Electrosurgery
Part II. Technology, applications, and safety of electrosurgical devices
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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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, Readers 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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Learning objectives
After completing this learning activity, participants should be able to compare and
contrast electrosurgery with other surgical methods; describe the different technol-
ogies used in different electrosurgical units for controlling the output power, tissue
effect, and patient and operator safety; and delineate the contraindications and
limitations of electrosurgery.
Date of release: April 2014
Expiration date: April 2017
2013 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2013.09.055
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607.e1
607.e2 Taheri et al J AM ACAD DERMATOL
APRIL 2014

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal
modes, with the primary difference between these modes being their safety profiles. A monopolar
electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2
active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no
dispersive electrode connected to the patients body and instead the earth acts as the return electrode.
Biterminal mode uses a dispersive electrode connected to the patients body, has a higher maximum
power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different
technologies for controlling the output power and for providing safety. A thorough understanding of these
technologies helps with a better selection of the appropriate surgical generator and modes. ( J Am Acad
Dermatol 2014;70:607.e1-12.)

Key words: bipolar; biterminal; electrosurgery; high frequency; monopolar; monoterminal; power;
radiofrequency.

INTRODUCTION helps to improve efficacy and safety of surgical

The term electrosurgery (radiofrequency surgery)
refers to the passage of high-frequency electrical
current through the tissue in order to achieve a
specific surgical effect. Previous generations of
electrosurgical generators used a spark gap and/or
a vacuum tube to make the desired high-frequency
electrosurgical currents. However, modern units use
transistors to make high-frequency currents with a
variety of waveforms. The shape of an electrosur-
gical current waveform does not have any direct
effect on the final tissue results of the current. The
only variables that determine the final tissue effects
of a current are the rate and depth at which heat is
produced.1-3 In electrosection, the ratio of peak to
average voltage of a current affects the depth of
coagulation on the incision walls; with higher-
peaked voltages there is deeper coagulation.2,4-6
Electrosurgical currents can be delivered to the
tissue in monopolar or bipolar and monoterminal
or biterminal modes, with the primary difference
between these modes being their safety profiles.
Different electrosurgical generators may have
different current waveforms, different technologies
for the control of output power, and different safety
technologies. A better understanding of these
technologies and their applications and an aware-
ness of potential complications of electrosurgery
procedures.
BIPOLAR VERSUS MONOPOLAR
ELECTROSURGERY
Key points
d In monopolar electrosurgery, there is an
active electrode and a dispersive electrode,
while in bipolar mode there are 2 active
electrodes
d In bipolar mode, electrical current passes
only through the tissue grasped between the
tips of the bipolar forceps
In electrosurgery, the prefixes mono- and bi-
polar refer to the number of active electrodes. In
monopolar electrosurgery, an active electrode
carries current to the tissue (Fig 1). Current then
spreads through the body to be collected and
returned to the electrosurgery unit by a large-
surface dispersive electrode. The dispersive elec-
trode is also known as the return, neutral, passive, or
patient plate electrode.
Two types of dispersive electrodes are in common
use today: conductive and capacitive. With the
conductive type, a metallic foil or conductive poly-
mer is attached to the patients skin. With the
capacitive type, the conductive foil has an insulating

