Keywords

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FormalPara Key Points

  • Cryosurgery requires minimal previous preparation.

  • Some preoperative procedures are common to all surgical procedures, such as having the patient complete a consent form, obtaining correct diagnosis before surgery, and choosing the best technique that suits the patient’s needs.

  • A careful explanation of the procedure and the expected results as well as the time required to obtain such results is mandatory. Many patients are not familiar with cryosurgery and will need to be given thorough explanations.

1 Introduction

Many common benign and malignant lesions are amenable to be treated with cryosurgery. As in any other type of intervention, patients need to receive a thorough explanation on the procedure and give their consent. Once decided that a lesion can be treated with cryosurgery, explain to the patient all the treatment options as well as the expected secondary effects, the possible complications, the postoperative care, and the time expected for final healing. Questions about pain are frequent. Let the patient know what to expect in order to reduce anxiety. Cryosurgery tends to be a quick procedure with a long postoperative period. The more explanations are given to patients on all the possible side effects, the better the compliance.

While some cryosurgical procedures can be performed without any previous preparation, in some cases better results can be obtained if the patient follows some simple instructions prior to the procedure.

The first questions must be asked by the physician himself/herself. Then, the physician will need to attend to queries from the patient or his/her family.

2 Doctor’s Queries

  1. 1.

    Has the correct diagnosis been made?

    Before attempting to freeze a lesion, be completely sure of the diagnosis. If in doubt, it becomes mandatory to biopsy. Never freeze if not completely certain what is about to be eliminated by the cold.

  2. 2.

    Is the patient’s type of lesion amenable to cryosurgical treatment?

    Once a diagnosis is made, one should stop and consider all of the options available for the removal of a lesion. For instance, pigmented lesions are very sensitive to cold. A lentigo solaris responds very well, while melasma treated with cryosurgery can be a disaster. It is therefore important to know where to freeze and where not to freeze.

  3. 3.

    Is the patient’s skin type adequate to ensure the expected result?

    Skin types I and II tend to have excellent cosmetic results with cryosurgery. In darker skin types, one can expect hyperpigmentation with light freezing or hypopigmentation with deep freezing. If one is doing a cosmetic procedure on someone having darker skin, it is recommended to treat a small lesion in a not visible area and observe the results before attempting to do all the lesions at once.

  4. 4.

    Location, location, location.

    Even when a lesion can be treated with cryosurgery, its anatomical location will help decide whether one surgical technique should be used over another. For instance, doing cryosurgery on a nodular basal cell carcinoma (BCC) on the earlobe or on the eyelids will give an excellent cosmetic result, while a BCC on the leg will take forever to heal and leave an anesthetic scar.

  5. 5.

    Is there one lesion or are there several lesions?

    If the patient has a single, small, actinic keratosis, probably cryosurgery is the faster and cheaper curative treatment. The same is true for single or multiple seborrheic keratoses. Instead, a patient with numerous warts might benefit from a previous treatment before attempting to freeze many lesions.

  6. 6.

    Will the patient benefit from a prior preparation?

    Preparing the skin for a cryosurgical procedure can reduce the time required to perform the procedure, reduce pain experienced by the patient, and produce better curative and cosmetic results. If one thinks that the patient will benefit from a prior preparation, explain this in detail to the patient in order to increase compliance, and postpone the procedure until the lesion/area has been properly prepared. Some suggested presurgical preparations are summarized in Table 6.1.

    Table 6.1 Some of the pretreatments suggested for the most frequent skin conditions amenable to cryosurgical treatment
    Full size table
  7. 7.

    What is the best technique?

    Choose carefully the technique and ensure that you have all the necessary instruments to carry out the procedure. Do not treat some skin tags in the neck with the open (spraying) technique when the tweezer technique will work better, even if it is more time-consuming.

  8. 8.

    Will someone be available to attend to the patient if needed in case of an unexpected occurrence?

    With any surgical procedure, doctors have a responsibility to ensure that the patient can be attended to in case of an unexpected event. In cryosurgery, the postoperative time can be of long duration; therefore, one has to mentally “draw” a timeline of the expected occurrences and the final healing time in order to make the necessary arrangements. The patient needs to have at hand the adequate staff to meet any eventuality. This is an important consideration to keep in mind: avoid extensive cryosurgical procedures (such as for large tumors) right before anticipated absences (physician, nurses, caretakers).

3 Patient’s Queries

  1. 1.

    Preoperative preparation

    Make sure the patient understands the need for preoperative preparation in order to guarantee compliance. An example of such preparations can be the simple topical application of local anesthesia. However, others involve using immunomodulators for a long period, which in themselves have side effects.

  2. 2.

    Pain

    Patients are usually concerned about the possibility of having to suffer through a surgical procedure, and this is quite normal. Reassure the patient about this. Pain threshold is different from one patient to another. Individuals vary in their sensitivity to cold. A single superficial freezing is usually well tolerated. However, multiple superficial freezings increase responsiveness to further freezing and make the patient reach his/her maximum level of tolerable pain.

