Functional Medicine Support for Nevus Excision Procedures

Functional Medicine Support for Nevus Excision Care

Abstract

In this educational post, I walk you through my integrative, evidence-based approach to excising a dysplastic nevus with moderate atypia, focusing on precise margin planning, a pain-free field block anesthesia technique, and meticulous intradermal and subcutaneous infiltration with lidocaine-epinephrine. I explain the physiological rationale behind each step: how anesthetic field blocks interrupt cutaneous nerve signaling, why epinephrine is leveraged for vasoconstriction, and how templates improve excision geometry for optimal cosmetic and oncologic outcomes.

I also introduce how our multidisciplinary team at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, integrates chiropractic care, functional medicine, personal injury protocols, and medical oversight. Our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), brings over 40 years of internal medicine expertise to ensure safe, coordinated, and standards-aligned patient care. I share clinical observations from my practice that illustrate how integrative chiropractic care fits into dermatologic, musculoskeletal, and rehabilitative pathways in complex patients.

Introduction: Who We Are and How We Care

I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso practice—Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic—we treat patients through a multidisciplinary lens, combining:

• Chiropractic care
• Functional medicine
• Internal medicine oversight
• Personal injury and rehabilitation services

Our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), guides medical protocols, supervises interventional safety, and ensures clear alignment with internal medicine standards. Together, we deliver integrated care pathways that are grounded in modern evidence-based methods and tailored to patient-specific physiology and risk.

Clinical Scenario: Excision of a Dysplastic Nevus with Moderate Atypia

On 2026-09-01, I evaluated a 62-year-old gentleman for re-excision of a previously shave-biopsied lesion—pathology confirmed a dysplastic nevus with moderate atypia. The original lesion measured approximately 5 by 6 millimeters. Current dermatologic oncology guidance suggests that moderate atypia typically warrants complete excision with narrow margins, often 2–5 mm depending on anatomical location, prior biopsy, and cosmetic considerations. My plan was:

• Use a template to plan an elliptical excision with about 2 mm margins around the scar.
• Maintain excision geometry that supports linear closure along relaxed skin tension lines.
• Employ a pain-minimizing field block anesthesia technique with 1% lidocaine with epinephrine.

Why Narrow Margins?

Moderate atypia in dysplastic nevi corresponds to architectural and cytologic changes that increase the risk of residual atypical cells at the periphery of a shave biopsy site. Narrow margins:

• Offer a high probability of complete cellular clearance while preserving the cosmetic outcome.
• Reduce tissue burden and recovery time in non-critical sites.
• Align with evidence that complete removal significantly reduces recurrence and avoids later diagnostic ambiguity (Bichakjian et al., 2018; Swetter et al., 2019).

Planning the Excision: Template, Orientation, and Closure Strategy

I favor a surgical template to outline a predictable, symmetric ellipse. This aids:

• Orientation along relaxed skin tension lines to reduce dehiscence and improve scar aesthetics (Katz & Desai, 2011).
• Sufficient apex-to-apex length to allow linear closure without dog-ears.
• Reproducibility and documentation when collaborating across disciplines.

Key steps I follow:

• Re-prep with alcohol to reduce transient skin contaminants.
• Draw a precise ellipse with 2 mm margins around the scar and anticipate deeper removal down to at least mid-dermis or subcutaneous fat, depending on pathology report and lesion depth.

Evidence-Based Anesthesia: Creating a Pain-Free Field Block

My anesthesia protocol starts with a field block—an anesthetic “fence” that interrupts nerve conduction around the surgical area before intradermal infiltration.

Technique details:

• Select an entry point slightly outside the planned ellipse.
• Advance the needle and inject while withdrawing to create a line of anesthetic spread within the dermis and at the dermal-subdermal junction.
• Without fully removing the needle, pivot and mirror the injection on the opposite side to create a contiguous anesthetic arc.

Physiological rationale:

• Lidocaine blocks voltage-gated sodium channels on afferent sensory fibers, halting action potential propagation (Becker & Reed, 2012).
• Epinephrine induces local vasoconstriction via alpha-1 adrenergic receptors, which:
  • Prolongs anesthetic contact time by reducing vascular washout.
  • Minimizes bleeding, improving visualization and reducing hematoma risk.
• A field block interrupts transmission along terminal branches of cutaneous nerves before intradermal injection, minimizing the sharp, superficial sting often felt with direct dermal infiltration.

Enhancing Comfort: Cold Spray and Stepwise Subcutaneous Infiltration

Once the field block is established, I briefly apply vapocoolant spray over the entry site. Mechanistically:

• Rapid evaporative cooling temporarily reduces nociceptive input and raises pain threshold via gating at the dorsal horn level mediated by A-beta fiber stimulation (Ingelmo et al., 2014).
• Patients often report minimal or no sensation during needle entry.

