CONTINUING
MEDICAL EDUCATION
Electrosurgery
Part I. Basics and principles
Arash Taheri, MD,a Parisa Mansoori, MD,b Laura F. Sandoval, DO,a Steven R. Feldman, MD, PhD,a,b,c
Daniel Pearce, MD,a and Phillip M. Williford, MDa
Winston-Salem, North Carolina
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The following is a journal-based CME activity presented by the American Academy of
Dermatology and is made up of four phases:
1. Reading of the CME Information (delineated below)
2. Reading of the Source Article
3. Achievement of a 70% or higher on the online Case-based Post Test
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Learning Objectives
After completing this learning activity, participants should be able to list the various
electrosurgical modalities and describe their indications and contraindications;
delineate the tissue effects of various electrical waveforms; recognize the factors
influencing depth of tissue injury; and identify the sources of possible complications
and describe strategies for the prevention of these complications.
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Statement of Need:
The American Academy of Dermatology bases its CME activities on the Academy’s core
curriculum, identified professional practice gaps, the educational needs which underlie
these gaps, and emerging clinical research findings. Learners should reflect upon clinical
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study.
Date of release: April 2014
Expiration date: April 2017
Target Audience:
Dermatologists and others involved in the delivery of dermatologic care.
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The editors involved with this CME activity and all content validation/peer reviewers
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Dr Feldman is a consultant and speaker, has received grants, or has stock options in
Abbott Labs, Amgen, Anacor Pharmaceuticals, Inc, Astellas, Caremark, Causa
Research, Celgene, Centocor Ortho Biotech Inc, Coria Laboratories, Dermatology
Foundation, Doak, Galderma, Gerson Lehrman Group, Hanall Pharmaceutical Co
Ltd, Informa Healthcare, Kikaku, Leo Pharma Inc, Medical Quality Enhancement
Corporation, Medicis Pharmaceutical Corporation, Medscape, Merck & Co, Inc, Merz
Pharmaceuticals, Novan, Novartis Pharmaceuticals Corporation, Peplin Inc, Pfizer
Inc, Pharmaderm, Photomedex, Reader’s Digest, Sanofi-Aventis, SkinMedica, Inc,
Stiefel/GSK, Suncare Research, Taro, US Department of Justice, and Xlibris. Drs
Taheri, Mansoori, Sandoval, Williford, and Pearce have no conflicts of interest to
declare.
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The planners involved with this journal-based CME activity have reported no relevant
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591.e1
591.e2 Taheri et al
J AM ACAD DERMATOL
APRIL 2014
The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency
alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the
mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage
is responsible for at least the majority—if not all—of the tissue effects in electrosurgery. Adjacent to the active
electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that
determines the final tissue effects of a current is the depth and the rate at which heat is produced.
Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation.
An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue
and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling
point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which
leads to tissue fragmentation and cutting. ( J Am Acad Dermatol 2014;70:591.e1-14.)
Key words: coagulation; current; electricity; electrocoagulation; electrodesiccation; electrofulguration;
electrosurgery; high frequency; radiofrequency.
INTRODUCTION
Key points
d
d
In electrosurgery, an electric current flows
from the active electrode through the patient’s body to the return electrode
Electrocautery differs from electrosurgery in
that an electrical current heats a metallic
probe that is then applied to tissue (hot iron
cautery). Because no heat is generated
in deeper tissue, electrocautery is more
suitable for the destruction of superficial
tissue layers
The concept of using heat for hemostasis goes
back hundreds of years. As technology evolved,
devices were created that used electricity to
heat tissue and control bleeding. These advancements eventually developed into modern-day electrosurgery. The term electrosurgery (also called
radiofrequency surgery) refers to the passage of
high-frequency electrical current through the tissue
in order to achieve a specific surgical effect, such as
cutting or coagulation (Table I). Each electrosurgical
device consists of a high frequency electrical generator and 2 electrodes (Fig 1). The electric current
flows from the active electrode through the patient’s
body and then to the return (dispersive) electrode,
From the Center for Dermatology Research, Departments of
Dermatology,a Pathology,b and Public Health Sciences,c Wake
Forest School of Medicine.
The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P.
