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The status of electrosurgery in dermatologic practice
Dermatologic
surgerv
III
The status of electrosurgery in dermatologic practice Jack E. Sebben, M.D. Davis, CA A survey was made of the electrosurgical practices of the members of the American Society of Dermatologic Surgery. Results showed that the majority prefer the traditional electrosurgical units, with the Hyfrecator (Birtcher Corp.) being by far the most popular. The most common forms of high-frequency electrosurgery are electrocoagulation and electrodesiccation. Very few dermatologists use cutting current, although many own machines with this capability. The majority do not use a strict sterile technic when performing electrosurgery. However, there appears to be an increasing awareness of contamination risks, and many dermatologists have started using disposable or sterilizable treatment electrodes. High-frequency electrosurgery is by far the most common method of electrosurgery. Electrocautery and surgical galvanism are very rarely used. (J AM ACAD DERMATOL 1988;19:542-9.)
Electrosurgery has been a very popular treatment modality in the offices of dermatologists and other medical specialists for several decades. Electrosurgery includes electrocautery, surgical galvanism, and high-frequency electrosurgery, with the latter being by far the most commonly used technique. In 1881 when D'Arsonval developed the circuitry for the generation of high-frequency electrical energy, he laid the foundation for modem high-frequency electrosurgery. ~ This treatment modality was not accepted for common medical use until 1928, when William Bovie developed a prototype o f the modern electrosurgical generator capable of both coagulation and cutting. 2 In 1937 the Hyfrecator (Birtcher Corp., E1 Monte, CA) was introduced as the first compact, low-cost electrosurgical device and made this modality available to nearly all physicians. The relatively recent development of medical laser technology has increased interest in m o d e m electrosurgical technics. For many medical problems, electrosurgery offers simple and economic alternatives to lasers.
Skill in the use of electrosurgery has been taken for granted by many physicians. Those who use electrosurgery should be familiar with the proper technics and should have an understanding of the basic principles of electrophysics. In addition, safety guidelines must be observed 3,4 to prevent uncommon complications such as contamination, 5'~ electric shock, 7 and thermal bums?
SURVEY METHOD A survey was taken from 1985 to 1986 to determine the electrosurgical practice standards among dermatologists experienced in dermatologic surgery. Survey forms were sent to the 1208 members of the American Society of Dermatologic Surgery who resided in the United States. Of these, 614 completed forms were returned, representing a return rate of approximately 51%. This is a high return rate for a survey of this nature, indicating an active interest in the subject by dermatologic surgeons.
RESULTS Popular electrosurgical units (Table I)
From the University of California, Davis. Reprint requests to: Dr. Jack E. Sebben, 3009 K St., Suite 202, Sacramento, CA 95816.
542
The Hyfrecator was by far the most popular electrosurgical device for office use; 66% of the
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Electrosurgery in dermatologic practice 543
Table L Electrosurgical units found in dermatologists' offices Hyfrecator* Bantam Boviet Cameron-MillerS Bovie Specialist# Burton Electricatorw Elmed[[ Valleylab82 Ellman# Standard Boviet National** Ritter Coagulatortt
66% 25% 14% 12% 10% 9% 4% 4% 3% 3% 1%
*Birtcher Corp., El Monte, CA. tSybron Corp., Rochester, NY. ~:Cameron Miller Inc., Chicago, IL. w Medical Products Inc., Van Nuys, CA, IlElmed Inc., Addison, IL. 82 Inc., Boulder, CO. #Ellman International Manufacturing, Inc., Hewlett, NY. **National Statham, Inc., Elmhurst, NY. ttRitter Biomedical Research, Mendham, NL
respondents use Hyfrecators regularly. The majority of these physicians own more than one unit (one unit, 19%; two units, 15%; three or more units, 32%). The second most popular machine was the Bantam Bovie (Sybron Corp., Rochester, Nu 25% of the respondents had these machines in their office. A few had more than one unit (one unit, 17%; two units, 5%; three or more units, 3%). Cameron-Miller (Chicago, IL) produces several models of electrosurgical generators; 14% of the respondents use one of these models (one unit, 11%; two units, 3%). The Bovie Specialist (Clinical Technology, Rochester, NY) has only been available for a few years, but is gaining in popularity; 12% of those surveyed owned a Bovie Specialist. As with the Bantam Bovie, most own one unit (one unit, 9%; two units, 3%; three or more units, <1%). Several other electrosurgical generators are also popular and are listed in Table I.
