Gems and jewels of radiofrequency surgery
Radiofrequency surgery is a marvelous technique. One can make effective use of all of its parts and functions to develop newer and novel applications. One can use the various waveforms for different indications, change electrodes to suit applications, bend electrodes to reach inside cavities or avoid adjacent tissue damage, use power from a minimum of 0.5–1 to 100 on a digital unit, perform small-hole surgeries, do epilation, do biopsies, and nowadays with flat or large dome-shaped electrodes do skin tightening in cosmetic dermatology.
While using the radiofrequency technique in practice I noticed that when I used it on a low power of 1 or 2 on the cut waveform and apply the round loop electrode finely at the margins of a depressed scar, I could literally shape the uneven skin surface of the scar at its edge to look better. Similarly, when I keep the thin wire electrode or straight needle electrode inside the bulk of the lesion (e.g., sebaceous cyst, neurofibroma, keloid) to be excised, kept the power above 4, and pressed the foot pedal for a few seconds, the concerned tissue would shrink or contract and flatten quickly to more than half of its original size. These two observations were amazing. I noticed this while working and experimenting in my early days of using radiofrequency surgery way back in 2000–2001.
This is how I started experimenting on deep, punched out scars of acne and trauma on the face. The ablative Er:YAG laser had just entered the aesthetic market to compete with the already present ablative CO2 laser. These were being used for acne scars then and dermatologists were learning these new aesthetic applications. Both lasers worked on the principle of photothermal vaporization.
While working on depressed or atrophic scars, I noticed that these scars had uneven or punched out edges that cast a shadow giving an ugly and unsightly appearance on the face. This shadowing effect was due to light physics that failed to reach the angulated portion of the edges of scars in the same intensity as the adjacent plane skin and the floor of the scars. The shadowing effect depends upon the angle from which the light falls on the scar. Light falling from the front, that is, perpendicular to the skin surface where the scar is, causes less shadowing effect compared to when falling from one of the sides or when there is uneven light in the same room or when it is twilight or when one is viewing the same scar in a room under artificial tube lights or LED lights. Hence, the most important defect that needed correction was the sloping or punched out or uneven scar edges. If these could be improved or resurfaced to alleviate their slope, angle, and unevenness, then much was expected to improve the shape of scars to allow more light inside leading to an improved appearance. This was a matter of artistic use of the radiofrequency method to cause this resurfacing.
This idea of artistic use of RF method to significantly alleviate the shadowing effect was boosted by understanding the working of microdermabrasion. The microdermabrasion technique causes buffing of the skin surface to polish the skin surface, but the handpiece, which either delivers crystals or has diamond fraises when it touches the skin surface, pulls up the skin inside the small hole by the vacuum developed in the machine. When working with the microdermabrasion technique for some acne scars giving some overlap passes at the scar borders, I observed that some resurfacing of these borders was occurring to lessen the shadowing effect, and the scars appeared somewhat improved in three to four treatments. This I guess was not just due to the buffing effect but also to the pulling of uneven scar skin inside the probe by the vacuum generated and mechanically finely abrading the skin at edges to soften sharp edges. This simple technique allowed more light inside the scar to give the virtual effect of improvement without the scar floor getting uplifted.
I experimented further with this idea on a few more patients with deep scars on the face and elsewhere. I tried using a low power and round loop electrode on scar edges stretching the skin between two fingers of the inactive hand under local anesthesia. This led to widening of the scar dimensions, though the edges looked smoother than before and the shadowing effect did lessen.
After more experimentation, I finally came to the conclusion that if I lifted the selected deep scar between the index finger and thumb of the inactive hand and worked on the scar edges to level and soften the sharpness of edges or borders, I could find the virtual scar improvement effect much better without widening of the scar dimensions.
I realized that to improve selected deep and punched out scars I should be able to lift the scar between two fingers to a critical height so that the scar floor is also lifted in the pinch and looks flat or slightly convex. Only if I could hold this position, then I could go further to soften the edges.
Softening of sharp edges was done with a round loop electrode using the cut waveform and power set at 3 or 4. This was bloodless. This was a fine cutting or ablation and not abrasion. The ablation was continued on the whole circumference of the scar. The point to note here is that the convexity of the adjacent normal skin made cutting edges and leveling much easier than when there was concavity due to stretching of skin.
I would like to compare this observation with a saucer design for better understanding. I would compare stretching of a scar to a regular saucer design where the cutting with electrode would likely give a widening effect (Figure 15.1). Whereas, I would compare lifting of a scar to an inverted saucer design (Figure 15.2), where the cutting would lead to better softening of sharp edges and better blending with adjacent skin. This edge ablation is done until the sharp edge is made blunt and scar floor level (plane) almost matches with the adjacent skin level (plane).