Experience tells you what to do and what not to do; confidence allows you to do it.
Radiofrequency (RF) surgery is one of the most enterprising tools in dermatologic surgery. I dare to say so because this tool gives you ample scope to not only improvise the surgical methods but also to refine approaches to suit today’s need of becoming aesthetically pleasing. Just as technological advances have revolutionized surgery from large incisions to laparoscopic miniaturization, radiofrequency surgery has refined dermatologic surgery from a primitive destructive method to a minimally invasive one.
This and the following three chapters will cover all the applications I have been practicing for the last 18 years when I first started using RF surgery in my clinic. It has been a very interesting period and a very satisfying one as well.
I started RF surgery in May 1999. Earlier I was using electrocautery, cryosurgery, and chemical cautery. As advised, I practiced all the waveforms on meat pieces before starting RF surgery on my first patient. My first patient was a case of single periungual wart on a finger. The patient was prepared for RF surgical excision under local anesthesia in my clinic’s procedure room. After giving local anesthesia, I set the machine on “fully filtered current.” A round loop electrode was fully inserted inside the handpiece. The power was set at 3. The wart was hydrated with a normal saline solution. I started the procedure by holding the electrode at a right angle to the wart and tried excising the wart. But the electrode dragged and got stuck in warty tissue. With some effort I detached the electrode to restart cutting. I increased the power to 5, but still I could only cut the wart in half and felt the need to increase it further. So I increased it to 6. To my surprise I cut through the wart within a split second but went farther down into the dermis leading to profuse bleeding. This alarmed me. The wart was fully excised but the last stroke with a slightly higher power caused a deeper cut than expected. Having never done dermatologic surgery with a scalpel in dermatology practice, I was very panicky to see profuse bleeding even though it was of capillary origin. I tried pressure hemostasis and electrocoagulation but that failed to stop it. Since I was not very confident using electrocoagulation, which as I mentioned requires a superficial touch, I finally called my surgeon friend who helped to stop the bleeding with hemostatic solution.
This incident for me was the only one of its kind. The reason I narrate this incident is that as dermatologists we get very panicky on encountering hemorrhage during operation, whereas our surgeon friends deal with it daily.
Radiofrequency surgery technique has changed my career to a flourishing one and this case was the start of it.
My second case was that of a few skin tags around the neck of a young lady. I excised all of them under local anesthesia. I was happy to have the procedure work well, but the patient had a lot of pain during the week until all postoperative wounds fully healed.
The third case was also of skin tags on the neck and in the axillae. I considered desiccating all of them under local anesthesia and followed this to experience a far more comfortable patient till all lesions fully cleared.
Next was a case of multiple warts over a knee. A few were treated using electrocautery by a dermatologist colleague. I would not have had any other opportunity better than this to compare both techniques. The warts treated by electrocautery healed with atrophic scars and the child’s mother was very upset. I gave them hope of the newer RF technique for a better outcome and excised them under local anesthesia. The result really proved the superior postoperative outcome of RF surgery.
Cases of milia, molluscum contagiosum, and dermatosis papulosa nigra on the face have been a matter of cosmetic concern. There were no specific references pertaining to each of these indications, but Dr. Sheldon Pollack’s book Electrosurgery of the Skin has guidelines for using electrodesiccation for various papilloma, skin tags, and so on. On those guidelines, I treated the aforementioned lesions with good results, but there were problems of postinflammatory hyperpigmentation and scarring in some cases.
As new indications came up, with few references in literature, I made some trials and errors to develop new applications based on the finer properties of RF–tissue interactions. Of course, this also required proper knowledge of histopathology of the treated lesions.
I started experimenting with the knowledge of RF–tissue interaction, RF waveforms, all points related to lateral heat dispersion into tissues, and histopathology of various skin lesions to be treated put together to use radiofrequency surgery for the common indications in dermatologic surgery. Once I was confident in using radiofrequency surgery, I further continued experimenting for newer indications.
I soon realized that radiofrequency surgery modality is a versatile method having many indications in dermatologic surgery. It was further realized that this same method can be used for nonsurgical facelifts or skin tightening. Discussion of this indication is beyond the scope of this book.
I classify the applications of radiofrequency surgery broadly as therapeutic and diagnostic.
Therapeutic application of radiofrequency surgery can be further classified into ablative and nonablative:
Ablative—Here, the skin lesions are incised and/or excised using waveforms of either cut or blend with or without electrocoagulation.
Nonablative—Here, the skin lesions are simply desiccated or fulgurated using those respective waveforms (here, though the lesions finally cleared from skin, these lesions are not actually excised or cut during the procedure).
Therapeutic ablative applications (excision) are the among the most common for which radiofrequency surgery is used. Facial and neck lesions amount to more than 50% of the share. People nowadays are very concerned about any and all blemishes on the face, from simple moles to freckles to postacne hyperpigmented spots to warts to new growths to larger moles and cysts. The age group is not the criteria because I see many middle aged and elderly aged ladies and gentlemen walking in my clinic to seek advice for removal of their blemishes on exposed portions of the face and neck that spoil their looks. It is the awareness, medical (fear of skin cancer), or cosmetic concern for which they come prepared to spend.
Therapeutic nonablative applications (desiccation/fulguration) form at least 30% of the total share of radiofrequency surgery patients. These are some of the relatively easier applications but are monetarily rewarding.