Year : 2007 | Volume
: 52 | Issue : 3 | Page : 134--137
Radiofrequency ablation in dermatology
Silonie Sachdeva, Alka Dogra
Department of Dermatology, Venerology and Leprology, Dayanand Medical College and Hospital, Ludhiana, Punjab - 141 001, India
1312, Urban Estate, Phase -1, Jalandhar - 144 022, Punjab
Radiofreqeuency ablation is a versatile dermatosurgical procedure used for surgical management of skin lesions by using various forms of alternating current at an ultra high frequency. The major modalities in radiofrequency are electrosection, electrocoagulation, electrodessication and fulguration. The use of radiofrequency ablation in dermatosurgical practice has gained importance in recent years as it can be used to treat most of the skin lesions with ease in less time with clean surgical field due to adequate hemostasis and with minimal side effects and complications. This article focuses on the major tissue effects and factors influencing radiofrequency ablation and its application for various dermatological conditions.
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Sachdeva S, Dogra A. Radiofrequency ablation in dermatology.Indian J Dermatol 2007;52:134-137
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Sachdeva S, Dogra A. Radiofrequency ablation in dermatology. Indian J Dermatol [serial online] 2007 [cited 2020 Apr 6 ];52:134-137
Available from: http://www.e-ijd.org/text.asp?2007/52/3/134/35091
Radiofrequency ablation (radiosurgery, high frequency electrosurgery) is a dermatosurgical procedure that aims at the surgical management of benign and malignant skin conditions by using various forms of alternating current at ultra high frequency (500-4000 kHz). It is also popularly known as "poor man's laser" or "cold cautery". The most common form of radiofrequency ablation used in dermatology involves the application of high-voltage electromagnetic energy in the form of a damped sine wave. This form of current may be applied by electrofulguration, electrodessication or electrocoagulation. , Radiofrequency ablation (RFA) has gained importance in the recent years as it is highly effective in the cutting of the skin lesions with adequate hemostasis at the same time because of good coagulation. Radiofrequency can be used for incisional techniques that produce full-thickness excision of nevi, shave techniques that produce partial-thickness removal of superficial lesions and removing vascular lesions such as hemangiomas or pyogenic granulomas [Table 1]. 
Principle of RFA,,,
Radiofrequency works on the principle of increasing the frequency and voltage while simultaneously decreasing the amperage of alternating current so as to generate oscillating radiowaves. These radiowaves are further modified to produce different waveforms that are passed into the lesion. Modern high-frequency radiosurgical devices transfer electrical energy to human tissue via a treatment electrode that remains cool. The electrical resistance of human tissue helps in converting this electrical energy into molecular energy; this causes the denaturation of intracellular and extracellular proteins, thereby resulting in coagulation or desiccation effects. Increasing the temperature of the intracellular water above the boiling point (400-600ºC) causes the cell membrane to rupture, thereby producing a cutting effect. The lateral spread of heat results in the residual thermal damage by causing dehydration and coagulation necrosis of the tissue proteins and carbonization.
Radiofrequency Equipment and Tissue Effects
The basic equipment comprises a radiosurgical unit with a ground plate (dispersive electrode), foot switch and hand piece [Figure 1]. ,, It is provided with tungsten electrodes of various shapes and sizes with bendable shafts that are fitted into hand piece. A suction device for the evacuation of smoke in extensive surgery is also attached to the equipment. Radiofrequency uses various waveforms with the following tissue effects. ,,,
a. Electrosection: The fully filtered and rectified waveform applied to the tissues in biterminal fashion provides a smooth cutting current resulting in elecrosection. An electrode tip in the shape of a fine needle, wire loop, diamond, ellipse or triangle is advanced slowly through the tissue, causing a steam envelope to advance around the tip and producing a smooth cutting effect. The fully rectified current simultaneously produces cutting and coagulation. This waveform produces least amount of lateral heat spread with minimum tissue destruction.
b. Deep tissue destruction (electrocoagulation): The partially rectified waveform applied to the tissues in a biterminal fashion causes electrocoagulation. It gives instant homeostasis and is used in the treatment of the vascular lesions in which coagulation is primarily required.
c. Superficial tissue destruction (electrodessication and electrofulguration): This is achieved by the application of markedly dampened current to tissues in monoterminal or biterminal fashion. Fulguration causes the greatest amount of lateral heat spread and has a potential dehydrating effect. It causes the superficial tissue destruction through dehydration and surface carbonization. The electrode is held at a distance from the skin lesion in fulguration, while the tissue is touched with the electrode in desiccation.
