Removal of Forehead Lesion: Techniques and Tips

Evidence-Based Nerve Blocks and Integrative Chiropractic Care for Forehead Lesion Removal: A Multidisciplinary Approach in El Paso, Texas

Abstract

In this educational post, I walk you through how I perform a targeted nerve block to comfortably remove a small forehead lesion, while explaining the anatomy, physiology, and evidence-based reasoning behind each step. I detail how the supraorbital and supratrochlear nerves are safely anesthetized, why precise landmarks matter, and how we layer local anesthetics around the lesion to optimize comfort and outcomes.

I also introduce our multidisciplinary model: I, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, work closely with Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine, NPI #1164426749, Texas MD License #J2933), the Medical Director and Collaborative Physician at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas. Together, we integrate chiropractic care, internal medicine oversight, functional medicine, rehabilitation, and personal injury services to deliver whole-person, evidence-based care. This post includes clinical observations from my practice and current research findings, focusing on comfort, safety, and outcomes.

Overview

• Who I am: Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST
• Our team: Dr. Maria Guadalupe Cardenas, MD, Internal Medicine, Medical Director and Collaborative Physician
• Clinic: Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), El Paso, Texas
• Focus: Forehead lesion removal with supraorbital and supratrochlear nerve blocks; integrative chiropractic care; functional medicine; personal injury rehabilitation
• Evidence: Modern research methods, anatomical precision, multimodal pain control, biomechanics, and neurophysiology

Patient-Centered, Anatomically Precise Forehead Lesion Removal

I’m Dr. Alexander Jimenez, and today I’ll share how I perform a comfortable, precise removal of a small lesion on the left forehead using targeted nerve blocks. My goal is always to minimize pain, respect anatomy, and create a calm patient experience while ensuring optimal conditions for a clean, efficient procedure.

The case begins with identifying the sensory nerves that innervate the forehead: the supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve. By anesthetizing these nerves at their exit points along the orbital rim, we can reliably numb the forehead skin and subcutaneous tissues, creating a predictable field for minor surgical procedures like lesion excision.

What follows is the step-by-step process, along with the integrative model we use in our clinic—where chiropractic care meets internal medicine supervision, functional medicine, rehabilitation, and personal injury care—to support tissue healing, reduce pain, and improve long-term outcomes.

Why We Target the Supraorbital and Supratrochlear Nerves

• The supraorbital nerve typically exits through the supraorbital notch or foramen above the mid-pupil line, carrying sensory fibers to the forehead and scalp.
• The supratrochlear nerve exits more medially, above the inner canthus of the eye, and supplies the medial forehead area.
• Targeting these nerves provides regional anesthesia to the forehead, reducing the need for multiple local injections around the lesion and improving comfort.

Physiological rationale:

• These nerves are branches of the ophthalmic division (V1) of the trigeminal nerve and carry nociceptive signals from the forehead skin and periosteum.
• A precise nerve block prevents pain transmission by temporarily inhibiting voltage-gated sodium channels in nerve fibers with local anesthetics like lidocaine, blocking action-potential propagation (Hah et al., 2020; Becker & Reed, 2012).
• By addressing the primary sensory inflow, we minimize peripheral sensitization and reduce the anesthesia volume needed.

Practical Technique: Landmark-Guided Nerve Blocks for Forehead Procedures

Here is how I perform the blocks in a calm, methodical way:

• Preparation
  • I cleanse the skin with alcohol to reduce surface contamination.
  • I position my thumb along the superior orbital rim to stabilize the area and ensure accurate depth and direction.
• Supraorbital nerve block
  • I identify the orbital rim and align directly superior to the center of the pupil.
  • I gently pinch the skin to stabilize and reduce the sting of the needle.
  • I advance until I lightly touch bone at the orbital rim. This tactile cue confirms depth near the nerve’s exit.
  • I inject approximately 0.5 mL of local anesthetic. I feel a mild bulge under my thumb as tissue accommodates the anesthetic.
• Supratrochlear nerve block
  • I move medially, above the inner canthus, along the orbital rim.
  • Again, I pinch the skin and advance to contact bone to orient and confirm position.
  • I inject another 0.5 mL of anesthetic, noting tissue expansion.
• Supplemental local infiltration
  • After the blocks, I provide a small ring of lidocaine around the lesion for local reinforcement, ensuring complete anesthesia of the immediate operative field.

Patient Comfort and Safety

• I communicate with the patient during the entire process. When she feels a sting, I acknowledge it and proceed gently.
• The combination of a regional block and local infiltration reduces the total anesthetic required and limits tissue distortion, which supports accurate excision margins.

