Electrosurgery

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14 Electrosurgery

Richard P. Usatine, MD, and John L. Pfenninger, MD

Electrosurgery is used in dermatologic practice to destroy benign and malignant lesions, to control bleeding, and to cut or excise tissue. Many types of electrosurgical units are available for use in the office setting. Modern high-frequency electrosurgery units transfer current to the patient through “cold” electrodes. The water molecules are energized to the point that cells literally vaporize as opposed to being burned. The term electrocautery implies that heat is transferred directly to tissue with a heated electrode; electrocautery is just one type of electrosurgery. The battery-powered units that produce a red wire when activated are an example of a simple cautery unit and are useful for draining a subungual hematoma and other minor procedures such as cauterizing the lumens of resected vas deferens where residual tissue damage is not an issue.

The major electrosurgical functions include fulguration, electrodesiccation, electrocoagulation, and electrosection (cutting). In fulguration, the electrode is held away from the skin so that there is a sparking to the surface (such as happens with lightning). In fact, the term fulguration comes from the Latin term fulgur, which means “lightning.” Fulguration produces a high-intensity but more shallow level of tissue destruction (Figure 14-1). With electrodesiccation, the active electrode touches or is inserted into skin to produce deeper tissue destruction (Figure 14-2). Epilation is a type of desiccation in which a fine-wire electrode is inserted into a hair follicle to literally “cook it.” Electrocoagulation is used to stop bleeding in deep and superficial surgery (Figure 14-3). In electrosection, the unit is set so the electrode cuts tissue (Figure 14-4). The higher the unit’s operating electrical frequency (not to be confused with power), the less tissue damage is left behind when using the cutting function.

FIGURE 14-1 In fulguration, the electrode is held away from the skin so that there is a sparking to the surface (such as happens with fulgur, “lightning”). Fulguration produces a high intensity but more shallow level of tissue destruction that may reach the upper dermis.

(Adapted from Sebben JE. Electrosurgery. In Ratz JL, ed., Textbook of Dermatologic Surgery. Philadelphia: Lippincott-Raven; 1998.)

FIGURE 14-2 With electrodesiccation, the active electrode touches or is inserted into the skin to produce tissue destruction deeper into the dermis.

(Adapted from Sebben JE. Electrosurgery. In Ratz JL, ed., Textbook of Dermatologic Surgery. Philadelphia: Lippincott-Raven; 1998.)

FIGURE 14-3 (A) Electrocoagulation is used to stop bleeding in deep and superficial surgery. In this image an indifferent electrode is being used to produce deeper tissue coagulation. Electrocoagulation can also be performed without an indifferent electrode. (B) Electrocoagulation is being performed in the undermined area of an ellipse using a Hyfrecator while the surgical assistant holds up the tissue with skin hooks.

(A: Adapted from Sebben JE. Electrosurgery. In Ratz JL, ed., Textbook of Dermatologic Surgery. Philadelphia: Lippincott-Raven; 1998.)

FIGURE 14-4 (A) In electrosection, the unit is set so the electrode cuts tissue. This mode requires an indifferent electrode. (B) Electrosection is being performed with a very tip electrode attached to a Surgitron. An indifferent electrode is placed under the patient near the surgical site.

(A: From Vidimos A, Ammirati C, Poblete-Lopez C. Dermatologic Surgery. London: Saunders; 2008.)

Current can be applied either in a unipolar or bipolar fashion. The majority of electrosurgical units (ESUs) are unipolar. Unipolar refers to the fact that the current enters a site at the point of the electrode and passes through the body to a grounding plate to complete the circuit. With bipolar applications, the current travels from one point of the electrode, through the tissue, to another point of the electrode (e.g., with fine forceps, from point to point). No grounding plate is needed for this type of use. This reduces possible complications from burns at unwanted sites where the current can exit. It also reduces complications with pacemakers. The bipolar units are ideal to control bleeding since forceps can pinpoint and grasp a bleeder. When the current is applied, only the tissue between the tips of the forceps is affected (Figure 14-5).

FIGURE 14-5 (A) Selection of bipolar forceps that could be used on a number of electrosurgical units. (B) Bipolar forceps in action for electrocoagulation while doing an elliptical biopsy. Note that a small gap is preserved between the ends of the bipolar forceps around the bleeding site. Clamping the forceps close together is not an effective method of electrocoagulation.

With dual-frequency (DF) ESUs, 1.7 MHz (1.7 million cps) is used in the bipolar function, which is better for coagulation because of the lower frequency, whereas unipolar functions (cut, blend) are at 4.0 MHz to decrease tissue damage in the cutting functions.

Electrosurgery Versus Cryosurgery

Cryosurgery is often the treatment of choice for seborrheic and actinic keratoses as well as simple warts. It is faster and easier to perform than electrosurgery for these indications because it does not require anesthesia. Cryosurgery also tends to cause less scarring than electrosurgery especially if the lesions are very superficial. However, cryosurgery may be more likely to cause hypopigmentation because the cold destroys melanocytes. This is especially important in a more darkly pigmented person. Electrosurgery can be more effective than cryosurgery for extensive condyloma, especially if a cutting current can be used.

There may be a risk of developing human papilloma virus (HPV) in the respiratory tract from inhaling the plume (smoke) from an HPV lesion as it is being treated.¹^–³ Intact HPV DNA has been isolated from the plume of verrucae that were treated with electrosurgery and lasers. Therefore, it is prudent for all physicians to use a smoke evacuator while performing laser and electrosurgical treatment of verrucae and other viral lesions. (See Safety Measures with Electrosurgery, p. 167.) Unfortunately, evidence is insufficient to measure the magnitude of these risks. These personal risks, however, may be one factor used to determine the physician’s choice of therapy for viral lesions.

One disadvantage of cryotherapy over electrosurgery is that with cryosurgery the final result cannot be seen immediately, and there is more subjective judgment involved in performing the treatment. However, the degree of damage can be estimated accurately with more experience and by following certain guidelines (see Chapter 15). Cryosurgery also causes more postoperative swelling, which may be uncomfortable for the patient but is only a transient phenomenon.

Electrosurgery Versus Scalpel

The traditional instruments for performing excisions and shave biopsies are the scalpel and razor blade. These are inexpensive, the blades are disposable, and the cuts are clean. The cold steel blades cause no heat-induced tissue damage that could obscure the pathology specimen. Using electrosurgery in place of a blade has the advantage of facilitating hemostasis while cutting. However, the lateral heat produced by the electrosurgical instrument can cause residual tissue damage that might result in slow healing as well as artifact on the edges of the biopsy specimen. The higher the frequency, the less residual damage on both the specimen removed and on the viable tissue remaining. Also, the cutting is very quick and it may go more deeply than desired, excising excessive amounts of tissue or damaging deeper nerves and vessels.

High-frequency electrosurgery on the pure cutting current will approach but not match the scalpel for producing an entirely burn artifact–free pathologic specimen. Therefore, if a malignancy (especially melanoma) is suspected, unless wide margins are being obtained, it may be best to obtain a biopsy with the scalpel (cold steel).

For excising benign lesions, the small amount of lateral heat may not interfere with wound healing when used carefully on a low-power cutting setting. A shave excision using a blade followed by electrosurgery with a loop electrode can lead to a nearly scar-free result and combines the best of both techniques to optimize the results. The mode can be set for either cutting/coagulation (blend) or preferably pure cutting only. Ideally then, the lesion (commonly a nevus or seborrheic keratosis) is shaved off with a blade and then the loop of the radio-frequency (RF) unit removes the residual tissue and controls any bleeding. If the loop will be used to perform the shave, the less the coagulation function will be used and, hence, the less damage that will result to the remaining tissue and to the biopsy specimen. Pure cutting will work just fine to make a smooth cut and control bleeding.

The Ellman Surgitron models are a high-frequency units (often termed a radio-frequency unit because it operates at 4.0 MHz, which is in the range of a radio). They employ a Vari-Tip fine-wire electrode that is adjustable in length for cutting through the skin for elliptical and other full-thickness excisions. On the pure cutting setting, the Vari-Tip electrode can cut with less lateral heat and can allow the physician to do quick and bloodless excision of benign lesions. A combined cold steel (blade) and electrosurgical procedure can also be used here. While the scalpel cuts through the skin to provide better depth control, deeper dissection/undermining and excision with cutting or blended cutting and coagulation can control bleeding.

In summary, no instrument can beat the scalpel (or razor blade) for cost and minimization of tissue damage. The high-frequency electrosurgery unit is more expensive to purchase and operate. A radiosurgery unit can be used to perform several kinds of surgery that have been traditionally performed with a scalpel. This may be beneficial if the lesion is benign and very vascular. However, with small biopsies it cannot match the scalpel for quality of pathologic specimen. Superior cosmetic results can be obtained when using the scalpel for a shave excision followed by light “brushing” of the RF loop over the base of the lesion on a pure cutting setting to smooth out any irregularities while at the same time controlling bleeding. This also tends to treat any sparse residual cells of the lesion that may persist.

