Fire and Ice. An introduction to electrosurgery and cryosurgery of the skin. CU SOM Rural Track Mark Deutchman MD

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1 Fire and Ice An introduction to electrosurgery and cryosurgery of the skin CU SOM Rural Track Mark Deutchman MD

3 Electrosurgery of the skin Uses: Cutting Coagulation during cold knife surgery or electrosurgery Tissue destruction both benign and malignant lesions Benign Lesions Skin tags Angiomas and telangiectasias Condyloma and warts Molluscum Nevi Seborrheic keratosis Pre-Malignant or malignant lesions Actinic keratosis Basal cell carcinomas

Principle: conversion of AC, RF energy to heat (300-500 KHz) Requires establishment of a circuit: Bipolar Both electrodes are located directly adjacent to tissue

4 Principle: conversion of AC, RF energy to heat ( KHz) Requires establishment of a circuit: Bipolar Both electrodes are located directly adjacent to tissue being treated ( tweezers ) Unipolar One electrode is the instrument, the other is attached to a distant site on the body ( active electrode and dispersive electrode.)

5 Fundamentals of Electrosurgery Part I: Principles of Radiofrequency Energy for Surgery Malcolm G. Munro

6 Cutting, coagulation and blend Cutting: Continuous, low voltage Coagulation: Intermittent, high voltage Blend Davison, J, Zamah, N, Glob. libr. women's med.,(issn: ) 2008; DOI /GLOWM.1002

7 The net result is HEAT At 100 o C, steam is produced At 200 o C, carbonization occurs Fundamentals of Electrosurgery Part I: Principles of Radiofrequency Energy for Surgery Malcolm G. Munro

8 Electrodes Cutting and blend : Blade shape or wire Coagulation: Ball shape

9 Cutting sharply confined effect, vessels not coagulated. Coagulation wider, deeper effect, vessels coagulated. Move the electrode slow Blend mixed. Move the electrode at medium speed. Fundamentals of Electrosurgery Part I: Principles of Radiofrequency Energy for Surgery Malcolm G. Munro

10 Use of loop on elevated lesions Photo credit: R. Usatine MD

11 Loop removal sequence Photo credit: R. Usatine MD

12 Activate Before Cutting Photo credit: R. Usatine MD

13 During Cutting move smoothly and quickly Photo credit: R. Usatine MD

14 After cutting specimen separated but lying in place Photo credit: R. Usatine MD

15 Crater left behind after specimen lifted off Photo credit: R. Usatine MD

16 Fulguration of base with ball electrode Photo credit: R. Usatine MD

17 Dessication and fulguration with needle or ball - often combined with sharp curettage Dessication: electrode touches skin Fulguration: electrode held above skin Am Fam Physician 2002;66:

18 Anesthesia Usually not required for small lesions

19 Safety Tissue destruction is deeper than it might appear. Energy can arc to metal objects causing unintended injury. Dispersive electrode ( grounding pad ) must be large to avoid burns at the pad site. Alcohol prep solutions can catch fire, igniting drapes! In perirectal procedures, flatus can be ignited! Viruses can be transmitted in steam/smoke plume. (HPV)

20 Equipment cost Generator: $1500 $2500 Electrodes: about $10 each Smoke evacuator: $500 - $1000

22 Cryosurgery of the skin Use to destroy skin lesions: Actinic keratosis Solar lentigo Seborrheic keratosis Warts, including anal and genital Hemorrhoids Molluscum contagiosum Dermatofibroma Basal cell carcinoma Squamous cell carcinoma Advantages: Fast Relatively inexpensive No anesthesia required Complications are rare Disadvantages: No pathology specimen! Hypopigmentation after healing

23 Cryogenic sources Liquid nitrogen (-196 o C) cotton applicator, sprayed on or by metal tip cryoprobe Nitrous oxide -89 o C Liquid nitrogen methods CO 2-70 o C Canned refrigerant -70 o C-90 o C Am Fam Physician 2004;69:

24 Liquid Nitrogen Equipment Nitrous oxide

25 The iceball using LN 2-20 o C to -30 o C kills benign lesions using 1-2 mm freeze margin for 5 to 30 seconds (see table). -40 o C to -50 o C kills malignant lesions and requires maintaining iceball for 30 seconds Slower thaw increases damage Refreezing increases damage Use circular or zig-zag motion or overlapping fields for large lesions Am Fam Physician 2004;69:

26 Immediate post-freeze appearance (the lesion is a seborrheic keratosis) Photo credit: D. Stulberg MD

27 Am Fam Physician. 2012;86:

28 Post-freeze sequence Erythema - immediate Blistering 1-2 days Sloughing days Healing- 1-2 weeks Photo credit: D. Stulberg MD

29 Deep plantar or palmar warts Pre-freeze paring/curettage/salicylic acid increases cure Re-treatment is commonly needed Am Fam Physician. 2012;86(12):

30 Cervical Cryotherapy Metal tip cryoprobe

31 Am Fam Physician 2004;69:

32 Am Fam Physician. 2012;86:

33 Cryotherapy equipment cost LN 2 tank, 6 liter to 10 liter: $200 to $300 on ebay Cost of refilling LN 2 tank: $50 Thermos-style LN 2 cryo gun: $500 to $650 on ebay N 2 O pen and cartridge: $700 N 2 O gun used with large tank: $350 - $550 on ebay

34 Compare methods Cryosurgery 1. less scarring 2. less likelihood of blood loss 3. local anesthesia not needed 4. no need for smoke evacuator or viral particle filter masks 5. Hypopigmentation and hair loss Electrosurgery 1. less hypopigmentation 2. less swelling 3. treatment results seen immediately 4. tissue available for pathologic examination 5. can combine with conventional suturing Am Fam Physician 2004;69: Am Fam Physician. 2012;86:

35 Coding/billing Skin Procedure Typical private insurance payment* Typical Medicare payment* removal of up to 15 skin tags $152 $ excision benign trunk lesion <0.5 cm $166 $ excision benign face lesion <0.5 cm $212 $ excision malignant face lesion <0.5 cm $260 $ destruction benign lesion any method $108 $ destruction of lesion of penis, simple $230 $ destruction of lesion of vulva, simple $238 $ destruction of lesion of anus, simple $288 $144 * Note: list prices are usually about three times higher than what Medicare pays. Private insurance payments vary based on the provider s contract with the insurance company.

36 More resources Cryosurgery video: Electrosurgery video cba92006ecbc2f4d66 Cervical LEEP video: Cervical cryotherapy video: Cryosurgery review article Zimmerman E, Crawford P. Cutaneous Cryosurgery Am Fam Physician. 2012;86: Electrosurgery review article Hainer B, Usatine R. Electrosurgery for the Skin. Am Fam Physician 2002;66:

37 Hands-on workshop Cryotherapy Safely handle LN 2 Create cotton applicator for use with LN 2 Use thermos-style spray gun with LN 2 Practice cryotherapy on banana and chicken breast Electrosurgery Electrosurgical unit equipment controls Types of electrodes Practice cutting, coag and blend on chicken breast

Very versatile tool for minor cosmetic procedures High frequency AC radiowaves generate cellular heat Cells vaporised Radiowaves pass through the

Dr Hans Raetz, Queenstown. Dr Peter Chapman-Smith, Whangarei. Very versatile tool for minor cosmetic procedures High frequency AC radiowaves generate cellular heat Cells vaporised Radiowaves pass through