressing Postural Strain: In this case, the patient is sitting for a procedure. If she has underlying postural issues, such as forward head posture or thoracic kyphosis, this can create tension in her neck and upper back. As a chiropractor, I can identify and address these biomechanical faults through specific adjustments, soft tissue therapies, and corrective exercises. This not only improves comfort during the procedure but also supports long-term musculoskeletal health, helping prevent future pain and dysfunction (Oakley, Harrison, & Harrison, 2005).

With Dr. Cardenas’s medical oversight and my capabilities as both a Nurse Practitioner and a Chiropractor, we offer a unique synergy. We can manage the medical necessity of a procedure like a lesion removal. At the same time, we simultaneously address the patient’s overall structural and neurological well-being. This is the essence of true integrative healthcare.

---

References

• Oakley, P. A., Harrison, D. D., & Harrison, D. E. (2005). Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. Journal of the Canadian Chiropractic Association, 49(4), 270–296. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1840024/
• Wirth, B., Gassner, A., & Helt, K. (2020). Neurophysiological effects of spinal manipulation therapy: A systematic review of the literature. Spine Journal, 20(11), 1827–1841. https://www.thespinejournalonline.com/article/S1529-9430(20)30282-5/fulltext