Electrosurgery Versus Laser

Laser is an acronym for light amplified by stimulated emission of radiation. Laser technology uses focused light energy to affect cells. Many types of lasers are available to perform different functions (see Chapters 26 through 30). Electrosurgery is less expensive than laser surgery but is more limited in utility. The standard electrosurgical units are a fraction of the cost of a laser (as low as $1000 to 4000 compared to laser units costing $30,000 to $200,000). Most physicians face the choice of referring a patient for laser surgery versus doing electrosurgery in their own office. As with electrosurgery, the CO₂ laser may be used to cut, coagulate, and ablate (destroy) tissue. It is most often used in the office for resurfacing procedures, such as in the treatment of rhytids (wrinkles) and skin surface irregularities; pigmentation; and small vessels. The pulsed dye laser or a similar yellow-light laser is unequivocally better than electrosurgery for treating large hemangiomas and maximizing the cosmetic result. These lasers are used very effectively to treat port-wine hemangiomas. Visible-light lasers obtain better cosmetic results when treating most other vascular lesions, such as angiomas and telangiectasias. They offer much less chance of scarring.

If high-frequency ESUs are used, the radio waves vaporize cells with much the same effect as light energy from lasers. In both cases, minimal tissue damage occurs since vaporization is accomplished using either light or radiowave energy. If cell destruction is desired (such as with the treatment of a basal cell carcinoma or verrucae) then there really is no benefit to either laser or radio-frequency compared to simpler units.

In some cases, it may be appropriate to allow the patient to choose between being treated with electrosurgery or laser treatment. It is helpful to inform the patient of the risks and benefits of the two. Ultimately, the patient needs to make the final decision (especially if the goal of therapy is purely cosmetic). Although different lasers offer more options for treatment, for the majority of conditions seen in the office, electrosurgery will be more than adequate.

Equipment

Thermal Pencil/Battery Cautery

An inexpensive thermal “pencil” cautery (Figure 14-6) is a useful device to have for small skin lesions. They are also used to occlude the cut ends of the vasa when doing a vasectomy. This disposable device consists of two penlight batteries in a housing connected to a wire filament that heats up when activated. Reusable models are also available with disposable tips. These battery cautery units can be a useful tool for treatment around the eyes and on patients with pacemakers. The devices come in high- and low-temperature varieties; low-temperature devices are preferred in skin surgery.

FIGURE 14-6 Note the red-hot tip of this handheld disposable electrocautery unit. This unit performs true hot electrocautery.

Thermal pencil cautery units are also excellent for opening a subungual hematoma. When the hot electrode perforates the nail, the heated tip is cooled by the blood from the hematoma, preventing damage to the nail bed.

Electrosurgical Units

Basic Electrosurgical Units (Noncutting, Lower Frequency)

• Aaron 940 (Bovie)

• Electricator (Delasco)

• Hyfrecator 2000 (ConMed) (Figure 14-7)

• SurgiStat II (Valleylab).

High-Frequency Units (up to 4 MHz)

• Aaron 950 (Aaron) (Figure 14-8)

• Cameron-Miller (various models)

• Finesse (Utah Medical)

• Force FX (Valleylab)

• LEEP (CooperSurgical)

• Quantum 2000 (Wallach Surgical)

• Surgitron FFPF EMC (Ellman)—unipolar only

• System 2450 (ConMed).

Dual-Frequency Units (Unipolar 4 MHz and Bipolar 1.7 MHz)

• Surgitron AcuSect (Ellman)—unipolar and bipolar (Figure 14-9A)

• Surgitron Dual RF (Ellman) (Figure 14-9B)

• Surgitron Dual RF S5 (Ellman) with built-in cooling system and more robust transistors and transformers for procedures that take longer such as skin tightening [Pellevé]).

FIGURE 14-7 The Hyfrecator 2000 from the ConMed Corporation is a commonly used electrosurgical unit in the office.

FIGURE 14-8 The Aaron 950 by Bovie is an electrosurgical unit that can be used for cutting, bipolar, and the other typical electrosurgical applications.

FIGURE 14-9 (A) The Ellman AcuSect is a new combined monopolar and bipolar unit that performs cutting with a reusable neutral electrode. (B) The Ellman Surgitron dual radio-frequency unit is powerful enough to use in the operating room but may also serve as an in-office all-purpose electrosurgical unit. It can perform all modes of electrosurgery discussed in this chapter.

Some RF units were primarily developed for dermatologic applications, whereas others were introduced when the large loop electrical excision procedure (LEEP) became available for cervical conizations. All units can be used for either purpose if the proper electrodes are available. Be mindful, however, that the goal for most skin procedures is to limit scarring. The higher the operating frequency of the unit, the less tissue damage that will result. For destructive procedures, frequency is of less concern.

Because the Hyfrecator and Surgitron are commonly used in the office setting, information provided here will be specific to these two instruments but it can be readily adapted to others. This is not meant as an endorsement of these units. However, their features will be used to provide practical advice for performing electrosurgery,

With many units, accessories are disposable, including grounding pads and standard handpieces. This adds a cost of $10 to $20 per procedure just for tips in addition to increasing waste. If a new grounding pad and handpiece must be used with each patient, the costs can approach $80 to $90 per procedure (e.g., when doing the LEEP procedure). When purchasing an ESU, consider whether reusable equipment is available.

Basic units will only be able to coagulate and fulgurate. To perform modern electrosurgery, units should be capable of pure cutting current, pure coagulation, or a mix of these two (“blend,” “cut and coag”) in addition to fulguration. “Pure cutting” will still have some coagulation function (e.g., Surgitron is 90% cutting with 10% coagulation). The more coagulation, the more tissue destruction. Higher end units are more versatile and digital settings allow the user to customize the cutting and coagulation percentages in the blend setting.

Comparison of Types of Electrosurgical Units

Radiosurgery is electrosurgery using an RF current in the electromagnetic spectrum of the AM radio. Radiosurgery is performed at a much higher frequency than that used by the other basic electrosurgery units (including the Hyfrecator). Radiosurgical units are more than three times the cost of basic ESUs, but are more versatile (especially for cutting).

True radiosurgery uses an “antenna” as the neutral or indifferent electrode. This replaces the grounding plate. This antenna does not have to make contact with the skin. When using a basic ESU, a neutral electrode is not needed. Some units incorporate safety features that will not allow the unit to operate if the patient is not grounded.

The major significant difference between radiosurgery units and a basic ESU is that the radiosurgery units allow for a cutting mode. If radiosurgery is used only for hemostasis and tissue destruction of benign and malignant lesions, there may be no real difference in outcomes between them.

Accessories

Ellman Surgitron Units

• Nondisposable (autoclavable) and disposable electrodes (loops, ball, Vari-Tip) (Figure 14-12)

• LEEP electrodes (Figure 14-13)

• Nondisposable bipolar forceps (Figure 14-5)

• Control handpiece—sterile and those made to be autoclaved (Figure 14-14)

• Neutral plate (Figure 14-15).

FIGURE 14-12 An assortment of medical electrodes for single use may be purchased from Ellman for use with the Surgitron.

FIGURE 14-13 Reusable LEEP electrodes for the Ellman Surgitron or other cutting units. The handles on these are long and sturdy for intravaginal use. However, these electrodes can also be used for the treatment of rhinophyma.

FIGURE 14-14 Reusable sterilizable hand switch for the Surgitron. Note the three buttons for cutting, cutting and coagulation blend, and hemo for pure coagulation.

FIGURE 14-15 The reusable indifferent or neutral electrode for the Surgitron. This does not need to touch the skin of the patient as it works to receive radio-frequency waves.

Note that the bipolar forceps are essentially the same for both instruments. These are especially useful for coagulation of small bleeding vessels because grasping the vessel and coagulation are done in one movement. Bipolar electrosurgery can be used in a bloody field and is safer than unipolar electrosurgery for patients with pacemakers.

Units can be activated using either a hand switch or foot controls. It is a matter of preference, but the clinician may have slightly better control of the handpiece for delicate procedures when foot switches are used for activation.

Smoke Evacuators

Electrosurgery creates a plume (smoke) with a putrid smell. The smoke itself has been shown to include HPV and HIV particles although it is not known if they are infectious. It is best to use some type of smoke evacuator to remove the plume created by the surgery, especially if extensive removal/destruction is being performed. When constructing or remodeling an office, consider installing an exhaust fan (a typical bathroom fan works) to help remove the smell. Types of smoke evacuators include:

• Acu-Evac II 220 (Acuderm)

• Aaron Medical Smoke Shark (Bovie)

• Buffalo Filter

• AER Defense (ConMed) (Figure 14-16)

• OptiMumm (for use with Valleylab units)

• SaftEvac—60 to 65 dB at 1 meter (Delasco)

• Surg-e-Vac (Ellman).

FIGURE 14-16 An example of a smoke evacuator. This one is an AER Defense by ConMed.

Indications for Use of Electrosurgery

• Excising tissue

• Vaporization of tissue fragments

• Controlling bleeding (coagulation)

• Destruction of tissue

• Cosmetic functions (skin tightening)

• Nail matrixectomy

• Epilation.