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 unre-
stricted 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 Pharmaceu-
ticals, Inc, Astellas, Caremark, Causa Research, Celgene, Cen-
tocor 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, Readers
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
VOLUME 70, NUMBER 4
Fig 1. A monopolar, biterminal electrosurgery circuit.
High-frequency electric current flows from the active
electrode, through the patients body, and then to the return
(dispersive) electrode. Heat generation is practically limited
to the area of high current density, meaning adjacent to the
active electrode. The arrows indicate the direction of the
electricity in 1 phase of current. In the next phase, the
current will flow in the opposite direction. (Reprinted with
permission from Taheri A, Mansoori P, Sandoval LF, Feld-
man SR, Pearce D, Williford PM. Electrosurgery. Part I: Basics
and principles. J Am Acad Dermatol 2014;70:591-604.)
Fig 2. A bipolar electrosurgery circuit. The electric current
flows from 1 forceps tine through the tissue placed
between the tips to the other forceps tine, and then back
to the electrosurgical generator. The bipolar mode is safer
than the monopolar mode with regard to the potential
extent of injury and possibility of distant site burns.
layer on the outside that prevents direct contact with
the patients skin. The insulated electrode and the
patients skin form a capacitor that passes a capac-
itive current.7 Both types of dispersive electrodes
have specific advantages and disadvantages.
Electrode failures and subsequent patient injury
can be attributed mostly to improper application,
electrode dislodgment, and electrode defects rather
than to electrode design.7
Monopolar electrosurgery should be performed
with caution on an extremity such as a finger or penis
because there is limited cross-sectional area for the
return current to spread across. Theoretically, this
may result in a higher current density and some
heating throughout the volume of the extremity,
leading to unintentional thermal damage if a high
power is used for a relatively long activation time.
Taheri et al 607.e3
Unlike monopolar electrosurgery, where the pa-
tients body forms a major part of the electrical
circuit, in bipolar electrosurgery, only the tissue
grasped between the tips of a bipolar forceps is
included in the electrical circuit (Fig 2). These bipolar
forceps act as 2 active electrodes.8,9
The bipolar mode is used primarily for the
coagulation of pedunculated benign tumors or he-
mostasis of blood vessels. It potentially causes less
damage to surrounding tissue and reduces risk of
distant site burn to the patient compared to monop-
olar electrosurgery.8,9
BITERMINAL VERSUS MONOTERMINAL
ELECTROSURGERY
Key points
d In monoterminal electrosurgery, no dispersive
electrode is connected to the patients body and
the earth acts as the return electrode. Mono-
terminal mode can only be performed using
earth-referenced electrosurgical units, which
have a return electrode connected to earth
d In isolated electrosurgical units, the return
electrode is not connected to earth. There-
fore, there will be no current flow and no
thermal effect unless the dispersive elec-
trode is attached to the patients body (biter-
minal mode)
d Biterminal mode has a higher maximum
power and theoretically may be safer than
monoterminal mode in certain settings
d Coagulation, fulguration, and electrosection
can be performed in either biterminal or
monoterminal mode; however, biterminal
mode is the preferred mode for electrosection
d Inadequate contact of the dispersive elec-
trode with the patients body may result in
a burn at this site. A contact quality moni-
toring system can disable the power if the
dispersive electrode is not in adequate con-
tact with patients skin
The prefixes mono- and bi- terminal refer to the
number of electrodes that are in contact with the
patients body (Figs 1 and 3). Bipolar electrosurgery
is always biterminal; monopolar electrosurgery
could be monoterminal or biterminal.
In so-called earth-referenced electrosurgical
units, the return electrode is connected to earth
(usually through the power supply cable), and
therefore the earth and all conductive objects around
the patients body can act as a capacitive dispersive
electrode (Fig 3). Electrosurgery can be performed
using these units regardless of whether a dispersive
electrode is attached to the patient. Performing
607.e4 Taheri et al
Fig 3. Monoterminal electrosurgery using an earth-
referenced unit. The return electrode is connected to the
earth. Therefore, the earth and all conductive objects
around the patients body can act as a capacitive return
electrode. The current passes through the earth and comes
back to the generator.
monopolar electrosurgery without using a dispersive
electrode is called monoterminal or single-electrode
electrosurgery (Fig 3). Because the maximum output
power is far lower when the dispersive electrode is
not used, only relatively low-powered electrosur-
gery can be performed in monoterminal mode.5
Monoterminal mode reduces the power but not the
peak voltage; therefore, a pure cut cannot be
performed using this mode. Biterminal is the
preferred mode for electrosection.4-6
During monoterminal electrosurgery with an
earth-referenced unit, if an electrically conductive
objectsuch as a metal table, electrocardiogram
electrode, or surgical staffcomes into contact
with the patients body, some current may select
the object as a low-resistance return pathway to the
ground. If the contact area is small, current concen-
tration at this point may result in a burn at this site
(Table I). For this reason, monoterminal mode can
be safely used only on conscious patients who
would be aware of such complications, and only
on carefully insulated tables with no exposed
metallic parts near the patients body. Using a good
return electrode ensures that current returns to the
path of least resistance and does not take any
alternative path through operators or environmental
objects. Therefore, use of the return electrode,
although not technically necessary for operation of
an earth-referenced unit, will enhance the power
and potentially safety of the electrosurgical appa-
ratus. Earth referenced electrosurgery units are not
commonly used in operating rooms today. However,
many surgeons still prefer them for outpatient,
office-based minor surgical procedures, avoiding
the additional time and cost associated with the use
of a dispersive electrode.
The type of electrosurgical unit commonly used in
operating rooms today is known as floating or
J AM ACAD DERMATOL
APRIL 2014
isolated. In contrast to the earth-referenced units,
the dispersive electrode is isolated from earth. This
means that the current can return to the electrosur-
gery unit only via the dispersive electrode. An
isolated generator will not work unless the disper-
sive electrode is attached to the patienta safety
feature of these units.3 During activation, if the
patients body comes in contact with an environ-
mental object, very low or no current passes through
the object and the risk of a burn is low. The surgeon
can touch an active electrode and not be burned so
long as he or she does not touch the patient or
dispersive electrode with the other hand.
Unfortunately, the isolation of these units from earth
or environmental objects is never complete, because
a high-frequency current is not always completely
confined by insulation. Current leakage does occur
by forming a capacitor between electrode cables and
the floor of operating room or conductive environ-
mental objects.3,4 There is still therefore a potential
for distant site burns.
Although a good dispersive electrode reduces the
risk of distant site burns, inadequate contact of the
dispersive electrode with the patients body may
result in a smaller contact area and current concen-
tration at this point that may lead to a burn at this
site.1,3,18,19 Most modern electrosurgery units include
a contact quality monitor for the dispersive electrode
that measures the quality of the contact between the
patients skin and dispersive electrode and also