Local anesthetic, i.e., lignocaine is administered before most radiosurgical techniques. The use of lignocaine with epinephrine further reduces blood loss, but the use of epinephrine at the tips of digits and the nose should be avoided. Another alternative is to use a eutectic mixture of local anesthetics (EMLA) cream that contains 2.5% lidocaine and 2.5% prilocaine. It is applied under occlusion to skin at least 1 h before the procedure to achieve topical anesthesia. Anesthesia may not be necessary for the electrosurgery of small lesions such as telangiectasias and small skin tags. 
Factors Affecting the Efficacy of RFA,,,,,,,
Intensity of the power setting: The cutting of the tissue should be brisk and with the smallest electrode and power setting that is required to minimize the tissue damage and bleeding. The correct output power can be determined by starting at a low power and increasing the power until the desired outcome is attained (destruction, coagulation or cutting). In general, coagulation requires higher power settings than cutting, which requires higher power settings than desiccation or fulguration. The power settings for treating cutaneous lesions are generally low (10-20W). Surface area of the electrode and contact time : An electrode of a small size causes less lateral heat spread and requires lower power setting. The cutting current procedures are best accomplished with a fine needle or wire electrodes. Movement of the electrode through the tissue should be continuous and fast to avoid build-up of lateral heat that causes tissue damage. The type of current selected : The selection of the waveform depends upon whether cutting or coagulation is the primary aim. This gives precise results with minimal tissue damage. Presence of moisture : The presence of moisture on the surface of the tissue prevents charring. Therefore, the surface should be moistened with saline soaked gauze. Waiting period : A waiting period of 10s is ideal between two passages of electrode used for cutting in the same surgical field. It allows adequate cooling and prevents cumulative heat damage.
RFA is a simple, safe procedure with wider applications. It causes less lateral heat spread and tissue damage and provides better control in comparison to electric cautery. The cutting mode of radiofrequency is more effective and versatile in comparison to the carbon dioxide laser. As hemostasis occurs simultaneously, the time required for the surgery is less. There are fewer side effects and complications. RFA can be easily combined with other surgical modalities such as cryotherapy and laser for treatment.
Dermatological Indications of RFA,,,,,,,,,,,,,,,
a. Diagnostic: Skin biopsy, excision of cysts and abscesses.
b. Infections: Verrucae, pyogenic granuloma and molluscum contagiosum.
c. Metabolic: Xanthelasma, xanthomas
d. Benign skin conditions: Freckles, dermatitis papulosa nigra, acne, skin tags, cherry angiomas, spider angiomas, naevi, trichoepithelioma, syringomas, apocrine hidrocystomas, stucco keratosis, papilloma, neurofibromas, cutaneous horn, keratocanthoma, rhinophyma, sebaceous hyperplasia and keloids.
e. Senile skin conditions: Actinic keratosis, sebborheic keratosis and senile lentigenes.
f. Malignant skin tumors: Squamous cell carcinoma, basal cell carcinoma, dermatofibroma sarcoma protuberans and carcinoma in situ lesions of the skin and orogenital mucosa.
g. Nail procedures: Nail matrixectomies, surgical hemostasis of ingrown toenail and onychogryphosis.
h. Cosmetic indications: Mole removal, telangiectasia, unwanted hair removal, scar revision, ear-lobe repair, development of flaps, oculoplastic procedures and blepharoplasties.