One of the most common uses of high-frequency electrosurgery is the cutting current that is used to smooth out the skin at the site of a shave removal that has been performed with a blade. After removing a nevus, bleeding often occurs and an irregular surface remains. The blood makes it difficult to see the tissue. Using a large skin loop at pure cutting (level 2 or 15 to 20 W) and using a light “brushing” technique, the residual base of tissue is not only smoothed out but bleeding is controlled. Any small residual lesion can be vaporized. This all affords an excellent cosmetic result. Although the removal can be performed using the loop itself (i.e., no blade is used first), two potential problems can arise: (1) it cuts so quickly it easily goes too deep and (2) the tissue sent to the pathologist will have very minimal but definite “burn artifact,” which can make interpretation difficult. If the power is set too high, the tissue can also be totally destroyed precluding any pathologic examination. For pure destruction of lesions, there is again no advantage to the high-frequency units.

Contraindications

There are really no absolute contraindications to using electrosurgery but there are some precautions relative to contraindications:

• Pacemakers (see Pacemaker Problems, p. 168).

• Electrosurgery/cautery is not indicated as a treatment modality or for obtaining a biopsy of pigmented lesions suspicious for dysplasia or melanoma.

• Electrodesiccation and curettage (ED&C) should generally be avoided in the following circumstances:

• Aggressive (morpheaform, sclerotic), large (greater than 1 cm), or recurrent basal cell carcinoma (BCC).

• BCC larger than 2 cm will have a higher recurrence rate with ED&C (see Chapter 34, Diagnosis and Treatment of Malignant and Premalignant Lesions).

• Squamous cell carcinoma (SCC) greater than 7 to 8 mm. Excise to be sure of complete removal because SCCs are more aggressive than BCCs by their very nature.

• Immune-suppressed patients, especially those who have had organ transplants, may be best served by excising the lesions to ensure complete removal in all but the smaller lesions (less than 7 to 8 mm).

• Patients with slow healing (diabetes, peripheral vascular disease) may do better with excisional rather than destructive methods.

Location is also an important consideration when using destructive techniques for nonmelanoma skin cancers (NMSCs). Higher recurrence rates are associated with NMSC in the following areas:

• Alar groove, preauricular and periocular.

• H-zone on the face. Associated with higher recurrence rates for recurrent BCC treated with surgery rather than Mohs surgery (see Chapter 37). This was not true for primary BCC in these regions treated with surgical excision. ED&C may be performed in the H-zone as long as the patient understands that there may be a higher recurrence rate than with surgery.⁴

• SCC on non–sun-exposed skin and mucous membranes such as the lip and eyelid margins (may also be more aggressive biologically).

Electrosurgical Techniques: General Principles

Power Setting

Every electrosurgical unit is different, and the desired setting will vary for each model, procedure, lesion, or patient. Even two supposedly identical electrosurgical models may require different settings. Therefore, the setting levels provided are only starting points (Tables 14-1 to 14-3 and Box 14-1). The basic principle for setting the correct power output is to start low and increase the power until the desired outcome (destruction, coagulation, or cutting) is achieved. For ablation/destruction, the tissue should bubble or turn gray. Keep in mind that destruction of tissue below the visible area of treatment can occur. The power setting for coagulation is generally higher than the setting needed for tissue destruction. A rule of thumb is to use the lowest power setting that accomplishes a given result so as to achieve cosmetically acceptable outcomes. It helps to moisten the tissue to provide better contact and allow a lower power setting.

TABLE 14-1 Range of Power Settings with the Hyfrecator 2000

Lesions	Power Setting (watts on low)	Type of Electrode
Benign
Angiomas (cherry)	2–2.5	Sharp or dull
Angiomas (spider)	2–2.5	Sharp or needle
Condyloma acuminata	12–18	Dull
Dermatosis papulosa nigra	2–2.5	Dull or sharp
Pyogenic granulomas	16–20 or switch to high	Dull
Sebaceous hyperplasia	2–2.5	Dull
Seborrheic keratosis	10–14	Dull
Skin tags (acrochordons)	2–2.5	Sharp
Syringomas	2–2.5	Sharp
Telangiectasias	2–2.5	Sharp or needle
Verrucae vulgaris	12–18	Dull
Verrucae plana	12–18	Sharp or dull
Malignant
Basal cell carcinoma	16–20	Dull
Squamous cell carcinoma	16–20	Dull

Disclaimer: Every patient and every electrosurgical unit is different. These numbers are just suggestions and each clinician must find the best settings based on experience with their patients and unit.

TABLE 14-2 Approximate Range of Power settings with Radio-Frequency Surgery (Using Dual-Frequency Ellman Surgitron)

TABLE 14-3 Approximate Range of Power Settings with Radio-Frequency Surgery (Using Ellman Surgitron FFPF EMC)

Box 14-1 Electrosurgical Settings

Suggested Settings for Hyfrecator 2000 or Bovie 900

Cosmetic destruction of angiomas, telangiectasias, sebaceous hyperplasia and skin tags without anesthesia: 2–2.5 W on low

ED&C: 14–18 on low

Coagulation after shave: 12–14 on low

Coagulation after removing a pyogenic granuloma: 16–20 on low

Coagulation during full-depth excision (punch, ellipse, or flap): 12–20 on low

Consider switching to high if coagulation on low at 20 is not working. However, it may be best to find and tie off a bleeding vessel or wait while applying pressure with gauze.

Suggested Starter Settings for Ellman Surgitron DF

Vari-Tip settings for cutting

3–6 on cut

6–9 on cut/coag (6 on the face and 9 on the back)

Loop settings for cutting

3–4 on cut (may use 2–3 for smaller loop)

4. on cut/coag

Large LEEP loops for cervix or treating rhinophyma

5–15 on cut

10–20 W on cut/coag

Ball electrode for coagulation: 20–35 on hemo

Fulguration for tissue destruction: 30. This is lower frequency at 1.7 MHz (like the Hyfrecator)

Bipolar: 35 on hemo

Toenail matrix ablation: 16–20 on hemo

Elliptical excision: start on cut at 3 for ellipse. Cut off specimen and do undermining on 4 with cut/coag

The usual radiofrequency modes are:

• Pure cutting current (that still has 10% coagulation)

• Blended cutting and coagulation (approximately 50% of each)

• Coagulation (hemo)

• Fulguration (similar to the Hyfrecator)

• Bipolar coagulation.

Anesthesia

Local anesthesia will be needed for virtually all electrosurgery with the exception of the treatment for telangiectasias, small skin tags, and fine angiomas where either no or topical anesthesia is adequate. Injecting 1% to 2% lidocaine with epinephrine before the procedure will provide painless electrosurgery. However, short bursts of low current can be less uncomfortable than needle anesthesia in some individuals. Topical anesthesia with ethyl chloride is contraindicated because ethyl chloride is flammable. Anesthetic creams (see Chapter 3, Anesthesia) can be used for anesthesia before treatment of facial telangiectasias and eliminates the effects of distortion from injectable anesthesia.

Practical Pearls Specific to Radiosurgery

1. Activate the electrode with the foot or hand switch before touching the skin/lesion with the electrode. Touching the lesion first inhibits current flow.

2. It helps to stabilize the physician’s operating hand against the patient’s body part so that if the patient moves, the hand with the electrode moves with the patient avoiding a laceration.

3. While cutting, move the electrode using a smooth uninterrupted movement. The intensity should be adjusted until the electrode moves through the tissue like a hot knife through butter.

4. Always use a neutral plate (“antenna”) or grounding plate as specified by the manufacturer. The neutral plate should be under the patient and not far from the operative site. The neutral plate does not have to touch the skin and will allow the use of lower power settings if closer to the operative site. A true grounding plate must be in direct contact with the skin and proximity to the operative site is of less importance.

5. To avoid excessive tissue damage when cutting, minimize lateral heat.

Lateral heat = The product of Time that electrode contacts tissue × Intensity of power × Electrode size × Nature of the waveform × the Resistance of the tissue (increases with the lack of moisture) divided by the frequency of the current.

• Electrode contact time. Keep this to a minimum.

• Intensity of power. If the intensity of the power is too high, it will cause sparking and increased tissue destruction. If too low, it will cause tissue drag, which can increase lateral heat and increase the risk of bleeding as well as a less desirable cosmetic outcome.

• Electrode size. Smaller electrodes with finer wire cause less lateral heat and require less power to operate than larger ones.

The Ellman Surgitron units operate at 4.0 MHz. The Hyfrecator operates at approximately 0.5 MHz and produces more lateral heat. However, because fulguration and desiccation are used to destroy tissue, the lateral heat is not a problem. It is during cutting that tissue destruction is to be avoided.

6. Tissue must be moist to obtain the desired effect. The moisture allows for the water molecules to vaporize and cause the desired effect. It will be almost impossible to obtain any effect whatsoever on highly keratinized (dry) tissue. Just wipe over most lesions with a moist 4 × 4 to provide the moisture needed.

