Electrosurgery Technique

Electrocautery is a form of direct transference of heat to the tissue. Instead of passing electrical current through the tissue, low-voltage, high-amperage, direct or alternating current is used to heat a handheld element, which is then applied to the tissue. ^[1] The resulting effect depends on the tissue; direct application to tumor leads to destruction of tumor cells, whereas application to vessels results in hemostasis. Electrocautery is most commonly used when high-frequency electrosurgery is contraindicated.

In electrodesiccation, the unheated electrode makes contact with the skin and results in superficial dehydration due to ohmic heating. ^[1] The effect is mostly in the epidermis and carries a minimal risk of scarring except at higher voltages, which increase the depth of destruction and may cause superficial scarring and hypopigmentation. ^[1]

ED&C is a commonly used form of electrosurgery. ^[1] ED&C is indicated for nodular and superficial forms of BCC, whereas micronodular, recurrent, or morpheaform BCC should be excised with adequate margins because of the likelihood of deeper infiltration in the dermis. ^{[5, 10]}

The success rate of ED&C for BCC depends on the clinician’s skill with the curette. When using the curette for BCC, the tumor’s physical consistency differs from surrounding healthy skin. A skilled clinician can detect subclinical extension of the tumor based on this physical consistency and obtain adequate margins beyond this subclinical border (usually 2-4 mm).

Reported recurrence rates are as low as 1.6% in a prospective cohort study of 93 patients treated with ED&C at a VA hospital ^[4] to a range of 5.7%-18.8% reported in a structured review, ^[5] but this may reflect selection bias, as a higher percentage of BCCs treated with ED&C are located on the trunk. ^[10]

The video below depicts the ED&C technique used by the authors.

Electrofulguration and electrodesiccation both use markedly damped, high-voltage, low-amperage current with a single terminal to produce local tissue destruction. ^[1] Electrofulguration distinguishes itself from electrodesiccation by the lack of direct contact of the unheated electrode with the skin. The result is superficial epidermal carbonization via sparks from the electrode, which is held 1-2 mm above the skin’s surface. ^[1] The carbonization tends to insulate the underlying tissue, minimizing deeper damage and reducing scarring. ^[1]

Electrocoagulation uses an electrode, which makes contact with the skin and an indifferent electrode (grounding pad) and low-voltage, moderately damped, high-amperage current to cause deeper tissue destruction (with minimal carbonization) and hemostasis of vessels less than 1 mm. ^[1] To obtain hemostasis, a dry surgical field is required; the electrode may then be applied directly to the vessel or by clamping the vessel with forceps and indirectly applying the current to the vessel by touching the treatment electrode to the forceps. ^[1] The collagen and elastic fibers are fused, and hemostasis is achieved. ^[1]

Electrosection also uses two electrodes (treatment electrode and indifferent electrode) and low-voltage, high-amperage current. ^[1] The effect on tissue depends on whether the current is undamped or slightly damped. Undamped electrosection results in cutting without coagulation, whereas a slightly damped current offers some coagulation. ^[1] Overall, the effect is tissue vaporization with minimal peripheral heat damage. ^[1] A major advantage of electrosection is the ability to cut tissue while simultaneously obtaining hemostasis. ^[1]