Coronavirus Disease 2019 State Guidelines on Elective Surgery

Considerations for Plastic and Reconstructive Surgeons

Benjamin A. Sarac, BS; Anna R. Schoenbrunner, MD, MAS; Stelios C. Wilson, MD; Ernest S. Chiu, MD; Jeffrey E. Janis, MD


Plast Reconstr Surg Glob Open. 2020;8(5):e2904 

In This Article


As a specialty that performs a large number of elective and outpatient surgeries, the long-term consequences of the COVID-19 pandemic on plastic surgery are unknown. With 71% of states currently recommending limitations on elective procedures, it is postulated that there will be a negative financial impact for both private and academic surgeons. But the state guidelines do not just impact plastic surgery; plastic surgeons play a role in the larger picture and can ultimately contribute positively or negatively to overall disease burden and PPE. To briefly assess the impact of the temporal trend compared with cases, the states of the authors' institutions can be analyzed. The 2 states under evaluation are Ohio and New York, both of which have published guidance during our data collection period. Ohio's guidelines, however, are published 6 days before New York's.[26,28] At the time of their respective publications, Ohio had 67 confirmed cases (0.57 cases per 100,000 people)[40] and New York had 12,339 confirmed cases (63 cases per 100,000 people).[41] If New York had issued guidance on the same day as Ohio, it would have occurred when the state was at roughly 5 cases per 100,000 persons. As it currently stands at the time of writing on April 10, 2020, Ohio has controlled the disease better than New York, at 50 and 486 cases per 100,000 persons, respectively. Although guidelines on elective surgery are certainly not the only factor influencing disease transmission, one can speculate the impact it has on disease burden as a single piece of a bigger objective toward overall eradication of the virus. Further, early data from China suggest a relatively high patient mortality rate of 20.5% when performing elective surgery during the asymptomatic incubation period of COVID-19.[42]

The other side of the double-edged sword, however, is how the guidelines will affect plastic and reconstructive surgeons. Those who have built practices in areas such as cancer reconstruction will less likely be affected than the surgeons in cosmetic-only service. Accordingly, 4 of the 18 states that gave specific guidance specifically mentioned cosmetic procedures, while leaving other areas, such as reconstructive surgery, without mention.[10,20,24,38] Although the current absence of elective procedures can be discouraging, Wang et al[43] in China have shown that volume will increase appropriately following adequate control of the disease, and as such, surgeons should be prepared to resume normal workload.

Furthermore, the response to the COVID-19 pandemic is unlike others encountered in world history, as Rohrich et al[44] explain in their recent article. In their article, they discuss that in case of other pandemics, such as the Spanish Flu, governing agencies did not provide public health mandates such as social distancing, and surely there were no elective surgery guidelines. Agencies such as CMS have adapted by providing detailed tiered systems on how to approach surgery during a global health crisis. Tiers range from lower acuity 1a to higher acuity 3b and are given recommendations of postpone, consider postponing, or do not postpone. The approach to cancer, though, is nuanced. "Most cancers" are placed into category 3a, meaning, do not postpone. However, the CMS guidelines do not provide commentary as to which aspects of oncology treatment should be postponed, leaving reconstructive surgeons without clear guidance.[2]

Using breast cancer as an example, the number of women who undergo immediate breast reconstruction following breast surgery ranges from 41% to 63%,[45] which necessitates the need for official direction on the approach to reconstructive breast surgery. For further insight into this specific scenario, providers are forced to consult other literature such as that published by Ueda et al,[46] the Society of Surgical Oncology,[47] or the American Society of Plastic Surgeons,[48] which have all published recommendations on this very situation even more recently than CMS. However, despite their advice, these 3 organizations urge providers to rely on institutional and/or local or state policy.

If a provider was to seek guidance from the state level, physicians in 15 of the 50 states would not find answers. Relating back to the breast cancer scenario described previously, only 12 states present information regarding malignancy or its related processes, none of which provide clarity on reconstruction.[6–8,10,14,20,21,25,28,30,31,38] And as Teven and Rebecca[49] point out in their letter to the editor, many of these cancer patients may be immunocompromised, thus putting them at higher risk for infection. Ultimately, reconstructive surgeons are forced to search elsewhere for official direction when not under the immediate guidance of institutional policy. It is clear that the vague language used in state recommendations needs to not only be improved in terms of quality, but quantity as well, and must extend to all 50 states.

In a global health crisis as serious as the COVID-19 outbreak, where the risk of disease transmission to patients and healthcare workers is high and PPE shortages loom, the need for decisive guidance is critical. In such situations, national societies and healthcare organizations need to step up to fill in the gaps of what the states cannot or will not provide. And although many national societies have chimed in, the input from multiple organizations can make it challenging for surgeons to interpret how to best conduct their practices during the COVID-19 pandemic. Ultimately, it is the responsibility of all plastic and reconstructive surgeons to operate under appropriate law while individualizing their practices to best suit the needs of their patients while being mindful of resource limitations and exposure risks.