7. Reusable electrodes must be clean and free of carbon to work well. Use fine sand paper to keep them “shiny”!

Safety Measures with Electrosurgery

Potential Hazards of Electrosurgery (To Patient and Physician)

• Fire and burns

• Electric shock

• Transmission of infection through electrode, smoke plume, or spattering blood

• Pacemaker interference.

Safety Precautions to Avoid Potential Hazards

Fire and Burns

• Be sure the alcohol has dried if used to prepare the skin. Do not leave alcohol swabs anywhere near active electrodes.

• Do not use ethyl chloride as the local anesthetic.

• Keep oxygen and other flammable material away from electrosurgical equipment.

• Make sure a fire extinguisher is available.

• Be careful of bowel gas, which contains methane in perirectal procedures. This is more of a problem with patients under general anesthesia who lack control. The gas can explode.

Electric Shock

• Keep electrosurgical equipment functioning properly; if there are signs of malfunction, have the equipment fixed before use.

• Use a three-pronged plug connected to an outlet that is not overloaded.

• Do not use the outlet in the treatment table.

• Make sure the patient is not grasping or touching metal portions of the treatment table.

Transmission of Infection through Electrode

• Always wear disposable gloves.

• When using reusable electrodes, clean them after each use by removing the char followed by sterilizing them in an autoclave or liquid solution. The char can be removed using fine sand paper, an ultrasonic cleaner, or by activating the electrode in a moist 4 × 4 gauze folded over the tip.

• Disposable electrodes are an option.

During sterile procedures options include the following:

• Use a sterilized handle and cord (reusable is preferred as a greener option).

• Place a nonsterile handle into a sterile sheath so that it covers the hand switch and a good portion of the cord. Another option is to use a sterile glove held open while an assistant places the nonsterile handpiece into a finger of the glove by holding the attached wire and lowering it. The electrode tip can then be used to pierce a finger of the glove so it can be secured in place. The physician can then hold the handpiece, which is now within a sterile glove.

• For short procedures in which minimal electrocoagulation is needed, an assistant who is not part of the sterile field can apply the electrosurgery tip to a hemostat or to pickups that are grasping a bleeder as needed.

Transmission of Infection through Smoke Plume or Spattering Blood

Transmission of infection through a smoke plume or spattering blood is a potential risk when treating lesions of viral origin. This is especially true when treating HPV infection in all types of warts. Intact HPV DNA has been recovered in the smoke plume of verrucae treated with electrosurgery and the carbon dioxide laser.¹^–³ One case report suggests that a physician acquired an HPV infection of the larynx (laryngeal papillomatosis) while performing laser therapy on HPV-infected lesions.¹

A publication of the National Institute for Occupational Safety and Health (NIOSH) states that research studies have confirmed that smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses.⁵ At high concentrations the smoke causes ocular and upper respiratory tract irritation in health care personnel. Smoke evacuators should be used and the various filters and absorbers used in smoke evacuators should be replaced on a regular basis. These materials should be disposed of with other biohazardous waste.⁵

Although there may also be a potential risk of transmission of hepatitis, herpes, or HIV through blood splatter or smoke plume, there is even less scientific evidence showing such transmission. Nevertheless, it is best to follow certain safety measures (especially if the lesion is of viral origin or the patient is known to be infected with HIV or hepatitis).

1. Use a smoke evacuator with the intake nozzle held within 2 inches of the operative area. It is essential to use the evacuator when treating any viral lesion.

2. The physician and treatment team should wear surgical masks and eye protection. Special N95 surgical masks that filter down to 0.5 micron are available and should be used for extensive cases.

3. Consider using a different treatment modality based on evaluation of the risks and benefits of treatment.

Pacemaker Problems

Electrosurgery should be limited in patients with pacemakers, implanted defibrillators, or cardiac monitoring equipment. Electrical current (especially in the cutting mode) may activate or inactivate these devices. Although all such devices are supposedly “shielded” from these effects, if an alternative method of treatment is acceptable, it should be considered. Battery cautery can be used safely but is not as versatile as the electrosurgical units. If electrosurgery remains the best option, use the lowest power setting possible, place the antenna/ground plate next to the lesion and as far away from the pacer as possible, use only short bursts of power, and try to avoid the cutting setting. Do not perform electrosurgery in proximity to the heart.

The use of bipolar forceps or true electrocautery (with heated wire) are the preferred options of experienced cutaneous surgeons when electrosurgery is required in a patient with a pacemaker or an implantable cardioverter-defibrillator (ICD).⁶ Routine precautions included utilizing short bursts of less than 5 seconds (71%), use of minimal power (61%), and avoiding use around the pacemaker or ICD (57%).⁶ One hundred sixty cutaneous surgeons reported the following complications: reprogramming of a pacemaker (six patients), firing of an ICD (four patients), asystole (three patients), bradycardia (two patients), depleted battery life of a pacemaker (one patient), and an unspecified tachyarrhythmia (one patient). Overall this was a low rate of complications (0.8 case/100 years of surgical practice), with no reported significant morbidity or mortality.⁶ Bipolar forceps were utilized by 19% of respondents and were not associated with any incidences of interference.⁶

Treating Specific Lesions

General Approach

Once the decision has been made to use electrosurgery, turn on the unit and choose the appropriate settings including mode and power. Some ESUs require a few moments to “warm up.” Be sure the antenna or grounding plate is in the proper position. If using a foot pedal, place it within ready reach. Choose the tip to be used for the particular application and place it in the handpiece. Check to see that when the foot pedal or the finger control is pressed, the unit activates.

When used in the cutting mode, the electrode will cut continuously. When set properly, it will move through tissue smoothly without catching or “stalling.” If the cutting is not smooth, try the following: make sure the mode selected is pure cutting; moisten the tissue; move slower; check to be sure the electrode tip is shiny and clean; confirm that the grounding pad/antenna is plugged in and placed properly; turn up the power. Excessive sparking and smoke means the power (wattage) is set too high and the tissue will often appear black. When adjusted properly, the newly cut tissue will appear almost normal but will not be bleeding.

When used in the fulguration or coagulation mode, be sure to leave space between the electrode tip and the tissue to produce a “spark gap.” Gently tap the lesion to obtain the desired effect. If the tip is applied to the tissue in a continuous fashion, the char will often prevent further tissue effects unless the power is turned up. However, this can cause more scarring. Ideally, the power will be set just high enough to cause graying or light charring of the tissue, which is then wiped away before the electrode is applied again (if needed). For optimal effects at the lowest setting, continue to wipe over dry areas with a moist 4 × 4 gauze. When treating areas that are bleeding, such as the base of a BCC that has been coagulated, slight amounts of blood will provide excellent conduction to desiccate/destroy the tissue. Too much blood, however, can disperse the energy and prevent tissue effects. Apply pressure to the base of the lesion with gauze or a cotton-tipped applicator to reduce bleeding and remove blood before proceeding.

Benign Lesions

The unit should be set for pure cutting with the power set based on the ESU and the loop size (see Tables 14-1 to 14-3). The condyloma should be “debulked” on the first pass and then the edges should be lightly “feathered” to ensure there is no remaining tissue and to blend the treated skin into the surrounding normal tissue. A common error is to go too deeply with the loop. Use caution. The penile skin is extremely thin and the RF loops cut very fast. Going too deeply will not only increase bleeding but also the secondary scarring. The same can happen with the vulvar and perianal tissues. If one attempts to perform a flat shave with a surgical blade, one often finds it difficult to cut on the mobile skin and bleeding readily obscures the operating field. That is the beauty of high-frequency electrosurgical removal: limited if any bleeding, controllable depth, minimal tissue destruction, and little scarring even with larger lesions. Using magnification during removal enhances all of these benefits even more.

The sequence for removal of a condyloma using high-frequency electrosurgery is as follows:

1. Soak the area with acetic acid (moistened 4 × 4s or spray bottle).

2. Examine under magnification (preferred).

3. Anesthetize as needed with 1% lidocaine (with or without epinephrine). Use a 30–gauge needle. Consider a penile block in males.

4. Turn on the unit and select pure cutting mode at the appropriate level. Test the setting on the top portion of the largest condyloma until it is just right (staying away from the base of the lesion until the setting is correct).

5. With magnification assistance, remove the lesion using a loop electrode in a superficial sweep, gradually going deeper until all visible abnormal tissue has been removed (Figure 14-18).

6. Wipe treated area with a 4 × 4 gauze moistened with acetic acid and reinspect area.

7. Apply aluminum chloride to any sites that may still be bleeding (ferric subsulfate has a tendency to leave an iron deposit stain especially in the genital area).

8. When all lesions have been removed, apply ointment of choice (an antibiotic or petrolatum) to hasten healing and to prevent treated tissue from adhering to undergarments. Lidocaine ointment 5% can also be used alone or with either of the other ointments to provide an anesthetic effect.

9. All tissue removed should be sent to pathology since it is difficult to discern bowenoid dysplasias from classic condylomas with the naked eye.

10. Because persistence of some virus and growth of small, grossly undetectable lesions is common, a follow-up exam is generally done in 4 to 6 weeks to check for recurrences.