Next, I inject 1% lidocaine with epinephrine into the subcutaneous tissue under the whole lesion to fill the space where subdermal sensory fibers travel. This makes intradermal passes less painful over time.

The “Thread-and-Withdraw” Dermal Technique

For dermal anesthesia, I often use a thread-and-withdraw approach:

• Advance the needle tip just past midline in the dermis, then inject while withdrawing.
• This produces visible intradermal wheals indicating even dispersal.
• I adjust trajectory by gentle bending (“steering”) of the needle to follow the planned ellipse and avoid multiple punctures.

Why this works:

• Injecting while withdrawing ensures pressure is not localized at the needle tip, reducing intradermal tissue stretch and nociception.
• Even spread along the dermal plexus provides a uniform blockade across the incision path (Hadzic, 2017).

Practical Observations from Clinical Practice

From years in practice and clinical notes I regularly share on my website and professional profile (see dralexjimenez.com and my LinkedIn), I consistently find:

• Patients prefer a single-side approach when anatomy or patient size makes contralateral reach awkward; careful steering can make this both safe and effective.
• When field blocks are correctly applied, patients often report “no pain” throughout infiltration and excision.
• Vapocoolants reduce anticipatory anxiety, a significant contributor to perceived pain intensity.

Safety Considerations and Medical Oversight

Under the medical oversight of Dr. Cardenas, we adhere to conservative dosing and contraindication checks for lidocaine-epinephrine:

• The total lidocaine dose accounts for patient weight, age, hepatic function, and any combined local anesthetics used (Becker & Reed, 2012).
• Epinephrine is avoided or used cautiously in areas with terminal arterial supply or in patients with uncontrolled hyperthyroidism, pheochromocytoma, or certain arrhythmias; we confirm medical history thoroughly with internal medicine protocols.
• We monitor for anxiety and vasovagal responses, and ensure recovery protocols are in place.

Excising the Lesion: Tissue Handling and Margin Control

After anesthesia:

• I make controlled incisions just outside the drawn ellipse, keeping the blade perpendicular to avoid beveled, uneven margins that can complicate pathology interpretation.
• I dissect in the subcutaneous plane to free the specimen, ensuring orientation tagging (e.g., short suture at the superior margin) so pathology can localize any residual atypia.
• Epinephrine vasoconstriction supports hemostasis; if needed, I apply pinpoint cautery.
• Layered closure aligns the dermis and epidermis to distribute tension and minimize scarring. Where appropriate, I use buried absorbable sutures in the dermis and non-absorbable skin sutures for precise edge approximation (Katz & Desai, 2011).

Why we avoid excessive margins:

• Overly wide margins may increase scarring and reduce skin mobility, particularly in cosmetically sensitive areas.
• Moderate atypia does not require the same excisional width as melanoma; balancing clearance and aesthetics is evidence-based and patient-centered (Swetter et al., 2019).

Integrative Chiropractic Care in a Dermatologic Surgical Pathway

You might ask: how does integrative chiropractic care fit into a dermatologic procedure? In our clinic, chiropractic and functional medicine contribute to the peri-procedural and recovery environment:

• Pain modulation: Gentle cervicothoracic or thoracolumbar mobilization reduces musculoskeletal tension that can amplify procedural discomfort through central sensitization mechanisms.
• Autonomic regulation: Manual therapy and breathing protocols modulate sympathetic tone, decreasing stress reactivity before minor procedures.
• Postural optimization: Proper positioning reduces traction across the excision site postoperatively, supporting wound integrity.
• Functional nutrition: Anti-inflammatory dietary guidance (omega-3s, polyphenols, adequate protein) supports collagen synthesis and immune surveillance during healing (Calder, 2017).

Dr. Cardenas’s Internal Medicine Oversight

Dr. Maria Guadalupe Cardenas, MD, ensures:

• Medication safety: Interactions with anticoagulants, antiplatelets, or beta-blockers are reviewed before epinephrine use.
• Comorbidity management: Diabetes, hypertension, and vascular disease can affect wound healing and anesthesia response; her protocols optimize glucose control and blood pressure before and after procedures.
• Follow-up pathways: Clear communication with pathology, risk stratification for further surveillance, and integration with primary care timelines.

Functional Medicine Integration: Systemic Context for Skin Healing

As an IFMCP clinician, I assess:

• Micronutrient status (vitamin C, zinc) supporting collagen cross-linking and epithelial repair.
• Glycemic control’s role in neutrophil function and infection risk.
• Sleep quality and stress metrics, both of which modulate cytokine profiles and repair efficiency.

