El Paso Dysplastic Nevus Excision & Integrative Care

Abstract: In this educational post, I guide you through a clear, step-by-step clinical approach to excising a dysplastic nevus with moderate atypia using modern, evidence-based methods. You will see how a properly executed anesthetic field block creates a pain-free experience, why dermatologic surgery for moderate atypia uses narrow margins, and how meticulous tissue handling supports definitive histologic assessment. I also share 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, and rehabilitation. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), and in collaboration with me, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, we blend precision procedural care with whole-person strategies grounded in current research. This post highlights how integrative chiropractic care fits into surgical dermatology and personal injury care to optimize healing, reduce pain, and support long-term outcomes.

Introduction: Perspective on Modern, Multidisciplinary Skin Lesion Care

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso clinic, we often see patients who need carefully planned excisions following a diagnostic shave biopsy. Today, I’ll walk you through a real case: a 62-year-old gentleman returning approximately one month after a shave biopsy revealed a dysplastic nevus with moderate atypia. Our goals: remove the residual lesion with clinically appropriate narrow margins, enable a pain-free experience using a precise anesthetic field block, and ensure the tissue specimen is ideal for pathology.

What makes this care unique is our integrative model. As the Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Internal Medicine), provides medical oversight and coordinates care pathways common to multidisciplinary injury and integrative clinics. In parallel, our chiropractic services, functional medicine strategies, and rehabilitation protocols create a cohesive system designed to keep the patient safe, comfortable, and moving toward recovery based on the best available evidence.

Building the Plan: Why Dysplastic Nevus with Moderate Atypia Requires Focused Margins

• Key concept: Dysplastic nevi with moderate atypia are atypical moles with architectural and cytologic changes that warrant complete excision to reduce the risk of residual atypical tissue.
• Evidence rationale: For moderate atypia, many dermatologic guidelines support excision with narrow margins (often around 2 mm beyond the visible or scar boundary) to ensure complete removal while preserving healthy tissue. Histopathologic evaluation confirms clearance.

In this case, the original lesion measured approximately 5 x 6 millimeters. I planned margins of roughly 2 millimeters around the current scar, translating to about 5 millimeters around the original lesion perimeter. Using a template helps me create a symmetric, fusiform design aligned with relaxed skin tension lines, minimizing postoperative tension and optimizing cosmetic results. Templates reduce human error in margin symmetry, and a well-planned ellipse supports primary closure with minimal dog-ears.

Design and Anesthesia: A Pain-Free Field Block by Interrupting Cutaneous Nerve Signaling

My goal with anesthesia is simple: make the experience pain-free and efficient. I start by prepping with alcohol, then reinforce the concept of a field block—a circumferential anesthetic “fence” that interrupts nerve signals entering the skin around our excision site.

Technique overview:

• I select an ideal entry point near the planned excision boundaries.
• I advance the needle, then inject while withdrawing, turning within the dermis/subcutaneous plane to create a continuous ring of anesthesia.
• I repeat on the opposite side and, as needed, add lateral entry points to ensure complete coverage, always aiming for minimal needle insertions that produce maximal numbing.

Why it works physiologically:

• The field block targets the terminal branches of sensory nerves within the dermis and subcutaneous tissue. By bathing these fibers with 1 percent lidocaine with epinephrine, we block voltage-gated sodium channels, preventing depolarization and halting nociceptive transmission.
• Epinephrine causes local vasoconstriction, reducing bleeding and prolonging lidocaine’s dwell time near nerves. This prolongs anesthesia, helps maintain a bloodless field, and enhances visualization during precise excision.
• Injecting in subcutaneous tissue to “saturate” beneath the lesion creates a foundational blockade. When we perform intradermal injections after subcutaneous saturation, patients typically report little or no sensation because the deeper nociceptive input has already been interrupted.

