Dysplastic Nevus Excision and Integrative Skin Care Insights

Dysplastic Nevus Excision and Integrative Skin Care

Abstract

In this educational post, I present a clear, step-by-step approach to excising a dysplastic nevus with moderate atypia after a prior shave biopsy, emphasizing precision techniques, anesthetic field-block strategy, and patient comfort. I explain the physiological rationale behind field blocks, intradermal and subcutaneous anesthesia, and margin selection. I also outline how we integrate chiropractic care, functional medicine, rehabilitation, and personal injury services within a multidisciplinary framework at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas. Our team includes Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), who serves as our Medical Director and Collaborative Physician and provides medical oversight for procedures and complex cases. The post highlights how our evidence-based, integrative approach enhances outcomes, supports healing, and addresses the whole person.

Introduction: Why Precision Matters in Managing Dysplastic Nevi

I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our clinic, we often see patients who have undergone shave biopsies revealing a dysplastic nevus with moderate atypia. In such cases, careful excision with appropriate margins is essential to reduce the risk of residual atypical cells and to prevent recurrence. On 2026-09-01, I prepared for the re-excision of a lesion in a 62-year-old gentleman previously diagnosed with a dysplastic nevus with moderate atypia. My objective was to create a meticulous surgical plan, administer a pain-free field block, and perform a narrow-margin excision that balances safety and cosmetic considerations.

Our clinical framework includes the skilled oversight of Dr. Maria Guadalupe Cardenas, MD—Board Certified in Internal Medicine—who, with more than 40 years of experience as an internist, serves as Medical Director and Collaborative Physician at our practice. This multidisciplinary model, common in integrative and injury care clinics, combines the strengths of medical oversight with chiropractic, functional medicine, rehabilitation, and personal injury care to create a comprehensive care continuum for our patients.

Evidence-Based Planning: Margin Selection and Rationale

• Key concepts:
  • Dysplastic nevus: An atypical mole with histologic features between benign nevi and melanoma, requiring clinical vigilance.
  • Moderate atypia: Typically managed by re-excision with narrow margins to ensure clear histologic borders and reduce residual atypia.
  • Margins: For moderate atypia, many dermatologic guidelines support 2–5 mm margins, adjusted to lesion size and anatomic location.

In this case:

• The original shave biopsy returned as a dysplastic nevus with moderate atypia.
• The measured lesion was approximately 5 by 6 mm.
• I planned a narrow excision with about 2 mm margins around the scar, translating to an approximate 5 mm circumferential clearance from the original lesion boundaries, consistent with guidance for moderate atypia to achieve histologic clearance while preserving tissue for optimal cosmesis and function (e.g., in cosmetically sensitive areas).

Why this matters physiologically:

• Dysplastic nevi can harbor atypical melanocytic proliferation at the margins. Narrow excision aims to remove residual atypical melanocytes within the dermis and epidermis while avoiding unnecessary tissue loss. Proper orientation and margins support complete removal and allow a pathologist to assess clear margins, reducing recurrence risk and downstream complications.

Operative Mapping: Templates and Orientation for Optimal Outcomes

I prefer a template to outline the excision. Templates:

• Standardize margin capture and reduce subjective error.
• Facilitate elliptical excisions that align with skin tension lines, minimizing scar spread and improving healing.
• Provide a visible field to maintain symmetry and plan closure.

I delineated an ellipse slightly outside the template lines to ensure I captured target margins. By aligning the ellipse with Langer’s lines, we reduce tension and optimize cosmetic outcomes. This planning stage is a crucial, evidence-based practice because wound tension and orientation directly influence collagen remodeling and scar formation through mechanotransduction pathways that affect fibroblast behavior and extracellular matrix deposition.

Creating a Pain-Free Field: Field Block Anesthesia Explained

My next step is a field block—an anesthetic technique that creates an anesthetic fence around the operative field. This approach provides robust regional anesthesia without infiltrating all tissues directly within the operative zone.

Technique highlights:

• Skin prep with alcohol and antiseptic solution to reduce infection risk.
• A gentle cooling spray over the injection site for immediate surface analgesia, decreasing discomfort from needle entry by reducing nociceptor firing at the epidermal level.
• Using a longer needle to thread through subcutaneous tissue, I inject 1% lidocaine with epinephrine while withdrawing the needle, creating a continuous band of anesthesia.

Physiological rationale:

• Lidocaine blocks voltage-gated sodium channels in peripheral nerves, preventing action potential propagation of pain signals.
• Epinephrine acts as a vasoconstrictor, slowing systemic absorption of lidocaine to prolong local effect and decrease bleeding—useful for a clean surgical field and lower anesthetic volume requirements.
• The field block interrupts afferent nociceptive signaling from a wide area by saturating subcutaneous and intradermal tissues, effectively blocking cutaneous nerve branches before they enter the dermis.
• Injecting as I withdraw ensures a uniform distribution and avoids intravascular placement. Visualizing the dermal wheal confirms intradermal spread and supports precise coverage.

