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


Plastic surgeons perform a broad range of procedures from head to toe and in different settings, whether electively or following trauma or oncologic resection. This may make it particularly difficult to determine which operations should be performed during the pandemic. Table 3 outlines a framework of essential versus nonessential procedures.

Head and Neck

All head and neck reconstruction, dental or oral procedures, and maxillofacial trauma need to be approached with a high level of understanding about aerosolization and the proximity of viral loads in the mucosal surfaces of the head and neck region. Because of the viral concentration in the head and neck mucosal regions, these patients need to be deemed high risk even if COVID-19 testing is negative because of false-negative results. For nonfacial lesions, there is little aerosolization risk based on the current data, and surgery may proceed with the surgeon and assistants using standard personal protective equipment protection: gown, gloves, surgical mask, and eye protection.

Any surgery around the mouth or lips may have a higher risk of infection. Instillation of local anesthesia in the tip of the nose or the ala can induce sneezing or tearing. Positioning the patient appropriately may require special care because some patients may cough if they are not sitting upright. For such cases, ideally, surgery should be postponed. If the operation has to proceed, full personal protective equipment is needed: N95 mask, gloves, gown, and eye protection. Consideration should be given if the surgery can be postponed without increasing the risk of cancer growth, bleeding, and unresectability while balancing the risk of transmission to the health care providers. The risk of transmission of disease to patients in the health care setting also needs to be weighed. The most difficult dilemma occurs in the management of growing tumors in elderly or immunocompromised patients who also have the highest risk both of complications from the procedure and also of mortality from COVID-19. For maxillofacial trauma, consider closed reduction of fractures, whenever feasible. If open reduction and fixation is necessary, consider using self-drilling screws.

Mohs micrographic surgery is a staged procedure performed under local anesthesia in which the tumor and some margin of normal appearing skin is removed and margins are assessed by frozen sections prepared by processing the tissue horizontally. Repeated sections are done until the tumor is cleared, after which reconstruction is performed. The patient is often in the office for several hours to almost a full day and may be moved from procedure room to waiting room and back to procedure room multiple times. Surgeons generally run multiple cases concurrently. During the coronavirus epidemic, the surgeon should reduce the number of cases so that the patient can stay in the procedure room from the beginning of the operation until discharge to home to minimize contact with large numbers of people. The room then needs to be cleaned fastidiously before the next patient, including airing the room out with high-efficiency particulate air filters for at least 30 minutes. Because of the time required for frozen section preparation, elderly or incapacitated patients may need an accompanying caretaker who would then need to stay in the procedure room with the patient during the entire procedure rather than sent to a waiting room where social distancing is difficult. Patients can wear a mask and goggles during the operation, provided that the surgical site is accessible.

Truncal/Breast Reconstruction

Although there are a number of breast reconstruction options available following mastectomy, whether with regard to type or timing of the procedure, performing the least resource-intensive procedures during this trying time may be warranted, both to maximize the much-needed supplies to treat COVID-19 patients and to decrease the risk of exposure to patients and health care workers. Plastic surgeons at centers and hospitals are currently weighing options of performing only a form of delayed breast reconstruction at this time (i.e., tissue expander placement) and planning for future autologous options in certain patients. Alloplastic and autologous reconstruction each has its positive and negative points. Although autologous reconstruction is associated with greater patient satisfaction and cost-effectiveness in the long term, it does demand increased resource use in the form of staffing or supplies, and longer operative time and hospital stay, when compared to alloplastic reconstruction.[47–49] Of note, operative time may be especially important to consider, given the increased exposure time to hazards such as surgery-induced aerosol generation. Taking into account the more extensive scope for autologous reconstruction, such as with regard to the additional burden of a donor site, there is also the potential for increased surgical complications, which may extend hospital stay and increase exposure. As such, it is our opinion that performing either immediate direct-to-implant reconstruction in patients suited for the procedure or delaying autologous breast reconstruction with placement of tissue expanders instead may be most prudent. Of note, for delayed reconstruction, the decision must also be weighed against risks such as scarring, larger skin paddles, or negative psychological impact, and it is ultimately up to the surgeon to determine the best course of action. Despite the comparatively low exposure to mucosal surfaces and respiratory secretions compared to head and neck reconstruction, there is still the potential risk of surgical instrument–generated aerosol exposure to consider until it has been studied further.

Extremity/Hand Surgery

All precautions regarding prevention of viral transmission and deferring elective hand procedures hold as well during this unprecedented time (e.g., trigger finger release, cyst removal). Although these operative areas do not involve mucosal areas, providers may consider minimizing cautery during procedures by the routine use of tourniquet compression where possible. During emergent cases such as replantation and revascularization, extreme care by all health care workers, especially during intubation and extubation, should be taken. Certain cases may be performed as in a local/regional situation for anesthesia.