by Steven Tetelbaum MD
A moratorium was placed on nonurgent surgery throughout much of the United States in mid-March 2020 due to surging numbers of COVID-19 cases. Several months later, and with new safety precautions in place, elective surgery gradually resumed. However, no data exist on the safety of plastic surgery during the pandemic.
This aim of this survey was to assess the safety of plastic surgery during the pandemic by quantifying: (1) the preoperative prevalence of SARS-CoV-2; (2) the risk of postoperative COVID-19; (3) outcomes and precious resource utilization for such cases; and (4) the risks to office staff.
Los Angeles plastic surgeons certified by the American Board of Plastic Surgery (ABPS) were sent an online survey in July 2020, during a local COVID-19 surge, querying about the number of procedures performed in the 8- to 10-week period since reopening, testing policies, surgical complications, and cases among staff.
In total, 112 surgeons reported 5633 surgeries since resuming elective surgery. Of these, 103 (91.96%) surgeons obtained a preoperative SARS-CoV-2 polymerase chain reaction (PCR) test for every patient. The preoperative PCR test was positive in 41/5881 (0.69%). Positive tests within 2 weeks postoperation occurred in 7/5380 (0.13%) of surgical patients, 3/8506 (0.04%) of injection patients, and 6/2519 (0.24%) of energy therapy patients. Nine offices reported at least 1 staff member who developed COVID-19. All cases were mild, with no hospitalizations or deaths.
These data demonstrate that plastic surgery can be performed safely during a COVID-19 surge by ABPS diplomates. This has profound impact for patients, plastic surgeons, and health policy regulators.
One cannot overstate the sense of portend that gripped the United States in March 2020. Cases of COVID-19 were rising rapidly, testing was limited, and there was fear that a deluge of critically ill patients would overwhelm the healthcare system. In a few dizzying days, most of the country went from normal to lockdown as various levels of government and health departments closed schools, issued stay-at-home orders, and shuttered nonessential businesses.
Most states also stopped nonurgent surgery. Hospitals needed to stock up on personal protective equipment (PPE), increase their supply of ventilators, convert operating rooms to ICUs, and conserve anesthetic drugs that were needed for ICU patients. Individual plastic surgeons and their societies responded by volunteering the use of their operating rooms, donating their PPE, and offering their ventilators to hospitals.1
By early May many states had passed their peak and started loosening restrictions on elective surgery. In many areas the backlog of postponed surgeries exceeded operating room availability. Systems were proposed to prioritize cases according to measures of necessity, urgency, and nonsurgical alternatives.2,3 A group at UCLA developed a Plastic Surgery Acuity Scale to determine the ideal prioritization of plastic surgery patients.4
Whereas the fundamental issue for the hospital setting was rationing limited operating room time, office-based and freestanding ambulatory surgery centers had an overabundance of operating room availability. For plastic surgeons operating in those facilities, their singular concern was patient safety.
At the start of the pandemic, The Aesthetic Society President Charles Thorne MD appointed James Fernau MD to become chairman of a task force on COVID-19 safety. His group put on a number of webinars and distributed detailed information about how to reduce the risks of performing plastic surgery during the pandemic.5 Plastic surgeons also received recommendations from other surgery societies, and via multiple publications that appeared throughout the surgical literature.6-10 But there was no certainty that these inchoate recommendations would be sufficient to protect patients and operating room personnel.
There was great concern about preventing patients, staff, and surgeons from infecting one another. This led to many suggestions about protective equipment, air circulation in the operating room, sterilization of anesthesia circuits, etc. The other issue had to do with the risks of anesthesia and surgery on patients who were infected but asymptomatic. At least 1 paper from China reported an increased risk of complications and mortality from COVID-19 infections after surgery compared with historic controls.11
For these reasons many—but not all—organizations recommended preoperative polymerase chain reaction (PCR) testing. If a patient were known not to be infected when they entered the operating room, then theoretically surgery would be every bit as safe as it was before SARS-CoV-2 reached our shores. But there were destined to be false negative tests. Would the testing be sensitive enough to catch most of the infected patients? Would there be many patients who were false negative, got infected between testing and surgery, or who might get infected during surgery? If so, what was their risk of getting a serious infection? Would getting plastic surgery give them a worse case of COVID-19 than they otherwise would have had? If so, would these patients use limited hospital resources? Might some die?
Alongside their concern about the safety of performing plastic surgery, plastic surgeons were also aware that public health department officials and politicians might decide to place another moratorium on elective surgery. If surgery were unsafe, plastic surgeons would choose not to operate; but there was widespread concern that even in the absence of data, a health official might take the reactionary step of curtailing elective surgery. Thus the need to develop these data was important for patient safety as well as to inform public policy makers.
METHODS
The Los Angeles Society of Plastic Surgeons (LASPS) sent a 17-question survey (SurveyMonkey, Palo Alto, CA) to approximately 409 plastic surgeons certified by the American Board of Plastic Surgery (ABPS) in the greater Los Angeles area in the third week of July 2020, inquiring about their practices since their reopening in late May (Table 1). Recipients were assured the results would be anonymous. Reminders were sent every other day during the 1-week period the survey was open. The data were collectively analyzed by the 3 authors. Because the survey did not request patient-specific information and the respondents were untraceable, institutional review board approval was not required nor sought and patient consent was not required. We followed the Declaration of Helsinki Guidelines and best ethical practice guidelines. Information about the prevalence of COVID-19 during the period of the study was retrieved from the website of the Los Angeles County Department of Public Health (http://publichealth.lacounty.gov/media/coronavirus/) and appears in Figures 1-3.