11. With the association of HPV and cervical cancer, be sure you have addressed all issues regarding pap smear screening, immunizations, and safe sex practices.

FIGURE 14-18 Removal of condyloma using radiofrequency shaving. A large dermatologic loop using a pure cutting mode is employed. Caution is needed lest the loop cut too deeply.

(Copyright John L. Pfenninger, MD.)

Neurofibromas

Neurofibromas are soft, benign tumors that are elevated above the skin surface (see Figure 33-30 in Chapter 30, Procedures to Treat Benign Conditions). Smaller lesions can appear to be nonpigmented nevi. However, if shaved off, a gelatinous material appears at the base, which is classic for neurofibromas and indicates the need for further treatment. Patients may request removal for cosmetic purposes, because they exist in areas of friction or trauma or because of fear that the lesion is not benign. Two possible electrosurgical methods for removal include (1) a shave with a scalpel and then electrocoagulation of the gelatinous residual or (2) a shave with a wire loop electrode using cutting and coagulation (blended) current going progressively deeper until the lesion is removed. In both instances, it is often easier to curette out the base, which often goes surprisingly deep, followed by the electrosurgery. For lesions over a centimeter in diameter, excision with suture closure provides faster healing with less scarring.

Before treating neurofibromas, advise patients that these lesions can regrow and that the area of the excision can become indented and/or hypopigmented.

Nevi (Moles) Benign

One excellent method for removal of benign nevi is to use high-frequency (radio-frequency) electrosurgery. It is this exact procedure for which RF really provides value over the other methods of simple shave excision. However, a brief discussion with some caveats is indicated regarding this approach to nevi.

If there is any suspicion that a presumed nevus is malignant, a full-thickness biopsy should be performed to rule out melanoma. It is not acceptable to do the primary removal/biopsy with electrosurgery using a loop (even the pure cutting mode) because the associated heat-induced tissue alteration, although minimal, can still interfere with the pathologic diagnosis and the determination of the depth of invasion in the case of a melanoma. If the power setting is too high or if any coagulation current is used, the “burn artifact” is even more pronounced and unacceptable.

All excised pigmented lesions regardless of method used for removal should be sent to the pathologist. Many nevi are removed because of cosmetic concerns or because of repeated trauma to them (e.g., under a bra strap, where routine shaving cuts them on the face or legs). When a lesion is almost certainly not a melanoma, a shave removal can be performed safely (see below for recommended technique). With atypical-appearing nevi, one has to ask the question, “Could this be a melanoma?” If the response is “Yes, it certainly could be,” then biopsy for depth. If the response is that a melanoma is quite unlikely, then removal using a shave technique is preferred. Shave removal is quicker, less costly, provides an adequate diagnosis in the majority of instances, and results in less scarring providing an excellent cosmetic result, especially with the RF technique described here (see Chapter 8, Choosing the Biopsy Type).

Much fear has been instilled into providers that they may shave a melanoma thus preventing adequate determination of the depth of the lesion. Depth is used both for prognosis and for delineating the type of treatment required. However, there is not enough time or expertise available for every atypical nevus to be excised with suture closure. It is far better to sample atypical nevi using the method described here than to put off doing so for fear of “doing it wrong” or not having the expertise to excise and do the closure, thus missing a deadly melanoma. Another consideration is that if the patient is left with large scars after a biopsy for minor lesions, they will be less apt to return for further biopsies, which increases the risk that they will experience a more advanced melanoma later. Shave or punch biopsies that do not remove the whole melanoma at once do not negatively influence survival.

Luckily, it is rare that it makes that much clinical difference if a melanoma is transected. (Everyone practicing clinical dermatology has sooner or later transected an unsuspected melanoma.)

The following electrosurgical technique is excellent for the removal of presumed benign nevi with RF (Figure 14-19):

FIGURE 14-19 (A) A benign intradermal nevus on the face has been anesthetized prior to shave excision. (B) The nevus is excised with a No. 15 scalpel blade. (C) The remaining tissue is feathered with RF surgery using a loop electrode. (D) Immediate result. (E) Cosmetic result 1 year later.

(Copyright John L. Pfenninger, MD.)

1. Anesthetize with 1 or 2% lidocaine with epinephrine. Be careful not to distort the lesion any more than necessary

2. Use a No. 15 scalpel blade or razor blade to shave off the lesion. If the lesion has no worrisome features, shave flat to avoid any depression of the scar. However, if there are some atypical features, shave in a saucer-like pattern with the central portion a little deeper than the margins to ensure complete removal of the entire lesion.

3. Using a high-frequency ESU and a wire loop electrode, “smooth out” the lesion to eliminate any residual tissue as well as to stop the bleeding using a light “feathering,” sweeping motion. Blend in the edges of the shave with the surrounding skin. Keep the tissue moist with a dampened 4 × 4 gauze to make this step easier.

4. Send the tissue to pathology.

Although radiosurgery is used to finish the shave, using the loop to remove the lesion primarily, instead of using a blade, is discouraged (due to burn artifact and the chances of the excision going too deeply). A well-done shave biopsy with a blade can also be completed with nothing more than aluminum chloride for hemostasis.

Pyogenic Granuloma

Pyogenic granulomas are very vascular benign tumors (Figure 14-20). They occur most commonly on the fingers, face, lips, and gingiva. Pyogenic granulomas often occur at the site of minor trauma and are more common in pregnancy. These vascular lesions are ideal for electrosurgical treatment.

FIGURE 14-20 (A) Pyogenic granuloma that started during pregnancy. (B) Shave excision after pregnancy. (C) Curettage. (D) Electrofulguration with visible spark to the remaining vascular tissue. (E) Final result. More than one cycle of curettage and electrodestruction may be needed to stop the bleeding and prevent recurrence.

(Copyright Richard P. Usatine, MD.)

In a randomized controlled study (RCT) comparing cryotherapy with liquid nitrogen versus curettage and electrodesiccation of patients with pyogenic granuloma, the curettage and electrodesiccation had the advantage of requiring fewer treatment sessions to achieve resolution and better cosmetic results.⁷

Before treatment, inject 1% lidocaine with epinephrine to cause blanching of the skin at the base of the lesion. Epinephrine is needed because of the extreme vascularity of these lesions. If the pyogenic granuloma is on a finger, start with a digital block with lidocaine and no epinephrine. Some physicians place a temporary tourniquet around the base of the finger to control bleeding during the procedure. If choosing this approach, the tourniquet may be left on for at least 30 minutes safely. (See page 217 for discussion of tourniquets.)

Wait at least a few minutes after the injection to gain the benefit of the epinephrine. Lab slips and forms can be filled out during this time. The elevated portion of the lesion is then shaved off with a scalpel blade. (Alternatively, a loop electrode using a cutting/coagulation current could have been used with the caution that it can easily penetrate too deeply, very quickly.) Send the specimen for histology to rule out the remote possibility that the lesion is an amelanotic melanoma. The base of the wound is curetted with a 3-0 to 5-0 dermal curette to remove the remaining tissue. Before electrocoagulating the base, compress the tissue with gauze to control bleeding. Pooled blood or active bleeding will diminish the efficacy of electrosurgery. In Figure 14-20, after blotting the blood away, the base is treated with electrodesiccation. (It may be necessary to use the higher power of electrocoagulation for these vascular lesions.) Further curettage and desiccation may be required a number of times to destroy the whole pyogenic granuloma and to stop the bleeding. If some tissue remains, the pyogenic granuloma will regrow.

Rhinophyma

Rhinophyma is a form of rosacea that can grossly disfigure the nose (Figure 14-21). In this case the bulbous tissue was also blocking the nostrils and impairing breathing. Patients are stared at in public places and may limit their activities to avoid public ridicule. The electrosurgical cutting devices provide an excellent treatment option for rhinophyma. Although the surgery is performed for more than cosmetic reasons, it is important to obtain prior authorization from the insurance company before proceeding with this procedure. It can be a difficult and time-consuming procedure so it is best to allocate 1 to 2 hours on the schedule. Payment is commensurate with the time invested. This is an advanced procedure and should be performed only when the clinician has significant experience with facial surgery and electrosection.

FIGURE 14-21 (A) Large disfiguring rhinophyma on a man who is not a heavy drinker. (B) A 30 gauge needle is inserted into the nose delivering lidocaine with epinephrine prior to surgery. The pressure of the anesthetic often causes sebum to exude from the dilated sebaceous glands. (C) Electrosection with a square LEEP electrode. (D) A strip of tissue is removed as the electrode cuts through the rhinophyma. (E) A semicircular LEEP electrode is being applied to the hypertrophy tissue of the nasal ala. (F) As the electrode cuts through the tissue, large white hyperplastic sebaceous glands are seen. (G) The ball electrode is used for hemostasis. (H) Much of the rhinophyma was excised, allowing the patient to breathe through unobstructed nostrils. All bleeding was stopped. (I) A happy patient after re-epithelialization from the rhinophyma electrosurgery.

(Copyright Richard P. Usatine, MD.)

