7
Chapter
Electrosurgery
Oliver J. Wisco and Paula S. Vogel
Clinical overview
The utilization of electricity to cause thermal tis-
sue destruction has revolutionized the approach
to surgery. This chapter discusses the basic sci-
ence and the various types of electrosurgery, and
how they can be utilized effectively in dermato-
logic surgery.
Basic science and terminology
Key Points
• The interaction of the electricity principles of
current, resistance, voltage, work, and power
determine the functionality of an electrosurgical
unit.
• Whether an electrosurgical unit is monoterminal
or biterminal will determine the spread of the
electrical current through the patient.
Electricity principles (Table 7-1)
Pearl
• Tissue must be patted dry before using an elec-
trosurgery unit as blood decreases the resist-
ance and prevents heat from being generated.
Waveform (Table 7-2 & Fig. 7-1)
• Shape of the electromagnetic fields generated
from a high-frequency alternating current.
• Determines the effect of the current on the
tissue.
Pearls
• Spark-gap electrosurgery units are typically used
for electrodessication, electrofulguration, and
electrocoagulation.
• Vacuum-tube electrosurgery units are typically
used for electrosection.
Monoterminal versus biterminal
The terms monopolar and bipolar are misnomers.
Instead, “monoterminal” and “biterminal” should
be used, as electrosurgery does not use electrodes
that are true positive or negative poles.
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Monoterminal
• Only one electrode delivers current to the
patient and electrons are randomly dispersed
to the environment.
• Used in electrodessication and
electrofulguration.
Biterminal
• Two electrodes are applied, with the current
flowing from one electrode to the other to
complete an electrical circuit.
• Used in electrocoagulation and electrosection.
Medical treatment options
Key Points
• Preoperative assessment is crucial when
performing electrosurgical procedures.
• Electrodessication, electrofulguration,
electrocoagulation, and electrosection are the
four types of electrosurgery.
Preoperative assessment
• Determine risk for excessive blood loss.
• Determine risk for poor wound healing.
• Identify patients with cardiac pacemakers
and implanted cardiodefibrillators as
electrosurgery may cause these devices to
malfunction.
• Have the patient remove all metal objects,
including jewelry, prior to surgery.
Electrosurgical procedures
Outlines of the procedures of electrodessication,
electrofulguration, electrocoagulation, and elec-
trosection are shown in Tables 7-3 & 7-�4.
Electrosurgery adverse reactions
See Box 7-1
Pearl
• Superficial electrosurgical wounds heal by
secondary intention and require only standard
postoperative wound care.
102 Dermatologic Surgery

Table 7-1  Electricity principles

Principle Definition Units Pearls/Application
Current Flow of electrons through a conductor per second Amperes The thinner the electrosurgical tip,
the greater the current density,
• Density = current/conductor cross-sectional area
resulting in greater tissue
destruction
Direct Electron flow is in one direction Used in iontophoresis and
electrolysis
Alternating Electron flow is constantly alternating direction; Frequencies of 500–2000 Hz generate
with high frequencies there is no cellular heat with no/minimal neuromuscular
depolarization resulting in the generation depolarization
of heat
Resistance A conductor’s ability to impede the passage of an Ohms Muscle: low resistance
electric current
Fat: high resistance
• Directly proportional to the length of the substance Skin: high when dry, low when wet
• Inversely proportional to the cross-sectional area
Voltage Electrical force that induces electron flow Volts Little heat is created with low
resistance
• Current flows from high to low electron
concentration
• Volts = current × resistance
Work Current flow over a distance due to voltage Joules Tissue resistance to current results
difference in heat generation
• Work = force × distance
Power Rate of heat generated due to tissue resistance Watts (joules/s) Power increases are greater with
to the passage of current created by a voltage increased current rather than voltage
potential
• Power = current × voltage

Tissue effect
Table 7-2  Waveform factors Continuous, undamped

Factor Description Pearls/Application

Undamped Pure sine wave Pure cutting Pure cutting
with minimal
hemostasis
Damped Amplitude Greater dampening Continuous, damped
decreases causes increased
progressively tissue destruction
and hemostasis Cutting and
coagulation
Continuous Uninterrupted Increased tissue
waveform heating, due to
longer current flow
Discontinuous, undamped
Discontinuous Interrupted Decreased tissue
waveform heating, due to
shorter current
Pure cutting
flow

