Forehead Lesion Treatment with Nerve Blocks and Integrative Care

Abstract

In this educational post, I will guide you through a common minor surgical procedure: removing a forehead lesion. My goal is to demystify the process by explaining the science behind a crucial component of patient comfort—the nerve block. We will explore the anatomy of the supraorbital and supratrochlear nerves, explain why a nerve block is a superior choice for pain management in this area, and detail the step-by-step technique we use in our clinic. I will also discuss how this procedure fits into our broader philosophy of integrative care at Injury Medical Clinic PA. Our model combines my expertise in chiropractic and functional medicine with the invaluable medical direction of Dr. Maria Guadalupe Cardenas, MD, our board-certified internist. This collaborative approach ensures we provide comprehensive, patient-centered care that addresses both immediate needs and long-term wellness.

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As a practitioner with a diverse background spanning chiropractic, advanced practice nursing, and functional medicine, I am deeply committed to a patient-first approach. At Injury Medical Clinic PA, we have fostered a unique environment where different medical disciplines converge to offer the most effective and comprehensive care possible. This collaborative spirit is embodied in my work alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD.

Dr. Cardenas is a highly respected, board-certified internist with over 40 years of clinical experience. Her vast knowledge and medical oversight are foundational to our practice. As my collaborative physician (NPI #1164426749, Texas MD License #J2933), she provides the essential medical direction that allows our multidisciplinary team to function seamlessly. This structure is common in modern integrative and injury care settings, where the expertise of a Doctor of Chiropractic (DC) like myself is complemented by the medical authority and diagnostic acumen of a Medical Doctor (MD). Together, we integrate chiropractic adjustments, functional medicine protocols, rehabilitation, and, when necessary, minor medical procedures to create a truly holistic treatment plan for our patients in El Paso, Texas.

Today, I want to take you behind the scenes of a procedure I recently performed, illustrating how we prioritize patient comfort and safety through evidence-based techniques.

A Case Study in Patient-Centered Care

A patient presented with a benign lesion on her left forehead that she wished to have removed. While the removal itself is relatively straightforward, my paramount concern is keeping the patient comfortable and pain-free. For facial procedures, especially on the forehead, a nerve block is often the most elegant and effective anesthesia option.

Why Choose a Nerve Block Over Local Infiltration?

Before we delve into the procedure, let’s understand the “why.” When anesthetizing an area, we have a few options. The most common is local infiltration, where an anesthetic like lidocaine is injected directly into and around the tissue we plan to excise. While effective, this method has drawbacks:

• Tissue Distortion: Injecting fluid directly into the surgical site can cause the tissue to swell and change shape. This distortion can make precise excision more challenging and may affect the cosmetic outcome.
• Increased Discomfort: Local infiltration often requires multiple injections around the lesion to achieve adequate numbness, which can be uncomfortable for the patient.
• Larger Volume of Anesthetic: Numbing a broad area via infiltration can require a larger total volume of anesthetic compared to the targeted approach of a nerve block.

A nerve block, by contrast, is a more sophisticated technique. Instead of numbing the target tissue itself, we anesthetize the nerve trunk that supplies sensation to that entire region. By depositing a small amount of anesthetic at a specific anatomical point where the nerve is accessible, we can achieve profound numbness over a wide area with minimal injections and no tissue distortion at the surgical site.

The Anatomy of Forehead Sensation

To perform a successful forehead nerve block, a detailed understanding of the underlying anatomy is non-negotiable. The sensory information from the forehead is primarily transmitted to the brain by two nerves, both of which are branches of the trigeminal nerve (Cranial Nerve V).

• Supraorbital Nerve: This is the larger of the two nerves. It exits the skull through a small opening or notch in the upper rim of the eye socket, known as the supraorbital foramen or notch. From there, it travels upward, providing sensation to the majority of the forehead on that side, extending nearly to the top of the head. Clinically, we can locate this exit point by drawing a vertical line upward from the center of the pupil while the patient looks straight ahead. The nerve emerges right on the bony ridge you can feel above your eyebrow (orbital rim).
• Supratrochlear Nerve: This smaller nerve emerges from the skull more medially (closer to the nose) than the supraorbital nerve. It exits just above the inner corner of the eye (medial canthus) and supplies sensation to the lower, central part of the forehead, near the bridge of the nose.

By targeting these two nerves, we can effectively anesthetize the entire half of the forehead, ensuring a completely pain-free experience for the patient during the lesion removal.

The Nerve Block Procedure: A Step-by-Step Explanation

With my patient prepped and comfortable, I began the nerve block. Here is a detailed breakdown of the technique, grounded in anatomical precision.

Step 1: Preparation and Anatomical Landmark Identification

The first step in any procedure is ensuring a sterile field. I had already cleaned the patient’s left forehead with an alcohol prep pad. Next, I precisely located the nerve exit points.