ThermaCool TC Radiofrequency,,
The ThermaCool™ system is a unique monopolar radiofrequency (RF) device. The differentiating factor between the ThermaCool system and other RF devices is a capacitive coupling electrode. Through capacitive coupling, deep, uniform and volumetric heating is deployed to tighten and contour both the skin and underlying tissues; meanwhile, cryogen cooling is concurrently applied to protect the epidermis. The ThermaCool TC has been introduced to induce the tightening of skin via a uniform volumetric heating into the deep dermis tightening, thereby resulting in a "non-surgical facelift." It causes immediate collagen contraction and also produces long-term collagen remodeling. It has been used to improve the neck and cheek laxity and periorbital rhytides and to elevate the eyebrows.
ThermaCool TC RF system represents a promising noninvasive method of obtaining moderate facial rejuvenation in the appropriately selected patient.
RFA in Combination with Other Physical Modalities
a. RFA with cryotherapy: Liquid nitrogen spray followed by light electrodesiccation treatment is helpful in the management of flat warts, small skin tags, seborrheic keratoses and cherry angiomas. 
b. RFA with laser: The combination of diode laser and RF energy is reported to decrease the appearance of wrinkles and improve the skin texture. Diode laser using a fluence of 30-50 J/cm 2 and RF energy of 80-100 J/cm 3 , has been used for nonablative wrinkle treatment of the face and neck.  The combination of 900 nm diode laser light and radiofrequency energy is also found to be effective for the treatment of facial venous malformations. It provides additional heating of the vessels without increasing the laser intensity. The side effects are minimal. 
c. RFA and combined RF: light source technologies are safe and effective for treatment of several dermatological procedures, including skin tightening, hair removal, acne scarring, skin rejuvenation and wrinkle reduction. 
RFA should be avoided in unstable cardiac patients and in the treatment of the lesions of the skin overlying a pacemaker. Special care should be taken while performing radiosurgery near eye. RFA should not be done in presence of oxygen as there is risk of explosion. It should be made sure that patient is in contact with the ground plate during procedure. The operator should consider wearing a surgical mask and eye protection when working on lesions containing HPV.
Side Effects and Complications,,
The common side effects that occur with radiofrequency are pain, tissue edema, bleeding, infection, post inflammatory hypo/hyper or depigmentation, scarring and keloid formation. The bacterial transference of Staphylococcus aureus through electrode from one patient to another is possible; however, it is much more possible during electrodessication than during electrocoagulation.
|1||Boughton RS, Spencer SK. Electrosurgical fundamentals. J Am Acad Dermatol 1987;16:862-7.|
|2||Sebbon JE. Electrosurgery: High-frequency modalities. J Dermatol Surg Oncol 1988;14:367-71.|
|3||Hainer BL. Electrosurgery for the skin. Am Fam Physician 2002;66:1259-66.|
|4||Sebbon JE. Electrosurgery principles: Cutting current and cutaneous surgery-Part-1. J Dermatol Surg Oncol 1988;14:29-31.|
|5||Sebbon JE. Electrosurgery principles: Cutting current and cutaneous surgery-Part-2. J Dermatol Surg Oncol 1988;14:147-50.|
|6||Chiarello SE. Radiovaporization: Radiofrequency cutting current to vaporize and sculpt skin lesions. Dermatol Surg 2003;29:755-8.|
|7||Sebbon JE. Electrodes for high-frequency electrosurgery. J Dermatol Surg Oncol 1989;15:805-10.|