between the electrode and the generator (Fig 4). If
the dispersive electrode becomes dislodged or there
is a high resistance between the dispersive electrode
and the patients skin, the unit will sound an alarm
and the power will be disabled. Theoretically, this
technology reduces the risk of burns at the dispersive
electrode, but there is no clinical evidence support-
ing this idea.20 There also have not been any clinical
trials comparing the rate of side effects between an
earth-referenced monoterminal device and a biter-
minal isolated device with or without a contact
quality monitor.
The best location for placement of the dispersive
electrode is a muscular site well supplied with blood
vessels and adjacent to the surgical field. If there is
any metal in patients body, the dispersive pad
should be placed between the metal and the surgical
site to prevent current from passing selectively
through the metal.
CONTROLLING THE OUTPUT POWER OF
ELECTROSURGICAL DEVICES
Key points
d In constant voltage electrosurgical genera-
tors, voltage is the output variable that can
Table I. Common complications and pitfalls associated with electrosurgery6,10-17
Complication and/or pitfall
Burns
Cardiac arrhythmia
Transmission of infection
Mechanism
Concentration of current on the skin
Ignition of flammable gases
Modern electrosurgical currents do not stimulate cardiac tissues;
however, if an internal defect were present in the generator, the
low-frequency input power theoretically may be connected to the
electrodes and pass through the patient body
Malfunction of electronic implanted devices
In electrosurgery, heat is generated in tissue; therefore, the active
electrode may remain cold during electrosurgery and transfer
bacteria and viruses to the surgical wound
Microorganisms, such as human papillomavirus, may become
aerosolized in blood microdroplets or in electrosurgical smoke
VOLUME 70, NUMBER 4
J AM ACAD DERMATOL
Prevention and management
When working with earth-referenced generators, using a dispersive
electrode in good contact with the skin decreases the chance of
burning
The patient should not touch environmental conductive objects
An earth-referenced generator should not be used in unconscious
patients, patients with neuropathy who cannot sense the pain of a
possible burn, and patients attached to an electrocardiogram or
blood gas monitor
When working with isolated generators, using a dispersive electrode in
good contact with the skin and a contact quality monitoring system
decreases the chance of burning at the return electrode site
The return electrode should be placed over an area of the skin with
good perfusion (over a muscular area) and enough sensation, not on
bony prominences, distal extremities, scar tissues, or foreign bodies
An active electrode cable should not be put near the patient
The surgeon should not touch the active electrode, even when gloved
Using nonflammable cleanser before surgery and avoiding flammable
anesthetic gases are mandatory. When using alcohol-based
cleansers, the surface should be completely dry for a few minutes
before beginning electrosurgery. Rich oxygen environments may
facilitate the ignition of flammable materials and should be avoided
If possible, the return electrode should be placed between the heart
and the surgical site to prevent current from passing selectively
through the heart. This theoretical complication is less likely to occur
with fully isolated units than with earth-referenced units
An alternative method, such as scalpel surgery, electrocautery, or CO2
laser may be used. For electrosurgery, a return electrode should be
placed between the device and the surgical site. Using bipolar mode
and low power reduces the risk. If the patient is not dependent on
the device, turning it off may reduce the chance of malfunction; the
patient should be closely monitored
Disposable or sterilized electrodes should be used
Taheri et al 607.e5
An alternative method such as cryotherapy may be used; a smoke
evacuator, surgical mask, and eye protection can be used; slow
coagulation does not induce explosion or smoke formation and is
safer than fulguration or cutting
607.e6 Taheri et al
Fig 4. An electrosurgery unit with a contact quality
monitor for the dispersive electrode. Contact quality is
monitored by splitting the return electrode into 2 parts and
measuring the resistance between the parts. If both parts
are in good contact with the skin, the resistance between
them will be low. If one or both parts are not in good
contact with skin, the resistance will be high and the
monitoring system will disable the power.
be adjusted on the display panel. The power
deployed in tissue is not only dependent on
this voltage but also on the resistance in the
electrodeetissue contact area
d When working with a constant voltage, the
quality of surgical effect is dependent on the
type of tissue and its electrical resistance, but
not on the size of the electrode used
d In some devices, an automatic power adjust-
ment mode provides a constant output po-
wer regardless of tissue resistance. In this
mode, the quality of surgical effect is depen-
dent on the size of the electrode used, but
not on the type of tissue or its electrical
resistance, as long as the power remains
constant
There are 2 types of electrosurgical generators
regarding the output-power control system: constant
voltage and automatic power adjustment (Fig 5).3,7
Most conventional electrosurgical generators use a
constant voltage output system. In these generators,
voltage is the output variable that can be adjusted on
the display panel. The dial setting for control of
voltage in these units is usually calibrated using
numbers from 1 to 10. These generators deliver less
power to the tissue with higher resistance compared
to the tissue with lower resistance, using the same
voltage setting (W = V2/R; where W = power, V =
voltage, and R = resistance).3,4,7 Therefore, working
J AM ACAD DERMATOL
APRIL 2014
Large electrodes Small electrodes
80
70
Power in Watts
C
60
50
40
B
30
20
A
10
0
0 200 400 600 800 1000 1200 1400 1600 1800 2000
Resistance in Ohms
Fig 5. Power-resistance curves of an electrosurgical unit.
A, Constant-voltage mode with a nominal load of 200
ohms, when the maximum power is set at 30 watts. B, The
same mode when the maximum power is set at 70 watts.
Increasing the size of the electrode leads to lower
resistance and higher power. Therefore, current density
at the electrodeetissue interface and quality of tissue effect
(except for the depth of effect) will not change signifi-
cantly with changing the size of electrode. However, a very
large electrodeetissue contact area with \200 ohms
resistance leads to a reduction in power and possibly an
inability to achieve the desired surgical effect. C, Auto-
matic power adjustment mode provides a constant output
power between 200 and 1400 ohms. These units do not
automatically adjust the power according to the electrode
size.
on a dried hyperkeratotic epidermis may need a
higher voltage setting than when working on the
dermis to achieve the same effect.
More recent constant voltage generators are
supplemented with an arbitrary dial setting with a
display calibrated in watts. The indicated power
refers to the maximum power that can be delivered
to the nominal resistance in the circuit (Fig 5). A
resistance in the circuit that is higher or lower than
the nominal resistance leads to an output power
lower than maximum power. Therefore, the power
actually delivered to the tissue is usually lower than
this maximum. This type of display has the advan-
tage of allowing a limited degree of comparison to be
made between different units or modes.
In electrosurgical generators with an automatic
power adjustment system (tissue-responsive or
tissue-adaptive generators), power is the output
variable that can be adjusted on the display panel,
with the dial setting calibrated in watts. These
generators can provide a constant power in a wide
range of resistances in the circuit (Fig 5, C ). They can
provide the same surgical effect in different tissues
with different electrical resistances at the same
 J AM ACAD DERMATOL Taheri et al 607.e7
VOLUME 70, NUMBER 4

