Electrosurgery is a basic and standard tool in nearly all surgical specialties because of its major advantages for cutting and sealing, allowing a bloodless surgical field and, therefore, fewer potential complications (e.g., hematoma, hemorrhage, infection). Since its introduction at the beginning of the 20th century, electrosurgery has undergone continuous development and refinement,1 among which the design of devices with ultrafine needle tips stands out, capable of delivering less energy to tissue and resulting in less tissue necrosis.2

The use of electrosurgery for skin incisions has been evaluated by other surgical specialties (e.g., neurosurgery, ophthalmology) vs the conventional cold scalpel, without significant differences being observed in complication rates and healing outcomes.3,4

However, in dermatologic surgery, the routine use of electrosurgery for skin incisions and tissue dissection still raises concerns regarding the theoretical risk of poor healing as a result of thermal damage.5

The aim of this study was to compare the cosmetic and healing outcomes associated with the use of an ultrafine electrosurgical tip (Colorado tip) or a conventional cold scalpel for skin incision and subcutaneous tissue dissection in dermatologic surgery.

We conducted a longitudinal, randomized, parallel-group comparative study from October 2022 through May 2023 in the Medical-Surgical Dermatology Department of Hospital Universitario Virgen Macarena (Seville, Spain), to identify differences in cosmetic and healing outcomes between skin incisions performed with an electrosurgical scalpel using a Colorado needle and those made with a conventional scalpel.

The study included patients aged 18–75 years who required simple excisions for removal of nonmelanoma skin cancer or for widening of scars from primary malignant melanoma eligible for reconstruction by approximation and direct suture. Lesions included in the study had to be located on the trunk or extremities and had to be amenable to complete resection under local anesthesia. The exclusion criteria were as follows: past medical history of healing disorders (hypertrophic scar, keloid); history of intolerance to suture materials; tumors on the head, neck, palms, or soles; clean-contaminated, contaminated, or infected wounds; connective tissue diseases; immunosuppression; and difficulty completing questionnaires.

The intervention under study consisted of the use of a Colorado-tip microdissection needle throughout the entire surgical procedure, both for skin incision and subcutaneous plane dissection and for hemostasis. Procedures were performed by a surgeon with more than 20 years of experience and a senior resident specialist with 4 years of experience.

For this purpose, the Valleylab FT10 electrosurgery platform (Medtronic®, Minneapolis, MN, USA) was used, set at 10W in cut mode for skin incision and subcuticular dissection, and at 15W in coagulation mode for hemostasis. In the control group, a No. 15 cold scalpel blade was used for skin and dermal incision, and dissection of the subcutaneous planes was performed with Metzenbaum scissors. In this group, electrosurgery was used only to seal bleeding blood vessels. All procedures were performed after local injection of 2% lidocaine. Absorbable 3-4/0 glyconate monofilament sutures were used for closure of the subcutaneous layer, with nonabsorbable 3-4/0 polypropylene monofilament sutures for simple skin stitches. Sutures were removed in both study groups after 14–16 days. Digital images were taken before and after surgery and at the follow-up visit. Follow-up visits for recording final outcomes were scheduled 3 months after the procedure. Consent forms were signed before patients were enrolled in the study.

At the initial visit, the following study variables were recorded: age, sex, skin phototype (Fitzpatrick scale), history of immunosuppression, anticoagulant/antiplatelet therapy, smoking status, diagnosis, lesion size, and anatomic location. On the day of surgery, the type of procedure, incision length (mm), defect width (mm), and duration of surgery (minutes), measured from incision to the final suture, were recorded.

At the 3-month follow-up visit, scars were evaluated by two independent investigators using the Observer Scar Assessment Scale (OSAS) (Spanish validated version) and a global scar assessment. Participants also completed the Patient Scar Assessment Scale (PSAS) for each scar. The primary outcome measures were the mean OSAS and PSAS scores and the mean global scar assessment. Wound complications were also recorded at the follow-up visit. Images of all scars were shown to a group of dermatologic surgeons from the same institution, who rated each scar from 1 (normal skin) to 10 (worst imaginable scar).

The Patient and Observer Scar Assessment Scale (POSAS) is a validated tool for scar evaluation6 and consists of the two previously mentioned scales (PSAS and OSAS), which assess 6 scar characteristics scored from 1 to 10, where 1 represents normal skin and 10 the worst imaginable scar. For patient-reported outcomes, POSAS evaluates color, pliability, thickness, pruritus, pain, and irregularity; for the observer questionnaire, it evaluates vascularity, pigmentation, pliability, thickness, relief, and surface area.

Patients meeting inclusion criteria were assigned to each study group using a simple randomization procedure. Descriptive analyses were performed to summarize baseline patient characteristics. To compare outcome measures between the two study groups, Student t test was used for quantitative variables and a paired proportions test for qualitative outcomes, with a 2-tailed alpha level of 0.05.

At the end of the study period, a total of 95 patients were included, 85 of whom attended the follow-up visit: 51.8% (n=44) in the electrosurgery group and 48.2% (n=41) in the conventional scalpel group. Table 1 summarizes the baseline demographic and clinical characteristics of both groups.