Evidence-Based Reasoning:

• Tactile confirmation of bone near the orbital rim matches anatomical consistency for nerve exits, improving block reliability (Patel et al., 2013).
• Using minimal volumes in well-defined compartments reduces the risk of soft-tissue swelling and helps maintain visibility of the lesion and surrounding landmarks (Neal et al., 2018).

Integrative Chiropractic Care in a Multidisciplinary Medical Model

Our El Paso practice uses a collaborative model common to integrative and injury care clinics. Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), serves as our Medical Director and Collaborative Physician at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic). With over 40 years of experience, Dr. Cardenas provides medical oversight, risk assessment, and evidence-based internal medicine guidance that complements the chiropractic, functional medicine, and rehabilitation services I deliver.

How we integrate care:

• Medical direction and safety
  • Dr. Cardenas reviews medical histories, medications, cardiovascular and metabolic risks, and contraindications to anesthesia or procedural interventions.
  • She oversees protocols for sterile technique, emergency readiness, and documentation.
• Chiropractic neuromusculoskeletal expertise
  • I evaluate cervical, thoracic, and cranial biomechanics, trigger points, fascial tension, and segmental dysfunction that may contribute to pain perception and healing.
  • Integrative chiropractic care helps optimize posture and cranial-cervical mechanics, which can influence tissue perfusion and lymphatic drainage in the face and scalp.
• Functional medicine lens
  • We assess systemic inflammation, glycemic control, and micronutrients relevant to wound healing—vitamin C, zinc, and protein intake—and tailor supportive plans (IFM, 2020).
  • This approach helps reduce prolonged inflammation and supports collagen synthesis during tissue repair.
• Rehabilitation and personal injury services
  • For patients with concomitant whiplash or head/neck strain, we address cervical stability, proprioception, and graded exercise to enhance recovery and reduce centralized pain.

The Physiology Behind Pain Control and Healing in Minor Procedures

Understanding nociception and regional anesthesia improves outcomes:

• Local anesthetics like lidocaine block voltage-gated sodium channels, stopping action potentials in A-delta and C fibers. This interrupts pain messages at their source (Hah et al., 2020).
• Regional blocks reduce the need for multiple infiltrations, minimizing local tissue acidification and edema that can sensitize nociceptors.

Tissue considerations in the forehead:

• The forehead skin is thin with limited subcutaneous fat, closely adherent to the frontalis muscle and galea aponeurotica.
• The periosteum along the orbital rim is highly innervated; touching bone provides a tactile landmark and reminds us to inject superficially to avoid intravascular entry.
• Proper anesthesia reduces reflex frontalis contraction, aiding precise lesion removal.

Why We Use Supplemental Infiltration Around the Lesion

Even with a well-placed regional block, micro-innervation around a lesion can remain sensitive. A small supplemental ring infiltration:

• Ensures coverage of accessory branches and local inflammatory hypersensitivity.
• Limits the need for larger regional volumes by targeting the operative field precisely.
• Helps maintain a clean margin and reduces patient movement during excision.

Clinical Observations

From years of clinical observation at our practice and shared cases on our platforms, including PushAsRx and LinkedIn, I’ve observed:

• Patients report reduced anxiety when we explain what they’ll feel and why. The simple act of saying “One, two, three” and narrating each step creates trust and decreases sympathetic arousal.
• Forehead blocks yield consistent anesthesia when landmarks are respected. Aligning with the mid-pupil for the supraorbital and medial canthus for the supratrochlear increases success rates.
• Gentle pressure after injection reduces bruising and spreads anesthetic evenly.
• Integrative chiropractic adjustments of the cervical spine and cranial regions, performed away from the operative site and timed appropriately, can reduce headache patterns that sometimes follow forehead procedures by modulating trigeminocervical convergence and improving neck biomechanics.
• Functional medicine strategies that support micronutrient sufficiency and glycemic control correlate with faster wound healing and lower post-procedural discomfort.

Sources:

• PushAsRx clinical insights: https://pushasrx.com/
• Professional updates: https://www.linkedin.com/in/dralexjimenez/

How Internal Medicine Oversight Enhances Procedural Safety

With Dr. Cardenas’ internal medicine expertise:

• We screen for anticoagulant use and adjust timing or technique to reduce bleeding risk.
• We consider allergy history, including reactions to local anesthetics or epinephrine sensitivity.
• We monitor for comorbidities—diabetes, hypertension, and arrhythmias—that influence anesthetic choice and wound healing.
• We use standardized documentation and follow-up protocols, ensuring we address any red flags swiftly.