Complaints with equipment Most of the complaints about electrosurgical equipment concerned poor quality, noise, fumes, and switching problems. Several respondents commented about shocks received by either the patient or the surgeon while using the Hyfrecator on the
Fig. 1. Some electrosurgical units generate a coagulating waveform that produces an excessive amount of blood spatter. In this illustration a Mohs surgery site was electrocoagulated by a Bovie Specialist with no attempt to shield the surrounding drape from the blood spatter.
high setting. This complaint was not mentioned with other units but, of course, the Hyfrecator enjoys by far the widest use. The most common complaints listed were from users of the Ellman units (Ellman International Manufacturing, Inc., Hewlett, NY). Many stated that the smoke generated by these units during electrosurgery had a particularly disagreeable odor. A number of Hyfrecator users complained about failure of the switching handles. Many of the users of the Bovie Specialist complained that it spattered many blood droplets during coagulation (Fig. 1). Use of a dispersive (grounding) plate Although a dispersive plate is required with the use of cutting current, it is optional during most coagulation and desiccation procedures. Indeed, 35% of the respondents stated that they never use a dispersive electrode and 27% said that they rarely used one.
Choice of electrode Sixty-seven percent of the dermatologic surgeons responding generally use the standard tapered electrode supplied with their electrosurgery unit (Table II). Furthermore, 14% use fine needle
544
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Sebben
Fig. 2. Disposable electrodes are becoming increasingly popular to prevent contamination. Adaptors are available that accept sterile disposable hypodermic needles. Table II. Most commonly used electrodes
Standard tapered point Disposable Needle Ball Epilating needle Wire loop Bipolar forceps Knife blade
67% 15% 14% 6% 1% 1% 1% 0.5%
cleaning or sterilizing procedure for electrodes between patients. Of the 32% who do use some cleaning procedure, 14% swab the electrode with alcohol and 10% sterilize the electrode. C u r r e n t activation
Fig. 3. Birtcher Corporation now manufactures a presterilized, disposable electrode for the Hyfrecator that is quite similar to the standard desiccation tip.
The foot switch is the most popular method for current activation, being used by 60%. Only 20% use a finger switch device and another 20% said they use both technics (Fig. 4). Electrocoagulation with incisional surgery
electrodes and only 6% commonly use a ball electrode. A total of 15% of respondents said that they use only disposable electrodes (Figs. 2 and 3). Considering recent concerns about contamination, this number will undoubtedly rise significantly in the near future. Cleaning
Most of the respondents feel that contamination is a small risk with c o m m o n electrosurgical procedures. As such, 68% said that they use no special
Electrocoagulation is very useful for controlling bleeding during the course of incisional surgery. The use of electrocoagulation with gloves and working in a sterile field was reported by 75%. The most popular technic for performing electrocoagulation under these circumstances is to have an assistant manipulate the handle, usually to contact a sterile hemostatic clamp; 16% use this technic. Another 14% manipulate the handle themselves by holding it with a sterile gauze sponge (Fig. 5). Ten percent cover the handle and cord
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Electrosurgery in dermatologic practice 5 4 5
Fig. 4. Many dermatologists prefer to use a switching handle for fingertip control of power delivery. However, the cords for these switching handles tend to be thicker and less flexible. The foot switch is still the most popular method.
Fig. 5. Some dermatologists prefer to grasp the handle with a sterile gauze sponge to prevent contamination.
546
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Fig. 6. Sterile disposable sleeves are available for covering electrosurgical handles to maintain sterility.
Fig. 7. Bipolar electrocoagulation permits very precise bleeder control and is preferred by some dermatologic surgeons. with a sterile sleeve or envelope (Fig. 6). Another 10% use a sterilized handpiece, and 6% state that they break sterility to perform electrocoagulation. A few mention that they change gloves after performing electrocoagulation, while only 1% mention the use o f bipolar forceps (Fig. 7; Table III).
Treatment of superficial lesions Superficial electrodesiccation, either alone or combined with shave excision, is a useful technic for a number of benign cutaneous lesions. There are some concerns about hypertrophic scarring secondary to electrodesiccation at certain anatomic sites. Nonetheless, 61% stated that they perform electrodesiccation on nevus shave excision sites. They reported that they rarely see scarring complications as a result of this procedure. Electrodesiccation is also popular for the treatment of telangiectatic blood vessels; 95% of the dermatologic surgeons responding said that they frequently use this technic for telangiectases of the
face. The same technic is used on the chest by 54%, and 32% said that they use it on the legs. Seventy-one percent stated that they have not had any complications from these procedures. The occasional complications noted by the other 29% include scarring, discomfort, treatment failure, and hyperpigmentation.
Cutting current High-frequency cutting current is useful for performing relatively bloodless excision. This modality is not an option with the popular Hyfrecator. A more advanced electrosurgical generator is required for the procedure and it is not particularly popular among dermatologic surgeons. Half (50%) of those surveyed stated that they never use cutting current and another 42% said that they rarely use it. Of the remaining 8% who occasionally use cutting current, most use it less than 10 times per week. The most common use for cutting current is for
Volume 19 Number 3 September 1988
Electrosurgery in dermatologic practice 547
Table III. Bleeder electrocoagulation
Table IV. Use of electrosurgery in patients
technic while gloved and working in a sterile surgical field
with cardiac pacemakers
Assistant manipulates handle Hold handle with sterile gauze Sterile handpiece Sterile sleeve or envelope Break sterility Disposable handle Alcohol wipe Sterile or disposable electrode Change gloves
16% 14% 10% 10% 6% 3% 2% 2% 1%
the treatment of rhinophyma, with 14% reporting this usage. Six percent use cutting current for the removal of very large lesions and another 5% use it for removing vascular lesions. Those who use cutting current also stated that it is occasionally used in the treatment of warts and scalp lesions.