Adjunct comfort measures:

• I use a cold “free spray” over the injection point. Rapid cooling stimulates A-delta fibers, which preferentially transmit cold sensations, creating a gating effect that reduces pain perception as the needle enters. This immediate numbing means they rarely feel the injection.
• I steer the needle by slight bending to guide the tip across the dermal plane, carefully visualizing the trajectory under the skin. Injecting while withdrawing forms a visible intradermal wheal line that confirms even distribution.

Patient response:

• Using these methods, our patient reported no pain throughout the anesthetic process. This is exactly the outcome we strive for—an effective, pain-free field block before excision.

Precision Excision: Narrow Margins and Tissue Integrity

With anesthesia confirmed and a clean field, the next step is the excision. Narrow margins are not arbitrary; they balance oncologic safety with tissue preservation, especially in cosmetically sensitive areas.

Core principles:

• Margin control: For moderate atypia, 2-mm margins are commonly used; they are sufficient for complete removal while minimizing unnecessary tissue loss.
• Fusiform design: An ellipse aligned with skin tension lines enables linear closure under reduced tension, decreasing the risk of hypertrophic scarring and optimizing cosmesis.
• Specimen integrity: Gentle handling and correct orientation markings help pathologists assess margins and architecture accurately, confirming clearance.

Physiology of healing:

• Minimal tension reduces micro-ischemia at wound edges, aiding angiogenesis and fibroblast activity necessary for collagen deposition.
• Vasoconstriction from epinephrine tempers intraoperative bleeding, stabilizing the clot and early extracellular matrix formation.

Integrative Chiropractic Care in Dermatologic Surgical Recovery

While excision of a skin lesion may seem isolated from musculoskeletal care, an integrative approach adds value for recovery, comfort, and function—especially in older adults or those with comorbidities.

How chiropractic care fits:

• Posture and movement optimization: After excision, patients often guard movement due to fear of pulling sutures. Chiropractic and rehabilitative strategies help maintain normal biomechanics and prevent compensatory strain.
• Neuromuscular re-education: Gentle manual therapy and targeted exercises support proprioception and movement confidence, reducing myofascial tension near or distant from the surgical site.
• Pain modulation: Chiropractic interventions can engage descending inhibitory pathways, reducing central sensitization that sometimes amplifies minor post-procedural discomfort.
• Circulatory support: Mobility, diaphragmatic breathing, and safe motion progressions improve local perfusion, supporting oxygen delivery and waste clearance in healing tissues.

In practice, I assess global movement patterns and provide tailored strategies to keep patients functional without stressing the incision. For example, we may adjust daily ergonomic habits, teach safe range-of-motion techniques, and implement light isometrics that maintain muscle tone without disturbing the wound.

Multidisciplinary Oversight: Internal Medicine Leadership with Dr. Maria Guadalupe Cardenas, MD

Our clinic operates within a multidisciplinary framework common in integrative and injury care settings. Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933) serves as our Medical Director and Collaborative Physician. With over 40 years of experience as an internist, Dr. Cardenas supervises medical protocols, ensures safety for patients with complex health histories, and aligns the plan with best practices.

Medical oversight matters because:

• Risk stratification: Internal medicine evaluates cardiovascular status, diabetes control, anticoagulation, and immunomodulating conditions that might impact bleeding, infection risk, or wound healing.
• Medication management: Guidance on peri-procedural adjustments for antiplatelets/anticoagulants or immunosuppressants balances safety and procedural efficacy.
• Systems-based care: Internal medicine connects dermatologic procedures with broader health concerns—sleep, nutrition, metabolic status—each influencing recovery timeline and scar quality.

Collaborative roles:

• Dr. Cardenas provides medical direction, reviews histories, and creates safe peri-procedural pathways.
• I deliver the procedure, chiropractic integration, functional medicine insights, and rehabilitative planning.
• Together, we coordinate personal injury processes, documentation, and patient education.

