The coronavirus pandemic has had a devastating impact on our communities. This virus, known as SARS-Cov-2, is new to humans and therefore preexisting immunity does not exist. The underlying nature and behavior of the virus is actively being studied while infection rates continue to surge in some locations. Vaccine development is under way and drugs are being studied to treat the symptoms as well as block the infection. Social distancing measures have thus far been our only defense. Most of us have completely shuttered or significantly limited our practices to exclude elective visits and procedures. A growing body of knowledge about SARS-Cov-2 reveals features that are germane to the implementation of our approach to patients. It has been shown that viral load is higher in the nasopharynx than in other areas of the respiratory tract. (1) Facial Plastic and Reconstructive Surgery involves close contact with the upper respiratory tract and the adjacent facial region. Many individuals with the disease are asymptomatic or presymptomatic for anywhere from 2-14 days.(2) There is some concern that patients who are intubated during the incubation period experience more severe morbidity postoperatively. (3) Patients may shed virus for several days after resolution of symptoms. (4) In addition to direct contact with contaminated regions of the face, many procedures that we perform as Facial Plastic and Reconstructive Surgeons carry the risk of exposure to aerosolized particle generation (APG). These can be generated from the patient during high flow actions such sneezing or coughing or during mechanically powered activity such as forceful spray (i.e. topical anesthetic or irrigation), powered drills, electrocautery, positive airflow, or laser vaporization of tissue. Intubation, extubation, as well as endoscopy (rigid and flexible) can create APG. Another important consideration is the fact the virus can remain on surfaces for up to 9 days and when aerosolized can linger in the air up to 3 hours. (5) Postoperative care of patients also carries risk of exposure to coronavirus for the physician, staff, and other close contacts. As many state and local authorities are allowing elective surgical procedures to resume, the risk factors that are unique to performing procedures in the head and neck region must be seriously factored into one’s decision to return to elective surgical practice. You must evaluate the availability and implementation of SARS-Cov-2 testing in the community, rate of infection, local incidence of COVID-19 hospitalization, as well as the availability of appropriate PPE now and in the case of a surge once restrictions are relaxed. The medical community and surgical facility within which you perform procedures will establish policies that will affect your practice.
All patient care decisions must be based on the unique set of risk factors of the individual patient, the reliability of incidence reporting in your community, availability of testing, and your ability to properly safeguard your patients and caregivers with appropriate PPE and disinfection practices. In the case of unintended postoperative admission to your local hospital, it is important to know if the hospital is willing and able to accommodate a patient who has had a surgical procedure in the head and neck especially if there is a risk of AGP. Last (but not least) you should also consider your own tolerance for risk as well as your own personal risk factors and the risk factors of your close contacts.
Furthermore, our knowledge base about the behavior and characteristics of this novel virus is ever evolving. A consensus regarding best practices has not been established within the global medical community. Some findings which are widely believed at one point in time to be valid are later abandoned. Vigilance regarding generally accepted medical findings and evolving infection rates is essential to the provision of safe care.
Basic guidelines for return to elective surgery have been put forth by the ACS as well as the CMS. We have endeavored to include additional considerations unique to the procedures that we perform as Facial Plastic and Reconstructive Surgeons as found in current literature as well as other resources. Henceforth, we have prepared the following suggestions for optimization of surgical protocols. As new information becomes available, we will continue to update this document which will be located on our COVID-19 Resource page. We welcome any members to communicate relevant information so that we can modify these resources as needed and/or share it for the general benefit of our members. Infection rates, local policies, testing availability, and PPE resources vary widely. These suggestions are under no circumstances to be perceived as a standard of care but rather a reference that should be considered within the context of each physicians’ unique setting, local and state regulations, and unique patient variables.
Considerations for Elective Facial Plastic Surgical and Reconstructive Procedures during SARS-Cov-2 pandemic Based upon review of current literature and other resources as of 5/1/2020.
In order to deliver the safest care possible, it is imperative that medical facilities establish and maintain an environment marked by clear and frequent communication and education, preparation of a safe work environment, execution of safe practices, and careful follow-up. Documentation of protocols including checklists, forms, and policy manuals will be paramount to optimize compliance and reduce confusion.