Electrosurgery and patients with cardiac pacemakers Many surgeons are cautious about the use of electrosurgery in patients with cardiac pacemakers. There have been reports of pacemaker interference, but most of these involved urologic patients and extremely high energy levels of cutting current. 9'~~Forty-four percent of the dermatologic surgeons stated that they use electrosurgery on these patients. They were asked about special precautions used for patients with pacemakers (Table IV); 3.6% of the respondents stated that they had experienced some form of cardiac pacemaker interference while performing electrosurgery. These rare reports included syncope, bradycardia, asysrole, and skipped beats.
Non-high-frequency modalities Electrocautery. A little more than one third (36%) said that they occasionally use some form of electrocautery. The most popular technic was to use a Concept, inc. (Clearwater, FL) cautery device or other small disposable unit. The Shaw scalpel (Oximetrix, Inc., Mountain View, CA) is a combination of a knife and cautery. This instrument is used by 10% of those who do use electrocautery.
Consult cardiologist Short bursts of current No special precautions Keep equipment away from patient Monitor patient Use only true cautery Avoid patient grounding Minimal power Use dispersive electrode
18% 15% 12% 9% 8% 8% 6% 5% 3%
It is interesting to note that there is some confusion about the difference between electrocautery and high-frequency electrosurgery: Nine percent of the respondents listed a high-frequency electrosurgery method as their means of electrocautery. Galvanic current. Galvanic current is rarely used by dermatologic surgeons. Only 17% stated that they use this modality and the most common method was electrolysis. CONCLUSION It is clear from the responses in this survey that there is a great deal of misunderstanding and confusion about various aspects of electrosurgery. This confusion is fed by the marketing technics of various manufacturers that discuss a multitude of waveforms and claim the superiority of various types of circuitry. A brief discussion about the basics of electrosurgery is in order at this point to put some of these principles in perspective. Although electrosurgery includes electrocautery and electrolysis, these methods are used infrequently and electrosurgery in dermatology is almost synonymous with high-frequency electrosurgery. High-frequency current for electrodesiccation or electrocoagulation may be produced either by a spark gap apparatus or by solid-state circuitry. Both methods of current production have similar effects on the tissue, although the solid-state circuits are said to be more reliable and more precisely adjustable. However, despite manufacturers' claims to the contrary, it is difficult to argue with the longevity and reliability of the oldfashioned "black box" Hyfrecator, which is a spark
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Fig. 8. Electrocautery consists of current passing through a high-resistance electrode. The red-hot electrode is then contacted with tissue, transferring only heat and no electric activity. gap apparatus. All of the high-frequency units produce radio frequency waves and have similar tissue effects. Another area of confusion concerns patient grounding and the use o f dispersive plates. When high-frequency alternating current is applied to the patient, electric energy is alternately entering and exiting the patient. After the application of electric current has stopped, there is no residual excess of remaining current in the patient. Where did this current go? Although we think of the current as entering the patient, it is actually rapidly bouncing between the machine and the patient. As the voltage gets very high, the current may be quite low and very little "bounce" is required. This is why simple electrodesiccation with a low-output unit, such as a Hyfrecator, does not require that a dispersive plate be placed against the patient. The inherent capacitance of the patient's body acts as a relative ground. However, for the higher current flow of coagulating current or cutting current, the current volumes are higher and the voltages are often lower. The patient may not have sufficient "bounce" or capacitance for the current to have much effect. Therefore, a dispersive plate is applied so that the machine alternates with itself, using the patient as a conduit rather than a bouncing device. Some high-output generators will function without a dispersive plate. For lower-output units, a dispersive plate is often not necessary but the effects of electrocoagulation may be enhanced by the application of a dispersive plate, even with the minimal current output of the Hyfrecator.