    Deep freezing is more painful than a superficial one. Once freezing begins, there is a cold sensation. When continuing to freeze, the sensation turns into a “burning” one. It improves when the procedure stops and then suddenly there is a new peak of pain which corresponds to the beginning of the thawing period. Explain this to patients from the beginning.

  3. 3.

    Location

    In cryosurgery, wounds heal by second intention. Daily cleaning and sometimes ointment application are necessary. The patient will need to let the surgeon know if he/she will be able to take care of the wound either on his/her own or with the help of someone else. Otherwise, one should wait to do the procedure. For example, in lesions of the back or those in anatomical locations not reachable by the patient, a patient will need help with postoperative care.

  4. 4.

    Healing time

    Once the patient knows how long the healing process will take, he/she will be able to decide the correct timing for the surgery. Sometimes it is best to wait until after a patient returns from a vacation or until after a special family event. The patient will also need to have at their disposition someone who will assist with the postoperative care.

4 Preoperative Considerations

Once the patient has agreed to have a cryosurgical procedure, the doctor will need to:

  • Obtain a signed consent form to include in the patient’s chart (Fig. 6.1). This consent form should include the operative and postoperative course of action. Every country/hospital/private clinic has different forms. Some are available online and can be adapted to your practice needs [1]. Ensure that the consent form is signed before doing a procedure. This is very important because it guarantees that the patient has all the necessary information, and it prevents legal issues for the physician. Dr Suhonen R. has suggested that it is best to have two different consent forms: a “small” consent form for small procedures and a “large” consent form in big procedures. An example of a “small” procedure could be freezing a seborrheic keratosis. An example of a “large” procedure could be the deep freezing of a skin cancer.

    Fig. 6.1
    figure 1

    A proposed consent form

    Full size image

  • Reduce expected pain. In most procedures, no anesthesia is required. In some procedures, topical anesthesia can be helpful such as: (a) superficial treatment in children (warts, molluscum) and (b) cryopeeling for sun-damaged skin. For procedures where one can expect pain, infiltrate local anesthetics will be required (deep freezing as in skin cancer treatment).

  • Reduce hyper-/hypopigmentation. For skin types III and darker, perform a test in a not-too-visible area and have the patient return later to the office so that the results can be observed.

  • Control for excessive edematous or allergic reaction. If the patient’s skin is very lax and the procedure is in the face and/or around the eyes, perform a test or do just a few lesions at a time in order to avoid excessive edema. If the doctor suspects that the patient might have an allergic reaction to cold, a small test on the inner side of the arm (with a few seconds of spraying) should be performed before the cryosurgical procedure.

  • Ask the patient face to face before a procedure if he/she has a trip, a party, or any important event coming up. The patient may not remember at first, but double-checking will be worth the time: the patient will be very upset if the procedure takes place and then he/she realizes that they had forgotten about such an event and now have a crust on the face due to the procedure, for example. This is something to be very aware of especially in those cases in which an in-office procedure is performed during a medical visit and has not required any preparation (like freezing one seborrheic keratosis in the face). It is best to postpone the procedure to another time when there are no special events planned in the patient’s life after a procedure.

  • Confirm that the presurgical procedure has been done properly. Some of the most common presurgical treatments are:

    1. (a)

      Warts: one small wart can be shaved and wet before freezing. Multiple lesions might be reduced in size and number by a previous 15–21-day shaving treatment and/or immunomodulator treatment.

    2. (b)

      Multiple molluscum in an atopic child: send the patient home for a few weeks of intensive skin hydration. Some of the lesions will simply fall off. The child will be very grateful to have less cryosurgery done on him/her.

  • Ensure that, for single recurrent lesions, a previous biopsy has been obtained. This is mandatory.

  • Last but not least, make sure to have enough LN before starting a procedure. One can have a waiting room full of patients and suddenly realize the Dewar is empty.

Essential Tidbits

  • In many instances, preparing the skin for cryosurgical treatment will yield better results.

  • Keratin removal will allow for a better penetration of the freezing front.

  • In skin cancerization, a previous removal of small subclinical lesions will leave only larger, hyperkeratotic lesions (additive effect).

  • Previous treatment can have an enhancing effect. The end result will be better than either cryosurgery or topical treatment used alone.

5 Conclusions

Patients need to be previously prepared for a cryosurgical procedure. Consent forms need to be signed. In addition, clear explanations of all surgical options, expected end results, required postoperative care, and possible complications are part of the information that should be made available to the patient.

Some procedures will have better cosmetic and curative results if a prior preparation of the lesion or the whole area is performed. Some of these are very simple and others are more time-consuming and have side effects of their own. Explaining them to the patient will help achieve better compliance.