Dermatology Online Journal

Fractionated Electroblation – Using electro surgery for cutaneous redundancies and bulky flaps
Tracy Campbell MD, Daniel B Eisen MD
Dermatology Online Journal 16 (6): 10

Department of Dermatology, University of California Davis Medical Center, Sacramento, California. tmac.2010@yahoo.com

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Abstract

Various techniques have been advocated for standing cone removal. A fine tipped electrosurgery epilating tip can be used to burn into the subcutaneous tissue in a grid-like pattern. This causes significant dermal tissue contraction and spares the overlying tissue. We have termed this technique, “fractionated electroblation.”

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Introduction

Many techniques have been used for bulky scar revision and redundant tissue or standing cone removal. Various scar revision modalities include observation, occlusive dressing, lasers, intralesional steroid injection, scar revision surgery, and dermabrasion. Of these, dermabrasion, excision, and intralesional steroid injections are among the most commonly utilized modalities for standing cone removal. Excisional surgery not only exposes the patient to another surgical procedure, but necessitates a sterile excision tray, an assistant, and other surgical resources. Ablative lasers are expensive, and not readily available to many dermatologists.

Alternatively, electrosurgical instruments are nearly ubiquitous in dermatologist’s offices and are used on a daily basis. The machine and the electrode tips can be adjusted to provide different depths of tissue ablation. When presented with redundant tissue, such as a surgery dog-ear, a fine tipped electrosurgery epilating tip can be used to burn into the subcutaneous tissue. When performed in a grid like pattern over the affected area it causes significant dermal tissue contraction while sparing the intervening overlying tissue. We have termed this method of tissue ablation “fractionated electroblation.”

Materials and Methods

For areas with cutaneous redundancies or bulky type of scars where the color match is already good and complete deep ablation of the entire skin surface is likely to cause atrophic scars we use fractionated electroblation. Prior to treatment the affected site is identified and cleansed with chlorhexidine antiseptic solution. Local anesthesia with 1 percent lidocaine with epinephrine 1:100,000 is infiltrated into the anticipated treatment site. An electrosurgical device (Hyfrecator 2000, ConMed Co., Centennial, Colorado) with a fine epilating needle is used on high power on a setting of 10 and advanced into the subcutaneous plane (Video 1). Immediate deep tissue contraction is usually seen. Treatment is paused and the needle is positioned to another location 4 to 6 mm from the previous treatment site. Treatment is continued in a grid-like pattern until the contour of the treated tissue is made to match that of the surrounding skin. Figure 1 demonstrates this technique with the obvious standing cone of redundant tissue on the cheek of a Mohs micrographic surgery patient eight weeks after a complex closure repair. In Figure 1B the grid like pattern is illustrated, and the redundant tissue has resolved eight weeks later in Figure 1C.

Figure 1	Video 1

After the procedure is complete, the patient is instructed to apply petroleum jelly to the treatment area with a cotton-tipped applicator twice daily until the site is reepithelialized. This usually occurs in one to two weeks, similar to that of dermabrasion and other ablative techniques.

Discussion

The primary advantages of fractionated electroblation are: 1. the ability to treat cutaneous redundancies or bulky flaps, 2. avoidance of any need for further incisional surgery, 3. faster procedure time, and 4. lack of requirement for activity restrictions. This novel idea stems from the idea of fractionated ablative lasers [1, 2]. Fractional photothermolysis uses microscopic columns of thermal injury called microscopic treatment zones (MTZ), surrounded by undamaged tissue. This fractional technique creates noncontiguous columns of thermal injury in the dermis surrounded by areas of non-specific thermal damage and normal tissue [1, 3]. The areas of injured tissue quickly heal by migration of the unaffected skin cells and there is minimal downtime. The depth of penetration of each microscopic treatment zone varies with the energy delivered via the ablative laser, similar to our technique in which the penetration varies depending on the electroblation settings. The effectiveness of this technique with carbon dioxide laser is well documented in the dermatologic literature for facial rejuvenation and acne scaring [1, 4].

Fractionated electroblation allows the physician a time sensitive, in-office, way to manage cutaneous redundancies with a common electrosurgical device instead of an expensive ablative laser. The risks of this procedure include scaring, hyper or hypo pigmentation, bleeding, infection, and the inability to resolve the standing cone. However, this saves the patient a second incisional procedure. Clearly, the risks of this procedure will likely be higher than for fractionated laser systems, which generate microscopic columns of destruction as apposed to the macroscopic ones described above [1, 2]. We have thus far found this to be an effective technique devoid of significant complications. A future study detailing outcomes with this technique is planned.

Conclusion

Fractional electroblation is a convenient and easy to perform method for addressing cutaneous redundancies and bulky flaps. Potential advantages of electroblation over laser systems include decreased expense, ease of use, and diminished bleeding. Anecdotally, this appears to require fewer visits than intralesional steroid use for this application. Future studies will be necessary to determine its complication profile and efficacy rate.

References

1. Chapas, A.M., et al., Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing. Lasers Surg Med, 2008. 40(6): p. 381-6. [PubMed]

2. Alexiades-Armenakas, M.R., J.S. Dover, and K.A. Arndt, The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol, 2008. 58(5): p. 719-37; quiz 738-40. [PubMed]

3. Graber, E.M., E.L. Tanzi, and T.S. Alster, Side effects and complications of fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg, 2008. 34(3): p. 301-5; discussion 305-7. [PubMed]

4. Alster, T.S., E.L. Tanzi, and M. Lazarus, The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg, 2007. 33(3): p. 295-9. [PubMed]

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