Plastic surgery is no longer viewed as relying solely on aesthetics; while it still relies on aesthetics to practice, this new specialty has flourished as a form and science. From the performance of cosmetic enhancements to the improvisation of reconstructive maneuvers, you as plastic surgeons depend on instruments that are extremely precise, easily controllable, and lead to minimal trauma on soft tissue. Among some of the most relied upon instruments in the current-day plastic surgery set are electrosurgical instruments, such as diathermy (or electrosurgery) pencils, bipolar devices, and cautery devices. 

Each of these instruments effectively uses electrical energy to either cut, coagulate, desiccate, or fulgurate tissue. The reliance on these devices has been revolutionary in elements of surgery, particularly in surgical endeavors involving the skin and soft tissue, where the precision in this environment can ultimately have significant ramifications in choices involving nuance, hemostasis, and the need to limit other adverse effects.

 In this blog post, we will talk about the various contributions of instrument reliance to surgical time, patient safety, and ultimately surgical outcomes in plastic surgery.

Understanding Electrosurgery in Plastic Surgery

Electrosurgery involves the use of high-frequency electrical currents to perform surgical tasks. Unlike traditional scalpels, electrosurgical tools reduce bleeding by sealing blood vessels as they cut. This dual function of dissection and coagulation is particularly valuable in plastic surgery, where clean fields and precision are paramount.

There are two main types of electrosurgery:

1. Monopolar Electrosurgery: Uses a single active electrode (e.g., a diathermy pencil) to deliver current, with a return electrode (grounding pad) completing the circuit.
   
2. Bipolar Electrosurgery: Current flows between two tips of the same instrument (e.g., bipolar forceps), without the need for a grounding pad.
   

Each type has distinct advantages and applications in skin and soft tissue work.

Diathermy Pencils: Precision in Dissection

The diathermy pencil is one of the most commonly used tools in any plastic surgery set. Also referred to as an electrosurgical pencil or electrocautery pen, this instrument delivers monopolar energy to cut or coagulate tissue.

Notable Features:

• Button or rocker switch to select cut or coagulation modes
• Interchangeable tips (needle, blade or ball electrodes)
• Insulated shaft to protect adjacent tissues
• Lightweight, ergonomic design for long duration use

Tissue Dissection and Diathermy Pencils:

• Skin Incisions: Though most plastic surgeons will use cold steel for their first incision associated with the best cosmetic outcomes, diathermy pencils are excellent for subcutaneous dissection. They minimize bleeding from the small vessels and allow for a clearer surgical field.
• Flap Elevation: Flaps of skin, such as in rhytidectomy (facelift) or breast reduction procedures, have to be elevated without excessive bleeding. Diathermy pencils provide sharp tissue dissection while coagulating vessels at the same time.
• Tumor Excision: In an oncologic reconstructive surgery context such as skin cancer excision and reconstruction, diathermy pencils allow for neat tissue removal while maintaining hemostasis.
• Scar Revision: Precise tissue remodeling and debridement can be done with minimal thermal spread, reducing tissue damage and promoting better healing.

Advantages:

• Minimizes need for additional hemostatic tools
• Shortens operative time
• Reduces blood loss
• Enhances visibility during dissection

However, the surgeon must be cautious with thermal spread, especially when working near vital structures or delicate tissue planes.

Bipolar Forceps: Controlled Coagulation with No Collateral Damage

Bipolar forceps provide a controlled and focused amount of electrical energy when compared to monopolar devices. In bipolar coagulation, current can only travel between the prongs of the forceps and will only affect the tissue between those prongs.

Characteristic Features:

• Tweezer-like design
• Integrated cable or detachable connector
• Different styles of tips to select from (fine, curved, blunt)
• Few damages with thermal spread

Plastic Surgery Applications:

• Facial Surgery: When performing eyelid surgery (blepharoplasty) and performing it with nose surgery (rhinoplasty) and, in addition, other types of facial cosmetic surgery, it is necessary to avoid collateral damage to surrounding tissues, as the aesthetic outcome of the surgery is preserved if there is no collateral damage. With bipolar forceps, coagulation can be performed in very tight anatomical spaces with minimal thermal spread.
• Microsurgical Flaps: When harvesting or anastomosing free flaps, bipolar forceps provide the necessary control to stop bleeding from small perforators or veins without collateral injury to adjacent structures.
• Burn Surgery: In the context of debridement and grafting, bipolar instruments are beneficial to coagulating bleeding occurring within capillary beds when not covered by de-epithelialized tissue.
• Nerve-Sparing Procedures: When working around motor or sensory nerves, bipolar coagulation enhances safety by limiting thermal damage to only the area of contact.