Journal of the American Academyof Dermatology
The dispersive plate is also referred to as a ground, a return electrode, and an indifferent electrode. The term "dispersive" is the only correct one. The plate is not a true ground, and because the current is alternating, it cannot be considered only a return electrode. It carries just as much current as a treatment electrode, so it certainly is not indifferent. 'j There is also much confusion about the terms "monopolar" and "bipolar." Because we are dealing with alternating current, there is no positive or negative pole. The terms monoterminal and biterminal are technically more correct but are much less common in regular usage. These terms refer to the number of treatment electrodes, i.e., the number of electrodes handling high-frequency electric current that has direct action on tissue. For example, consider the following. The common use of the Hyfrecator without a dispersive plate involves one treatment electrode and is hence monopolar (monoterminal) treatment. If a dispersive plate is added to the patient with a Hyfrecator or similar machine or a dispersive plate is used with a cutting current electrode as required, there is still only one treatment electrode. This is therefore referred to as monopolar treatment with a dispersive electrode. If the dispersive electrode is used but is greatly decreased in size to equal the size of the treatment electrode, we have two treatment electrodes with equal activity on the tissue, making the dispersive electrode become a second treatment electrode. This, then, is true bipolar (biterminal) treatment because there are two active electrodes. It is the principle of bipolar forceps.12.~3 The survey showed that some physicians do not understand the difference between electrocautery and electrocoagulation. A larger number of physicians understand the difference but still use the term electrocautery when they actually mean electrocoagulation. Electrocautery involves current passing through a material of high resistance, usually a small wire, that becomes red hot. This is much like a branding iron and has a similar effect on the tissue, with the transfer only of heat and no electric activity. High-frequency generators such as the Hyfrecator and Boyle do not produce any cautery current (Fig. 8). Most of the dermatologic surgeons surveyed
Volume 19 Number 3 September 1988
considered the Hyfrecator to be the best all-around unit, and there were minimal complaints considering that it is used by 66% of the respondents. For those who require the addition of the cutting current modality, users of the Bantam Bovie seemed most satisfied and there were very few complaints. However, the Bantam Bovie is an older design and does not offer the features and options available in newer units. It appears that users of the newer model Bovie Specialist feel that it is not as good as the Bantam Bovie, particularly because of its blood spatter problems. The Ellman unit received the most complaints, most of which were related to smoke and odor problems. Newer electrosurgical units offer many additional features and it can be expected that these models will see a continued increase in popularity. It is difficult to interpret some of the complaints because many of the users have not compared a large number of electrosurgical units. For example, as mentioned above, complaints about electric shocks are probably more a function of technic rather than of any particular unit. However, the complaints about odor and spatter for specific units were usually accompanied by statements that these units seemed to be worse than other units tried. Although sterile procedures associated with electrosurgery are still minimal, we can expect to see an increased observance of sterile technic as well as the use of sterile disposable electrodes and needles. This will result in part from concerns of viral contamination. Studies have shown that there is the potential risk of hepatitis B transfer from high-frequency electrosurgical electrodes. ~ The issue of blood spatter and aerosol formation has only recently begun to be addressed but has the potential of being a highly significant risk.6 It is also interesting to note that nearly 30% of the respondents mentioned problems with hypertrophic scarring at electrodesiccation sites. If hypertrophic scarring is a problem, it seems prudent to reassess one's technic. Either the electrosurgical technic should be modified, or the use of other hemostatic agents should be considered for very superficial lesions in cosmetically crucial or scarprone regions.
Electrosurgery in dermatologic practice 549
It is informative to observe the profile of those surveyed. Although this survey did not include personal information about the respondents, comments indicate that many of the older dermatologists are less likely to observe strict sterile technic and that younger dermatologists are more cautious in this respect. When the respondent stated that no cleaning or sterile technics were followed, there was often an additional comment that they had been doing it this way for 20 to 30 years without any problems and this served as their justification. The last one to two decades have brought an increased awareness of viral contamination problems, litigation threats, and the maturation of dermatologic surgery. Times have changed and so will technics.
REFERENCES 1. d'Arsonval A. Action physiologique des courants alternatifs. Soc Biol 1891;43:283-6. 2. Goldwyn RM. Bovie: the man and the machine. Ann Plast Surg 1979;2:135-53. 3. Sebben JE. The hazards of electrosurgery [Editorial]. J AM ACADDERMATOL 1987;16:869-72. 4. Sebben JE. Electrosurgery and cardiac pacemakers. J'AM ACAD DERMATOL I983;9:457-63. 5. Sherertz EF, Davis GL, Rice RW, Harris BA, Franzini DA. Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use. J AM ACAD DERMATOL 1986;15:1242-6. 6. Berberian BJ, Burnett JW. The potential role of common dermatologic practice technics in transmitting disease [Letter]. J AM Acht) D~aMA'rOL 1986;15:1057-8. 7. Watson AB, Loughman J. The surgical diathermy: principles of operation and safe use. Anaesth Intensive Care 1978;6:310-21. 8. Neufeld GR, Foster KR. Electrical impedance properties of the body and the problem of alternate site burns during electrosurgery. Med lnstrum 1985;19:83-7. 9. O'Donoghue JK. Inhibition of a demand pacemaker by electrosurgery. Chest 1973;64:664-6. 10. Schultz W. Transurethral electro-resection in patients with cardiac pacemakers. Urologe 1979;18:247-9. 11. Hatch DJ, Raber MB. Grounding and safety. IEEE Trans Biomed Eng 1975;22:62-5. 12. Ramsay JW, Shepard NH, Butler M, et al. A comparison of bipolar and monopolar diathermy probes in experimental animals. Urol Res 1985; 13:99-102. 13. Chehrazi B, Collins WF. A comparison of effects of bipolar and monopolar eleetrocoagulation in brain. J Neurosurg 1981 ;54:107-203.