Dr Feldman is a consultant and speaker, has received grants, or
has stock options in Abbott Labs, Amgen, Anacor Pharmaceuticals, Inc, Astellas, Caremark, Causa Research, Celgene, Centocor Ortho Biotech Inc, Coria Laboratories, Dermatology
Foundation, Doak, Galderma, Gerson Lehrman Group, Hanall
Pharmaceutical Co Ltd, Informa Healthcare, Kikaku, Leo Pharma
Inc, Medical Quality Enhancement Corporation, Medicis
where current flows back to the electrosurgical
generator. Adjacent to the active electrode, tissue
resistance to the passage of alternating current converts electrical energy to heat, resulting in thermal
tissue damage. While heat generation occurs within
the tissue, the treatment electrode acts as a conductor
that only passes the current and may remain cooler
than the treated medium.1,2 Electrocautery differs
from electrosurgery in that an electrical current heats
a metallic probe that is then applied to tissue (hot iron
cautery). In electrocautery, no current flows through
the patient’s body (Fig 2).3 Because no heat is
generated in deeper tissue, electrocautery is more
suitable for the destruction of superficial tissue layers.
The term diathermy was originally applied to the
therapeutic (nonablative) heating effect of passing
high-frequency electrical current through deeper
parts of the body. This term was later used to
describe cutting tissue.4,5 While the term diathermy
is still used today, the term electrosurgery is
preferred when referring to cutting or coagulation.
Although electrosurgical instruments are used
routinely, familiarity with the principles behind
how these instruments produce their effect is
limited.6,7 An understanding of the basic principles
of electrosurgery can help increase efficiency of use
and reduce complications.
Pharmaceutical Corporation, Medscape, Merck & Co, Inc, Merz
Pharmaceuticals, Novan, Novartis Pharmaceuticals Corporation,
Peplin Inc, Pfizer Inc, Pharmaderm, Photomedex, Reader’s
Digest, Sanofi-Aventis, SkinMedica, Inc, Stiefel/GSK, Suncare
Research, Taro, US Department of Justice, and Xlibris. Drs
Taheri, Mansoori, Sandoval, Williford, and Pearce have no
conflicts of interest to declare.
Reprint requests: Arash Taheri, MD, Department of Dermatology,
Wake Forest School of Medicine, 4618 Country Club Rd,
Winston-Salem, NC 27104. E-mail: arataheri@gmail.com.
0190-9622/$36.00
J AM ACAD DERMATOL
Taheri et al 591.e3
VOLUME 70, NUMBER 4
Table I. Electrosurgical modes and definition of common terms used in electrosurgery
Method
Electrical current or
mode of choice
Alternative currents
Electrocautery
Direct current
Electrosurgery
High-frequency alternating
current
Electrocoagulation (contact
coagulation)
Continuous current (cutting
mode)*
Interrupted currents (eg,
blend, coagulation, or
fulguration modes)
Electrodesiccation
Same as electrocoagulation
Same as electrocoagulation
Electrofulguration (spray or
noncontact coagulation)
Interrupted current
(fulguration mode)
Interrupted current
(coagulation mode)
Electrosection, pure cutting
Continuous current (cutting
mode)
—
Electrosection, blend cutting
Interrupted current (blend or
coagulation modes)
—
Bipolar electrosurgery
Monopolar electrosurgery
Bipolar mode
Monopolar modes (for
cutting, coagulation,
desiccation, and
fulguration)
Biterminal electrosurgery
All modes (for cutting,
coagulation, desiccation,
and fulguration)
Monoterminal electrosurgery All modes except for pure
cutting (monoterminal
mode is not suitable for
pure cutting)
Alternating current
—
—
—
—
—
Definition
An electrical current heats a
metallic probe that is then
applied to tissue
A high-frequency electrical
current is passed through
the tissue in order to
achieve a specific surgical
(thermal) effect, such as
cutting or coagulation
The tissue is heated below
the boiling point and
undergoes thermal
denaturation
Vaporization of the water
content and drying occurs
at superficial tissue layers
at the end of coagulation
The active electrode is held a
few millimeters above the
tissue. The electric current
bridges the air gap by
creating a spark
A sudden increase in tissue
temperature above the
boiling point leads to
tissue fragmentation and
cutting. In pure cutting,
there is little coagulation
on the incision walls and
little hemostasis
In blend cutting, there is
more coagulation on the
incision walls and more
hemostasis than pure
cutting
There are 2 active electrodes
There is 1 active and 1
dispersive (return)
electrode
Both active and return
electrodes are in contact
with the patient’s body
Return electrode is not
connected directly to the
patient’s body; instead, it is
connected to the Earth
and the Earth acts as an
indirect return electrode
*The cutting mode in some electrosurgical units cannot provide a very low power output that is necessary for a superficial coagulation using
a fine-tip electrode.
591.e4 Taheri et al
Fig 1. An electrosurgery circuit. Current flows through the
tissue, generating heat within the tissue. Heat generation is
practically limited to the area of high current density,
meaning adjacent to the active electrode. The characteristics of the current flow affect the depth, speed, and
degree of tissue heating and determine the tissue results.
