Tips and tricks to minimize complications

Dermatologic surgery is fortunate not to have systemic complications as in other surgical specialties. That should not be an excuse for being casual in approach as any dermatologic surgery done without planning, with improper technique or equipment, or by inexperienced clinicians have potential to cause permanent complications on the skin. Though complications of scarring are far less with radiofrequency surgery does not mean one is safe.

Complications due to anesthetics

Before I discuss the postsurgical complications, I would like to caution about problems that may occur due to local anesthetic. Both surface and local injectable anesthesia can cause complications of allergy. Surface anesthesia using cream of lidocaine and prilocaine can occasionally cause itching, burning, or swelling on application. Though this is very rare, if noticed one must wipe it off immediately and clean the area thoroughly with nonsoapy cleanser. In that case the procedure may have to be postponed if the inflammation or rash is significant. Sometimes, a patient does not report mild symptoms before the procedure but reports it later when we will notice more-than-expected inflammation on the operated sites. This may lead to postinflammatory dyschromia. I have never seen vesicular eruption to surface anesthesia. The allergic manifestations can be easily noticed on eyelids than other areas when treating periocular lesions of milia, syringoma, and molluscum. I have experienced only nine cases of allergy to surface anesthesia in my use over 12 years. Injectable local anesthesia of lignocaine 2% with or without adrenaline may cause problems from vasovagal shock to frank anaphylaxis. Hence, a presurgical test dose is a must. Informing patients and relatives about such complications when the test dose is given is mandatory for immediate reporting.

Complications due to equipment, electrical inappropriateness, and electrode problems

Though the complications are uncommon, one should be aware of the following:

Equipment may stop working unexpectedly while doing surgery. This happens very rarely, and surgery will have to be performed using other equipment (which can never match the same features) and hence results are affected. I have had this experience once while working with my equipment when in between surgery of a mole I had to switch over to the available local make of radiofrequency equipment for the rest of my patients since I was at a distant place from my hometown. All my surgeries done later on the substitute machine showed inferior cosmetic results with scarring. This will never occur with a scalpel.
Improper electrical fittings and overused wires may sometimes cause shock. Electric power failure may unexpectedly occur and unless you have a generator or inverter backup, surgery will come to a standstill.
Overused electrodes may suddenly break during surgery and unless you have a spare one you may have to work with some other configuration electrode like a triangular or diamond-shaped electrode instead of a round loop electrode, or work with a larger round loop electrode when a small-sized round loop electrode breaks. Even newer electrodes may break unexpectedly if the tissue is thick and hyperkeratotic or dry or otherwise the power used is too low and the electrode may stick in tissue and break. This spoils surgery outcome.

Complications due to inappropriate technique, lack of experience, or overzealous approach

Inappropriate technique and lack of experience can lead to a bigger injury due to high power or using pressure while cutting; tissue charring due to inappropriate selection of waveform (selecting electrocoagulation when electrosection or blend waveform is applicable); using a power higher than 1 when desiccating lesions, using a ball electrode for tiny lesions of verruca plana or syringoma or milia, and using the electrocoagulation waveform for such lesions on the face; using electrocoagulation for hemostasis of facial lesions. These complications can occur more commonly for newcomers and those who have shifted to radiofrequency surgery from other modalities.
An overzealous approach is always disastrous. It can happen to experienced and inexperienced doctors who may spoil the patient’s skin due to an overenthusiastic approach or under pressure from patients. This will lead to ugly scarring (Figures 18.1).