Discontinuous, damped
Surgical approach (Box 7-2)
Key Points Desiccation and
coagulation
• Multiple conditions can be treated with
electrosurgery. The most common are those with
a superficial process.
• Electrodessication and curettage is an effective Figure 7-1  Types of waveform. Adapted from Robinson
option for superficial cutaneous malignancies. et al (2005) with permission from Mosby Publishing

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 7

Chapter
Electrosurgery 103

Table 7-3  Electrodessication and electrofulguration

Electrodessication
Use: superficial destruction, capillary hemostasis
Properties: monoterminal, high voltage, low amperage
Description: Touch the electrode to the skin to cause direct
superficial tissue dehydration with resultant damage localized
to the epidermis with lower settings. Higher power settings can
cause scarring due to dermal involvement
Electrofulguration
Use: superficial destruction
Properties: monoterminal, high voltage, low amperage
Description: Hold the electrode 1–2 mm from the skin to cause
superficial skin dehydration through sparks with resultant damage
localized to the superficial epidermis

Superficial tissue Sparks cause superficial

No electrode
Electrode dehydration epidermal carbonization
contact
contact

Epidermis Epidermis

Dermis Dermis

Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.

Electrodessication and curettage • The element is very hot in electrocautery,

• Used for the treatment of superficial benign
and malignant neoplasms.
• Sequence of curettage followed by
electrodessication repeated two or three times.
• Not effective for deeper lesions or lesions that
extend down the hair follicles.
• Limited use in areas of high cosmetic
importance due to the risk of scarring.
Comparative outcomes
Key Points
• Electrocautery is not a true form of electrosurgery
as no current flows through the patient.
• Electrosection primarily has the benefit of a
faster incision time and less incisional blood loss
compared with scalpel surgery.
Electrocautery
• Low voltage, high amperage and direct or
high-frequency current that heats an element
causing superficial tissue destruction or
hemostasis through the direct transfer of heat.
• Useful in the setting of an implanted cardiac dev­
ice as no current is transferred into the patient.
whereas the electrode in electrosurgery
remains cool.
Electrosection versus conventional
scalpel surgery
• Incisional time and incisional blood loss are
less for electrosurgery.
• There is no significant statistical difference in
infection rate or healing time.
• Electrosection may have a superior cos­metic
outcome and decreased postoperative
pain.
Controversies
Key Points
• One of the most important issues when
employing electrosurgery is its use in the
setting of implanted cardiac devices such as
pacemakers and automatic defibrillators.
• Bipolar forceps are useful in the setting of
implanted cardiac devices as the forceps’ electrode
tips allow pinpoint electrocoagulation without
the spread of electrical current to the rest of the
body.

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104 Dermatologic Surgery

Table 7-4  Electrocoagulation and electrosection

Electrocoagulation
Use: deep tissue destruction, arteriole hemostasis
Properties: biterminal, low voltage, high amperage
Description: Place indifferent electrode on opposite side of the
body from the surgical site. Touch the electrode to the skin to
cause direct deep tissue destruction and coagulation
Electrosection
Use: tissue cutting
Properties: biterminal, low voltage, high amperage
Description: Place indifferent electrode on opposite side of the
body from the surgical site. Apply the electrode to the tissue
in the same fashion as incising with a scalpel, but with less
pressure, to cut through the tissue. Undamped current allows
cutting without coagulation, whereas damped current causes
cutting with coagulation

Electrode contact and

Deeper tissue tissue cutting with
Electrode coagulation or without coagulation
contact

Epidermis Epidermis

Dermis Dermis

Indifferent electrode Indifferent electrode

Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.

B ox 7 - 1

Electrosurgery pitfalls and their management

Burns • The surgeon should not make or break contact with the
patient during current delivery.
• Use a nonflammable cleanser such as chlorhexidine or
povidone–iodine.
Transmission of infection
• Avoid alcohol cleanser, ethyl chloride anesthesia, and flowing
oxygen. • Use a smoke evacuator with the intake nozzle 2 cm from the
operative site.
• Ensure that the indifferent electrode has broad contact with
skin and is not placed over a bony prominence, scar tissue, or • Wear a surgical mask and eye protection when working with
implanted metal. human papillomavirus-related lesions.