The arrows indicate the direction of the electricity in 1
phase of current. In the next phase, the current will be in
the opposite direction.
Fig 2. An electrocautery circuit. No current flows through
the patient’s body. Current heats the tip of the probe,
which can then be used to heat superficial tissue layers.
FUNDAMENTALS OF ELECTRICITY
Key points
d
d
d
d
In a high-frequency alternate current circuit,
cables and pathways of electricity always
form capacitors with each other and with
nearby conductive environmental objects.
Therefore, all insulation on instruments
and cables is relative and some energy always leaks through it as a capacitive current
If the active electrode cable comes in close
proximity to the patient’s body, current
leakage may result in a burn
When a direct or low-frequency current
enters the body, a chemical reaction called
electrolysis occurs at the electrodeetissue
interface. The chemical effects of electrolysis
disappear at higher frequencies
A direct or low frequency current can depolarize cell membranes and cause neuromuscular excitation. Neuromuscular stimulation
becomes negligible at higher frequencies
J AM ACAD DERMATOL
APRIL 2014
Fig 3. The peak and average voltage of alternating
electrical currents. The left waveform has a higher ratio
of average to peak voltage than the right waveform.
Electricity and currents
There are 2 types of electrical current: direct and
alternating. Direct current uses a simple circuit and
flows only in 1 direction, whereas alternating current
switches, or alternates, the direction of the flow of
electricity back and forth. Household electrical wall
outlets, for example, have alternating currents.
During each phase of an alternating current, voltage
and current fluctuate between a maximum (peak)
and a minimum (0). The effective or average voltage
is lower than the peak voltage (Fig 3) and is usually
used to describe an alternate current source and to
calculate the power.
A continuous circuit must be present in order for
a direct current to flow. However, an alternating
current can pass through some breaks and insulations by several mechanisms, the most important of
which is capacitance. In its simplest form, a capacitor consists of 2 nearby conducting plates separated
by a nonconducting medium (Fig 4). Higher frequency alternating currents can pass a capacitor
more easily than lower frequency alternating currents. The flow of an alternating current through a
capacitor is known as a capacitive current. In an
alternate current circuit, cables and pathways of
electricity always form capacitors with each other
and with nearby conductive environmental objects.
Therefore, high-frequency alternating currents are
impossible to insulate completely. All insulation on
instruments and cables is relative, and some energy
always leaks through insulations as capacitive
current.8,9
In an electrosurgery circuit, the tissue adjacent to
the active electrode acts as a resistor that induces
heating (Fig 1). If the active electrode cable comes in
close proximity to the dispersive electrode cable or
J AM ACAD DERMATOL
Taheri et al 591.e5
VOLUME 70, NUMBER 4
Fig 4. An alternate current circuit with a generator, a
resistor (R), and a capacitor (C). A capacitor consists of 2
nearby conducting plates separated by a nonconducting
medium. When a direct current voltage source is applied
to a capacitor, there is an initial surge of current. Electrons
flow into 1 of the plates, giving it a negative charge, and
are taken off the other plate, causing that plate to become
positively charged. While the capacitor is charging, current
flows, usually for a fraction of a second. The current will
stop flowing when the capacitor has fully charged. However, if the current changes its direction, as in the case of an
alternating current, the current will flow and charge the
capacitor every time the electricity changes direction.
Therefore, some current will be allowed to pass in each
phase of the cycle. As the frequency of alternations
increases, more current passes the capacitor every second.
The result is that higher frequency alternating currents can
pass the capacitor more easily than lower frequency
alternating currents.
to the patient’s body, a capacitor is formed that
passes some of the current through an alternate path
(Fig 5). This is called current leakage.10 Current
leakage may result in a burn on the patient or anyone
that comes in contact with the cable (Fig 5).11
As detailed earlier, higher frequency alternating
currents can pass the capacitors more easily than
lower frequency currents. Ultra-high frequencies
([5 MHz) are not used in electrosurgery because
the leakage effect is too great to fall within the limits
set by safety standards.12,13
Electricity and biologic tissues
Electrical conduction differs depending on the
conductive material. In metals, the charge carriers
are primarily electrons, whereas in gases and liquids
the carriers are ions.14,15 Gases are nonconductive
materials. When a nonconductive gas is placed in a
sufficiently high voltage electric field (eg, between
the 2 poles of a high-voltage generator), the gas will
be ionized. This ionized gas is called plasma and
conducts the electrical current as a spark. Two
common examples of plasma are lightning in nature
and fulguration in electrosurgery.