To do this procedure in the office, the patient should be in relatively good health with no unstable cardiopulmonary disease. This is a potentially bloody surgery so it does help to make sure all nonessential anticoagulants are stopped. The patient should understand that the nose will be red and raw for 1 to 2 weeks after the surgery. Make sure the patient changes into a gown and removes all upper clothing before beginning.

When first performing this procedure, consider treating only a portion of the nose and doing the surgery in two stages. This gives the patient a chance to see what the surgery and recovery periods are like without committing to having the entire nose treated in one sitting.

Appropriate-sized cutting loops are essential. The loops used for cervical LEEP procedures (Figure 14-13) are excellent for this purpose. Other large electrosurgical loops can also be used. Place the neutral plate below the patient’s head. A smoke evacuator is definitely needed and it helps to have two assistants. One will be needed to hold the smoke evacuator tubing and to make adjustments in the electrosurgical settings. The other assistant can help remove the strips of skin and apply pressure for hemostasis when needed.

Perform infraorbital blocks bilaterally before starting with the local anesthetic. See Chapter 3 for a guide to regional blocks. Then inject 1% lidocaine and epinephrine into the affected area (Figure 14-21B). Although this is the nose, it is crucial to have epinephrine to keep the bleeding to a minimum.

Start by shaving down the nose with the loop. The pure cutting setting with levels as high as 30 W may be needed. Move the loop across the nose in one long continuous motion (Figure 14-21C). The assistant can hold the strip of skin up while you finish the pass (Figure 14-21D). Large white areas of sebaceous hyperplasia will be encountered (Figures 14-21E and F). Shape the nose and compare the sides for symmetry. Leave some definition of the nasal alae as they come off from the central nose. This procedure literally sculpts a new nose. The abnormal tissue will be soft and cut easily. Do not remove too much tissue. A second procedure to remove more tissue can be done if needed.

Hemostasis can be obtained along the way with pressure from gauze and electrocoagulation. A bipolar forceps attached to the same electrosurgical unit may be ideal. Alternatively, change the loop electrode over to the ball electrode as needed for hemostasis (Figure 14-21G). If a second electrosurgical unit is in the room, that unit could be dedicated to hemostasis while keeping the RF cutting unit for the loop only.

At the end of the procedure (Figure 14-21H) cover the nose with petrolatum and gauze. One way to keep the gauze in place is to wrap a long gauze around the back of the head. Send the patient home with a prescription for a pain medication such as hydrocodone and acetaminophen. Have the patient return in 2 days for a wound check to make sure there are no signs of infection and that bleeding is not a problem. Moist healing postoperative care is essential.

These patients are very appreciative because this procedure often provides a new life free from the fear of going out in public (Figure 14-21I).

Sebaceous Hyperplasia

Sebaceous gland hyperplasia of the face is a common condition as people age. It is asymptomatic and not dangerous, but patients often ask for treatment for cosmetic reasons. Occasionally it may be unclear whether what appears to be sebaceous hyperplasia may actually be a BCC. If the diagnosis is uncertain, a biopsy is indicated. It is easiest to do a shave biopsy with a scalpel or sharp curette and send the specimen for pathologic diagnosis. The base can then be cauterized lightly.

If the diagnosis is certain because the sebaceous hyperplasia is typical, the condition can be treated with tissue destruction using cryosurgery or electrodesiccation. Either of these approaches will not yield a specimen for pathology. When using electrodesiccation, a low-power setting should be used to avoid scarring (Figure 14-22).

FIGURE 14-22 The blunt electrode is being used to treat sebaceous hyperplasia of the face without and no local anesthesia. The Hyfrecator is set at approximately 2 W.

(Copyright Richard P. Usatine, MD.)

Seborrheic Keratosis

If there is any question about whether a presumed seborrheic keratosis is malignant, perform a biopsy with a scalpel or razor blade to obtain a good specimen for pathology. If the lesion is shaved or excised with electrosurgery, the heat-induced tissue destruction may interfere with the pathologic diagnosis. When removing a seborrheic keratosis with shave biopsy using a scalpel, hemostasis can be easily achieved with aluminum chloride or Monsel’s solution, and electrosurgery is not needed.

When dealing with a classic, thin seborrheic keratosis, another technique is to lightly fulgurate the lesion and then wipe it off with a gauze or curette. Because this does not provide tissue for pathology, this approach should not be used if the lesion has suspicious features (i.e., may be a melanoma). The advantage to this technique is that the desiccated seborrheic keratosis is easily removed from the skin below, without going deeper than necessary (Figure 14-23). This allows for good control of the depth of removal and can minimize scarring. However, these lesions are very hyperkeratotic and thus quite dry often making any electrosurgical attempts at removal more difficult unless they are hydrated first using water-moistened 4 × 4 gauze.

FIGURE 14-23 Electrosurgery can be used in conjunction with a curette to superficially remove seborrheic keratoses.

(Copyright Richard P. Usatine, MD.)

When using radiosurgery to shave these lesions, it may help to outline the lesion with a surgical pen. A large round loop electrode can be used to shave off the lesion with a single initial pass using a pure cutting setting. See Tables 14-1 to 14-3 for power settings. The skin can be smoothed, using the loop like an artist painting with a brush, while keeping the electrode at a 90-degree angle to the skin surface. Gentle strokes are used to feather the edges of the lesion into the normal skin. A moist 4 × 4 gauze is used between passes of the electrode to remove tissue and moisten the skin. Because the electrical current kills potential infectious organisms, there is no need to use sterile water or saline to moisten the gauze; tap water is fine. Remember that radiosurgery, if set at too high of a power or with any coagulation setting, may still cause more tissue destruction than just a surgical blade, so that the chance of hypopigmentation or scarring may be greater. However, using a combined technique like that described for a nevus above optimizes ease of removal while limiting complications.

Skin Tags (Acrochordons)

There is no absolute cutoff for differentiating between large, medium, and small skin tags. We define the smallest skin tags as those lesions that are too small to be grasped easily with a forceps and therefore are difficult to shave or snip off. The largest wide-based lesions are those that would be difficult to remove with a single snip of a sharp iris scissor. These are best shaved off with a scalpel.

To treat a small or medium skin tag with electrosurgery, light electrodesiccation (ball electrode) or fulguration (ball or pointed tip) should be used. After the lesion is charred, the char can be removed with a gauze or it can be allowed to fall off on its own.

The eyelid is a location where it is important to be very careful when using chemicals for hemostasis. When used carefully, light electrodesiccation allows for hemostasis without endangering the eye. For radiosurgery of a skin tag, a loop electrode with a cut and coagulation setting of 4 to 6 W should be used after lidocaine and epinephrine are injected first. The skin tag should be shaved off with the loop alone or grasped with the forceps in the loop first (Figure 14-24).

FIGURE 14-24 An electrosurgical loop on a cutting instrument is about to transect an eyelid skin tag. Local anesthetic was injected prior to cutting with RF current. This method allows for cutting and coagulation simultaneously, thereby avoiding getting blood or hemostatic chemicals into the eye.

(Copyright Richard P. Usatine, MD.)

Telangiectasias

Telangiectasias (Figure 14-25) are fine veins (“spider angiomas,” “spider veins”) that occur commonly on the face and legs. Laser treatment can be effective but is more costly and is not as readily available as sclerotherapy or electrosurgery. Very fine veins of the lower extremities may do well with laser but generally, sclerotherapy is the treatment of choice for lesions 1 to 5 mm that are extensive. Unless the veins are very focal on the legs, RF/electrosurgery does not perform well. Facial veins are usually more limited and, without the hydrostatic pressure that is present in the legs, treatment with electrosurgery can provide excellent results. Fine telangiectasias on the face are the best candidates since anything over a diameter of 1 mm is likely to bleed and persist. As with all procedures, discuss the risks and benefits of electrosurgical treatment and obtain informed consent before proceeding. Treatment of these lesions is generally for cosmetic reasons so it is even more important to review the various options and the possible complications.

FIGURE 14-25 (A) Electrosurgical treatment of facial telangiectasias using a sharp disposable electrode with approximately 2 W of energy and no local anesthetic. (B) Electrocoagulation of nasal telangiectasias using a specialized epilation needle. The tip of the needle is inserted into the telangiectasias and the current is actuated for approximately 1 second.

(Copyright Richard P. Usatine, MD.)

Before treating telangiectasias discuss with the patient the pros and cons of using topical anesthesia.

1. It is possible to treat without anesthesia in many cases. Areas around the nose, however, are especially sensitive. If a topical anesthetic is used, allow it to remain in place at least 15 minutes. Injecting the area with a local anesthetic can obscure the lesion.

2. Choose a fine-needle (33-gauge) electrode or sharp tip of the Hyfrecator electrode. The Ellman company provides fine-needle electrodes for the Surgitron that are specially coated with Teflon for treating telangiectasias. This limits burning of the overlying skin. Only the very tip is active while the rest of the needle is shielded. ConMed also provides fine-needle electrodes for use with the Hyfrecator.

3. Magnification loops are very helpful since the smaller telangiectasias respond best and will be more easily identified.

