Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating intradermal naevi with Ellman radiosurgery. This is the classical skin-coloured ‘mole’, elevated from the skin’s surface. They are not pigmented because the tumours originate deep within the dermis, rather than at the junction of the epidermis and dermis where the melanocyte layer is situated.

1. SKIN/DERMATOLOGY
53
Aesthetic Medicine • December 2014/January 2015
SPONSORED BY
CASE FILES
www.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating intradermal naevi with Ellman radiosurgery
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish Association of Cosmetic Doctors and Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is European medical advisor to Network Lipolysis and Consulting Rooms and holds higher qualifications in dermatology, laser technology and skin resurfacing. In 2012 and 2013 he won awards for ‘Best Innovative Techniques’ for his contributions to facial aesthetics and hair transplants. Dr Treacy also sits on the editorial boards of three international journals and features regularly on international television and radio programmes. He was a faculty member at IMCAS
Paris 2013, AMWC Monaco 2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
AA 53 year-old Northern Irish school bus driver presented with 12 small skin coloured lesions that were raised from the surrounding skin. He said some had appeared spontaneously but most of them had grown in size from pre-existing moles and developed during his teenage years and throughout adulthood. In recent years, he felt he was now becoming an object of ridicule from the children who he was carrying to school.
Examination revealed numerous small lesions with the same degree of pigmentation as the surrounding skin. They were raised some being dome-shaped, while others were pedunculated or having a warty appearance. Each measured approximately 1.5 × 2.5 cm. Based on the clinical findings; a diagnosis of multiple intradermal nevi was made and an excision biopsy was not considered necessary.
CHARACTERISTIC FEATURES INTRADERMAL NEVUS
This is the classical skin-coloured ‘mole’, elevated from the skin’s surface. They are not pigmented because the tumours originate deep within the dermis, rather than at the junction of the epidermis and dermis where the melanocyte layer is situated. Tumours originating at this level usually become junctional or compound naevi. Their appearance is very characteristic, although an inexperienced practitioner may struggle to differentiate them from an early basal cell carcinoma or a neurofibroma. Basal cell carcinoma will not have being present for a long period and usually have associated blood vessels.
TREATMENT
An Ellman RF Surgitron was used both to incise and coagulate these lesions. This was done at a setting of 20/24 under 2% lignocaine with adrenaline. The Ellman RF Surgitron has two working programs, one for cutting with a loop electrode and one for coagulation to seal the remaining surface. This device provides a fast and inexpensive method of removing epidermal and dermal lesions and is ideally suited for pedunculated lesions raised above the level of the surrounding skin. A smoke evacuator is preferably used during radiosur gery to prevent inhalation of heat-disseminated viral particles and I normally use the same one that is already attached to the CO2 laser. Images of another patient are sued here to demonstrate the technique.
Radiosurgery is ideally suited to dermatological physicians or surgeons already familiar with the characteristics of common skin lesions. This is because the radio-frequency generator produces differing choices of waveforms that can coagulate or cut the tissue that is being treated

2. 54 Aesthetic Medicine • December 2014/January 2015
CASE FILES SPONSORED BY www.aestheticmed.co.uk
S K I N/ D E RMATOLOGY
DISCUSSION
Ellman radiosurgery can be used for incisional techniques that
produce full-thickness excision of nevi, for shave techniques
that produce partial-thickness removal of superficial lesions,
and for removing vascular lesions such as heamangiomas
or pyogenic granulomas1. Radiosurgery is ideally suited to
dermatological physicians or surgeons already familiar with
the characteristics of common skin lesions. This is because
the radio-frequency generator produces differing choices
of waveforms that can coagulate or cut the tissue that is
being treated. Facial lesions that are being removed purely
for aesthetic purposes should preferably be treated by a
dermatological surgeon or plastic surgeon, particularly in
young patients, due to the high risk of medicolegal claims in
this area of practice if there is a poor cosmetic outcome2.
CONCLUSION
Ellman radiosurgery is a good method for removing intradermal
lesions, with apparently better cosmetic results than excision
biopsy3. The experience of the treating clinician will always
determine which lesions require further histologic examination
by skin biopsy. It goes without saying that suspicious pigmented
lesions should not be shaved because of radiosurgery artefact
and that the long-term prognosis of a malignancy may depend
on the full thickness of the lesion on histologic analysis. AM
An Ellman RF Surgitron
was used both to incise
and coagulate these lesions…
This device provides a fast and
inexpensive method of removing
epidermal and dermal lesions and
is ideally suited for pedunculated
lesions raised above the level
of the surrounding skin
REFERENCES
(1) Electrosurgery for the skin. Hainer BL.Am Fam Physician. 2002 Oct 1; 66(7):1259-66.
(2) Zuber TJ; Dermal electrosurgical shave excision. Am Fam Physician. 2002 May
1;65(9):1883-6, 1889-90, 1895.
(3) Electrosurgery principles: cutting current and cutaneous surgery--Part I. Sebben
JE. J Dermatol Surg Oncol. 1988 Jan; 14(1):29-31.
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