Electrical conduction in biologic tissues is primarily caused by the conductivity of body fluids and is
therefore predominantly ionic.16,17
A
F
B
C
Fig 5. Current leakage in electrosurgery circuit. Current
leakage from active electrode cable to the patient’s body
may result in a burn. It can occur as a result of putting the
active cable near the patient’s body (A) or near any
conductive element that is in direct contact or close
contact to the patient’s body or surgical staff (B; object
F). Examples of object F can be a surgical table or a
metallic clamp that is used for securing the cable to the
surgical drapes over the patient’s body. On the other hand,
if the active and dispersive electrode cables are put near
each other, current will leak from the active to
dispersive electrode cable before reaching the active
electrode (C). As a result of this power loss, the power
dissipated in tissue will be less than the output power of
the generator.
Chemical effects of electrical currents on
tissues
When a direct current enters the body through a
metallic electrode, a chemical reaction called
J AM ACAD DERMATOL
591.e6 Taheri et al
APRIL 2014
Fig 6. Electromagnetic spectrum. Electrosurgical units use alternating currents with
frequencies which are part of the radio-wave frequency range.
electrolysis occurs at the electrodeetissue interface.
This chemical reaction may cause destruction of a
thin layer of tissue around the electrode very
slowly.18 Electrolysis has been used as a method of
hair removal (galvanic depilation) and for the
treatment of telangiectasia.19-21 A low-frequency
alternating current can cause similar chemical reactions. However, because the chemical reaction of
each phase can be neutralized by the opposite
phase, these chemical effects diminish as the frequency of alternations increase and almost disappear at high frequencies ([5 to 10 kHz).2,17,22-26
d
d
d
Effects of electrical currents on cell
membranes
A direct or low-frequency alternate current can
depolarize cell membranes and cause neuromuscular excitation. This stimulation may cause pain,
muscle contraction, and even cardiac arrhythmia.
Neuromuscular stimulation decreases as the frequency of current increases above 1 kHz, and
becomes negligible at frequencies of 100 to 300
kHz.22,23,26-28 At these high frequencies, current
reversal is so rapid that cellular ion position change
is essentially nil and depolarization fails to occur.
High-frequency alternating current therefore makes
it possible to exploit the heating effects of electricity
while avoiding the undesirable neuromuscular effects. Whereas physiologic reasons dictate the lower
limit of the frequency used, as detailed earlier,
practical and safety considerations place restrictions
on the upper limit of current frequency used by
electrosurgical units. Electrosurgical units typically
produce alternating currents in the frequency range
of 0.3 to 5 MHz. These frequencies are part of the
radiowave frequency range (Fig 6); this is why
electrosurgery is also called radiofrequency (RF)
surgery or high-frequency electrosurgery. Although
these terms are used synonymously, the term electrosurgery has a more specific meaning in applied
biomedical engineering and is the preferred
term.10,29,30
BASIC MECHANISM OF
ELECTROSURGERY
Key points
d
An active electrode can concentrate the current at a small area and provide a sufficiently
high current density to induce heating and
thermal tissue damage. The large return
electrode disperses the current, reducing
the current density to levels where tissue
heating is minimal
Electrocoagulation occurs when tissue is
heated below the boiling point and undergoes thermal denaturation
An additional slow increase in temperature
leads to vaporization of the water content
and tissue drying, a process called
desiccation
A sudden increase in tissue temperature
above the boiling point causes rapid explosive vaporization of the water content in the
tissue adjacent to the electrode, which then
leads to tissue fragmentation and cutting
Although precisely how electrosurgery works is
not completely understood, heat production and
thermal tissue damage caused by tissue resistance to
the passage of the alternating electrical current is
responsible for at least the majority—if not all—of
the tissue effects in electrosurgery.16,29,31-34 The
electrical current is applied to the surgical site with
a small active electrode and is collected by a largesurface return electrode that is attached to the
patient’s body. An active electrode can concentrate
the current at a small area in its immediate vicinity
and provide a sufficiently high current density to
induce heating and thermal tissue damage.16,29 The
large return electrode disperses the current, reducing
the current density to levels where tissue heating is
minimal.
Electrocoagulation occurs when tissue is heated
below the boiling point and undergoes thermal
denaturation.29 An additional slow increase in temperature leads to vaporization of the water content in
the coagulated tissue and tissue drying, a process
called desiccation. As more superficial coagulated
tissues dry out, they become less electrically conductive, potentially preventing the current from
continuing to flow and heat the tissue, thereby
limiting the depth of coagulation.