The most common indication for surgery was excision of basal cell carcinoma (83.5%, n=71), followed by melanoma scar widening (8.2%, n=7), excision of other tumors (4.7%, n=4), and squamous cell carcinoma (3.5%, n=3). Most lesions were located on the back (42.4%, n=36), chest (21.2%, n=18), upper extremities (22.3%, n=19), lower extremities (9.4%, n=8), and abdominal region (4.7%, n=4). No statistically significant differences were observed between study groups in terms of smoking status, immunosuppression, phototype, or anticoagulant use (Table 1). Defect width and length were also comparable between the two groups (Table 1). The mean scar width was 2.83mm (95%CI, 2.44–3.22) in the cold scalpel group and 3.47mm (95%CI, 2.96–3.97) in the intervention group (P=.480).

Regarding the primary outcome measures, no statistically significant differences were found in mean PSAS and OSAS scores, objective global assessment, subjective global assessment, or external observer global assessment scores (Table 2 and Figs. 1 and 2). The mean duration of surgery was 9.32min (95%CI, 8.18–10.46) for the cold scalpel procedure and 9.98min (95%CI, 8.99–10.97) for surgery performed with the Colorado tip (P=.381). No significant differences were identified in scar characteristics according to observer evaluation (Table 3).

Fig. 1.

Excellent cosmetic outcome of a scar resulting from skin incision with a Colorado microdissection needle (global OSAS 2.00). Appearance of the scar 3 months after surgery.

Fig. 2.

Excellent results following use of a cold scalpel (global OSAS 2.30). Appearance of the scar 3 months after surgery.

The overall complication rate in the study population was 4.7% (7.3%, n=3 in the cold scalpel group and 2.3%, n=1 in the Colorado microdissection needle group; P=.272). Suture dehiscence was the most frequent complication.

In this study, the use of a Colorado-type microdissection needle for skin incisions in dermatologic surgery was not associated with worse healing outcomes vs the use of a cold scalpel and dissection scissors, according to both independent observer and patient assessments. In addition, this device proved to be safe, as it did not increase the frequency of wound complications.

These results are consistent with those of former studies conducted in other anatomic locations and by other surgical specialties. In a retrospective study by Gonzalez-Lopez et al., the cosmetic outcome (also measured using the POSAS scale) of periorbital skin incisions performed with a cold scalpel or a Colorado microdissection tip was similar in both groups.3 In other studies in neurosurgery4,7 and general surgery8 (with lesions located on the scalp and inguinal region), no differences were observed in cosmetic outcomes, although this was not the primary endpoint of those studies. Subsequent meta-analyses and systematic reviews have confirmed these findings.9,10 The present study differs in that it specifically evaluates the use of this surgical device in dermatologic surgery.

The use of an ultrafine microdissection needle at low power allows electrical current to be concentrated in a small area of the skin, enabling incision and dissection with minimal energy dispersion and resulting in minimal tissue necrosis.2 Therefore, a higher complication rate would not be expected, as observed in this comparative study. Moreover, this minimal thermal damage should not interfere with proper microscopic analysis of resection margins in excised tissue, a concern often cited against the use of electrosurgery for skin incision in dermatologic surgery. However, this hypothesis warrants specific investigation and is currently under study at our center.

In theory, a potential advantage of the routine use of the Colorado tip could be a reduction in surgical time. Although this study did not demonstrate such an advantage, it should be noted that the procedures analyzed were simple excisions with direct closure, with a mean duration of 9.88min. It is possible that this benefit may be observed in longer procedures, such as complex flap reconstructions requiring greater tissue mobilization. Similarly, surgery in other anatomic regions more prone to bleeding (e.g., the face and scalp), which were not included in this study, may also benefit from the use of electrosurgery.

Although the main limitation of this study is its single-center design, this also reduces interoperator variability. In addition, anatomic locations with greater cosmetic impact (e.g., the face) were intentionally excluded. Outcome measures were assessed 3 months after surgery. Wound healing is a prolonged and dynamic process that may extend beyond 1 year.11 Furthermore, the 3-month follow-up period may be too short to identify hypertrophic scars and keloids. Similarly, the vascular component of scars may have been overestimated at this time point, which could explain why vascularity was the scar characteristic receiving the lowest scores.

The strengths of this study include its comparative group design with random allocation, the use of a validated assessment tool (POSAS), and blinded evaluation of scars. Procedures were performed by a surgeon with more than 20 years of experience and a senior resident with 4 years of experience, enhancing the external validity of the findings.

In light of these results, further studies are needed to assess scar outcomes in other anatomic regions, such as the cephalic area, to increase dermatologic surgeons’ confidence in the use of this device.

In conclusion, this study showed that the use of the Colorado tip for skin incision and tissue dissection in dermatologic surgery of lesions located on the trunk and extremities is comparable to the use of a cold scalpel and dissection scissors in terms of healing, cosmetic outcomes, and safety. Considering the abovementioned limitations and strengths, these findings provide high-quality evidence, previously unavailable in this field, supporting the use of the Colorado tip in dermatologic surgery.

The authors declare no conflict of interests.