Integrated Care Pathway for Minor Forehead Procedures

Our integrated pathway:

• Assessment
  • Detailed history, medications, allergies, bleeding risk, and neurologic review.
  • Anatomical mapping of the lesion, nearby vasculature (e.g., supraorbital artery), and nerves.
• Anesthesia plan
  • Supraorbital block: 0.5 mL lidocaine without epinephrine when close to the periorbital region to reduce vasoconstrictive risk; epinephrine is considered when appropriate for hemostasis outside the periorbital area.
  • Supratrochlear block: 0.5 mL lidocaine in the medial rim region.
  • Supplemental infiltration: minimal-volume ring around the lesion.
• Procedure
  • Gentle, precise excision with appropriate margins.
  • Hemostasis achieved with direct pressure or topical agents as needed.
• Post-procedure care
  • Instructions on wound care, signs of infection, and activity modification.
  • Chiropractic and rehabilitation considerations: cervical posture strategies, soft-tissue work away from the site, and graded movement to prevent compensatory strain.
  • Functional medicine support: hydration, protein intake, vitamin C, zinc, and glycemic control to support collagen and immune function.

Why Integrative Chiropractic Care Matters Even in Minor Procedures

Even small procedures benefit from a whole-person approach:

• The trigeminocervical complex integrates nociceptive input from the face and upper cervical spine. Cervical dysfunction can amplify facial pain via convergent pathways.
• By optimizing cervical alignment and reducing suboccipital muscle tension, integrative chiropractic care can help reduce postoperative headache and improve comfort.
• Fascial continuity between cranial and cervical regions means that gentle myofascial techniques can enhance lymphatic drainage and reduce swelling.

Evidence-Based Practice, Modern Methods, and Outcomes

We continually update protocols with modern, evidence-based methods:

• Anatomical studies refine landmark accuracy for cranial nerve blocks (Patel et al., 2013).
• Local anesthetic pharmacology guides safe dosing and selection, including considerations for vasoconstrictors and patient comorbidities (Neal et al., 2018).
• Functional medicine frameworks highlight nutritional and lifestyle factors that impact healing, inflammation, and pain modulation (IFM, 2020).
• Neuroscience research on nociception and central sensitization informs multimodal strategies to reduce acute pain and prevent transitions to chronic pain (Hah et al., 2020).

Procedure Step-by-Step

Here’s how I guide a patient through the process:

• I begin by identifying the orbital rim above the left eyebrow. With my thumb on the rim, I position the needle directly above the center of the pupil.
• I pinch the skin gently. I let the patient know they may feel a quick sting, and I count softly: “One, two, three.”
• I advance the needle until I touch bone at the rim. Keeping my thumb fixed ensures I know exactly where I am in relation to the landmark.
• I inject 0.5 mL of lidocaine and feel the subtle bulge against my thumb—this tells me the anesthetic is in the correct plane.
• I move medially to the inner canthus, find the rim again, pinch, and repeat: contact bone, then inject another 0.5 mL for the supratrochlear nerve.
• I apply gentle pressure with gauze to limit bruising and aid diffusion.
• I finish with a small supplemental infiltration around the lesion to ensure complete anesthesia of accessory branches.
• With the field numb, I carefully remove the lesion, maintaining hemostasis and comfort.
• I provide post-care instructions and coordinate follow-up, which may include chiropractic evaluation for cervical mechanics and functional medicine support for healing.

Multidisciplinary Team in Action at Injury Medical Clinic PA

Our team-based model at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) emphasizes:

• Collaboration: Dr. Cardenas directs medical safety; I deliver chiropractic and procedural care; our rehab specialists guide movement and recovery.
• Communication: Unified documentation and patient education ensure consistency.
• Continuity: From initial assessment to rehabilitation, patients experience coordinated care focused on outcomes.

Key Takeaways

• Supraorbital and supratrochlear nerve blocks provide efficient, comfortable anesthesia for forehead procedures.
• Landmark-guided technique improves reliability and safety.
• Supplemental infiltration ensures complete coverage of the operative field.
• Integrative chiropractic care supports postoperative comfort and reduces cervicogenic contributions to facial pain.
• Internal medicine oversight enhances safety, especially with comorbidities and medications.
• Functional medicine and rehabilitation accelerate healing and restore function.

---

References

• Local anesthetics and peripheral nerve block mechanisms (Hah, J., Bicket, M., & Cohen, S. P., 2020). Canadian Journal of Anesthesia, 67(7), 733–747.
• Local anesthetics: Pharmacology and clinical use (Becker, D. E., & Reed, K. L., 2012). Journal of Evidence-Based Dental Practice, 12(3 Suppl), 247–258.
• Anatomy and landmarks for cranial nerve blocks (Patel, P., Gohil, R., & Alexander, S., 2013). Journal of Neurological Surgery Part B: Skull Base, 74(4), 252–259.
• Regional anesthesia safety and dosing principles (Neal, J. M., Barrington, M. J., & Brull, R., 2018). Regional Anesthesia and Pain Medicine, 43(5), 559–571.
• Functional medicine and wound healing support (Institute for Functional Medicine, 2020).