A sudden increase in tissue temperature above the
boiling point results in rapid explosive vaporization
of the water content in the tissue adjacent to the
electrode. This leads to tissue fragmentation, which
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Taheri et al 591.e7
Fig 7. Different alternating electrosurgical current waveforms at equivalent output power
settings. Cutting mode uses a continuous waveform that is able to provide the maximum output
power of the generator. Coagulation mode uses an intermittent waveform that pulses on and
off thousands of times per second. Coagulation waveform usually has a lower maximum power
than cutting waveform because the delivery of the current is off for some periods of time. A
coagulation waveform incorporates higher voltage than a cut waveform at the same power
setting. Fulguration mode has the highest peak voltage ($ 10,000 volts), which helps with large
spark formation. Interrupted modes have a higher ratio of peak to average voltage than
continuous mode. In previous generations of electrosurgical units, damped currents were
commonly used to provide currents with high ratio of peak to average voltage. Theoretically,
the surgical effects of damped currents are not different from interrupted undamped currents.
allows the electrode to pass through the tissue and is
the mechanism of tissue cutting in electrosurgery
(electrosection).35-37
CURRENT WAVEFORMS
Key points
d
d
d
Cutting mode uses a continuous waveform
that is able to provide the maximum output
power of the generator
Intermittent currents have a lower
maximum power and a higher ratio of
peak-to-average voltage than a continuous
current
Fulguration mode usually has the highest
peak voltage
Electrosurgical generators are able to produce a
variety of electric waveforms (Fig 7). The name of
each waveform or mode does not necessarily translate to the final effect the mode has on tissue
(Table I). The only variable that determines the final
tissue effects of a current is the depth and the rate at
which heat is produced. The waveform, voltage, and
power of electrosurgical current and the size of
electrode tip can affect the depth and the rate of
heat production and indirectly influence the final
effect of current on the tissue.29,38,39
In an intermittent waveform, the voltage,
amperage, and power fluctuate between 0 or
minimum in off phases and maximum in on phases.
In this article, we use the term peak voltage to refer to
maximum voltage of the current during on phases
and the terms amperage and power to refer to the
mean amperage and mean power of the current.
ELECTROSURGICAL MODALITIES
Electrocoagulation
Key points
d Coagulation can be performed in contact
mode or in spray (fulguration) mode. However, the term electrocoagulation is usually
used to refer to electrocoagulation in contact
mode
d At the end of contact electrocoagulation, the
more superficial coagulated tissues may dry
out (desiccation). The current may decrease
or stop flowing at this time, a popping sound
may be heard, and sparking may occur
through the dried, nonconductive layer,
leading to explosion and fragmentation of
the dried layer
d Practically, a fine-tip electrode can be best
used for superficial electrocoagulation and a
large-tip electrode with a large contact area
only for deep coagulation
d In contact mode, depth of coagulation is
proportional to the size of electrode tip,
Depth of tissue injury
Size of area
Superficial destruction Small
with low collateral
damage
Large
Medium depth
destruction with
some collateral
damage
Small to
large
Method of application
of current
Electrical current or
mode of choice
Alternative currents
Setting
Possible indications*
Continuous current
(cutting mode)
APRIL 2014
J AM ACAD DERMATOL
Small seborrheic keratosis,
Usually a very low power
Interrupted current
freckle, lentigo, plane
setting is used. The
(blend or coagulation
wart, common wart,
power is started very low
modes)
genital wart, molluscum
and is increased until a
contagiosum, dermatosis
reasonably fast
papulosis nigra, very
movement of the
small skin tag, syringoma,
electrode on the target
cherry angioma, spider
can be attained.
angioma and
Coagulated materials can
telangiectasia, and
be wiped off and a
sebaceous hyperplasia
second pass may be
performed if necessary
Fine- or large-tip
Interrupted current
Interrupted current
Depending on the speed of Seborrheic keratosis,
electrode and
verrucous epidermal
(fulguration mode)
(coagulation mode)
movement of electrode,
fulgurationy (spray)
nevus, and rhinophyma
a low to medium power
setting is used. The
method
power is started low and
is increased until a
reasonably fast
movement of the
electrode on the target
can be attained.
Coagulated materials can
be wiped off and a
second pass may be
performed if necessary
Medium-tip electrode
Genital wart,z rhinophyma,
Needs more power than
Depending on the
Interrupted currents
and contact method,
superficial destruction. If
method (see above)
(blend or coagulation
Bowen disease, actinic
or fine- or large-tip
curettage or shaving is
modes)
keratosis, mucous cysts,
electrode and
performed before
and pyogenic
fulgurationy (spray)
electrosurgery,
granulomax
achievement of
method
hemostasis using
electrosurgery can be
(but not necessarily) an
indicator of adequacy of
treatment
Fine-tip electrode and
contact method
591.e8 Taheri et al
Table II. Settings of electrosurgical units for destruction/coagulation based on the indication and type of procedure46-57
J AM ACAD DERMATOL
Taheri et al 591.e9
*Although electrosurgery can be used for the mentioned indications, it is not necessarily the treatment of choice.
y
Depending on the power and the speed of movement of the electrode on the target, electrofulguration potentially can induce either a very superficial or a relatively deep destruction.
z
Because of the risk of viral transmission through the smoke, electrofulguration is not a preferred method for the treatment of viral warts.
x
Fragile tumors can be treated using curettage and electrodesiccation as an alternative to excision. However, depending on variables, such as tumor type, location, and size, for many cases of basal
cell carcinoma and keratoacanthoma and most cases of squamous cell carcinoma excision rather than curettage and electrodesiccation is preferred.