• Ensure the patient is not touching grounded metal objects. Eye injuries
• Place the indifferent electrode away from vital structures to • Avoid using treatment electrode close to the eye, if
decrease the risk of current channeling into a substance that is possible.
more conductive than skin (e.g. nerve or vessel), especially if
it leads to an isolated region such as the penis or finger. • Use plastic corneal shields if working close to the eye.

Electric shock Interference with implanted cardiac devices

• Use a three-pronged receptacle that is not overloaded. • See discussion in the Controversies section.

• Do not use treatment table outlets.

Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.

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 7

Chapter
Electrosurgery 105

B ox 7 - 2 B ox 7 - 3

Common dermatologic indications Guidelines to minimize interference with

for electrosurgery cardiac pacemakers and implantable
cardiodefibrillators
Electrofulguration/ • Sebaceous hyperplasia
electrodessication Use the following:
• Squamous cell
(superficial skin • Bipolar forceps
carcinoma
ablation)
• Syringoma • Battery-operated heat generating electrocautery device
• Acrochordon
• Telangiectasia • Short bursts (<5 s)
• Actinic keratosis
• Trichoepithelioma • Minimal power
• Angioma (small)
• Verruca vulgaris • Ground away from device
• Basal cell carcinoma
(all locations) • Avoid electrosurgery near device (preferably more than
(superficial and nodular)
10 inches away)
• Bowen’s disease Electrosection (skin
• Epidermal nevus incision/excision)

• Hemostasis • Acne keloidalis nuchae

(capillary bleeding) • Blepharoplasty incision
• Lentigo • Debulking procedures Further reading
• Verruca plana • Hair transplant strip Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology.
• Seborrheic keratosis harvesting Edinburgh: Mosby, 2003.
• Rhinophyma repair Hainer BL. Electrosurgery for the skin. Am Fam
Electrocoagulation Physician 2002;66(7):1259–1266.
• Rhytidectomy incisions
(deep skin ablation) Massarweh NN, Cosgriff N, Slakey DP. Electrosur-
and undermining
• Angiofibroma gery: history, principles, and current and future
• Scar revision uses. J Am Coll Surg 2006;202(3):520–530.
• Angioma (large) Pollack SV. Electrosurgery. In: Bolognia JL, Jorizzo JL,
• Shave removal of benign
• Basal cell carcinoma skin lesions (fibromas, Rapini RP, eds. Dermatology. Edinburgh: Mosby,
(superficial and nodular) nevi, etc.) 2003:2197–2203.
• Bowen’s disease • Skin flap incisions and Robinson JK, Hanke CW, Sengelmann RD,
undermining Siegel DM, eds. Surgery of the Skin: Procedural
• Hemostasis Dermatology. Philadelphia: Mosby, 2005.
(arterial bleeding) • Skin resurfacing (under Soon SL, Washington CV. Electrosurgery, electro­
investigation) coagulation, electrofulguration, electrodessication,
• Hirsutism
• Surgical excision of electrosection, electrocautery. In: Robinson JK,
• Ingrown
malignant or benign skin Hanke CW, Sengelmann RD, Siegel DM, eds.
toenail matrixectomy
lesions Surgery of the Skin: Procedural Dermatology.
• Banal melanocytic nevi Philadelphia: Mosby, 2005:177–190.
Yu SS, Tope WD, Grekin RC. Cardiac devices and
Adapted from Bolognia et al (2003) with permission from Mosby Publishing electromagnetic interference revisited: new radio­
Company. frequency technologies and implications for der-
matologic surgery. Derm Surg 2005;31:932–940.

Dermatologic electrosurgery
interference with pacemakers
and defibrillators
The use of electrosurgery in dermatologic sur-
gery may cause interference with pacemakers
or defibrillators (Box 7-3). It is recommended to
­discuss with the patient’s cardiologist the need
for preop­erative/postoperative evaluation and/or
intra­operative monitoring.

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