surgerv
III
The status of electrosurgery in dermatologic practice Jack E. Sebben, M.D. Davis, CA A survey was made of the electrosurgical practices of the members of the American Society of Dermatologic Surgery. Results showed that the majority prefer the traditional electrosurgical units, with the Hyfrecator (Birtcher Corp.) being by far the most popular. The most common forms of high-frequency electrosurgery are electrocoagulation and electrodesiccation. Very few dermatologists use cutting current, although many own machines with this capability. The majority do not use a strict sterile technic when performing electrosurgery. However, there appears to be an increasing awareness of contamination risks, and many dermatologists have started using disposable or sterilizable treatment electrodes. High-frequency electrosurgery is by far the most common method of electrosurgery. Electrocautery and surgical galvanism are very rarely used. (J AM ACAD DERMATOL 1988;19:542-9.)
Electrosurgery has been a very popular treatment modality in the offices of dermatologists and other medical specialists for several decades. Electrosurgery includes electrocautery, surgical galvanism, and high-frequency electrosurgery, with the latter being by far the most commonly used technique. In 1881 when D'Arsonval developed the circuitry for the generation of high-frequency electrical energy, he laid the foundation for modem high-frequency electrosurgery. ~ This treatment modality was not accepted for common medical use until 1928, when William Bovie developed a prototype o f the modern electrosurgical generator capable of both coagulation and cutting. 2 In 1937 the Hyfrecator (Birtcher Corp., E1 Monte, CA) was introduced as the first compact, low-cost electrosurgical device and made this modality available to nearly all physicians. The relatively recent development of medical laser technology has increased interest in m o d e m electrosurgical technics. For many medical problems, electrosurgery offers simple and economic alternatives to lasers.
Skill in the use of electrosurgery has been taken for granted by many physicians. Those who use electrosurgery should be familiar with the proper technics and should have an understanding of the basic principles of electrophysics. In addition, safety guidelines must be observed 3,4 to prevent uncommon complications such as contamination, 5'~ electric shock, 7 and thermal bums?
SURVEY METHOD A survey was taken from 1985 to 1986 to determine the electrosurgical practice standards among dermatologists experienced in dermatologic surgery. Survey forms were sent to the 1208 members of the American Society of Dermatologic Surgery who resided in the United States. Of these, 614 completed forms were returned, representing a return rate of approximately 51%. This is a high return rate for a survey of this nature, indicating an active interest in the subject by dermatologic surgeons.
RESULTS Popular electrosurgical units (Table I)
From the University of California, Davis. Reprint requests to: Dr. Jack E. Sebben, 3009 K St., Suite 202, Sacramento, CA 95816.
542
The Hyfrecator was by far the most popular electrosurgical device for office use; 66% of the
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Electrosurgery in dermatologic practice 543
Table L Electrosurgical units found in dermatologists' offices Hyfrecator* Bantam Boviet Cameron-MillerS Bovie Specialist# Burton Electricatorw Elmed[[ Valleylab82 Ellman# Standard Boviet National** Ritter Coagulatortt
66% 25% 14% 12% 10% 9% 4% 4% 3% 3% 1%
*Birtcher Corp., El Monte, CA. tSybron Corp., Rochester, NY. ~:Cameron Miller Inc., Chicago, IL. w Medical Products Inc., Van Nuys, CA, IlElmed Inc., Addison, IL. 82 Inc., Boulder, CO. #Ellman International Manufacturing, Inc., Hewlett, NY. **National Statham, Inc., Elmhurst, NY. ttRitter Biomedical Research, Mendham, NL
respondents use Hyfrecators regularly. The majority of these physicians own more than one unit (one unit, 19%; two units, 15%; three or more units, 32%). The second most popular machine was the Bantam Bovie (Sybron Corp., Rochester, Nu 25% of the respondents had these machines in their office. A few had more than one unit (one unit, 17%; two units, 5%; three or more units, 3%). Cameron-Miller (Chicago, IL) produces several models of electrosurgical generators; 14% of the respondents use one of these models (one unit, 11%; two units, 3%). The Bovie Specialist (Clinical Technology, Rochester, NY) has only been available for a few years, but is gaining in popularity; 12% of those surveyed owned a Bovie Specialist. As with the Bantam Bovie, most own one unit (one unit, 9%; two units, 3%; three or more units, <1%). Several other electrosurgical generators are also popular and are listed in Table I.
