AAFPRS Guidance on Resumption of Elective Facial Plastic Surgical Procedures—Maximizing Safety and Reducing the Risk of COVID-19 Transmission

CLICK TO DOWNLOAD PDF VERSION:  AAFPRS Guidance on Resumption of Elective FPS Procedures  

AAFPRS COVID-19 Task Force and AAFPRS Patient Safety, QI, and Accreditation Committee
Reviewed and Approved by AAFPRS Board 5/13/2020 

Please Note: The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) offers the AAFPRS Guidance on Resumption of Elective Facial Plastic Surgical Procedures—Maximizing Safety and Reducing the Risk of COVID-19 Transmission as being a set of practical and sensible protocols for physicians to consider implementing in an effort to attempt to minimize COVID-19 transmission during facial plastic surgical procedures. Application of such guidance should be exercised in light of federal, state and local directives related to COVID-19 conditions where the medical practice is located—in conjunction with prudent and ethical medical judgement regarding the unique nature of each patient’s clinical, social and environmental conditions, within the distinct circumstances of each practice setting.

Introduction

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. 

Communication/Education

1. Maintain awareness about your local testing, hospitalization and infection rates as well as available testing and PPE supplies.
2. Educate staff on SARS-Cov-2 disease symptoms, transmission, and prevention. 
3. Train staff on proper PPE donning and doffing, infection control and decontamination protocols, social distancing and flow within your facility, screening and documentation procedures for patients. 
4. Establish and document staff symptom and screening protocols for your office as well as policies for quarantine after exposure, suspected infection or documented infection.
5. Communicate to patients via email, social media, patient portals and/or by phone of your protocols for all encounters. And create a clear script for your staff to follow in communicating these new safety protocols with your patients.

Prior to Consideration for Surgical Consultation

1. Communicate and train your staff on all screening protocols to identify possible active or presymptomatic COVID-19 infection by phone or EMR prior to any patient encounters.
   
   • Cough, Shortness of breath or difficulty breathing, Fever, Chills, Repeated shaking with chills, Muscle pain, new loss of taste or smell 
   • History of recent travel or other potential exposure 
   • History of contact with people showing symptoms, known COVID-19 infection, or travel outside the local area 
2. Avoid any in person encounters with patients who have suspected or confirmed infection or exposure for 14 days. Consider testing with RT-PCR test (+/- serology testing) prior to entering your office or surgical procedure. 
3. Assess comorbid patient risk factors for COVID-19 infection: 
   • People 65 years and older
   • People who live in a nursing home or long-term care facility
   • People of all ages with underlying medical conditions, particularly if not well controlled, including
     
     • chronic lung disease or moderate to severe asthma
     • serious heart conditions
     • hypertension
     • immunocompromised state-including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
     • severe obesity (body mass index [BMI] of 40 or higher)
     • diabetes
     • liver disease
     • Strongly consider postponing surgical procedures in patients with these conditions 
4. Consider the use of COVID-19 consent forms to communicate the additional risk level of SARS-Cov-2 infection that may be encountered during elective surgery (consult with your attorney and/or malpractice carrier).

Consultation, Preoperative Screening, and Preparation

After the initial remote screening of symptoms and premorbid conditions as well as all other medical and relevant information if the patient is deemed a potential surgical candidate: 

1. Schedule the patient/physician consult.
   • virtual consults reduce the risk of exposure using secure HIPPA telehealth platforms
   • 2D-imaging may be done virtually
   • 3D-imaging and standardized photos may be performed at the office at a later date (if desired) such as the preoperative appointment or second consultation
2. Paperwork should be transacted by phone, secure email, or EMR prior to the visit. Consents may need to be signed in person depending on local regulations and software capabilities. Appointments may be expedited by securely sending consents ahead of the office appointment for patients to review.
3. If a patient is a good candidate for surgery an in-person consult may be necessary or desired to do a more thorough assessment and examination of the patient.
4. Office may request that patient bring their own clean mask to preserve office PPE.
5. Prior to entering the facility, a standardized procedure for patient contact should be implemented:

