ELECTROSURGERY AND CRYOSURGERY

Electrosurgery is used to destroy benign and malignant lesions, to control bleeding, and to cut or excise tissue. (1-3) Electrosurgery is simple to perform and is useful for treating a variety of skin lesions, especially small superficial lesions (skin tags and small angiomas). The major modalities in electrosurgery are electrodesiccation, fulguration, electrocoagulation, and electrosection.

Modern, high-frequency electrosurgical devices transfer electrical energy to human tissue via a treatment electrode that remains cool. Most electrosurgical units work at frequencies just below the AM radio frequency band. The electrical resistance of human tissue helps convert this electrical energy into molecular energy, which causes denaturation of intracellular and extracellular proteins, resulting in coagulation or desiccation effects. Raising intracellular water above the boiling point causes cell membrane rupture to produce a cutting effect

Electrosurgery has many applications in cutaneous surgery: incisional techniques that produce full-thickness excision of nevi; shave techniques that produce partial-thickness removal of superficial lesions, such as warts, without the need for suturing; and removal of vascular lesions such as hemangiomas or pyogenic granulomas with little or no blood loss. Electrosurgery has become familiar to family physicians who treat cervical dysplasia using the technique of loop excision of the transformation zone of the cervix. This technique is performed using the same electrosurgical equipment and procedures as in skin surgery.

Electrosurgery is often incorrectly referred to as electrocautery. In electrocautery, the electrode tip, rather than human tissue, serves as the source of electrical resistance. In electrocautery, the electrode tip becomes hot and can cause a burn in tissue. While electrocautery is a form of electrosurgery, it is inaccurate to refer to electrosurgical techniques that use a cool electrode tip as electrocautery.

Electrodesiccation and Fulguration
In electrodesiccation, an active electrode touches or is inserted into the skin to produce tissue destruction. Electrodesiccation can be used to treat fine telangiectasias and spider angiomas. In fulguration, the electrode is held away from the skin to produce a sparking at the skin surface and more shallow tissue destruction.

Fulguration is especially useful in treating superficial epidermal lesions, such as a superficial basal cell carcinoma of the trunk.

Electrocoagulation

Electrocoagulation is ideal for clotting small blood vessels (less than 2 to 3 mm in diameter) in deep and superficial surgery. Usually, a 2- to 5-mm metallic sphere at the end of a treatment electrode is the optimal tip for hemostasis of small vessels. These electrode tips can be directly applied to the relatively dry surface of a surgical bed that has been momentarily compressed or used indirectly by touching a hemostat or Adson's forceps which is used to grasp the small bleeder.

Electrosection
In electrosection, the electrode is used to cut tissue. An electrode tip in the shape of a fine needle, wire loop, diamond, ellipse, or triangle is advanced slowly through the tissue, causing a steam envelope to advance around the tip and producing a smooth cutting effect with little sense of pressure against the tissue by the operator.

This minimization of power produces a specimen with minimal heat damage along its margins and clinical wound healing the same as when surgical steel blades are used. The specimen should be acceptable for pathologic interpretation compared with specimens produced with laser techniques. Wound edges can be approximated with sutures when an excisional biopsy is performed. Cosmetic results are similar to those seen with scalpel and suturing.

Cryosurgery
Cryosurgery is a highly effective treatment for a broad range of skin problems. . Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most areas of the body. Spray methods include the timed spot freeze technique, the rotary or spiral pattern, and the paintbrush method. Benign skin lesions that are suitable for freezing include actinic keratosis, solar lentigo, seborrheic keratosis, viral wart, molluscum contagiosum, and dermatofibroma.

Cryosurgery requires little time and fits easily into the physician's office schedule. Advantages of this treatment include a short preparation time, low risk of infection, and minimal wound care. In addition, cryosurgery requires no expensive supplies or injectable anesthesia, and the patient does not have to return for suture removal.

Potential side effects include bleeding, blister formation, headache, hair loss, and hypopigmentation, but rarely scarring. Skin lesions often can be treated in a single session, although some require several treatments.