Continuous current
(cutting mode)
Small to
large
Loop excision
A thin wire in
loop shape
Medium
Large-tip electrode
to large
and contact method
Deep destruction
(usually used as
an alternative to
excision)
Continuous current
(cutting mode)
Basal cell carcinoma,x
Medium to high power
Interrupted currents
setting. The power
(blend or coagulation
keratoacanthoma,x and
should be enough for a
modes)
squamous cell
slow desiccation (hearing
carcinomax
a popping sound after a
few second). The slower
desiccation process, the
deeper damage
Interrupted currents
The type of the current and An alternative to shave
excision and hemostasis;
(blend or coagulation
the power setting should
not suitable for biopsy
modes)
be selected depending
for histopathologic
on the amount of desired
evaluation; rhinophyma
hemostasis
VOLUME 70, NUMBER 4
d
power, and duration of activation time. However, a relatively low power may be able to
provide a deeper maximum coagulation
depth than a higher power because of delayed occurrence of desiccation with lower
power
Fulguration mode can provide a superficial
coagulation if a relatively low power is used.
It can cause deeper tissue damage if a relatively higher power is used or if the activated
electrode is kept over a confined area for a
longer period of time
The rate at which the tissue temperature rises is
proportional to the current density in tissue. For
coagulation, the current density is lower than that
used for cutting to prevent tissue explosion and
fragmentation. Electrocoagulation can be performed in contact mode or in spray (fulguration)
mode. However, the term electrocoagulation is
usually used to refer to electrocoagulation in contact
mode.
For superficial coagulation of small areas (eg, the
destruction of small seborrheic keratoses) a fine-tip
electrode should be used to concentrate the current
to a fine point (Table II). This allows the same
tissue effect to be achieved with a lower power
setting. When using a fine-tip electrode, the current
density in tissue rapidly decreases with distance
from the electrode (Fig 8); therefore, heat generation is practically confined to the vicinity of the
electrode tip, potentially decreasing the depth of
dermal damage and possibility of visible scar
formation.25
When using a large-tip electrode with a large
electrodeetissue contact surface, a higher power
output should be used to achieve the desired current
density and tissue effect (Fig 8).40 Current density
decreases with distance from the electrode surface
more slowly compared to a fine electrode. A higher
power output (higher amperage) and slower
decrease in current density leads to presence of a
higher current density in deeper layers, resulting in
deeper tissue injury. A large electrode tip (ie, ball- or
disc-shaped electrodes), therefore, should be used
only for deep coagulation (eg, the destruction of
reticular dermis after curettage of a malignant skin
tumor).41 Because superficial coagulation of large
areas (eg, the destruction of large, flat seborrheic
keratoses or hemostasis of oozing surfaces) using a
fine-tip electrode is a slow process and takes time,
spray mode coagulation or electrofulguration was
developed (Table II).
In electrofulguration, the active electrode is
held a few millimeters above the tissue. Using an
591.e10 Taheri et al
Fig 8. Electrocoagulation. A fine-tip electrode needs a low
power setting and is suitable for superficial coagulation. A
large-tip electrode is suitable for deep coagulation. A large
electrode cannot provide a superficial coagulation
because current density decreases with distance from the
electrode surface slowly.
interrupted high-peaked voltage output (fulguration
mode), the gap of air between the electrode and the
tissue will be bridged by an electric discharge arc
(spark). The arc rapidly jumps and moves from one
location to the other, reestablishing itself at different
locations. In this approach, the current is spread over
an area larger than that of just the tip of the
electrode.42 By moving the electrode and spraying
the current over tissue, coagulation can be achieved
on a large surface area faster than when operating in
contact with tissue. Spray coagulation can be
achieved with a fine- or large-tip electrode.