• Patient should call or text the office from outside the office and wait until staff admits the patient
• Patient should come alone unless there is a critical need for a support person 
• Mask should be donned or provided by office to place prior to office entry
• Language barriers can be addressed with previously arranged virtual translation by a family member or professional (phone or live video)
• Phones should be stowed during the visit unless critically necessary
• The patient should be screened with a contactless infrared thermometer (and possibly a pulse oximeter if the physician chooses to do so). Temperature should be <100.4 F/38 C (02 saturation >94)
• Patient flow should be designed to optimize social distancing and minimize the time spent in the facility and in close contact with others
• Standardized photographs should be documented as well as a physical exam
• Any further discussion and consent process can be completed, and forms can be signed at that time or remotely

If Surgery is Determined to be Mutually Desirable

1. Consider preoperative testing to rule out COVID-19 infection. Real-time reverse transcription polymerase chain reaction (RT-PCR) testing is currently the most widely accepted screen for active infection although False negatives have been reported as high as 30 percent. Retesting may be considered as a standing protocol or in certain situations such as exhibition of symptom or exposure.
2. The decision to test may depend upon available reliable testing resources, physician judgement, as well as requirements of the chosen surgical facility.
   • Commercially available in-office PCR testing kits from vendors as well as rapid serological test kits that test for IgM and IgG may be considered, however, it is important to make sure these tests are FDA approved or EUA certified (Emergency Use Authorized) by the FDA and they reliably reflect presence of infection. Tests demonstrating previous exposure are not currently considered reliable indicators for immunity or lack of active infection. (6) 
3. Self-quarantine for a desired number of days prior to surgery and especially after testing should also be considered.
4. Reinforce the need for repeat screening of patient by staff of symptoms and potential exposure during the 2-week preoperative period via phone or EMR.
5. Ensure that the patient is prepared for the possibility of infection with COVID-19 infection in the postoperative period including the possibility of admission to the hospital. Considerations should include availability of caregivers for dependents, insurance coverage, and an advance directive should all be discussed.

Prior to Scheduling Surgery in an Outpatient Surgical Facility

1. Carefully review the facilities COVID-19 specific prevention policies and procedures to determine if they meet the level of care that you require and to avoid any unnecessary delays if certain prerequisites are not fulfilled.
2. Inquire as to their testing and PPE requirements for all office employees as well as their visitor policies. 
3. If you have your own in-office facility, stay in close communication with your certifying agency to ensure compliance. 
4. If operating within an uncertified setting such as your office, create extensive written guidelines to optimize patient and staff safety.
5. Communicate with the anesthesia provider prior to scheduling any procedures to make certain that you are both solidly on the same page with respect to protocols and preferences.
6. Inquire about the likelihood of being rescheduled for higher priority cases.
7. Ask about the availability of "block time" to attempt to secure more ideal start times that are less likely to be delayed or bumped.

Preoperative Process

1. Obtain infrared temperature, pulse oximetry and symptom screen prior to admission to facility.
2. Patient should be alone in the intake area and clean PPE provided. If support person is required appropriate PPE should be provided.
3. Consider testing with rapid onsite testing if reliable and available.
4. Consider antimicrobial gargle with poviodine-iodine solution. (7)(8)
5. Transport patient directly to OR with face mask in place. Avoid keeping patient in a communal setting such as a preop holding area near other patients.
6. All OR personnel (including surgeon) should have been prescreened for symptoms and signs of COVID-19.
7. All OR personnel should don (including surgeon) freshly professionally laundered scrubs that are stored at the OR facility (no outside scrubs, jackets, or caps should be worn).
8. Shoe covers should be donned, and hair completely covered.
9. Surgeon, anesthesia staff, and surgical assistants, as well as any circulating personnel should wear optimal PPE to minimize the risk of exposure to APG. Including N95, PAPR (for high risk of APG), face shield, and goggles.