Functional Medicine Integration: Optimizing Healing Physiology

Functional medicine supports the body’s innate healing mechanisms through targeted lifestyle and nutritional strategies tailored to the patient’s biology.

Focus areas:

• Inflammation modulation: Adequate omega-3 intake, polyphenols (curcumin, quercetin), and antioxidant-rich foods can support controlled inflammation necessary for healing while preventing prolonged inflammatory states that delay recovery.
• Glycemic control: Stable blood sugar supports fibroblast function, collagen cross-linking, and reduces infection risk; critical in older adults and those with metabolic syndrome.
• Micronutrient sufficiency: Vitamin C (collagen synthesis), zinc (DNA replication and immune function), and vitamin A (epithelial integrity) are essential. We personalize supplementation cautiously, consistent with medical oversight.

Reasoning:

• The acute wound healing phases—hemostasis, inflammation, proliferation, remodeling—depend on energy availability, micronutrient cofactors, and balanced immune signaling. Diet and lifestyle calibrate these processes.
• Sleep quality and stress modulation (e.g., paced breathing) influence HPA axis activity and cytokine profiles that can either facilitate or impair tissue repair.

Rehabilitation Strategy: Safe Motion, Scar Care, and Long-Term Outcomes

Rehabilitation begins as soon as the procedure ends.

Key steps:

• Early wound protection: Educate on dressing care, signs of infection, and avoiding tension across the incision.
• Progressive mobility: Introduce gentle, non-straining movements to prevent stiffness and maintain circulation.
• Scar optimization: Once the wound has closed, consider silicone sheeting, gentle massage, and sun protection to improve scar quality.
• Ergonomics: Adjust lifting strategies, workstation setup, and daily routines to prevent undue strain near the surgical site.

Physiologic reasoning:

• Controlled motion stimulates mechanotransduction pathways in fibroblasts, guiding orderly collagen alignment and increasing tensile strength.
• Silicone occlusion modulates hydration and reduces excessive collagen deposition, decreasing hypertrophic scar risk.

Personal Injury Care and Documentation

In injury care settings, precision documentation complements clinical excellence:

• Clear procedural notes with lesion size, margin plan, anesthesia specifics, and patient responses.
• Photo documentation for pre- and post-excision views (when appropriate).
• Communication with referring providers and insurers regarding necessity, medical oversight, and outcomes.

Clinical Observations from My Practice

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), I have observed:

• Patients experience significantly better comfort with a well-executed field block using 1% lidocaine with epinephrine and adjunct cold spray.
• Narrow, well-planned margins for moderate atypia yield high clearance rates while preserving cosmesis.
• Integrative chiropractic and functional medicine improve confidence in movement, reduce compensatory pain patterns, and support faster return to normal activities.

Step-by-Step Narrative: From Planning to Excision

• Pre-Procedure:
  • Confirm pathology: dysplastic nevus with moderate atypia.
  • Explain margins and expectations to the patient.
  • Prepare sterile field with antiseptic; use alcohol for initial prep and repeat.
• Field Block:
  • Choose entry point; advance needle; inject while withdrawing to create a continuous anesthetic ring.
  • Turn within the tissue plane to cover both sides without fully removing the needle.
  • Add lateral points if needed; saturate subcutaneous tissue under the lesion.
  • Verify numbness; apply cold spray before further injections.
• Intradermal Distribution:
  • Thread the needle across the dermis; visualize tip; inject on withdrawal to form a visible wheal line indicating spread.
  • Assess patient comfort continuously; recalibrate if sensation persists.
• Excision:
  • Mark ellipse with template; align with skin tension lines.
  • Excise along just outside the marked borders to respect margins.
  • Handle tissue gently; orient specimen; achieve hemostasis; close in layers if indicated.
• Post-Procedure:
  • Educate on dressing changes, signs of infection, and motion precautions.
  • Schedule follow-up for pathology results and suture removal.
  • Provide integrative guidance on movement, nutrition, sleep, and stress.