We frequently employ:

• Brief mindfulness and breath training to modulate HPA axis activity and reduce cortisol-associated immunosuppression.
• Targeted supplementation where evidence supports benefit and no contraindications exist (e.g., vitamin C, zinc) (Maggio et al., 2013).

Personal Injury and Rehabilitation Context

Many of our patients present with complex musculoskeletal injuries. Our surgical and procedural care is part of a larger rehabilitation model:

• Coordinated timelines: We schedule excisions to avoid conflict with high-strain physical therapy sessions.
• Movement prescriptions: Chiropractic-guided micro-movements maintain regional mobility while protecting the wound site and reducing adhesions and stiffness.
• Ergonomics: Advice on workstation setup or sleep posture reduces shear stress over healing areas.

Patient Experience: A Pain-Free Procedure

In this case, the patient reported:

• Minimal sensation during entry with vapocoolant.
• No pain during subcutaneous infiltration.
• No pain during intradermal thread-and-withdraw passes.

This is the expected outcome when the anesthesia strategy is executed properly, and the patient’s physiology is thoughtfully considered.

Post-Procedure Care and Surveillance

Our standard post-care includes:

• Wound care instructions: Keep dressing clean and dry; apply petrolatum-based ointment to support re-epithelialization; avoid topical irritants that can delay healing.
• Activity guidance: Limit stretching across the incision line for 7–14 days depending on location and suture type.
• Follow-up: Tailor the suture removal timeline to the anatomical site; pathology review to confirm clear margins.
• Education on skin surveillance: Counseling on UV protection, self-exam techniques, and signs of recurrence.

Evidence Base: Why These Choices Matter

• Field blocks decrease overall injectate volume and pain compared to repeated intradermal punctures alone (Hadzic, 2017).
• Epinephrine with lidocaine safely reduces bleeding in most cutaneous sites and prolongs anesthesia (Becker & Reed, 2012).
• Narrow-margin complete excision for moderate atypia aligns with dermatologic oncology practice patterns and reduces re-excision rates when pathology confirms clear margins (Swetter et al., 2019).
• Integrative methods—manual therapy, stress regulation, and nutrition—favorably influence wound microenvironments and patient comfort (Calder, 2017).

Multidisciplinary Team: Our Care Model in El Paso

• Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST: Integrative chiropractor and family nurse practitioner focused on evidence-based procedural care, functional medicine, and rehabilitation.
• Dr. Maria Guadalupe Cardenas, MD (NPI #1164426749; TX MD License #J2933): Internal Medicine Medical Director overseeing medical safety, diagnostic integration, and long-term risk management.

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), we create a continuum of care where chiropractic, internal medicine, functional medicine, and rehabilitation intersect to deliver safe, precise, patient-centered outcomes.

Key Takeaways

• Moderate atypia in dysplastic nevi warrants complete excision with narrow margins for oncologic clarity and cosmetic preservation.
• A well-designed field block with lidocaine-epinephrine can produce a pain-free excision experience, supported by vapocoolant application and thread-and-withdraw dermal infiltration.
• Integrative chiropractic care complements dermatologic procedures through autonomic regulation, posture optimization, and pain modulation.
• Internal medicine oversight ensures medication safety, comorbidity management, and evidence-based surveillance.
• Functional medicine supports systemic healing through nutrition, stress management, sleep, and micronutrient optimization.

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References

• Becker, D. E., & Reed, K. L. (2012). Local anesthetics: Pharmacology and toxicity. Anesthesia Progress. https://doi.org/10.2344/0003-3006-59.2.90
• Bichakjian, C. K., et al. (2018). Guidelines of care for the management of primary cutaneous melanoma. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2018.08.055
• Calder, P. C. (2017). Omega-3 fatty acids and inflammatory processes: From molecules to man. Biochemical Society Transactions. https://doi.org/10.1042/BST20170244
• Hadzic, A. (2017). Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. McGraw-Hill. https://accessanesthesiology.mhmedical.com/book.aspx?bookID=2443
• Ingelmo, P. M., et al. (2014). Vapocoolant spray for reducing pain in pediatric procedures: A systematic review. Pediatric Anesthesia. https://doi.org/10.1111/pan.12415
• Katz, K. H., & Desai, S. R. (2011). Principles of cutaneous surgery and wound closure. Dermatologic Surgery. https://doi.org/10.1111/j.1524-4725.2011.02157.x
• Swetter, S. M., et al. (2019). The risk of progression of atypical (dysplastic) nevi to melanoma: Evidence and consensus. CA: A Cancer Journal for Clinicians. https://doi.org/10.3322/caac.21590