{'fraction_non_alphanumeric': 0.028922523602577552, 'fraction_numerical': 0.021654428293121534, 'mean_word_length': 5.370883054892602, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
PLASTIC SURGERY AND THE COVID-19 PANDEMIC: A REVIEW OF CLINICAL GUIDELINES.

Abstract Background A novel coronavirus disease (COVID-19) was first reported in December 2019 in China and was soon declared a pandemic by World Health Organization. Many elective and non-essential surgeries were postponed worldwide in an effort to minimize spread of disease as well as to conserve resources. Our goal with this article is to review current practice guidelines in setting of the COVID-19 pandemic, based on available data and literature. Methods Websites pertaining to surgical and medical societies, and government agencies were reviewed, along with recently published literature to identify recommendations related to COVID-19 and plastic surgery procedures. Results Clinical practice modifications are recommended during the pandemic, in outpatient and perioperative settings. Use of personal protective equipment is critical for aerosol generating procedures such as surgery in the head and neck area. Care for trauma and malignancy should continue during the pandemic, however definitive reconstruction could be delayed for select cases. Specific recommendations were made for surgical treatment of cancer, trauma and semi-urgent reconstructive procedures based on available data and literature. Conclusion The risk and benefit of each reconstructive procedure should be carefully analyzed in relation to necessary patient care, minimized COVID-19 spread, protection of health care personnel and utilization of resources. Recommendations in this manuscript should be taken in the context of each institute’s resources and prevalance of COVID-19 in the region. It should be emphasized that the guidelines provided are a snapshot of current practices and are subject to change as the pandemic continues to evolve.


BACKGROUND
A novel human coronavirus named "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" was first reported in Wuhan, China in December 2019, and the outbreak of coronavirus disease 2019 (COVID-19) was declared a pandemic by World Health Organization on March 11 th , 2020. 1 As of April 24th 2020, there are 2,626,321 confirmed cases of COVID-19 worldwide, 181,938 of which resulted in death. 2 In comparison to prior coronavirus outbreaks (2003 SARS pandemic and 2012 MERS outbreak) SARS-CoV-2 so far has shown a lower casefatality rate. 3,4 However, potential transmission from minimally symptomatic and even asymptomatic patients 3,5 has posed difficulties in regards to case detection and isolation strategies. 3 Means of transmission include respiratory droplets, direct human contact, fecal-oral route, aerosol and fomite (contaminated surface) transmission. 4,[6][7][8][9][10][11] Duration of viral shedding has been reported from 1 to 37 days 12,13 and critically ill patients may possess an enhanced ability of viral shedding. 14 As the outbreak spreads, intensive research on vaccine development and medical treatment continues worldwide. [15][16][17][18][19][20][21] However, to-date, there is no widely available and effective medical treatment or prevention against COVID-19. Health care personnel (HCP) continue to work at the frontlines, at risk of contracting the disease, while providing care to many patients in need. A recent publication from the Chinese Center for Disease Control and Prevention reported that out of 44,672 COVID-19 cases, 3.8% were HCP. 22 This number was reported be as high as 9% in Italy. 23 In the midst of the pandemic, non-essential procedures have been postponed or deferred in many countries per government recommendations. Almost all surgical disciplines have modified their operative approach in an attempt to off load the health care system. In the United Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

A C C E P T E D
States, as of March 2020, plastic surgeons have stopped performing elective procedures, in accordance with guidance from American Society of Plastic Surgeons, American College of Surgeons, American Medical Association, and Centers for Medicare & Medicaid Services . [24][25][26][27] As we continue to carry out necessary reconstructive surgeries, the risk and benefit of each surgical procedure should be carefully analyzed. Our practice should reflect a balance of patient care, protection of HCP, minimized COVID-19 spread, and resource conservation.
Our goal with this article is to summarize practices in plastic surgery during the COVID-19 pandemic and provide recommendations regarding perioperative care and case prioritization based on current evidence. As more data becomes available, it is likely that the strategies outlined in this document will change accordingly.

OUTPATIENT VISITS
During the pandemic it is imperative that patients avoid unnecessary travel to health care facilities where they could expose themselves or others' to further illness. Telemedicine services (audio and video calls) are now being offered for many non-urgent appointments, routine surveillance encounters, and follow-ups. In the United States, these visits are considered the same as in-person visits and are paid at same rate as regular, as per CMS guidelines. 28 Physicians are encouraged to maintain relationship with patients using virtual visits to reassure continuation of care, instead of simply cancelling or postponing appointments.
If an in-person visit is indicated, patients must be querried about COVID-19 symptoms before they come in to the facility. During the visit, patients should be kept in one physical location if feasible and their interaction with multiple HCP should be minimized. Practitioners should carry out an expedient visit, use appropriate PPE, and perform a more focused physical Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 29 Clinical scenarios with a higher risk of disease transmission to practitioner include examination of ear, nose, mouth or throat, placement/removal of nasal packing, tracheostomy care or any procedure that involves manipulation of mucosa. Such procedures should be limited to patients who have a clear indication as infectious aerosols can remain in the room for three hours or more. 10 Patients who are asymptomatic and untested should be approached as COVID-19 positive.