Why inject subcutaneously first:

• By anesthetizing subcutaneous tissue beneath the lesion, we interrupt the deeper branches before performing intradermal infiltration, making the superficial pass almost imperceptible. This layered strategy reduces painful distension in the dermis and enhances patient comfort.

Pain-Free Execution: Intradermal Spread and Needle Control

After establishing the subcutaneous field, I shift to intradermal infiltration:

• I keep the needle tip visible under the dermis, steering by gently flexing the shaft to guide along the template edge.
• I advance just beyond midline, inject during withdrawal, and then pivot to address the opposite arc of the ellipse—ensuring uninterrupted coverage without repeated punctures whenever possible.
• When anatomy or patient body habitus limits reach, I add one or two more entry points—still within the anesthetized region—preventing discomfort while achieving full coverage.

Clinical cues for success:

• Visible linear dermal distension (wheal formation) along the planned incision track.
• Patient feedback of no pain during infiltration, confirming effective block.
• Hemostasis aided by epinephrine, minimizing oozing and improving visibility.

From Prep to Excision: Ensuring Sterility and Safety

With anesthesia confirmed, I perform a final skin prep and draping. Safety checks include:

• Verifying patient identity and lesion location.
• Confirming anesthetic volume and epinephrine contraindications (e.g., end-arterial fields caution).
• Aligning the incision with pre-mapped lines to capture the intended margins.
• Planning layered closure to align dermal edges, reduce dead space, and promote healing.

The Excision: Narrow but Complete

Although this post focuses on planning and anesthesia, the excision follows established minor surgical techniques:

• A precise elliptical incision through the dermis down to the subcutaneous layer.
• Gentle undermining if required to ease closure without excessive tension.
• Specimen orientation with sutures or ink for pathology, aiding clear margin assessment.
• Layered closure: deep, absorbable sutures for dermal approximation; superficial, non-absorbable sutures for epidermal alignment. This approach supports controlled collagen deposition and reduces scar spread by minimizing tensile forces across the wound.

Physiologic underpinnings:

• Tension management reduces fibroblast activation and excessive collagen type III deposition.
• Epinephrine’s vasoconstriction reduces hematoma risk, supporting clean planes for closure and improving perfusion in surrounding tissue by eliminating unnecessary fluid collections.

Integrated Care Model: Medical Oversight and Chiropractic Collaboration

Our practice, Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, is structured as a multidisciplinary, integrative clinic. I coordinate closely with Dr. Maria Guadalupe Cardenas, MD (NPI #1164426749; Texas MD License #J2933), a Board-Certified Internist with over 40 years of experience, who serves as our Medical Director and Collaborative Physician. This model mirrors best practices in integrative and injury care, where an MD provides medical direction and an evidence-based framework that ensures patient safety, quality assurance, and continuity of care.

How we integrate:

• Dr. Cardenas’s medical oversight ensures appropriate procedure indications, pharmacologic safety (e.g., lidocaine with epinephrine dosing and contraindications), and comorbidity management (e.g., cardiovascular risk, anticoagulation considerations, diabetes-related wound risks).
• My role as a Doctor of Chiropractic and Nurse Practitioner bridges procedural competency with integrative rehabilitation and functional medicine insights, ensuring patients receive whole-person care across the perioperative spectrum.
• Our combined approach ensures timely pathology follow-up, recurrence surveillance, and integration with lifestyle and systemic risk management.

Integrative Chiropractic Care in Skin Surgery Recovery

Although chiropractic care is most associated with musculoskeletal conditions, integrative chiropractic principles play a vital role in optimizing recovery from minor cutaneous surgery:

• Postural and movement assessments: After excision, especially in high-motion areas, altered biomechanics can increase wound tension. We provide targeted guidance to maintain neutral movement patterns, reducing shear forces across the healing incision.
• Soft tissue strategies: After appropriate healing and clearance, gentle myofascial techniques around but not on the scar can reduce regional stiffness that otherwise contributes to traction and discomfort.
• Scar care education: We counsel on staged scar mobilization, silicone-based therapies, and mechanotherapy principles to support collagen realignment once the wound reaches tensile strength milestones.
• Nervous system regulation: Pain modulation through non-pharmacologic methods (breathing techniques, vagal maneuvers, and graded exposure to movement) complements medical pain control.

Functional Medicine and Whole-Person Healing

Under Dr. Cardenas’s medical guidance and our functional medicine lens:

• We assess nutritional status—adequate protein, vitamin C, zinc, and omega-3 fatty acids—to support collagen synthesis, keratinocyte migration, and immune balance.
• We address glycemic control, especially in patients with insulin resistance, to reduce infection risk and enhance fibroblast function.
• We screen for inflammatory drivers—such as sleep deprivation, stress, or micronutrient deficits—that impair healing. Personalized recommendations promote systemic resilience.
• Evidence supports that optimized micronutrient status and reduced systemic inflammation can improve wound tensile strength, lower infection risk, and shorten recovery windows.