|8||Hainer BL. Fundamentals of electrosurgery. J Am Board Fam Pract 1991;4:419-26.|
|9||Brown JS. Radiosurgery: A new instrument for minor operations. Practitioner 1995;239:446-8. |
|10||Savant SS. Radiosurgery. In : Savant SS, Gore D, Atal-Shah R, Sarangi K, editors. Textbook and atlas of dermatosurgery and cosmetology. 2 nd ed. ASCAD: Mumbai, India; 2005. p. 305-14.|
|11||Valinsky MS, Hettinger DF, Gennett PM. Treatment of verrucae via radio wave surgery. J Am Podiatr Med Assoc 1990;80:482-8.|
|12||Tosti A, Piraccini BM. Warts of the nail unit: Surgical and nonsurgical approaches. Dermatol Surg 2001;27:235-9.|
|13||Yu TC, Rahman Z, Ross BS. Actinic keratosis-surgical and physical therapeutic modalities. Cutis 2003;71:381-4.|
|14||Gupta S, Handa U, Handa S, Mohan H. The efficacy of electrosurgery and excision in treating patients with multiple apocrine hidrocystomas. Dermatol Surg 2001;27:382-4.|
|15||Clark DP, Hanke CW. Electrosurgical treatment of rhinophyma. J Am Acad Dermatol 1990;22:831-7.|
|16||Rex J, Ribera M, Bielsa I, Paradelo C, Ferrandiz C. Surgical management of rhinophyma: Report of eight patients treated with electrosection. Dermatol Surg 2002;28:347-9.|
|17||Sheridan AT, Dawber RP. Curettage, electrosurgery and skin cancer. Australas J Dermatol 2000;41:19-30.|
|18||Reynolds PL, Strayer SM. Treatment of skin malignancies. J Fam Pract 2003;52:456- 64.|
|19||Imai Y, Habe K, Imada M, Hakamada A, Isoda KI, Yamanishi K, et al . A case of a large dermatofibrosarcoma protuberans successfully treated with radiofrequency ablation and transcatheter arterial embolization. J Dermatol 2004;31:42-6.|
|20||Hettinger DF, Valinsky MS, Nuccio G, Lim R. Nail matrixectomies using radio wave technique. J Am Podiatr Med Assoc 1991;81:317-21.|
|21||Harris DR. Using a low current radiosurgical unit to obliterate facial telangiectasia. J Dermatol Surg Oncol 1991;17:382-4.|
|22||Rotunda AM, Bhupathy AR, Rohrer TE. The new age of acne therapy: Light, lasers and radiofrequency. J Cosmet Laser Ther 2004;6:191-200.|
|23||Bridenstine JB. Use of ultra high frequency electosurgery (Radiosurgery) for cosmetic surgical procedures. Dermatol Surg 1998;24:397-400.|
|24||Abraham MT, Chiang SK, Keller GS, Rawnsley JD, Blackwell KE, Elashoff DA. Clinical evaluation of non-ablative radiofrequency facial rejuvenation. J Cosmet Laser Ther 2004;6:136-44.|
|25||Narins DJ, Narins RS. Non-surgical radiofrequency facelift. J Drugs Dermatol 2003;2:495-500.|
|26||Finzi E, Spangler A. Multipass vector (mpave) technique with nonablative radiofrequency to treat facial and neck laxity. Dermatol Surg 2005;31:916-22.|
|27||Spiller WF, Spiller RF. Cryoanesthesia and electrosurgical treatment of benign skin tumors. Cutis 1985;35:551-2.|
|28||Sadick NS, Trelles MA. Nonablative wrinkle treatment of the face and neck using a combined diode laser and radiofrequency technology. Dermatol Surg 2005;31:1695-9. |
|29||Lapidoth M, Yaniv E, Ben Amitai D, Raveh E, Kalish E, Waner M, et al . Treatment of facial venous malformations with combined radiofrequency current and 900 nm diode laser. Dermatol Surg 2005;31:1308-12.|
|30||Sadick N, Sorhaindo L. The radiofrequency frontier: A review of radiofrequency and combined radiofrequency pulsed-light technology in aesthetic medicine. Facial Plast Surg 2005;21:131-8.|
|31||Sebben JE. The hazards of electrosurgery. J Am Acad Dermatol 1987;16:869-72.|
|32||Sebben JE. Electrosurgery and cardiac pacemakers. J Am Acad Dermatol 1983;9:457-63.|
|33||Bennett RG, Kraffert CA. Bacterial transference during electrodesiccation and electrocoagulation. Arch Dermatol 1990;126:751-5.|