Advantages:

• Superior for coagulating small, delicate vessels
• No need for grounding pads
• Reduced risk of unintended burns or shocks
• Ideal for use in pediatric or compromised patients

Because the energy is limited to the target tissue, bipolar forceps are favored for procedures requiring meticulous hemostasis in sensitive zones.

Electrocautery Tools: Versatility in Skin and Soft Tissue Work

Though often confused with electrosurgery, electrocautery specifically refers to heating a metallic instrument tip via direct current (DC), which is then used to burn or cauterize tissue. It does not involve current flow through the body.

Types of Electrocautery:

• Unipolar: Delivers heat through a single point.
• Battery-operated cautery pens: Used in office-based or minor procedures.

Role in Plastic Surgery:

• Hemostasis in Small Procedures: In minor lesion excisions, mole removal, or skin tag excision, cautery pens provide quick hemostasis and tissue ablation.
• Control of Hemorrhage Intraoperatively: Surgeons often use cautery instruments intraoperatively to manage difficult-to-manage bleeding points that cannot be managed using sutures or clips.
• Management of Wound Edges: In cosmetic procedures, management of capillary oozing around the edges of a wound will improve clarity of the operative field and may help decrease postoperative bruising.
• Postoperative Bleed Control: In-office follow-ups, minor bleeding can be managed with portable cautery units without the need for reoperation.

Advantages:

• Simple and effective
• Portable and easy to use in outpatient settings
• Less equipment setup compared to electrosurgery units

While not as sophisticated as monopolar or bipolar systems, electrocautery tools remain a vital component of the plastic surgery toolkit, particularly in minor or remote settings.

Integration in Contemporary Plastic Surgery Sets

Modern plastic surgery instrument sets are curated not just for cutting and clamping, but for current energy delivery systems. Depending on your use, a basic set will have some assembly of:

• Diathermy pencil with interchangeable tips
• Footswitch or hand-held controlled
• Fine tip bipolar forceps (various sizes)
• Portable cautery pen or battery units
• Insulated holders for instruments
• Smoke evacuation adapter (to manage plume during surgery)

Likewise, in sets for microsurgery and aesthetic work, instrument sets contain some combination of magnification loupes, a suction source, and vessel clips for minimally invasive and fine detail work.

Safety and Best Practices

Electrosurgical instruments are useful tools, and potential complications such as burns, delayed healing, and inadvertent tissue damage can occur, especially if they are used improperly. Below are some safety recommendations:

• Use the lowest effective power setting
• Avoid activation near flammable materials (e.g., alcohol based preps)
• Keep tips clean to maximize energy transfer
• Use smoke evacuators to minimize exposure from toxins released from tissue plume
• Continually check cables and insulation for defects

Training and comfortability with these instruments are vital for all members of the surgical team participating in plastic surgery cases.

Conclusion

Electrosurgical instruments, including diathermy pencils, bipolar forceps, and electrocautery devices, are an important part of the plastic surgical armamentarium. These instruments enhance precision of incision with hemostasis, increasing safety, improving outcomes, and decreasing operating times, from the delicate surgical facial procedures to the reconstructive procedures with large volumes of soft tissue. These plastic surgery instruments provide a valuable resource for the surgeon to advance precision and create optimal accoutrements.

As it does with many other facets of practice, plastic surgery continues to evolve, and the advances in technology related to electrosurgical instruments are advancing with new devices being created with smart energy-control delivery systems, temperature-controlled tips, and better ergonomic properties for ease of use. For now, the use of electrosurgical instruments has become a measure of exemplary care in the specialty of plastic and reconstructive surgery.