In electrofulguration, each spark carries the current to a very small point at a moment, acting as a
very fine electrode. Given a relatively low power, the
temperature is extremely high only at the end of each
spark, leading to tissue explosion and fragmentation
or charring. However, the temperature drops rapidly
with increased distance from the end of the spark,
and thermal damage is contained. Therefore, tissue
destruction and coagulation appears within a thin
superficial layer of tissue, and fulguration can be
J AM ACAD DERMATOL
APRIL 2014
suitable for superficial tissue destruction. However, if
a fulgurating electrode is kept over a confined area,
continuous heat production on the superficial layers
can cause heating of deeper layers, primarily via heat
conduction. In such cases, fulguration can potentially cause deep coagulation.
During electrocoagulation, the more superficial
tissues may dry out. This stage of coagulation, called
desiccation, is important because the current may
decrease or stop flowing at this time, limiting the
maximum depth of coagulation (Fig 9). When this
occurs, a popping sound may be heard and/or
sparking may occur through the dried nonconductive layer, leading to explosion and fragmentation of
the dried layer. Desiccation is not a method or a
distinctive final result—it is only a stage that may or
may not happen, and it may happen at any time
during the course of coagulation, regardless of the
depth of the coagulated tissue. The timing of the
occurrence of desiccation during the course of
coagulation depends on the rate of increase in
temperature that is the result of current density.
With lower current density, there may be a
deep coagulation before desiccation happens.29
Therefore, for deep coagulation (eg, after curettage
of a malignant skin tumor), a relatively low power
should be chosen to provide a slow coagulation and
late occurrence of desiccation. However, a very low
power may not be able to provide the desired
coagulation. Although there are no published data,
it seems that choosing a power which can provide
desiccation (popping sound) after 4 to 7 seconds can
result in a relatively deep destruction. Achievement
of hemostasis is not necessarily an indicator of a
deep coagulation.
It seems that definitions have at times hindered a
higher level of understanding of electrosurgery. The
term electrodesiccation has been used in literature
as a distinctive method from coagulation. Some
authors use the term electrodesiccation to refer to
monoterminal electrocoagulation while reserving
the term electrocoagulation to refer to biterminal
electrocoagulation.18,43,44 Others use the term electrodesiccation to refer to contact electrocoagulation
as opposed to spray electrocoagulation (fulguration).13,45 A common and appropriate usage of the
term electrodesiccation is in reference to a deep
contact coagulation caused by a large electrode up to
the stage of tissue drying.29 This use of ‘‘electrodesiccation’’ is what is referred to in ‘‘electrodesiccation
and curettage,’’ a widely used surgical technique in
dermatologic surgery. Although tissue drying may
also occur during fulguration, the term electrodesiccation is mainly used to refer to the final stage of
contact mode coagulation.
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Taheri et al 591.e11
during destruction of flat seborrheic keratoses), the
activation time should be short or divided into
multiple pulses separated by periods of time long
enough to allow the tissue to cool before the next
pulse.
A
B
C
Fig 9. Electrocoagulation and electrodesiccation. The
process starts with coagulation (A). At the end of coagulation, the more superficial coagulated tissue dries out
(desiccation) and become less electrically conductive,
potentially preventing the current from continuing to
flow (B). However, sparking may then occur through the
nonconductive desiccated layer, leading to disruption of
this layer, passage of more current, more heat production,
and deeper thermal damage (C).
Factors influencing the depth of coagulation
While the amount of heat generation and
resulting tissue damage is proportional to the electrodeetissue contact surface area (ie, the size of the
electrode tip) and the power setting (ie, waveform
and voltage) used, it also depends on the duration of
active contact between the active electrode and
tissue. A longer activation time results in more heat
generation and wider and deeper tissue damage.
One may propose that choosing a low power
setting and a longer activation time is safer and
produces the same result as choosing a higher
power and a shorter activation time. However, this
is not the case. Longer activation times result in more
heat conduction and collateral tissue damage before
the desired outcome is attained.11,40 This is similar to
choosing pulse duration of lasers. Therefore, in
order to minimize the collateral tissue damage (eg,
Electrosection
Key points
d For a pure cutting (relatively clean incision
with little hemostasis) a thin electrode and a
continuous cutting current (cut mode) is
used. The cutting of the tissue should be
brisk, using the lowest possible power
setting
d A thick electrode cannot provide a pure
clean cut
d Blend cutting can be performed using an
interrupted current (blend or coagulation
mode)
Electrosection provides a means of cutting tissue
in place of a scalpel. The major advantage of this
method of cutting is that hemostasis is achieved
immediately upon incision by coagulation on either
side of the incision wall. Larger blood vessels may
still require additional spot coagulation at the
completion of the cutting to achieve hemostasis.