Anesthesia Considerations

1. Review anesthesia plan with anesthesia provider prior to initiating any treatment to ensure coordinated and synchronized goals. Debate in the OR should be avoided.
2. The choice of anesthesia technique will depend on the length of the procedure, the likelihood of generation of aerosolized particles, patient risk factors, resources available at the facility, policy of the facility, preference of anesthesiologist and surgeon.
3. Local with sedation or MAC for certain procedures can be performed with care not to compromise the ability of the patient to comply with keeping a mask in place and with minimal risk of unprotected cough, sneeze, or gag-reflex.
4. Patients who do not receive General Anesthesia (GA) should wear a surgical mask at all times, including throughout the procedure. If supplemental oxygen is required, the oxygen face mask or low flow nasal cannula should be placed under the surgical mask.
5. Unplanned conversion from regional anesthesia to GA should be avoided if at all possible since the likelihood of unexpected Aerosolized Generated in an uncontrolled setting is riskier.
6. Laryngeal mask airways are considered less optimal by some authorities for the inability to seal the airway as effectively as intubation and therefore may generate more aerosolized particles. (9)
7. For procedures involving the airway such as rhinoplasty, for longer procedures, or in the pediatric population, general endotracheal anesthesia is likely preferable. 

Induction of Patient Undergoing General Endotracheal Intubation

While these guidelines pertain to administration of general anesthesia which is typically delivered by anesthesia professionals, it is important for the surgeon to be familiar with good practices, especially if the surgeon is the responsible supervising physician for a CRNA administering care.  Clear communication and coordination between Anesthesia Team and Surgical Team as well as with OR personnel is critical.

1. Minimize the number of people in the operating room during intubation to one intubator (ideally the most experienced individual) and one other assistant skilled in airway management.
2. Follow institutional protocols for the length of time before other personnel can return to the OR after intubation.
3. Keep the patient’s face covered with a surgical mask in place during induction. Oxygen delivered by Nasal cannula or non-rebreather mask is considered preferable to forced air via face mask to minimize aerosol generation. (8)(9)
4. Perform a rapid sequence induction and intubation, modified as necessary for patient factors.
5. If a modified rapid sequence induction with mask ventilation is felt to be necessary, use low pressure, small volume breaths, maintaining a tight mask seal. Consider use of two-person mask ventilation with one holding the mask in a tight seal and the other ventilating.
6. Consider covering the patient's head to reduce aerosol spread during intubation, including using clear plastic drapes or clear boxes.
7. Consider use of a videolaryngoscope, to increase distance between the operator and the patient's oropharynx especially in the difficult airway.
8. Consider placing wet gauze or towels around the airway and/or nose may be helpful in reducing leaks during mask ventilation or with the use of a supraglottic airway.
9. Use a closed suction system as necessary for tracheal suction, or for oral suction prior to extubation.
10. Place all used airway equipment into a double zip-locked plastic bag for subsequent decontamination.
11. Awake fiberoptic intubation should be avoided unless absolutely necessary, since there is a higher risk of coughing and subsequent aerosol generation with this technique. If awake intubation is performed, meticulous airway anesthesia should be achieved, using topical local anesthetic ointment or gel, and/or nerve blocks. Nebulized and transtracheal injection of local anesthetic should be avoided.