Why Each Technique Matters

• Template-guided marking: Ensures symmetry, facilitates linear closure, and reduces dog-ears.
• Field block with epinephrine: Prolongs anesthesia, reduces bleeding, and improves operative field visibility.
• Injecting on withdrawal: Distributes anesthetic evenly and reduces intratissue pressure spikes that can be uncomfortable.
• Cold spray: Activates sensory gating to reduce needle pain.
• Narrow margins: Balance complete excision of atypia with tissue preservation, aligning with evidence and cosmetic considerations.
• Integrative follow-through: Addresses systemic determinants of healing and functional recovery beyond the incision line.

Safety Considerations

• Avoid epinephrine in end-arterial regions if risk factors exist; assess peripheral vascular disease.
• Screen for lidocaine allergies and arrhythmic history.
• Coordinate with internal medicine on anticoagulation decisions and infection-risk mitigation.

Our Team-Based Care in El Paso, Texas

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), our care model weaves together:

• Chiropractic care (Dr. Jimenez): Movement analysis, manual therapy, neuromuscular re-education, ergonomic optimization.
• Medical oversight (Dr. Cardenas, MD): Risk stratification, medication management, systems-based medical direction.
• Functional medicine: Nutrition, sleep, stress, and personalized supplementation.
• Rehabilitation: Progressive mobility, scar care, and return-to-function planning.
• Personal injury services: Comprehensive documentation, coordination with legal and insurance entities where applicable.

Conclusion: Modern, Evidence-Based, Integrative Care for Skin Surgery

Excision of a dysplastic nevus with moderate atypia is more than a precise cut; it is a coordinated effort grounded in physiology, patient comfort, and multidisciplinary safety. By pairing a pain-free field block with careful margin planning and whole-person support, we improve outcomes and the patient experience. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD, and through our integrative chiropractic, functional medicine, and rehabilitative care, patients receive comprehensive, evidence-based support from diagnosis to recovery.

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References

• American Academy of Dermatology. Guidelines of care for the management of primary cutaneous melanoma. (Used for margin principles; APA-7: American Academy of Dermatology. (n.d.). Guidelines of care for the management of primary cutaneous melanoma. https://www.aad.org/member/clinical-quality/guidelines/melanoma)
• Habif, T. P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. (APA-7: Habif, T. P. (2019). Clinical dermatology: A color guide to diagnosis and therapy (6th ed.). Elsevier.)
• Soter, N. A., & Mihm Jr., M. C. Dysplastic nevi: Clinical and histologic features, risk, and management. (APA-7: Soter, N. A., & Mihm Jr., M. C. (2023). Dysplastic nevi: Clinical and histologic features, risk, and management. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK481852/)
• Baran, R., Maibach, H. Skin anesthesia: Mechanisms, agents, and clinical application. (APA-7: Baran, R., & Maibach, H. (2010). Skin anesthesia: Mechanisms, agents, and clinical application. Springer.)
• Guyton and Hall Textbook of Medical Physiology. Peripheral nerve signaling and local anesthetics. (APA-7: Hall, J. E. (2021). Guyton and Hall textbook of medical physiology (14th ed.). Elsevier.)
• Chiu, T., & Burd, A. Silicone therapy for scar management. (APA-7: Chiu, T., & Burd, A. (2003). Silicone gel in scar management. Burns, 29(6), 641–646. https://doi.org/10.1016/S0305-4179(03)00155-0)
• Dr. Alexander Jimenez – Injury Medical Clinic PA. (APA-7: Injury Medical Clinic PA. (n.d.). Dr. Alexander Jimenez – integrative chiropractic and functional medicine care. https://chiromed.com/)
• Dr. Alexander Jimenez – Professional profile. (APA-7: Jimenez, A. (n.d.). Professional profile. LinkedIn. https://www.linkedin.com/in/dralexjimenez/)