A thin needle or wire can concentrate current on
a small area in the same way that a fine-tip
coagulation electrode does, and allows the same
cutting effect to be achieved with a lower power
setting. This leads to less heat production and less
collateral tissue coagulation compared with a
thicker electrode.37,58 Therefore, a thin needle or
wire is used to make a relatively clean incision with
minimal coagulation and hemostasis on either side
of the incision wall (Fig 10). A thick needle
electrode can cut through the tissue if a very high
power current is used. In this case, current density
and temperature decreases from electrode more
slowly compared with a thin electrode.25 The result
is a deeper coagulation margin during cutting that
leads to more effective hemostasis and also more
tissue damage. This mode is called blend cut,
meaning a blend of cutting and coagulation
(Fig 10).
When the cutting electrode comes in contact with
the tissue, an initial tissue heating and explosive
vaporization of the medium around the electrode
leads to isolation of the metallic electrode from the
tissue. Ionization of the vapor around the electrode
allows maintaining the current through the vapor
cavity by spark. Therefore, the cutting may continue
without a direct contact between the active electrode
and tissue.25,35 The higher the peak voltage of the
J AM ACAD DERMATOL
591.e12 Taheri et al
APRIL 2014
essentially ‘‘sticking.’’34 If large arcing or sparking is
seen across the surface of the tissue, the voltage is too
high and should be appropriately reduced.
Practically, after determining the best power setting,
this setting can be used for each successive patient,
maybe with some fine tuning.
Fig 10. Cross section of tissue with 3 cutting electrodes.
Left, A thin needle is able to concentrate a lowepeaked
voltage, low-power current (cutting current with relatively
low power) on a small area and make a relatively clean
incision with very little coagulation on the incision walls.
Middle, A thick electrode can cut through the tissue if a
higher power current is used. The result is deeper
coagulation margins. Right, A highepeaked voltage current (blend or coagulation waveforms) produces large
sparks and acts as if a thicker electrode is being used that
cannot concentrate the current.
current, the larger the sparks. Larger sparks can
spread current to a wider area of tissue around the
electrode and act as if a thicker electrode is being
used that cannot concentrate the current in a small
area, resulting in a deeper coagulation (Figs 8 and
10).24 Therefore, an interrupted highepeak voltage
current provides deeper collateral tissue coagulation
on either side of the incision walls and better
hemostasis than a continuous lowepeak voltage
current (Figs 7 and 10).29,59 Blend mode or coagulation mode currents have a higher ratio of peak to
average voltage than pure cut currents and can be
used for making a blend cut. Depending on the
technique used, the depth of coagulation on either
side of an electrosurgical incision varies from 0.1 to 2
mm.60-62 Fulguration mode currents have a very high
ratio of peak to average voltage (Fig 7) and produce
very thick coagulation on the incision walls if used
for cutting. While there are conflicting reports of
postoperative results comparing pure electrosection
of the skin to scalpel surgery, electrosection, especially blend cut, is seldom used when a primary
closure is planned.63-66
In order to have less collateral tissue damage and
coagulation on the incision walls, contact time
should be reduced to minimize heat production
and conduction.11 Therefore, the cutting of the tissue
should be brisk with the lowest effective power
setting.36,37 When the power setting is too low, the
cutting process may be slow, resulting in wider
collateral coagulation.36 The correct output power
for a clean incision can be determined by starting low
and increasing the power until the maximum cutting
speed can be attained. If the power is insufficient, the
electrode does not glide through the tissue easily,
CONCLUSIONS
The superficial coagulation of small areas (eg,
small, flat, benign epidermal tumors) can be performed with a fine-tip electrode. Cutting, blend,
coagulation, or fulguration mode currents can be
used; however, fulguration or coagulation mode
currents are more likely to cause tissue fragmentation and deeper destruction by producing spark
through the desiccated tissues. Therefore, fulguration current should be avoided for a very superficial
coagulation in contact mode (contact coagulation).
On the other hand, the cutting mode in some
electrosurgical units cannot provide a very low
power output that is necessary for a superficial
coagulation using a fine-tip electrode. In this case,
coagulation mode, which may have a lower minimum output power, may be used. A large-tip
electrode is used for deep coagulation of a large
area. A high power is usually necessary; therefore,
the cutting mode may be needed. Making a relatively
clean incision with little hemostasis (pure cutting)
requires a thin electrode and a cutting current
(cut mode). Blend cutting can be performed using
an interrupted current (ie, blend or coagulation
mode).
Cutting mode current is suitable for all electrosurgical methods except for fulguration, which requires
a higher peak voltage. This is the reason some
electrosurgical units only provide cut and fulguration
modes.
A knowledgeable selection of the electrosurgical
circuit, electrode configuration, power, waveform,
voltage, and activation time is necessary for
achieving the best possible surgical results.
Surgeons should be familiar with the principles of
electrosurgery and its electrophysical properties.
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