A Multidisciplinary Approach and Review of Safety Recommendations for Plastic Surgeons During the COVID-19 Pandemic

Are N95 Masks Enough?

Scharukh Jalisi, M.D., M.A.; Austin D. Chen, M.D.; Ernest Gomez, M.D.; Radhika Chigurupati, D.M.D.; Ryan Cauley, M.D., M.P.H.; Suzanne Olbricht, M.D.; Bernard T. Lee, M.D., M.B.A., M.P.H.; Samuel J. Lin, M.D., M.B.A.


Plast Reconstr Surg. 2021;148(2):467-474. 

In This Article

Operating Room

Personal Protection

If possible, negative-pressure rooms are recommended. All personnel in the operating room need to have a planning huddle. Intubation should be performed by anesthesia personnel with appropriate personal protective equipment; surgeons can be outside the room. Full personal protective equipment should be donned, including N95 masks, gowns, gloves, and eye shields.[9,10] Personal protective equipment should be kept on until the patient is out of the operating room and no further immediate contact is planned, as aerosol may land on clothing or even unprotected mucous membranes, such as when extubation is performed.


Certain procedures may generate aerosol and therefore expose medical professionals to the risk of infection. Eight families of virus, including Coronaviridae, have been in particular noted as high risk based on being infectious by means of aerosol, evidence that they are found in the respiratory tract, and previous reports of nosocomial transmission.[27] Although it is unknown whether COVID 19 is transmissible through plasma or serum and there is no current evidence supporting transmission in this regard, the literature has also reported that viral RNA can be detected in the bodily fluids of infected patients. This is especially of note given that there have been previous reports on the aerosolization of infected fluids, such as blood.[28,29]

Moreover, smoke or plume generated from Bovie use or lasers may also carry with it this potentially infectious aerosol.[30] There do not appear to be current studies on the viral load found within generated aerosols from COVID-19 patients; however, there has been an example of detectable viral load in surgical smoke for hepatitis B, Corynebacterium, human papillomavirus, poliovirus, and human immunodeficiency virus.[31–36] In particular, as reported in the literature, surgical smoke has been linked to transmission of human papillomavirus,[37] which has a diameter of approximately 50 to 60 nm and is most commonly transmitted sexually, compared to a diameter of approximately 60 to 140 nm for COVID-19, which is most commonly transmitted by means of respiratory droplets.[38,39] In addition, there is evidence to suggest the potential for deposition of particulate matter on the respiratory tracts of surgical staff from surgical smoke, as illustrated by a study demonstrating the substantial mass concentration and size distribution of smoke particles following electrocautery of porcine tissue.[40] Table 1 notes various potential routes of viral transmission in different procedures and Table 2 notes the risk of different exposures and recommended safety precautions.

Surgical smoke particles typically range from 0.01 to 1 μm, with 77 percent being smaller than 1.1 μm. Particles smaller than 10 μm are inhalable, and those smaller than 2.5 μm precipitate in the alveolar region of lungs and those smaller than 0.1 μm deeply penetrate the respiratory system.[41,42] The Centers for Disease Control and Prevention has recommended the use of mechanical local exhaust ventilation smoke evacuation systems with high-efficiency filtration systems when performing procedures on human papillomavirus–infected tissues,[43] and this may be applicable when operating on COVID-19 patients, especially taking into account our current lack of understanding regarding it transmissibility in this regard. It has also been recommended to have filtered central wall suction units, install local exhaust ventilation suction apparatuses no more than 2 inches away from the source with a capture velocity of 100 to 150 feet/minute, and avoid electrosurgery when possible.[44–46]

Care of the Tracheostomy

Tracheostomy care needs to be approached with caution, including placement of tracheotomy during the case because of high aerosolization, and it has been previously reported during the severe acute respiratory syndrome–coronavirus outbreak that health care workers performed or being exposed to tracheal intubation procedures had a higher risk of transmission.[29] This requires communication with anesthesia to create apnea when the tracheostomy tube is inserted in the patient. Cuffed, nonfenestrated tubes should be used and the cuff inflated, and the patient should be attached to the ventilation circuit. Postoperative management also requires all personnel involved to wear full personal protective equipment, including N95 respirators, gowns, gloves, and masks.

Microvascular Surgery

The goal should be to reduce the time spent in the operating room; thus, the most experienced surgeons should be performing the operation. Exposure of trainees especially in a COVID-19– positive patient needs to be minimized. Potential avoidance of electrocautery, as noted earlier, is one strategy to eliminate viral loads in a Bovie plume.