Complaints with equipment Most of the complaints about electrosurgical equipment concerned poor quality, noise, fumes, and switching problems. Several respondents commented about shocks received by either the patient or the surgeon while using the Hyfrecator on the
Fig. 1. Some electrosurgical units generate a coagulating waveform that produces an excessive amount of blood spatter. In this illustration a Mohs surgery site was electrocoagulated by a Bovie Specialist with no attempt to shield the surrounding drape from the blood spatter.
high setting. This complaint was not mentioned with other units but, of course, the Hyfrecator enjoys by far the widest use. The most common complaints listed were from users of the Ellman units (Ellman International Manufacturing, Inc., Hewlett, NY). Many stated that the smoke generated by these units during electrosurgery had a particularly disagreeable odor. A number of Hyfrecator users complained about failure of the switching handles. Many of the users of the Bovie Specialist complained that it spattered many blood droplets during coagulation (Fig. 1). Use of a dispersive (grounding) plate Although a dispersive plate is required with the use of cutting current, it is optional during most coagulation and desiccation procedures. Indeed, 35% of the respondents stated that they never use a dispersive electrode and 27% said that they rarely used one.
Choice of electrode Sixty-seven percent of the dermatologic surgeons responding generally use the standard tapered electrode supplied with their electrosurgery unit (Table II). Furthermore, 14% use fine needle
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Fig. 2. Disposable electrodes are becoming increasingly popular to prevent contamination. Adaptors are available that accept sterile disposable hypodermic needles. Table II. Most commonly used electrodes
Standard tapered point Disposable Needle Ball Epilating needle Wire loop Bipolar forceps Knife blade
67% 15% 14% 6% 1% 1% 1% 0.5%
cleaning or sterilizing procedure for electrodes between patients. Of the 32% who do use some cleaning procedure, 14% swab the electrode with alcohol and 10% sterilize the electrode. C u r r e n t activation
Fig. 3. Birtcher Corporation now manufactures a presterilized, disposable electrode for the Hyfrecator that is quite similar to the standard desiccation tip.
The foot switch is the most popular method for current activation, being used by 60%. Only 20% use a finger switch device and another 20% said they use both technics (Fig. 4). Electrocoagulation with incisional surgery
electrodes and only 6% commonly use a ball electrode. A total of 15% of respondents said that they use only disposable electrodes (Figs. 2 and 3). Considering recent concerns about contamination, this number will undoubtedly rise significantly in the near future. Cleaning
Most of the respondents feel that contamination is a small risk with c o m m o n electrosurgical procedures. As such, 68% said that they use no special
Electrocoagulation is very useful for controlling bleeding during the course of incisional surgery. The use of electrocoagulation with gloves and working in a sterile field was reported by 75%. The most popular technic for performing electrocoagulation under these circumstances is to have an assistant manipulate the handle, usually to contact a sterile hemostatic clamp; 16% use this technic. Another 14% manipulate the handle themselves by holding it with a sterile gauze sponge (Fig. 5). Ten percent cover the handle and cord
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Electrosurgery in dermatologic practice 5 4 5
Fig. 4. Many dermatologists prefer to use a switching handle for fingertip control of power delivery. However, the cords for these switching handles tend to be thicker and less flexible. The foot switch is still the most popular method.
Fig. 5. Some dermatologists prefer to grasp the handle with a sterile gauze sponge to prevent contamination.
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Fig. 6. Sterile disposable sleeves are available for covering electrosurgical handles to maintain sterility.
Fig. 7. Bipolar electrocoagulation permits very precise bleeder control and is preferred by some dermatologic surgeons. with a sterile sleeve or envelope (Fig. 6). Another 10% use a sterilized handpiece, and 6% state that they break sterility to perform electrocoagulation. A few mention that they change gloves after performing electrocoagulation, while only 1% mention the use o f bipolar forceps (Fig. 7; Table III).
Treatment of superficial lesions Superficial electrodesiccation, either alone or combined with shave excision, is a useful technic for a number of benign cutaneous lesions. There are some concerns about hypertrophic scarring secondary to electrodesiccation at certain anatomic sites. Nonetheless, 61% stated that they perform electrodesiccation on nevus shave excision sites. They reported that they rarely see scarring complications as a result of this procedure. Electrodesiccation is also popular for the treatment of telangiectatic blood vessels; 95% of the dermatologic surgeons responding said that they frequently use this technic for telangiectases of the
face. The same technic is used on the chest by 54%, and 32% said that they use it on the legs. Seventy-one percent stated that they have not had any complications from these procedures. The occasional complications noted by the other 29% include scarring, discomfort, treatment failure, and hyperpigmentation.
Cutting current High-frequency cutting current is useful for performing relatively bloodless excision. This modality is not an option with the popular Hyfrecator. A more advanced electrosurgical generator is required for the procedure and it is not particularly popular among dermatologic surgeons. Half (50%) of those surveyed stated that they never use cutting current and another 42% said that they rarely use it. Of the remaining 8% who occasionally use cutting current, most use it less than 10 times per week. The most common use for cutting current is for
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Electrosurgery in dermatologic practice 547
Table III. Bleeder electrocoagulation
Table IV. Use of electrosurgery in patients
technic while gloved and working in a sterile surgical field
with cardiac pacemakers
Assistant manipulates handle Hold handle with sterile gauze Sterile handpiece Sterile sleeve or envelope Break sterility Disposable handle Alcohol wipe Sterile or disposable electrode Change gloves
16% 14% 10% 10% 6% 3% 2% 2% 1%
the treatment of rhinophyma, with 14% reporting this usage. Six percent use cutting current for the removal of very large lesions and another 5% use it for removing vascular lesions. Those who use cutting current also stated that it is occasionally used in the treatment of warts and scalp lesions.