4. Use a low-power coagulation/hemostasis setting. For the Ellman, 2 W work well. Use 2 to 2.5 W for the Hyfrecator.

5. Wipe off the topical anesthetic if used. With the patient in a supine position to limit movement, insert the fine needle into the vein superficially, enough to penetrate into the lumen. The needle may even pass through the small diameter vessel but remain as close to the surface as possible to limit tissue damage. Do not cannulate the vein; instead, place the needle in a perpendicular position to it. Generally, it is not helpful to find the “feeding trunk” since the entire vein will need to be treated anyway or they will recur. If the “feeder” is treated first, the vessel may go into spasm, making the remainder of the vein hard to find. With this in mind, start distally with the smallest part of the vein and march toward the central (larger portion) of the vessel. Keep the electrode activated and just “tap” into the vein every 3 mm along the entire path. The hand holding the handpiece should rest on the patient so that it moves with the patient should the patient suddenly jerk or pull away.

6. Bleeding is not uncommon, especially as the vessels become larger. Cautiously turn up the power slightly. If this does not help, apply pressure. If the vessel continues to bleed, it is likely that it is not occluded and chances for recurrence are higher.

Complications include the discomfort while doing the procedure, bleeding (controlled with pressure), recurrence, and persistent red or brown marks. The discoloration generally clears but takes time and is more common if the power is set too high or if sensitive skin is treated. If the vessels are extensive and very fine or, very “large” such as those seen with rhinophyma and rosacea, it is best to go with a laser treatment. Limited sclerotherapy is also an option that provides excellent results if the vessels are large enough to cannulate.

Warts (Verruca Vulgaris)

Patients seek treatment for warts (lesions caused by the human papilloma virus/HPV) because warts can cause pain, can be unsightly, and can spread to other parts of the body or to other individuals. HPV can infect many parts of the body. In this section, we will only address those HPV infections of the skin: verruca vulgaris, plantar warts, and planar (flat) warts.

In general, most warts can be treated effectively and easily with cryotherapy as described in Chapter 15 or with intralesional injection as discussed in Chapter 16. Patients may even use topical agents effectively at home. However, some warts are refractory to all treatments. Also, if the warts are small (a few millimeters) and there are only a few lesions, electrosurgery has the advantage of allowing the physician to obtain good cure rates with a single in-office treatment. Electrosurgery offers the advantage that the complete removal of the wart can be seen at the time of treatment. With cryotherapy, one must base treatment on the size of the ice ball halo, the freezing time, and most importantly the thaw time. Cryotherapy and intralesional injection methods are more likely to require multiple visits for treatment. Cryotherapy may be more painful in the days that follow the treatment and it frequently leads to an open wound (as does electrosurgery) or a blister.

Electrosurgery of warts always requires local anesthesia. If treating the digits (Figure 14-26), local infiltration with epinephrine-free anesthetic or a digital block should be used. In some cases, local infiltration with lidocaine and epinephrine can be used if the digital artery is avoided. For other locations, the use of epinephrine in the local can aid in obtaining a blood-free field. Fulguration or electrodesiccation/coagulation/hemostasis settings are used to destroy the wart (Figure 14-26B). Refer to Tables 14-1 to 14-3 for power settings. The ball or pointed tip electrode is generally used. With smaller lesions, desiccated tissue is then wiped away with a moist gauze or a curette (Figure 14-26C). If any wart tissue remains, the remaining tissue should receive additional electrosurgery and be wiped away until the final deep layer shows a uniform clear dermis (Figures 14-26D and E). The base of the lesion, however, is often charred by the treatment obscuring the underlying tissue so this needs to be wiped off to inspect the base. Warts are an epidermal lesion so care should be used not to penetrate through the dermis.

FIGURE 14-26 (A) Common wart not responding to cryosurgery. (B) Electrodesiccation with the Hyfrecator and smoke evacuator. (C) Charred tissue removed with gauze. (D) Repeat electrodesiccation. (E) Immediate result.

(Copyright Richard P. Usatine, MD.)

If the wart is large and protuberant, the tissue can be shaved off first (“debulked”) with a scalpel, curette, or a loop electrode using a cutting or cut/coag setting. Caution is in order to ensure that the excision does not go too deep. Also, warts are very hyperkeratotic and thus very dry, so the electrosurgical application may not work. Soaking with a moistened 4×4 gauze or with K-Y jelly beforehand will help. An alternative way to remove the bulk of the tissue is to use a sharp curette. After “debulking,” the residual base can then be coagulated and wiped away. Care should be taken not to burn surrounding tissue excessively, which can cause painful permanent scarring. In the fingers, use care to avoid the digital nerves and arteries on the sides of the digits.

There is no special benefit to using RF methods in the destruction of warts unless the debulking process will include loop debulking.

Possible general complications include significant pain, recurrence, and hypopigmentation and scarring. Caution must be used on the plantar surfaces because scarring can cause long-term problems of pain with ambulation. Treatment around the nails may lead to deformities of the nail if the matrix is injured. In some instances, before resolving, treatment can induce a paradoxical reaction where the wart may grow or multiply.

Malignant Lesions

If the nature of a lesion is in doubt, it is always best to biopsy it before definitive treatment. As one gains experience, some lesions may be able to be treated on the day of the first evaluation when they have a “classic” clinical history, appearance, and “feel.” All tissue specimens are best sent for histologic confirmation whether they were biopsied previously or not. Shave or curettement biopsies are generally adequate for NMSCs. If the lesion is potentially a melanoma, a full-thickness biopsy should be performed with no further electrosurgical treatment. Performing wide excisions on a “presumed” diagnosis is costly, creates more potential for complications, and often will over- or undertreat a lesion (see Chapter 8, Choosing the Biopsy Type).

Electrodesiccation and Curettage

Electrodesiccation and curettage (ED&C) is a useful method of treating NMSCs. It should never be used with melanomas. With curettement, one can feel where the soft tissue ends.

There are contraindications for using electrosurgery to treat BCC or SCC based on the histology and location. Sclerosing (morpheaform), micronodular, “aggressive” BCCs as well as SCCs in non–sun-exposed areas over 7 to 8 mm can be more aggressive and are best treated with excision. The superficial type of BCC or SCC in situ may be successfully treated with ED&C.

One study compared recurrence rates of 268 consecutive primary nonmelanoma tumors (BCCs and SCCs) treated by surgical excision or ED&C. The recurrence rates between the two types of treatment were not found to be significantly different.⁸ A meta-analysis of all studies reporting recurrence rates of BCC between 1947 and 1987 reported a 5-year recurrence rate of approximately 8% for ED&C.⁹

An analysis of recurrence rates of 2314 previously untreated BCCs removed by ED&C showed that increasing lesion diameter, high-risk, and middle-risk anatomic sites were independent risk factors for high recurrence rates.¹⁰ From 1973 to 1982 the following recurrence rates were found (Figure 14-27):

FIGURE 14-27 Risk stratification for basal cell carcinoma on the face and head.

(From Robinson J, Hanke W, Sengelmann R, Siegel D. Surgery of the Skin: Procedural Dermatology, 2nd ed. Philadelphia: Mosby; 2010.)

• Low-risk sites (neck, trunk, and four extremities). BCCs of all diameters responded well to curettage-electrodesiccation with an overall 5-year recurrence rate of 3.3%.

• Middle-risk sites (scalp, forehead, preauricular and postauricular, and malar areas). BCCs less than 10 mm in diameter had a recurrence rate of 5.3%.

• High-risk sites (nose, paranasal, nasal-labial groove, ear, chin, mandibular, perioral and periocular areas). Lesions less than 6 mm in diameter had a recurrence rate of 4.5%.¹⁰

The authors concluded that BCCs less than 6 mm in diameter, regardless of anatomic site, as well as selected larger BCCs depending on their anatomic site, are effectively treated by ED&C.¹⁰

Recurrence rates of primary NMSCs treated by excision versus ED&C ×3 were studied in a private dermatology practice. Tumors up to 2 cm in size were included. One percent of excised tumors recurred, whereas 3% treated with ED&C did. This study found the recurrence rates to be essentially the same in spite of the fact that they used electrosurgery to treat tumors larger than generally recommended. ED&C was quicker, less costly, has fewer complications, and the scars were often less.⁸

Organ transplant recipients frequently develop multiple SCCs. In one study, appropriately selected low-risk SCCs in 48 organ transplant recipients were treated by ED&C. Only histologically confirmed SCCs were considered in this study.¹¹ The mean follow-up time was 50 months, and 13 residual or recurrent SCCs were observed in 10 patients. The overall rate of residual or recurrent SCCs was 6%, with 7% for SCCs on the dorsum of the hands or fingers, 11% for SCCs on the head and neck, 0% for the forearms, and 5% for the remaining non–sun-exposed areas (shoulder, legs). In organ transplant recipients with many SCCs, ED&C can be a safe therapy for appropriately selected low-risk SCCs, with an acceptable cure rate.¹¹

Using ED&C with BCC or SCC: Step-by-Step Instructions

1. Inject the skin surrounding the lesion with 1% to 2% lidocaine with epinephrine.

2. Curette the softer tissue of a BCC first before using electrosurgery (Figure 14-28A). A sharp dermal curette, usually 3 to 5 mm depending on lesion size is used for this. Reusable curettes are adequate but must be sharpened periodically. Disposable curettes are always sharp but clinicians need to be careful to not remove normal tissue since they can cut through normal tissue if too much pressure is applied. Curettement is effective because the BCC is softer than the surrounding normal skin and it also has a characteristic almost gelatinous appearance. (Ice cream provides a good analogy. Think of normal tissue as being hard, frozen ice cream. It is difficult to scoop it out compared to somewhat thawed ice cream, which is very easy to scoop out. Neoplastic tissue is softer like the thawed ice cream because of abnormal connections between cells. Exceptions include morpheaform BCCs and keratoacanthomas.) The abnormal tissue is removed by scraping with the curette in all directions.