power setting.3,7 However, if the electrodeetissue

Note: Some electrosurgical units show an index named crest factor that is the ratio of peak voltage to average voltage of their continuous cutting current. Generators with lower crest factors are

no strong evidence showing any relation between frequency of electrosurgical currents and their effects on tissue. A few studies are available but can be criticized because of poor study methods.21
available modes and flexibilities; some

able to provide cleaner cuts with less collateral damage and less hemostasis in pure cutting mode. Most available electrosurgical units in the market have an output frequency of 0.3-5 MHz. There is
ability to provide a very low output
contact area is increased, power is not increased in

have only 1 interrupted current for

Expensive; some devices may lack an

Lower safety profile; may have fewer

May be less convenient to use than

power for very superficial minor
proportion with the contact area. Therefore, the
power setting should be increased manually to

coagulation and fulguration

provide enough power to warm up a larger area
Disadvantages

and create the same surgical effect. Both technolo-

earth-referenced units
gies have specific advantages and disadvantages.
The choice of one technology may depend on the
surgeons preferences and the price of the unit
destructions

(Table II).

CLINICAL CONSIDERATIONS IN
ELECTROSURGERY
Key points
Electrosection results in the histologic
More cost-effective and convenient to

d
More available modes and flexibilities

distortion of surgical margins. For speci-

mens requiring histopathologic analysis,
scalpel surgery is preferred
d Hemostasis of a bleeding vessel can be per-
Advantages

formed by clamping the vessel and passing a

relatively low-power continuous current
(cutting mode) through the clamp. Current
flow should be stopped when a popping
Safest profile

sound is heard or spark is seen

d For hemostasis of an oozing surface, con-
use

tact coagulation is the preferred mode.

Fulguration usually is less efficient because
Table II. The choice of the electrosurgical unit based on the surgical setting

it results in fragmentation of the coagulated

watts), isolated units, with constant-

layer
watts), earth-referenced units, with
isolated generators, with constant-
High power (usually 200-400 watts),

Penetrating proximally insulated electrosur-

Low power (usually around 40-100

Low power (usually around 70-200

d
constant-voltage output mode

gical electrodes can be used for coagulation

Commonly used devices

voltage or automatic power

of subcutaneous targets, such as tumors or

varicose veins
voltage output mode

d Fractional radiofrequency skin rejuvenation

adjustment mode

devices which use penetrating electrodes are

used for fractional heating of the dermis and
collagen remolding while preserving the
epidermis
Electrosection versus scalpel surgery
Electrosection results in more collateral tissue
damage compared to scalpel surgery, creating
some histologic distortion of surgical margins.
(urologic) procedures in operating

Thermal damage causes carbonization at the exci-

Minor dermatologic procedures on

sion margin, vessel thrombosis, and collagen dena-

Major surgeries and endoscopic

Most dermatologic procedures

turation.22,23 Cellular changes may include vacuolar

degeneration, shrunken and shriveled cell outlines
with condensation and elongation of the nuclei, or
conscious patients

fusion of cells into a structureless homogeneous

Setting and indications

mass with a hyalinized appearance.24 In frozen

sections, normal structures may mimic tumors, such
as basal cell carcinaoma.25 It also may make it
rooms

