Selection of surgical modality

Selection of surgical modality



Dermatologic surgical procedures are performed most commonly in an office. As I have said earlier, this surgery fits into the category of minor surgery. There are various modalities used in surgery from the gold-standard scalpel to the latest lasers. Each modality has certain properties of its own. These properties may be suitable for certain dermatologic surgeries but not all, considering the depth of lesion and requirement of cosmesis.


Salient features and advantages and disadvantages of all the surgical modalities are listed next. This will facilitate the reader to better understand radiofrequency surgery.




  • Scalpel surgery




    • Conventional method.



    • Simplest of all modalities.



    • Easy to arrange anywhere.



    • Does not depend on electricity.



    • Functions can be modified by changing the blades.



    • Requires skill to operate.



    • Intraoperative bleeding is a major disadvantage.



    • Cannot be used effectively for superficial epidermal skin lesions.



    • Very suitable for skin biopsy, incisional or excisional.



    • Cut is thicker than radiofrequency and lasers.



    • More postoperative pain and downtime compared to radiofrequency and lasers.



    • Chances of scarring are more compared to radiofrequency and lasers.



    • Suturing is a must for most cases.



  • Hyfrecator




    • Small inexpensive equipment working on electricity.



    • High frequency, high voltage but low current is used.



    • Unipolar equipment (no antenna plate) is commonly used in dermatologic surgery.



    • Portable, easy to shift, or carry to distant places for treatment.



    • Functions of electrodesiccation, fulguration, and electrocoagulation are used.



    • Good for superficial skin lesions of warts, skin tags, xanthelasma, and keratosis.



    • Good for vascular skin lesions.



    • Quick and effective modality for superficial skin lesions.



    • Local anesthesia infiltration is not required in most lesions; only surface anesthesia suffices commonly.



    • Skin lesions are literally destroyed by heat generation, which causes dehydration and necrosis, and the lesion remains sterile and stuck on, then desquamate in a week’s time with negligible scarring.



    • Vascular lesions may be treated repeatedly until final result.



    • Postoperative pain is minimal with one-week downtime.



    • Good cosmetic results.



    • Not useful for skin biopsy as the lesion is destroyed, hence biopsy must be done prior to treatment.



  • Electrocautery




    • Small, inexpensive equipment working on electricity.



    • Portable, easy to carry anywhere.



    • Popular among dermatologists.



    • Low voltage, high current is used.



    • Rheostat or resistor heats the electrode red-hot.



    • Heat of electrocautery either excises or destroys the skin lesions.



    • Good for coagulation, hence intraoperative bleeding is rare.



    • Effective for vascular lesions.



    • Good for superficial skin lesions like skin tags, xanthelasma, molluscum contagiosum, warts, granuloma pyogenicum, vascular lesions like hematoma, and hemostasis after excision of any skin lesion.



    • Easy to operate.



    • Some postoperative pain.



    • Postoperative downtime is more.



    • Postoperative healing is slow.



    • Residual scarring is more likely to occur due to tissue destruction by red-hot electrode.



    • Biopsy must be taken prior to electrocautery treatment.



  • Cryosurgery




    • One of the simplest and popular methods.



    • No electricity.



    • Liquid nitrogen is used commonly.



    • Containers and flasks containing liquid nitrogen need very careful handling.



    • Local anesthesia is uncommonly required.



    • Good results for superficial lesions of warts (cutaneous and mucosal), keratosis, skin tags, and molluscum contagiosum.



    • Good results for basal cell carcinoma, superficial squamous cell carcinoma, and hemangiomas in experienced hands.



    • Repeat treatments are necessary at intervals of 2 to 4 weeks for final results.



    • Recurrence in warts and molluscum contagiosum possible.



    • Can damage deeper tissues and superficial nerves in inexperienced hands.



    • Posttreatment pain can be significant in some cases.



    • Posttreatment hypopigmentation is common; takes a few weeks to months to recover.



    • Posttreatment scarring is possible due to unpredictable level of freezing around treated lesions.



    • Biopsy of treated lesion is possible by picking up the lesion with a punch or curette immediately after treatment, as the histology is not damaged in frozen lesion.



  • Radiofrequency surgery




    • Among the latest effective methods for dermatologic surgery.



    • Small portable equipment works on electricity.



    • Good quality equipment is at least five times the cost of electrocautery.



    • Equipment generates high-frequency radio waves above 1 MHz.



    • The higher the radiofrequency, the finer the cut.



    • Electrode remains cold throughout surgery, hence tissue damage is minimal.



    • Pressureless precise incision is hallmark.



    • Blending of cut and coagulation makes surgery dry and bloodless.



    • Very fine cutting ability leads to very clean postoperative wounds, faster healing.



    • Postoperative pain is much less.



    • Postoperative scarring is negligible, virtually scarless removal of lesions.



    • Very good for all kinds of dermatologic surgery.



    • Requires operative skills.



    • Very good alternative method for doing biopsy, as the lateral tissue thermal damage is minimal.



  • Ablative lasers




    • Latest equipment for dermatologic surgery.



    • Much larger in size, far more expensive (more than 20 times the cost of a good electrocautery).



    • Works on electricity.



    • Requires special training.



    • Two major varieties, namely, Er:YAG and CO2 lasers, are used.



    • Cut is thicker than radiofrequency.



    • Chances of charring are more in inexperienced hands.



    • Dermatologic surgery with lasers requires good practice to avoid scarring.



    • Postlaser pain is less compared to electrocautery and cryosurgery.



    • Postlaser downtime similar to radiofrequency surgery.



    • Er:YAG laser is good for superficial lesions only.



    • CO2 laser is good for superficial and deep skin lesions.



    • CO2 laser is good for vascular lesions, but not Er:YAG laser.



    • Postinflammatory hyperpigmentation is more common after CO2 laser than Er:YAG laser.



    • Postlaser scarring is minimal.



    • Laser teaching curve and experience is very important, without which chances of inferior results and cosmesis are very likely.



    • Higher maintenance costs.



    • Biopsy must be taken beforehand.


Some other dermatologic surgical modalities like the age-old chemical cautery and newer electrosurgery are not covered here. Chemical cautery is almost outdated and hardly practiced by today’s doctors, except by practitioners in nonurban areas and classical clinical dermatologists. Electrosurgery equipment has features similar to radiofrequency surgery. Electrosurgical equipment has frequency less than 1 MHz and the results are inferior, though the equipment prices are much cheaper than radiofrequency surgery equipment. I consider radiofrequency surgery as nothing but “modern electrosurgery.”

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Nov 6, 2018 | Posted by in Dermatology | Comments Off on Selection of surgical modality
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