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Subject: Cryosurgery of the Skin
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Liquid nitrogen sprayer and liquid nitrogen
Nitrous oxide tank, regulator, and Cryogun
Cotton-tipped applicator, forceps (optional), cotton ball, Dewer flask, polystyrene cup, and liquid nitrogen
Mucocele of the lip
Superficial basal cell carcinoma
Capillary hemangioma of the newborn
Solar-induced pigmentation and wrinkling
Lesion for which tissue pathology is required
Lesion located in an area with compromised circulation
Patient unable to accept possibility of pigmentary changes
Proven sensitivity or adverse reaction to cryosurgery
Sclerosing basal cell carcinoma or recurrent basal cell or squamous cell carcinoma, particularly when located in a high-risk area (e.g., temple, nasolabial fold)
Cold intolerance (relative)
Cold-induced urticaria (relative)
Collagen disease or autoimmune disease (relative)
Concurrent treatment with immunosuppressive drugs (relative)
Heavily pigmented skin (relative)
Lesions located in pretibial areas, eyelid margins, nasolabial fold, ala nasi, and hair-bearing areas (relative)
Multiple myeloma (relative)
Pyoderma gangrenosum (relative)
Raynaud disease (especially for procedures on the digits) (relative)
Active, severe ulcerative colitis
PITFALL: Blood at the surface of the skin acts like an insulator against cryosurgical destruction. Do not perform cryosurgery on an actively bleeding lesion.
PITFALL: Do not tap the applicator against the lip of the cup (in an attempt to shake off excess liquid nitrogen), because this may remove so much that an adequate freeze will not be possible.
PITFALL: Adenovirus is capable of survival in liquid nitrogen. The same source of liquid nitrogen should not be used with different patients.
PEARL: Nozzle sizes B and C are suitable for the treatment of most benign and malignant lesions.
PEARL: Pulsing direct spray is useful to avoid an overexpansion of the treatment site.
PEARL: Ice ball margins for most benign lesions should extend 1 to 2 mm beyond the visible pathologic border. Premalignant lesions need treatment margins of 2 to 3 mm. Malignant lesions require margins of 5 mm of clinically normal skin to ensure adequate depth of treatment.
PEARL: The planned freeze area (with margins) may need to be marked with a skin marker pen before starting the freeze, because freezing may blur the lesion’s margin.
PITFALL: Inadequate treatment of warts using a tip that is too small may result in the formation of a ring wart. Formation of a ring wart does not always imply inadequate treatment, because 5% of properly treated warts result in ring wart formation.
PITFALL: A large, flat tip applied over a small lesion produces excessive tissue destruction and potential scarring.
PITFALL: Use the size of the ice ball to guide the duration of the procedure. Physicians often use freeze times to guide therapy. Freeze times vary substantially because of factors such as the pressure (amount of refrigerant) in the tank, skin or lesion temperature, and thickness of the lesion.
PITFALL: Do not pull the cryotip off the target tissue before it has defrosted. Withdrawal of applicator tips before defrosting often results in the removal or denuding of the tissue surface.
Picture courtesy of Dr. Richard Usatine.
PEARL: Lesions will fall off within 1 week and usually heal without problems.
PITFALL: This method is slow and primarily used when few lesions are present.
Picture courtesy of Dr. Russell Roberts.
Headache (after treatment of facial lesions)
Syncope (vasovagal; rare)
Excess granulation tissue formation (rare)
Permanent hair loss
Alteration of sensation
Temporary, sensory nerve damage (rare)
Wallach Surgical, 235 Edison Road, Orange, CT 06477. Phone: 203-799-2000. Web site: http://www.wallach.com/.
Brymill Cryogenic Systems, 105 Windermere Avenue, Ellington, CT 06029-3858. Phone: 1-800-777-2796. Web site: http://www.brymill.com/.
Delasco, 608 13th Avenue, Council Bluffs, IA 51501-6401. Phone: 1-800-831-6273; fax: 1-800-320-9612; e-mail: email@example.com: http://www.delasco.com/pcat/1/Cryosurgery/.