impossible to distinguish squamous and melanocytic

neoplasms. For specimens requiring histopathologic
analysisespecially during the excision of tumors
607.e8 Taheri et al
that require the margins to be assessedscalpel
surgery is preferred. Electrosection in pure cutting
mode may cause less thermal damage artifact than
using a blend cut.26,27
Electrosection often serves as an alternative to
scalpel surgery; however, there is conflicting evidence
in studies comparing these modalities with respect to
outcomes, such as postoperative pain, infection,
wound healing, and scar formation. While many
studies support better outcomes using scalpel surgery,
there is also literature favoring electrosection.26,28-30 A
general concept is to avoid electrosection for cutting
skin when a primary closure is planned.
Electrosection versus CO2 laser surgery
Like electrosection, CO2 laser can provide coag-
ulation of the incision walls and hemostasis. Both
techniques, especially electrosection, are operator-
dependent and cannot be standardized. Therefore, it
is not easy to compare these methods in clinical
settings. There is conflicting evidence in studies
comparing the depth of collateral injury and final
results of surgery using these modalities. While some
studies show more collateral coagulation using a
CO2 laser, others report the opposite results.27,29-36
Compared to CO2 lasers, electrosurgery generally is
less expensive, does not require eye protection, and
is more accessible.
Electrocoagulation for achieving hemostasis
Hemostasis of a bleeding vessel can be performed
by clamping the vessel and passing a monopolar
current through the clamp or using a bipolar elec-
trode.37 Care should be taken to prevent spark for-
mation and tissue fragmentation or charring at the end
of coagulation. A relatively low-power continuous
current (cutting mode) is the preferred current in order
to prevent large spark formation. A popping sound
may be heard or a spark may be seen at the time of
desiccation, and at this time current flow should be
stopped.5 For hemostasis of an oozing surface, contact
coagulation is the preferred mode. Fulguration usually
is less efficient because it results in fragmentation of
the coagulated layer. Wiping of the coagulated area
should be avoided if possible, because it can cause
disruption of the coagulated layer and result in
more bleeding. One should remember that coagula-
tion of a surface for achieving hemostasis results in
damage to the surface that may adversely affect
postoperative and aesthetic outcomes.4-6,38
To optimize hemostasis, the operative field
should be dry, because blood diffuses the current
flowing from the electrode. A dry operative field is
also essential for cutting and coagulation. Proximally
insulated bipolar electrodes can help with more
J AM ACAD DERMATOL
APRIL 2014
effective hemostasis in wet environments.
Electrocautery, as opposed to high-frequency elec-
trosurgery, may function in wet environments,
although not as effectively as in dry fields.
Electrosurgery for hair removal
Hair removal can be performed using a needle
electrode that enters the hair follicle and applies a
direct electrical current (galvanic current). The
resulting chemical reaction (electrolysis) around
the electrode destroys the hair follicle. The process
is relatively slow and time-consuming. Using an
electrosurgical alternating current, the follicle can
be destroyed using thermal damage (thermolysis).
This process is faster than electrolysis; however,
there is a greater risk of damage to the dermis around
the hair follicle and scar formation.39-41
Electrosurgery in the treatment of malignant
skin tumors
Curettage and electrodesiccation has been used
successfully in the treatment of many different
benign and malignant skin tumors.42-44 For treatment
of cancers, this procedure is usually repeated $ 2
times in an attempt to remove any small tumor
extensions. The procedure may be less morbid,
faster, and more cost-effective to perform than
excision and repair in certain cases with certain
tumors. A great advantage of curettage over surgical
excision arises from the ability of a semisharp curette
to differentiate and remove friable abnormal tissue
from the normal surrounding tissue with minimal
sacrifice of normal skin.44 However, this method is
operator-dependent and cannot be easily standard-
ized because the depth of coagulation achieved is
dependent on many factors, such as size of the
electrode and power used.45 Treatment of basal cell
carcinoma with curettage and electrodesiccation
results in cure rates ranging from 88% to 99%
depending on the location and size of tumor and
the surgical method used. Studies that reported the
highest cure rates destroyed a wider peripheral
margin around the initial curettage, ranging from 2
to 8 mm.6,46-50
Electrosurgery in the treatment of benign
superficial skin tumors
Upon a mild thermal coagulation, the epidermis
and papillary dermis turns to a soft material (lique-
faction) that can be easily wiped off of the surface of
the skin surface. However, the reticular dermis does
not respond in the same way; instead, it maintains its
durability and remains solid and cannot be wiped off
after coagulation or desiccation.51 This phenomenon
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
helps the surgeon to distinguish the papillary from
the reticular dermis.
For the treatment of superficial epidermal over-
growths, such as seborrheic keratoses or plane warts,
a very superficial coagulation using a fine-tip elec-
trode or electrofulguration with a low output power
can be performed. The area may be wiped off after
coagulation to see if any epidermal tissue remains in
place that requires a second pass of superficial
coagulation.
To achieve a very superficial coagulation using a
fine-tip electrode, a very low power should be
chosen. Spark formation that occurs at the time of
desiccation indicates the occurrence of deeper injury
and should be avoided by reducing voltage, power,
and/or contact time.
Penetrating insulated electrosurgical electrode
for the destruction of subcutaneous targets
Electrocoagulation of a variety of tumors in inter-
nal organs has been performed using penetrating,
proximally insulated electrodes.52,53 Recently, this
approach has been used for the treatment of the
deeper component of infantile hemangioma of the
skin.54
Endovascular thermal ablation of varicose veins
using a long, flexible electrosurgical electrode with
insulation on the proximal parts is used as a less
invasive alternative to traditional surgery.55,56
Compared to surgery, this approach provides the