• Locating the Supraorbital Nerve: I asked the patient to look straight ahead. I then visually drew a line from her pupil up to her eyebrow. With my non-dominant thumb, I palpated the bony orbital rim until I felt the slight indentation of the supraorbital notch. This is the target. Placing my thumb firmly on the orbital rim just below this point serves two purposes: it confirms my landmark and acts as a physical barrier to prevent the needle from accidentally going below the rim and endangering the eye.

Step 2: Anesthetizing the Supraorbital Nerve

I used a syringe containing lidocaine, a fast-acting local anesthetic.

1. I gently pinched the skin just above my thumb. This technique, known as the gate control theory of pain, can help distract from the initial needle prick by activating non-pain nerve fibers.
2. I told the patient, “One, two, three,” and inserted the needle perpendicular to the skin. The goal is to advance the needle until it gently makes contact with the bone (periosteum) just above the orbital rim. This confirms the correct depth.
3. With the needle in position, I slightly withdrew it to ensure I was not inside a blood vessel (a technique called aspiration) and then slowly injected approximately 0.5 mL of lidocaine.
4. As I injected, I felt the fluid create a small bulge, or bleb, against my palpating thumb. This tactile feedback confirms that the anesthetic is being delivered to the correct tissue plane, bathing the supraorbital nerve as it exits the foramen.

Step 3: Anesthetizing the Supratrochlear Nerve

Next, I moved to the second target.

1. Locating the Supratrochlear Nerve: I palpated the medial aspect of the orbital rim, just above the inner corner of the eye. The supratrochlear nerve is located here. Again, I placed my thumb on the rim for safety and guidance.
2. Following the same process, I informed the patient and inserted the needle, advancing it until it touched bone.
3. After aspirating, I injected another 0.5 mL of lidocaine. Once more, I felt the fluid expand in the correct location against my thumb, confirming a successful block of the supratrochlear nerve.

After both injections, I applied gentle pressure to the sites for a moment to help disperse the anesthetic and minimize any potential bruising. Within minutes, the patient’s entire left forehead became profoundly numb, allowing me to proceed with the lesion removal without causing any pain. I gave a small supplemental injection of lidocaine right around the lesion as a final precaution, and the procedure was completed smoothly and efficiently.

The Role of Integrative and Chiropractic Care

You might be wondering how a procedure like this fits into a practice that has chiropractic care at its core. This is where our integrative model shines. At Injury Medical Clinic PA, we see the patient as a whole, interconnected system.

My training as a Doctor of Chiropractic provides me with a deep understanding of the neuromusculoskeletal system. This perspective is invaluable, even in minor surgical procedures. For example, chiropractic insights help with patient positioning, post-procedural muscle tension in the neck and shoulders due to anxiety, and the body’s overall inflammatory response.

• Managing Systemic Inflammation: A cornerstone of both chiropractic and functional medicine is managing inflammation. Even minor procedures trigger a local inflammatory response. Our protocols, which may include dietary recommendations, targeted supplementation (like curcumin or omega-3 fatty acids), and lifestyle advice, help the body manage this response more effectively, promoting faster and cleaner healing (Maroon & Bost, 2006).
• Addressing Somatic Responses to Pain and Stress: The experience of pain or even the anticipation of it can cause a person to hold tension in their body. This often manifests as tightness in the neck, shoulders, and upper back. As a chiropractor, I can identify and address this somatic dysfunction through manual adjustments, soft tissue therapy, and postural correction. This not only improves patient comfort but also helps prevent the procedure-related stress from causing secondary musculoskeletal issues.
• A Foundation of Trust: The hands-on nature of chiropractic care builds a strong therapeutic alliance between practitioner and patient. This trust is essential when performing any procedure. Patients who know and trust me through their chiropractic and functional medicine journey feel more at ease, which research shows can improve outcomes and reduce perceived pain (Kelley et al., 2014).

Our integrated approach, with the expert medical direction of Dr. Cardenas, ensures we always practice to the highest standards of safety and efficacy. Whether a patient comes to us for a spinal adjustment following a car accident, a functional medicine workup for chronic fatigue, or the removal of a skin lesion, they receive care that is coordinated, comprehensive, and centered on their total well-being.

By understanding the “why” and “how” behind even the most routine procedures, we empower our patients with knowledge and reassure them that their health is in capable, caring hands.

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References

Kelley, J. M., Kaptchuk, T. J., Cusin, C., Lipkin, S., & Fava, M. (2014). The role of the patient-clinician relationship in the placebo effect. In Placebo (pp. 95-106). De Gruyter. https://doi.org/10.1515/9783110309975.95

Maroon, J. C., & Bost, J. W. (2006). ω-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4), 326–331. https://doi.org/10.1016/j.surneu.2005.10.023

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