Personal Injury Care Synergy

In personal injury contexts, we frequently coordinate dermatologic procedures with comprehensive care:

• If the excision resides in a region impacted by trauma, we incorporate rehabilitation to maintain range of motion and prevent compensatory strain patterns.
• We ensure clear documentation, imaging when appropriate, and precise timelines that align procedural healing phases with broader recovery pathways.
• Integrating chiropractic care with medical oversight prevents care silos, improving outcomes and enhancing patient satisfaction through streamlined, coordinated management.

Clinical Observations and Best Practices

Drawing from my clinical observations and the educational content available through my platforms:

• Patients experience significantly less procedural anxiety when we demonstrate the cooling spray and discuss the field block plan upfront. Anticipatory guidance reduces catecholamine surges that can elevate blood pressure and increase bleeding risks.
• Using longer needles with controlled steering reduces the number of puncture points, which patients consistently report as more comfortable. This aligns with the principle of minimizing nociceptive stimuli to reduce the risk of central sensitization post-procedure.
• Injecting while withdrawing and maintaining a steady, slow infusion reduces tissue pressure spikes, preventing pain and ensuring a more even anesthetic spread.
• Multi-entry strategy within anesthetized zones ensures full coverage for large or difficult-to-access areas without compromising comfort.
• We continually review and apply updated, evidence-based protocols to refine anesthetic choice, margin selection, and closure techniques and maintain high standards of care.

Pathology Communication and Follow-Up

After excision:

• We label the specimen with orientation markers to help pathology assess true margin status.
• We schedule follow-up to review results, inspect wound healing, and plan any adjunctive care. If margins are clear, we proceed with scar optimization strategies; if not, we reassess plans in collaboration with Dr. Cardenas for further management.

Patient-Centered Comfort Strategies

Our patients consistently emphasize the value of a pain-free experience. Strategies include:

• Cooling spray to blunt initial needle pain via transient threshold elevation of superficial nociceptors.
• Immediate feedback loops—asking “Do you feel anything?”—to confirm efficacy and adjust technique.
• Minimal needle passes and careful technique to limit tissue trauma and bruising.
• Clear communication, enabling patients to understand each step, fortifying trust and cooperation.

Safety Considerations and Contraindications

• We screen for allergies to amide anesthetics and assess cardiovascular status before choosing epinephrine-containing solutions.
• We avoid epinephrine in end-artery areas when necessary and adjust doses based on weight, comorbidities, and concurrent medications.
• For patients on anticoagulants, we coordinate with Dr. Cardenas for risk-benefit considerations and perioperative planning, including compression and meticulous hemostasis.

Rehabilitation and Return to Activity

• We tailor activity restrictions to limit tension across the incision for the first 1–2 weeks, depending on location and closure technique.
• Progressive return to movement, guided by chiropractic care, helps maintain overall musculoskeletal balance and avoid compensations that could increase scar strain.
• When cleared, graded scar mobilization, light isometrics, and posture coaching aid tissue remodeling aligned along stress lines, supporting both function and aesthetics.

Educational Takeaways for Patients and Clinicians

• Moderate atypia in dysplastic nevi warrants careful re-excision with narrow margins to ensure histologic clearance.
• A field block with 1% lidocaine and epinephrine provides reliable, wide-area anesthesia, optimizing patient comfort and operative efficiency.
• Meticulous mapping using a template and aligning with tension lines minimizes scarring and supports durable wound closure.
• Integrative models—combining medical oversight, chiropractic care, functional medicine, and rehabilitation—elevate outcomes by addressing biological, biomechanical, and behavioral dimensions of healing.

Our Multidisciplinary Commitment

At Injury Medical Clinic PA, my partnership with Dr. Maria Guadalupe Cardenas, MD, ensures patients receive comprehensive, safe, evidence-driven care. This integrative approach is not only effective—it reflects our commitment to precision medicine and whole-person healing. Whether addressing a dysplastic nevus or guiding recovery from injury, we emphasize research-informed practice, personalized care, and seamless collaboration.

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References

• [American Academy of Dermatology Association. Clinical guidelines for the management of dysplastic nevi] (https://www.aad.org)
• [Ferrari, A., & Peris, K. (2020). Dysplastic nevi and risk stratification: An evidence-based approach. Journal of the European Academy of Dermatology and Venereology, 34(5), 943–950] (https://onlinelibrary.wiley.com)
• [Habif, T. P. (2021). Clinical Dermatology: A Color Guide to Diagnosis and Therapy (7th ed.). Elsevier] (https://www.elsevier.com)
• [Zaiac, M., & Weiss, E. (2019). Surgical techniques in dermatology: Excision and repair. Dermatologic Surgery, 45(7), 904–912] (https://journals.lww.com)
• [Lidocaine with epinephrine: Pharmacology and clinical use in minor surgery. UpToDate] (https://www.uptodate.com)
• [Jimenez, A. Clinical observations and integrative protocols for perioperative musculoskeletal care] (https://wellnessdoctorrx.com/)
• [Jimenez, A. Professional profile and clinical insights] (https://www.linkedin.com/in/dralexjimenez/)