same efficacy with less postoperative morbidity
and a lower rate of adverse events.57 Proximally
insulated needles can also be used for treating
telangiectasias.58
Penetrating insulated electrodes have also been
used for ablation or denervation of corrugator super-
cilii muscle for treatment of hyperdynamic vertical
glabellar furrows.59-61
Electrosurgical currents in aesthetic medicine
and skin rejuvenation
High-frequency electrical currents (radiofrequency
technology) has been used for the treatment of
cellulite, acne scar, inflammatory acne, skin resurfac-
ing, and nonablative tightening of skin to improve
laxity and reduce wrinkles.62-70 Most of the devices
marketed for these purposes use $ 1 electrodes to
deliver the current to the skin surface (epidermis).
However, the manner in which some of these devices
work is not completely understood.71 For skin tight-
ening, the most acceptable explanation is that the
heating of dermal tissue by high-frequency (radio-
frequency) currents results in remodeling of collagen
fibers and subsequent neocollagenesis.66,72 Most of
these methods have struggled to gain attention in the
Taheri et al 607.e9
scientific literature, and there is a paucity of well-
conducted randomized trials supporting their effi-
cacy.72 There is evidence, however, of the success of
fractional radiofrequency systems with penetrating
electrodes in dermal heating and collagen remodel-
ing. In contrast with the devices that deliver the
current to the epidermis, these devices deploy energy
directly to the dermis.73-77 Multielectrode pins of these
devices provide heating of the areas that are directly
targeted by the electrodes, leaving intact or only
slightly affected zones between the targeted areas.73-77
The preserved tissue serves as a pool of cells that
promote rapid wound healing.
Depending on the technology used, when an
electrode of a fractional radiofrequency device enters
the skin, the maximum heating effect can be around
the tip of the electrode in dermis because high-
frequency electrical currents have a tendency to
propagate toward the center of the bulk of tissue.78
This phenomenon can preserve the epidermis during
dermal heating and reduce the risk of postprocedural
side effects, including postinflammatory dyspigmen-
tation. By insulating the proximal end of the pene-
trating electrode, the epidermis will escape injury
more efficiently during heating of the dermis.79 In
contrast to radiofrequency currents, laser-based frac-
tional resurfacing may produce greater tissue injury
on the surface of the skin (epidermis) than in the
reticular dermis.80,81 However, to our knowledge
there is no clinical trial comparing these modalities.
Electrosurgery and implantable electronic
devices
Electrosurgery has been reported to cause
destruction, reprogramming, depleted battery, and
inhibition or activation of implantable electronic
devices. Skipped beats, asystole, bradycardia, ven-
tricular fibrillation, and unspecified tachyarrhythmia
have been reported with use of electrosurgery in
patients with cardiac implantable electronic de-
vices.82-84 The incidence of interference is higher
when using the monopolar rather than bipolar
mode, using a higher power, working near the
implanted device, or having the pacemaker between
the active and dispersive electrode.82 Recent im-
provements in electrical shielding and filtering sys-
tems have made implanted electronic devices more
resistant to outside electrical interference.84 Heat
electrocautery is a safe alternative to electrosurgery
in patients with implanted electronic devices.
Practical differences between different
electrosurgical units
Electrosurgical units have different output power,
output frequency, and can provide different modes.
607.e10 Taheri et al
The choice of the unit depends on the surgical setting
and the desired applications (Table II).
CONCLUSIONS
Bipolar electrosurgery is primarily used for the
coagulation and hemostasis of small- to medium-
sized blood vessels or in certain situations, such as
surgery on a finger or a patient with an implantable
electronic device. The bipolar mode theoretically
can be safer than the monopolar mode with regard to
the potential extent of injury and possibility of distant
site burns.
With regard to safety, the monoterminal mode
may be limited in electrosurgery, especially when
using a high power on an unconscious patient or a
patient with neuropathy who cannot sense the pain
of possible burns. However, if an earth-referenced
device cannot provide a very low power for a fine
coagulation, the monoterminal mode can be used to
reduce output power. The correct use of a return
electrode increases the power and safety of the
electrosurgical device.
Although the application of electricity in
surgery dates back 100 years, progress in technol-
ogy still leads to the introduction of new methods
and indications. More recent applications of
electrosurgery include the treatment of varicose
veins, treatment of benign subcutaneous tumors,
and fractional skin rejuvenation. A thorough
understanding of the technology and its possible
complications can promote effective application
of electrosurgical techniques and improved
outcomes.
REFERENCES
1. Brill AI. Electrosurgery: principles and practice to reduce risk
and maximize efficacy. Obstet Gynecol Clin North Am 2011;
38:687-702.
2. Tokar JL, Barth BA, Banerjee S, Chauhan SS, Gottlieb KT,
Konda V, et al. Electrosurgical generators. Gastrointest
Endosc 2013;78:197-208.
3. The Association of Surgeons in Training web site. Principles
of electrosurgery. Available from: http://www.asit.org/assets/
documents/Prinicpals_in_electrosurgery.pdf. Accessed
February 2, 2013.
4. Bussiere RL. Principles of electrosurgery. Edmonds (WA):
Tektran Inc; 1997.
5. Pollack SV. Electrosurgery of the skin. 1st ed. New York:
Churchill Livingstone; 1990.
6. Soon SL, Washington CV. Electrosurgery, electrocoagulation,
electrofulguration, electrodesiccation, electrosection, electro-
cautery. In: Robinson JK, Hanke CW, Siegel DM, Fratila A,
editors. Surgery of the skin: procedural dermatology. 2nd ed.
New York: Elsevier; 2010. pp. 225-38.
7. Eggleston JL, von Maltzahn WW. Electrosurgical devices. In:
Bronzino JD, editor. The biomedical engineering handbook.
2nd ed. Boca Raton (FL): CRC Press; 2000.
8. Brill AI. Bipolar electrosurgery: convention and innovation.
Clin Obstet Gynecol 2008;51:153-8.
J AM ACAD DERMATOL
APRIL 2014
9. Rioux JE. Bipolar electrosurgery: a short history. J Minim
Invasive Gynecol 2007;14:538-41.
10. Netherton BL, Stecker MM, Patterson T. Mechanisms of
