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

Outpatient Evaluation

Use of proper personal protective equipment is paramount. When examining patients, examiners need to understand that certain regions, such as the head and neck, are high risk because of coronavirus transmission by droplets and the high potential for aerosolization because of the high concentration of viral load in the nasopharynx. To et al. noted a viral load of 5.2 log10 copies per milliliter found in the respiratory specimens from 23 of their infected patients.[6] Although the infectious viral load has not yet been identified, there are a few facts that have been reported. We know that the virus can be spread through human transmission and potentially lingers in the air for up to 3 hours, and on various surfaces from 24 hours to 3 days.[7] Studies have shown that the virus concentration peaks following initial presentation of symptoms and declines over the course of 1 week, with the virus being easily transmittable from asymptomatic or mildly symptomatic people.[6,8] Another study revealed that concentration levels of viral RNA may be associated with the severity of symptoms.[9]

The Centers for Disease Control and Prevention has already recommended contact and airborne protections with personal protective equipment and N95 masks.[5,10] Use of N95 masks, which can filter particles 0.3 μm or smaller, are especially crucial, given that surgical masks do not provide the recommended minimum level of protection by the Occupational Safety and Health Administration. Although surgical masks can certainly protect providers from large droplets, they are not as reliable for smaller particles, given that they do not adhere to the same standards as N95 masks. Moreover, the primary design of surgical masks is to protect the other party from the wearer; in this case, the patient from the provider. There are also standards of fit and seal that do not apply to surgical masks and therefore decrease the effectiveness of protection from airborne disease. According to the data, protectiveness against particles for surgical masks is eight to 12 times less than that for N95 masks.[11] One other consideration is the difference between the duckbill and the more standard dome-shaped N95 masks, with the former sometimes being considered more comfortable. It was found that 70.6 percent of reused duckbill N95 masks versus 27.5 percent of reused dome-shaped N95 masks failed fit testing.[12] The impact of appropriate ventilation is also important when used for COVID-19–suspected or –positive patients, with the Centers for Disease Control and Prevention suggesting negative-pressure rooms for any continuous aerosol procedures being performed and closed private doors otherwise.[13]

One other mechanism that may often be overlooked is ocular transmission, making eye protection in the form of goggles or face shields imperative. Viruses such as influenza or severe acute respiratory syndrome–coronavirus, and human papilloma virus or respiratory syncytial virus, have all been reported to be transmissible through contact with the mucous membranes of unprotected eyes.[14–17] Not only that, there have been reports of COVID-19 potentially transmitting by means of the ocular route, supported by symptoms of conjunctivitis and the virus being found in ocular secretions, and anecdotal cases of individuals infected following exposure to COVID-19 patients despite wearing personal protective equipment apart from eye protection.[18–20]

Precautions need to be taken for any asymptomatic patient, which would include at a minimum gloves, mask, eye protection for the examiner, and mask for the patient. For any patient who is suspected of having or is positive for COVID-19, ideally, the examination should be deferred until the patient has recovered. Alternative means of evaluation by means of telehealth (video conference) should be considered. If such a patient needs to be evaluated in an urgent manner, full personal protective equipment is needed, including N95 masks, gown, gloves, hat, eye protection for the examiner, and surgical mask for patient. The examination should be performed by the most experienced provider.