Electrosurgery and patients with cardiac pacemakers Many surgeons are cautious about the use of electrosurgery in patients with cardiac pacemakers. There have been reports of pacemaker interference, but most of these involved urologic patients and extremely high energy levels of cutting current. 9'~~Forty-four percent of the dermatologic surgeons stated that they use electrosurgery on these patients. They were asked about special precautions used for patients with pacemakers (Table IV); 3.6% of the respondents stated that they had experienced some form of cardiac pacemaker interference while performing electrosurgery. These rare reports included syncope, bradycardia, asysrole, and skipped beats.
Non-high-frequency modalities Electrocautery. A little more than one third (36%) said that they occasionally use some form of electrocautery. The most popular technic was to use a Concept, inc. (Clearwater, FL) cautery device or other small disposable unit. The Shaw scalpel (Oximetrix, Inc., Mountain View, CA) is a combination of a knife and cautery. This instrument is used by 10% of those who do use electrocautery.
Consult cardiologist Short bursts of current No special precautions Keep equipment away from patient Monitor patient Use only true cautery Avoid patient grounding Minimal power Use dispersive electrode
18% 15% 12% 9% 8% 8% 6% 5% 3%
It is interesting to note that there is some confusion about the difference between electrocautery and high-frequency electrosurgery: Nine percent of the respondents listed a high-frequency electrosurgery method as their means of electrocautery. Galvanic current. Galvanic current is rarely used by dermatologic surgeons. Only 17% stated that they use this modality and the most common method was electrolysis. CONCLUSION It is clear from the responses in this survey that there is a great deal of misunderstanding and confusion about various aspects of electrosurgery. This confusion is fed by the marketing technics of various manufacturers that discuss a multitude of waveforms and claim the superiority of various types of circuitry. A brief discussion about the basics of electrosurgery is in order at this point to put some of these principles in perspective. Although electrosurgery includes electrocautery and electrolysis, these methods are used infrequently and electrosurgery in dermatology is almost synonymous with high-frequency electrosurgery. High-frequency current for electrodesiccation or electrocoagulation may be produced either by a spark gap apparatus or by solid-state circuitry. Both methods of current production have similar effects on the tissue, although the solid-state circuits are said to be more reliable and more precisely adjustable. However, despite manufacturers' claims to the contrary, it is difficult to argue with the longevity and reliability of the oldfashioned "black box" Hyfrecator, which is a spark
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Fig. 8. Electrocautery consists of current passing through a high-resistance electrode. The red-hot electrode is then contacted with tissue, transferring only heat and no electric activity. gap apparatus. All of the high-frequency units produce radio frequency waves and have similar tissue effects. Another area of confusion concerns patient grounding and the use o f dispersive plates. When high-frequency alternating current is applied to the patient, electric energy is alternately entering and exiting the patient. After the application of electric current has stopped, there is no residual excess of remaining current in the patient. Where did this current go? Although we think of the current as entering the patient, it is actually rapidly bouncing between the machine and the patient. As the voltage gets very high, the current may be quite low and very little "bounce" is required. This is why simple electrodesiccation with a low-output unit, such as a Hyfrecator, does not require that a dispersive plate be placed against the patient. The inherent capacitance of the patient's body acts as a relative ground. However, for the higher current flow of coagulating current or cutting current, the current volumes are higher and the voltages are often lower. The patient may not have sufficient "bounce" or capacitance for the current to have much effect. Therefore, a dispersive plate is applied so that the machine alternates with itself, using the patient as a conduit rather than a bouncing device. Some high-output generators will function without a dispersive plate. For lower-output units, a dispersive plate is often not necessary but the effects of electrocoagulation may be enhanced by the application of a dispersive plate, even with the minimal current output of the Hyfrecator.