electrode induced injury. Part 3: practical concepts and
avoidance. Am J Electroneurodiagnostic Technol 2007;47:
257-63.
11. Kushiyama S, Inoue K, Morioka T, Isa T. New safety system for
prevention of inadvertent skin burn in the use of electrosur-
gical unit. Am J Surg 1978;135:868.
12. Rabhan NB. Electrosurgery electrode safety. J Am Acad
Dermatol 1987;17(2 Pt 1):312.
13. Sebben JE. The hazards of electrosurgery. J Am Acad
Dermatol 1987;16:869-72.
14. Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L.
Principles and safety measures of electrosurgery in laparos-
copy. JSLS 2012;16:130-9.
15. Mowatt G, Cook JA, Fraser C, McKerrow WS, Burr JM.
Systematic review of the safety of electrosurgery for tonsil-
lectomy. Clin Otolaryngol 2006;31:95-102.
16. Safety in laparoscopic electrosurgery. OR Manager 1999;15:
30.
17. Odell RC. Electrosurgery: principles and safety issues. Clin
Obstet Gynecol 1995;38:610-21.
18. ECRI. Higher currents, greater risks: preventing patient burns
at the return-electrode site during high-current electrosur-
gical procedures. Health Devices 2005;34:273-9.
19. Edrich J, Cookson CC. Electrosurgical dispersive electrodes
heat cutaneous and subcutaneous skin layers. Med Instrum
1987;21:81-6.
20. Van Way CW, Hinrichs CS. Electrosurgery 201: basic electrical
principles. Curr Surg 2000;57:261-4.
21. Maness WL, Roeber FW, Clark RE, Cataldo E, Riis D,
Haddad AW. Histologic evaluation of electrosurgery with
varying frequency and waveform. J Prosthet Dent 1978;
40:304-8.
22. Mausberg R, Visser H, Aschoff T, Donath K, Kruger W.
Histology of laser- and high-frequency-electrosurgical in-
cisions in the palate of pigs. J Craniomaxillofac Surg 1993;
21:130-2.
23. Matsumoto K, Suzuki H, Usami Y, Hattori M, Komoro T.
Histological evaluation of artifacts in tongue tissue produced
by the CO2 laser and the electrotome. Photomed Laser Surg
2008;26:573-7.
24. Elliott JA Jr. Electrosurgery. Its use in dermatology, with a
review of its development and technologic aspects. Arch
Dermatol 1966;94:340-50.
25. Revercomb CH, Stewart CE, Bux RC. Artifact from an
electrosurgical ground pad. Am J Forensic Med Pathol
1997;18:293-4.
26. Kashkouli MB, Kaghazkanai R, Mirzaie AZ, Hashemi M,
Parvaresh MM, Sasanii L. Clinicopathologic comparison of
radiofrequency versus scalpel incision for upper blepharo-
plasty. Ophthal Plast Reconstr Surg 2008;24:450-3.
27. Courey MS, Fomin D, Smith T, Huang S, Sanders D, Reinisch L.
Histologic and physiologic effects of electrocautery, CO2
laser, and radiofrequency injury in the porcine soft palate.
Laryngoscope 1999;109:1316-9.
28. Loh SA, Carlson GA, Chang EI, Huang E, Palanker D,
Gurtner GC. Comparative healing of surgical incisions
created by the PEAK PlasmaBlade, conventional electro-
surgery, and a scalpel. Plast Reconstr Surg 2009;124:
1849-59.
29. Silverman EB, Read RW, Boyle CR, Cooper R, Miller WW,
McLaughlin RM. Histologic comparison of canine skin bi-
opsies collected using monopolar electrosurgery, CO2 laser,
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
radiowave radiosurgery, skin biopsy punch, and scalpel. Vet
Surg 2007;36:50-6.
30. Sinha UK, Gallagher LA. Effects of steel scalpel, ultrasonic
scalpel, CO2 laser, and monopolar and bipolar electrosurgery
on wound healing in guinea pig oral mucosa. Laryngoscope
2003;113:228-36.
31. Basterra J, Zapater E, Moreno R, Hernandez R. Electrosurgical
endoscopic cordectomy with microdissection electrodes: a
comparative study with CO2 laser. J Laryngol Otol 2006;120:
661-4.
32. Schemmel M, Haefner HK, Selvaggi SM, Warren JS, Termin CS,
Hurd WW. Comparison of the ultrasonic scalpel to CO2 laser
and electrosurgery in terms of tissue injury and adhesion
formation in a rabbit model. Fertil Steril 1997;67:382-6.
33. Schoinohoriti OK, Chrysomali E, Iatrou I, Perrea D. Evaluation
of lateral thermal damage and reepithelialization of incisional
wounds created by CO(2)-laser, monopolar electrosurgery,
and radiosurgery: a pilot study on porcine oral mucosa. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2012;113:741-7.
34. Schoinohoriti OK, Chrysomali E, Tzerbos F, Iotaatrou I. Com-
parison of lateral thermal injury and healing of porcine skin
incisions performed by CO2-laser, monopolar electrosurgery
and radiosurgery: a preliminary study based on histological
and immunohistochemical results. Int J Dermatol 2012;51:
979-86.
35. Stelter K, de la Chaux R, Patscheider M, Olzowy B. Double-
blind, randomised, controlled study of post-operative pain in
children undergoing radiofrequency tonsillotomy versus
laser tonsillotomy. J Laryngol Otol 2010;124:880-5.
36. Zapater E, Frias S, Perez A, Basterra J. Comparative study on
chronic tissue damage after cordectomies using either CO2
laser or microdissection electrodes. Head Neck 2009;31:
1477-81.
37. KLS Martin Group web site. Electrosurgery. Available
from: http://www.klsmartin.com/fileadmin/Inhalte/Downloads_
Prospekte/HF-Geraete/90-604-02-04_09_06_Handbuch_HF.
pdf. Accessed February 2, 2013.
38. Nguyen TH, Erickson QL. Hemostasis. In: Robinson JK, Hanke
CW, Siegel DM, Fratila A, editors. Surgery of the skin:
procedural dermatology. 2nd ed. New York: Elsevier; 2010.
pp. 225-38.
39. Wagner RF Jr, Tomich JM, Grande DJ. Electrolysis and
thermolysis for permanent hair removal. J Am Acad Dermatol
1985;12:441-9.
40. Olsen EA. Methods of hair removal. J Am Acad Dermatol
1999;40(2 Pt 1):143-55.
41. Liew SH. Unwanted body hair and its removal: a review.
Dermatol Surg 1999;25:431-9.
42. Sheridan AT, Dawber RP. Curettage, electrosurgery and skin
cancer. Australas J Dermatol 2000;41:19-30.
43. Stevenson TR, Swanson NA. Syringoma: removal by electro-
desiccation and curettage. Ann Plast Surg 1985;15:151-4.
44. Ghodsi SZ, Raziei M, Taheri A, Karami M, Mansoori P, Farnaghi
F. Comparison of cryotherapy and curettage for the treat-
ment of pyogenic granuloma: a randomized trial. Br J
Dermatol 2006;154:671-5.
45. Blackwood WD, Silvis SE. Standardization of electrosurgical
lesions. Gastrointest Endosc 1974;21:22-4.
46. Rodriguez-Vigil T, Vazquez-Lopez F, Perez-Oliva N. Recur-
rence rates of primary basal cell carcinoma in facial risk areas
treated with curettage and electrodesiccation. J Am Acad
Dermatol 2007;56:91-5.
47. Reymann F. Treatment of basal cell carcinoma of the skin
with curettage. II. A follow-up study. Arch Dermatol 1973;
108:528-31.
Taheri et al 607.e11
48. Mitchell JC, Hardie M. Treatment of basal cell carcinoma by
curettage and electrosurgery. Can Med Assoc J 1965;93:
349-52.
49. Williamson GS, Jackson R. Treatment of basal cell carcinoma
by electrodesiccation and curettage. Can Med Assoc J 1962;
86:855-62.