Intraoperative Considerations to Minimize APG and Reduce Contamination

1. Time out is conducted with special attention to COVID-19 preventative measures.
2. Patient is prepped by surgeon for optimal exposure and local anesthesia of surgical site as needed.
3. Intranasal anesthesia should be delivered via pledgets (avoid intranasal sprays).
4. Consider swabbing or Instilling dilute poviodine/iodine 7.5% 1:3 with saline (< 2% concentration) into the oral/nasal cavity after intubation (tracheal cuff inflated), but just prior to procedures that require instrumentation of the upper airway mucosa. Leave the solution in for approximately 1 minute before irrigating with saline then suction it out to limit absorption and tissue staining. (10)
5. Facial cleansing by OR staff is then performed with cleanser known to eradicate SARS-Cov2 (such as betadine).
6. Consider placement of sterile adhesive drapes or towels to seal the airway to minimize exposure to APG.
7. Negative pressure rooms should be used when surgery on a confirmed or suspected COVID-19 infected patient requires surgery (further discussion of this patient is outside the scope of this guideline since this is about elective surgical procedures).
8. Avoid instrumentation that generates APG such as irrigation of the airway, electrocautery, powered dissection such as ultrasonic techniques, within the nasopharynx or oropharynx, or laser vaporization of airway or oral mucosa.
9. Liberal use of closed suction with appropriate filters (i.e. HEPA) and disposable components should be used for removal of fluids and if required for smoke. 
10. Consider quilting sutures in the septum instead of splints or packing of the nose when possible.

Extubation

1. Avoidance of airway irritation is critical when extubating. Consider extubating while the patient is still deep after confirmed reversal of paralysis. Avoid suctioning the airway while the patient is not paralyzed.
2. Similar to endotracheal intubation, non-anesthesia personnel should leave the room during extubation and return after the recommended time per facility protocol.
3. Administer prophylaxis for postoperative nausea and vomiting.
4. Consider prophylaxis for coughing before extubation including topical, or intracuff lidocaine, low dose opioids.
5. To reduce spread of secretions during extubation consider placement of wet gauze or plastic drape over the patients mouth and nose just prior to extubation or if the patient begins to cough.
6. After extubation place a surgical mask over the patient's airway. Apply a plastic mask for supplemental oxygen over the surgical mask or nasal prongs under the surgical mask.
7. Transport to Recovery Room with face mask in place. Place nasal canula or oxygen mask under face mask.

Postoperative Care

1. Follow the same protocols as other preoperative visits to minimize patient encounter time.
2. Conduct visits virtually whenever possible.
3. Use dissolvable sutures whenever possible.
4. Avoid the use of nasal packing if possible.
5. N95 and disposable gowns as well as face shields must be worn by any staff who may be exposed to APG during visit. 
6. Consider guidelines for postoperative COVID-19 testing of symptomatic patients. Fevers and atelectasis are not uncommon postoperatively. 

References

(1) N Engl J Med 2020; 382:1177-1179; DOI: 10.1056/NEJMc2001737; https://www.nejm.org/doi/full/10.1056/NEJMc2001737 
(2) https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html  
(3) https://www.thelancet.com/pdfs/journals/eclinm/PIIS2589-5370(20)30075-4.pdf 
(4) https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0524LE 
(5) Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. Lloyd-Smith, Emmie de Wit, Vincent J. Munster. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine, 2020; DOI: 10.1056/NEJMc2004973
(6) https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-anesthetic-concerns-including-airway-management-and-infection-control 
(7) Kirk-Bayley, Justin and Combes, James and Sunkaraneni, Vishnu and Challacombe, Stephen, The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Reduce Cross Infection and Protect Healthcare Workers (March 28, 2020). Available at SSRN: https://ssrn.com/abstract=3563092 or http://dx.doi.org/10.2139/ssrn.3563092 
(8) High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion; Jie Li, James B. Fink, Stephan Ehrmann. European Respiratory Journal Jan 2020, 2000892; DOI: 10.1183/13993003.00892-2020; https://erj.ersjournals.com/content/early/2020/04/08/13993003.00892-2020 
(9) https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-anesthetic-concerns- including-airway-management-and-infection-control
(10) Parhar, HS, Tasche, K, Brody, RM, et al. Topical preparations to reduce SARS‐CoV‐2 aerosolization in head and neck mucosal surgery. Head & Neck. 2020; 1– 5. https://doi.org/10.1002/hed.26200

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