SURGICAL PROCEDURES
A judicious approach in clinical practice would be to to postpone all elective surgery, carrying out urgent and emergency procedures only, to preserve resources and minimize viral spread. (Table 1) 25,26,30,31 Allowable and appropriate operations are those where a delay would have significant negative impact on outcome of the condition. There are valuable resources from surgical and medical societies, and government agencies to help guide the decision making process in patient and procedure selection. We should also realize that regional prevalence of COVID-19 and individual institutional factors such as the availability of resources or patient's need for postoperative care (i.e Intensive care unit (ICU) care) will impact decision making.
As the pandemic continues to evolve and hopefully declines, the scope of practice can be broadened according to emerging guidelines. Transitioning to normal function should be undertaken in a tiered approach. Recommendations in Table 1 can be employed in reverse order, i.e gradually resuming treatment of skin cancers, breast reconstructions and eventually phasing in all elective surgeries and cosmetic procedures. The transition is subject to change depending on the number of cases in that particular region, resources of individual institutions, as well as capacity of the health care system in general.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

A C C E P T E D
Below, we present recommendations for perioperative care as well as management of specific medical conditions, as it relates to plastic surgery practice.

Perioperative Care
The patient's COVID-19 status should be determined prior to surgery, if possible. 25,32 Reverse transcriptase polymerase chain reaction (RT-PCR) is the preferred laboratory-test todate 33,34 , with diagnostic accuracy in the range of 56%-83%. 35,36 As availability and reliability of PCR tests increase, preoperative assessment of COVID-19 status will presumably become standard of practice. Patients who are positive should be operated in designated operating rooms with a team dedicated to their care. 14,[37][38][39] The positive pressure airflow environment of the operating room may enhance the risk of viral transmission, therefore conversion to negativepressure airflow room should be considered. 14 Since the viral pathogen survives on environmental surfaces for extended periods of time, usual cleaning practices may be inadequate and need adjustment. 10,[40][41][42] Multi-faceted perioperative infection control will ensure that the patients are appropriately cared while the HCP is protected. 38,43,44 (Table 2) Another important step in delivering health care is identification of aerosol-generating procedures (AGPs), where more stringent precautions are advised due to a higher risk of disease transmission to health care personnel. Such procedures typically involve airway manipulation (i.e intubation), breach of mucosa, gastrointestinal tract surgery and thoracic surgery 14,29,45,46 The coronaviruses have been shown to be also present in the blood stream and body fluids 6,7,14,25,37,44 thus bone-sawing procedures and electro-cautery use is also related with increased potential exposure. 44,47 A list of high risk AGPs that plastic surgeons may encounter are summarized in Table 3. 25,29,48 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

A C C E P T E D
One of the most commonly debated topics in setting of COVID-19 pandemic is choice of personal protective equipment (PPE). Despite conflicting practices worldwide, use of respirator masks that efficiently filtrate airborne particles (i.e N95 respirator), eye protection and isolation gowns are usually recommended. 14,25,38,49 Most institutions have developed individual protocols adapted from guidelines of World Health Organization. 50 Utilization of appropriate PPE during head and neck surgery is particularly important due to high risk of viral transmission. When performing high-risk aerosol generating procedures, health care personnel should wear a N95 mask with goggles/face shield, or powered air purifying respirators (PAPR), gown and double gloves to achieve adequate protection. 29 Practitioners are advised to take precautions regardless of COVID-19 status, as asymptomatic cases are not uncommon and testing may be limited.

Cancer care
Though cancer surgery is not considered elective, surgical interventions need prioritization. With diminished resources oncologists must consider what treatments are most likely to be successful, symptom relieving, or lifesaving. For select patients, delays in surgical treatment may be acceptable as they undergo neoadjuvant treatment. 51 A multidisciplinary tumor board conference is most helpful to determine if the patient is a candidate for surgery versus alternative treatments or observation and should be documented in patient's chart. Evidence shows that cancer patients have a higher risk of contracting COVID-19 and developing severe events related to disease necessitating ICU admission, along with higher mortality rate. 52,53 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. there is no sign of orbital apex/fissure syndrome and no entrapment of extraocular muscles that can lead to necrosis. 71 Similarly, nasal, mid-face, and zygomaticomaxillary complex fractures can be treated conservatively if there is no significant functional impairment. 71 Plan for same day discharge should be made for all such cases unless airway compromise is a significant risk. Patients for whom surgery is deemed "non-essential" are those with chronic problems whose surgery can certainly be delayed without significant harm to the patient or eventual outcome. Although an argument can be made for the need for surgery in some individuals due to pain or functional impairment, the determining principle is that delaying treatment will not significantly alter the eventual outcome. Such conditions are: tendonitis of the hand, wrist, elbow, trigger finger, De Quervain's tendonitis, medial and lateral elbow epicondylitis, nerve compression syndromes and degenerative joint disease. All these patients can be assessed and followed-up with virtual visits and prescribed NSAIDS or oral steroid and placed in splints.
Injections of steroid into the tendon sheaths and joints in the hand and wrist can be considered for patients who failed the first line of treatment. 69 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.    Cancers involving oral and nasal mucosa, including larynx Ear surgery, including mastoidectomy -Dental extractions -Tracheostomy -Bone-sawing procedures, amputations -Electrocautery of blood, and any body fluids -Suctioning of blood, and any body fluids -Intubation/extubation, bag-valve ventilation -Cardiopulmonary resuscitation