Journal of the American Academyof Dermatology
The dispersive plate is also referred to as a ground, a return electrode, and an indifferent electrode. The term "dispersive" is the only correct one. The plate is not a true ground, and because the current is alternating, it cannot be considered only a return electrode. It carries just as much current as a treatment electrode, so it certainly is not indifferent. 'j There is also much confusion about the terms "monopolar" and "bipolar." Because we are dealing with alternating current, there is no positive or negative pole. The terms monoterminal and biterminal are technically more correct but are much less common in regular usage. These terms refer to the number of treatment electrodes, i.e., the number of electrodes handling high-frequency electric current that has direct action on tissue. For example, consider the following. The common use of the Hyfrecator without a dispersive plate involves one treatment electrode and is hence monopolar (monoterminal) treatment. If a dispersive plate is added to the patient with a Hyfrecator or similar machine or a dispersive plate is used with a cutting current electrode as required, there is still only one treatment electrode. This is therefore referred to as monopolar treatment with a dispersive electrode. If the dispersive electrode is used but is greatly decreased in size to equal the size of the treatment electrode, we have two treatment electrodes with equal activity on the tissue, making the dispersive electrode become a second treatment electrode. This, then, is true bipolar (biterminal) treatment because there are two active electrodes. It is the principle of bipolar forceps.12.~3 The survey showed that some physicians do not understand the difference between electrocautery and electrocoagulation. A larger number of physicians understand the difference but still use the term electrocautery when they actually mean electrocoagulation. Electrocautery involves current passing through a material of high resistance, usually a small wire, that becomes red hot. This is much like a branding iron and has a similar effect on the tissue, with the transfer only of heat and no electric activity. High-frequency generators such as the Hyfrecator and Boyle do not produce any cautery current (Fig. 8). Most of the dermatologic surgeons surveyed
Volume 19 Number 3 September 1988
considered the Hyfrecator to be the best all-around unit, and there were minimal complaints considering that it is used by 66% of the respondents. For those who require the addition of the cutting current modality, users of the Bantam Bovie seemed most satisfied and there were very few complaints. However, the Bantam Bovie is an older design and does not offer the features and options available in newer units. It appears that users of the newer model Bovie Specialist feel that it is not as good as the Bantam Bovie, particularly because of its blood spatter problems. The Ellman unit received the most complaints, most of which were related to smoke and odor problems. Newer electrosurgical units offer many additional features and it can be expected that these models will see a continued increase in popularity. It is difficult to interpret some of the complaints because many of the users have not compared a large number of electrosurgical units. For example, as mentioned above, complaints about electric shocks are probably more a function of technic rather than of any particular unit. However, the complaints about odor and spatter for specific units were usually accompanied by statements that these units seemed to be worse than other units tried. Although sterile procedures associated with electrosurgery are still minimal, we can expect to see an increased observance of sterile technic as well as the use of sterile disposable electrodes and needles. This will result in part from concerns of viral contamination. Studies have shown that there is the potential risk of hepatitis B transfer from high-frequency electrosurgical electrodes. ~ The issue of blood spatter and aerosol formation has only recently begun to be addressed but has the potential of being a highly significant risk.6 It is also interesting to note that nearly 30% of the respondents mentioned problems with hypertrophic scarring at electrodesiccation sites. If hypertrophic scarring is a problem, it seems prudent to reassess one's technic. Either the electrosurgical technic should be modified, or the use of other hemostatic agents should be considered for very superficial lesions in cosmetically crucial or scarprone regions.
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It is informative to observe the profile of those surveyed. Although this survey did not include personal information about the respondents, comments indicate that many of the older dermatologists are less likely to observe strict sterile technic and that younger dermatologists are more cautious in this respect. When the respondent stated that no cleaning or sterile technics were followed, there was often an additional comment that they had been doing it this way for 20 to 30 years without any problems and this served as their justification. The last one to two decades have brought an increased awareness of viral contamination problems, litigation threats, and the maturation of dermatologic surgery. Times have changed and so will technics.
REFERENCES 1. d'Arsonval A. Action physiologique des courants alternatifs. Soc Biol 1891;43:283-6. 2. Goldwyn RM. Bovie: the man and the machine. Ann Plast Surg 1979;2:135-53. 3. Sebben JE. The hazards of electrosurgery [Editorial]. J AM ACADDERMATOL 1987;16:869-72. 4. Sebben JE. Electrosurgery and cardiac pacemakers. J'AM ACAD DERMATOL I983;9:457-63. 5. Sherertz EF, Davis GL, Rice RW, Harris BA, Franzini DA. Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use. J AM ACAD DERMATOL 1986;15:1242-6. 6. Berberian BJ, Burnett JW. The potential role of common dermatologic practice technics in transmitting disease [Letter]. J AM Acht) D~aMA'rOL 1986;15:1057-8. 7. Watson AB, Loughman J. The surgical diathermy: principles of operation and safe use. Anaesth Intensive Care 1978;6:310-21. 8. Neufeld GR, Foster KR. Electrical impedance properties of the body and the problem of alternate site burns during electrosurgery. Med lnstrum 1985;19:83-7. 9. O'Donoghue JK. Inhibition of a demand pacemaker by electrosurgery. Chest 1973;64:664-6. 10. Schultz W. Transurethral electro-resection in patients with cardiac pacemakers. Urologe 1979;18:247-9. 11. Hatch DJ, Raber MB. Grounding and safety. IEEE Trans Biomed Eng 1975;22:62-5. 12. Ramsay JW, Shepard NH, Butler M, et al. A comparison of bipolar and monopolar diathermy probes in experimental animals. Urol Res 1985; 13:99-102. 13. Chehrazi B, Collins WF. A comparison of effects of bipolar and monopolar eleetrocoagulation in brain. J Neurosurg 1981 ;54:107-203.