50. Zwald F. Immediate curettage and electrodessication
following biopsy of suspected basal cell carcinoma at initial
visit. JAMA Dermatol 2013;149:981.
51. Burkhardt BR, Maw R. Are more passes better? Safety versus
efficacy with the pulsed CO2 laser. Plast Reconstr Surg 1997;
100:1531-4.
52. Ambrogi MC, Fanucchi O, Cioni R, Dini P, De LA, Cappelli C,
et al. Long-term results of radiofrequency ablation treatment
of stage I non-small cell lung cancer: a prospective
intention-to-treat study. J Thorac Oncol 2011;6:2044-51.
53. Zhang B, Moser M, Zhang E, Zhang WJ. Radiofrequency
ablation technique in the treatment of liver tumours: review
and future issues. J Med Eng Technol 2013;37:150-9.
54. Taheri A, Mansoori P, Feldman SR, Williford PM, Pearce D.
Electrosurgical coagulation of a deep infantile hemangioma
using a penetrating insulated electrode: disease modification
with minimal superficial scarring. J Am Acad Dermatol 2013;
68:AB1.
55. Tolva VS, Cireni LV, Bianchi PG, Lombardo A, Keller GC, Casana
RM. Radiofrequency ablation of the great saphenous vein
with the ClosureFAST procedure: mid-term experience on
400 patients from a single centre. Surg Today 2013;43:741-4.
56. Braithwaite B, Hnatek L, Zierau U, Camci M, Akkersdijk G,
Nio D, et al. Radiofrequency-induced thermal therapy:
results of a European multicentre study of resistive
ablation of incompetent truncal varicose veins. Phlebology
2013;28:38-46.
57. Siribumrungwong B, Noorit P, Wilasrusmee C, Attia J,
Thakkinstian A. A systematic review and meta-analysis of
randomised controlled trials comparing endovenous ablation
and surgical intervention in patients with varicose vein. Eur J
Vasc Endovasc Surg 2012;44:214-23.
58. Kobayashi T. Electrosurgery using insulated needles: treat-
ment of telangiectasias. J Dermatol Surg Oncol 1986;12:
936-42.
59. Zendejas GH, Guerrerosantos J. Percutaneous selective
myoablation in plastic surgery. Aesthetic Plast Surg 2011;
35:230-6.
60. Utley DS, Goode RL. Radiofrequency ablation of the nerve to
the corrugator muscle for elimination of glabellar furrowing.
Arch Facial Plast Surg 1999;1:46-8.
61. Hernandez-Zendejas G, Guerrero-Santos J. Percutaneous se-
lective radio-frequency neuroablation in plastic surgery.
Aesthetic Plast Surg 1994;18:41-8.
62. Alexiades-Armenakas M, Dover JS, Arndt KA. Unipolar radio-
frequency treatment to improve the appearance of cellulite.
J Cosmet Laser Ther 2008;10:148-53.
63. Gold MH, Biron JA. Treatment of acne scars by fractional
bipolar radiofrequency energy. J Cosmet Laser Ther 2012;14:
172-8.
64. Gold MH, Heath AD, Biron JA. Clinical evaluation of the
SmartSkin fractional laser for the treatment of photodamage
and acne scars. J Drugs Dermatol 2009;8(11 Suppl):S4-8.
65. Lee SJ, Goo JW, Shin J, Chung WS, Kang JM, Kim YK, et al. Use
of fractionated microneedle radiofrequency for the treat-
ment of inflammatory acne vulgaris in 18 Korean patients.
Dermatol Surg 2012;38:400-5.
66. Zelickson BD, Kist D, Bernstein E, Brown DB, Ksenzenko S,
Burns J, et al. Histological and ultrastructural evaluation of
607.e12 Taheri et al
the effects of a radiofrequency-based nonablative dermal
remodeling device: a pilot study. Arch Dermatol 2004;140:
204-9.
67. Alexiades-Armenakas M, Dover JS, Arndt KA. Unipolar versus
bipolar radiofrequency treatment of rhytides and laxity using
a mobile painless delivery method. Lasers Surg Med 2008;40:
446-53.
68. Sadick NS, Sato M, Palmisano D, Frank I, Cohen H, Harth Y.
In vivo animal histology and clinical evaluation of multi-
source fractional radiofrequency skin resurfacing (FSR) appli-
cator. J Cosmet Laser Ther 2011;13:204-9.
69. Javate RM, Cruz RT Jr, Khan J, Trakos N, Gordon RE.
Nonablative 4-MHz dual radiofrequency wand rejuvenation
treatment for periorbital rhytides and midface laxity. Ophthal
Plast Reconstr Surg 2011;27:180-5.
70. Grekin RC, Tope WD, Yarborough JM Jr, Olhoffer IH, Lee PK,
Leffell DJ, et al. Electrosurgical facial resurfacing: a prospec-
tive multicenter study of efficacy and safety. Arch Dermatol
2000;136:1309-16.
71. Zinder DJ. Common myths about electrosurgery. Otolaryngol
Head Neck Surg 2000;123:450-5.
72. Krueger N, Sadick NS. New-generation radiofrequency tech-
nology. Cutis 2013;91:39-46.
73. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar
fractional radiofrequency treatment induces neoelastogene-
sis and neocollagenesis. Lasers Surg Med 2009;41:1-9.
74. Hruza G, Taub AF, Collier SL, Mulholland SR. Skin rejuvena-
tion and wrinkle reduction using a fractional radiofrequency
system. J Drugs Dermatol 2009;8:259-65.
75. Lee HS, Lee DH, Won CH, Chang HW, Kwon HH, Kim KH, et al.
Fractional rejuvenation using a novel bipolar radiofrequency
system in Asian skin. Dermatol Surg 2011;37:1611-9.
76. Seo KY, Yoon MS, Kim DH, Lee HJ. Skin rejuvenation by
microneedle fractional radiofrequency treatment in Asian
J AM ACAD DERMATOL
APRIL 2014
skin; clinical and histological analysis. Lasers Surg Med 2012;
44:631-6.
77. Seo KY, Kim DH, Lee SE, Yoon MS, Lee HJ. Skin rejuvenation
by microneedle fractional radiofrequency and a human stem
cell conditioned medium in Asian skin: a randomized
controlled investigator blinded split-face study. J Cosmet
Laser Ther 2013;15:25-33.
78. Taheri A, Mansoori P, Sandoval LF, Feldman SR, Williford PM,
Pearce D. Entrance and propagation pattern of high-fre-
quency electrical currents in biological tissues as applied to
fractional skin rejuvenation using penetrating electrodes.
Skin Res Technol doi: 10.1111/srt.12115. Published online
November 21, 2013.
79. Hantash BM, Renton B, Berkowitz RL, Stridde BC, Newman J.
Pilot clinical study of a novel minimally invasive bipolar
microneedle radiofrequency device. Lasers Surg Med 2009;
41:87-95.
80. Brightman L, Goldman MP, Taub AF. Sublative rejuvenation:
experience with a new fractional radiofrequency system for
skin rejuvenation and repair. J Drugs Dermatol 2009;8(11
Suppl):S9-13.
81. Peterson JD, Palm MD, Kiripolsky MG, Guiha IC, Goldman MP.
Evaluation of the effect of fractional laser with radiofre-
quency and fractionated radiofrequency on the improve-
ment of acne scars. Dermatol Surg 2011;37:1260-7.
82. Govekar HR, Robinson TN, Varosy PD, Girard G, Montero PN,
Dunn CL, et al. Effect of monopolar radiofrequency energy
on pacemaker function. Surg Endosc 2012;26:2784-8.
83. Riordan AT, Gamache C, Fosko SW. Electrosurgery and
cardiac devices. J Am Acad Dermatol 1997;37(2 Pt 1):250-5.
84. Voutsalath MA, Bichakjian CK, Pelosi F, Blum D, Johnson TM,
Farrehi PM. Electrosurgery and implantable electronic de-
vices: review and implications for office-based procedures.
Dermatol Surg 2011;37:889-99.