3. Then fulguration is performed at the base of the lesion including 2 mm of the surrounding normal tissue (Figure 14-28B). The general rule for a BCC is that a margin of 3 mm of normal tissue should be removed with an excision. ED&C provides this margin. Many will curette with a larger curette first (5 to 7 mm), then follow with a smaller curette (3 mm) purportedly to remove any small pockets of tissue. Although this is an interesting idea, it has not been clinically proven.

4. Two additional cycles are performed for a total of three cycles (Figure 14-28C). Treatment time is 5 minutes or less.

FIGURE 14-28 (A) Curettage of a nodular basal cell carcinoma on the arm. (B) Electrodesiccation after curettage of the BCC. (C) Final electrodesiccation after the third cycle of curettage. The blunt electrode is moved back and forth across the treated area and a small margin of normal tissue is treated using a circular motion around the periphery.

(Copyright Richard P. Usatine, MD.)

One caveat is that should the curettement penetrate into the subcutaneous fat, it indicates either that the tumor has invaded deeply or that the curettement was overzealous. It is best to perform a full excision at that point.

Realize that an initial shave excision or the curetted pieces are likely to be read as “margins positive” by the pathologist. Indicate in the EMR and/or on the requisition and the final report that “Margins will be positive due to nature of the procedure.” This will at least document that the report was reviewed and considered.

The wound may take 3 to 4 weeks to heal, usually with some hypopigmentation. It is essential that the patient understand the principles of moist healing and adhere to them.

Learning the Techniques

Regardless of the unit used, it is possible to practice the electrosurgery techniques with a piece of uncooked beef steak. The steak should be a fresh, inexpensive cut of steak that is not too fatty and without many tendinous attachments. Pig’s feet can even be used (e.g., after a suturing workshop). It is not necessary to use a smoke evacuator while practicing on meat, but there will be the smell of a foul barbecue!

Practicing with the Hyfrecator

To practice with the Hyfrecator, the meat should be touched broadly with the nonoperating hand to create a ground. Begin with the handpiece plugged into the low setting. Practice activating the handpiece and coming close to the steak until the sparks of fulguration appear. Turn up the current to see how the sparking and tissue destruction (cooking of the steak) increase. Try the same exercise with the electrode touching the beef to produce electrodesiccation. Then plug the handpiece into the high setting. Observe the increased destruction of tissue.

Practicing Radiosurgery

Follow these guidelines for practicing with the Ellman Surgitron and other high-frequency units:

1. To practice cutting with the Surgitron, the meat should be placed on a paper towel sitting on top of the “antenna” plate. Begin with a round wire electrode (either small or large, with the latter requiring slightly more power but providing a flatter excision) in the handpiece, and set the unit to “cut” on a mid-range setting. Be sure the meat is moist and not dried out on top. Cut through the meat, keeping the loop at a right angle to the tissue. Perform the usual sequence and activate the electrode before touching the meat to provide a smooth cut with minimal tissue damage. Compare how this looks and feels to activating the electrode after touching the meat. Note that when doing it this way, the electrode will often not cut at all.

2. Repeat this exercise after turning the power up to a much higher setting and observe more spark and smoke. The tissue will also have more char (damage). The ideal setting will provide enough power to cut smoothly through the meat without catching (“stalling”), and yet leave little tissue damage behind.

3. Now turn the power to a low setting. Note how the electrode drags. Determine which setting will allow the electrode to move through the meat without either sparking or a drag. Try this with a forceps holding the meat before activating the loop. Be sure to grasp the tissue with the forceps through the loop before starting the cutting.

4. Practice making true vertical incisions in the meat using the Vari-Tip electrode, again on the “pure cut” setting. Change the length of the electrode to see how the depth of the cut can be varied. Increase and decrease the power as above.

5. Remove the antenna plate (neutral electrode) from under the meat and try cutting with a loop on a setting that was optimal. Note that it is almost impossible to cut at all. Increasing the power may allow cutting, but there will be more tissue burn artifact. This demonstrates the value of having the neutral electrode close to the lesion.

6. The cut and coagulation setting should also be tried to feel how the electrode moves slightly more slowly through tissue with comparable power settings. The power most likely will have to be increased for a “smoother” cut.

7. Try the above exercises in the coagulation setting with the wire loop. Unless the power is set very high, the loop will not cut. Coagulation can be accomplished with any electrode (ball, pointed tip, fine needle/Vari-Tip) but most commonly will be used with the ball electrode. Use a light touch, barely touching the tissue while moving the electrode gently over the area to be coagulated. The electrode must be activated before touching the meat and works best when used in a gentle tapping fashion. If excessive char builds up, it must be wiped away or moistened for the tip to be effective. Bleeding can be controlled in a surgical field by grasping the bleeder with forceps or hemostats and touching any active electrode to the instrument.

One method that can be used to test ESU cutting settings on the patient without consequences to healing is to remove the tissue of concern with a circle before finishing the ellipse with two additional triangles. This circle will not be the area that needs to heal for the patient and therefore will allow for evaluation of the settings before the final cuts are made (Figure 14-29).

FIGURE 14-29 Testing the electrosurgical cutting settings on a patient without consequences to healing. The melanoma in situ is being cut out with a circle before finishing the ellipse with two additional triangles. This circle will not be the area that needs to heal for the patient and therefore will allow for evaluation of the settings before the final cuts are made to complete the ellipse. The setting is excellent as there is no bleeding and no excessive char. The Vari-Tip electrode moved smoothly through the tissue without dragging or sparking.

(Copyright Richard P. Usatine, MD.)

Coding and Billing Pearls

Electrosurgery is one modality used throughout dermatology for diverse procedures. When electrosurgery is used for tissue destruction, coding is based on the skin destruction codes found in Tables 38-5, 38-6, and 38-11 of Chapter 38, Surviving Financially. Benign and premalignant tissue destruction has essentially been divided into three types of CPT codes based on these diagnoses:

• Skin tags: 11200, 11201

• Benign other than skin tags or cutaneous vascular lesions (includes warts and seborrheic keratoses): 17110, 17111

• Premalignant (actinic keratoses): 17000, 17003, 17004.

(Note that laser destruction of cutaneous vascular lesions has separate codes.)

The general destruction codes shown in Box 14-2 are usually independent of the method of destruction and the location of the lesions. However, for destructions of benign lesions, certain specific parts of the body are reimbursed at a higher rate including the anus, penis, vulva, vagina, and eyelid. The CPT codes and typical fees charged for these are detailed in Table 38-6 of Chapter 38. Do not forget to use these codes because they do pay better than 17110 and 17111. These specific location codes are not based on the exact number of lesions and a single lesion may be reimbursed the same as many lesions.

Box 14-2 CPT General Destruction Codes

11200 Removal of skin tags by electrosurgery or any other technique, any area, up to and including 15 (billed once only)

11201 Removal for each additional 10 lesions or portion thereof (may be billed more than once)

17110 Electrosurgery (destruction any means) warts/benign lesions other than skin tags up to 14 lesions (this is a single code used once only regardless if 1 or 14 lesions are treated)

17111 15 or more lesions (stand alone code, not per lesion)

17000 Electrosurgery (destruction any means), all premalignant lesions (AKs), first lesion

17003 Second through 14th lesion (this code is billed for each lesion from 2 to 14) (charge each lesion)

17004 15 or more lesions (stand-alone code, not per lesion)

Insurance companies will not pay for removal of skin tags unless there are documented medical reasons (strangulation, pain, or bleeding). Even with documentation many skin tag removals will be denied payment. When patients just do not like the looks of them, the procedure is considered a cosmetic removal. In this instance, patients should be advised in advance that they will be responsible for payment and an estimate should be given. Interestingly, an office visit E/M code can be charged to insurance but the removal fee is the patient’s responsibility.

Note that malignant skin destruction codes (Table 38-11 in Chapter 38) are based on size and location of the cancer and not on the type of skin cancer. Electrodesiccation and curettage of BCCs and SCCs are reimbursed based on these codes.

When electrosurgery is used for cutting or coagulating during a biopsy or excision, there are no additional codes for this. The electrocoagulation is part of the procedure just as giving the local anesthetic is.

A specific code is used for rhinophyma correction. CPT code 30120 is used for excision or surgical planing of skin of nose for rhinophyma. The national Medicare reimbursement rate is $492.