Commentary on: The Safe Resumption of Elective Plastic Surgery in Accredited Ambulatory Surgery Facilities During the COVID-19 Pandemic

“The Safe Resumption of Elective Plastic Surgery in Accredited Ambulatory Surgery Facilities During the COVID-19 Pandemic” by Brown et al in this issue of the Aesthetic Surgery Journal observed no postoperative COVID-19 complications in a large cohort of Canadian patients who underwent specific screening and safety protocols.1 As the incidence of this virus fluctuates, the population becomes vaccinated, rapid testing becomes more available, and variants with different clinical characteristics emerge, those recommendations will undoubtedly change. Notwithstanding these issues, this outstanding paper should leave a legacy beyond its specific findings, and therefore is worthy of a thorough discussion. This investigation is the apotheosis of study design, one rare not just for a plastic surgery publication but for all of the medical literature: it is a prospective, multicenter, consecutive case series with a consistent period of postoperative follow-up. This Herculean task required extraordinary organizational skills and coordination. Such a study design is the standard to which all others should be compared. In contrast, the study that I was a part of and published in the January 2021 issue of ASJ discussing the safety of plastic surgery in Los Angeles during the 2020 summer surge was based on a retrospective, anonymous survey.2 The reliability of the data in the current paper is immeasurably superior. But attaining such high-quality data came at a price: this study followed 368 cases at 6 centers, whereas the Los Angeles paper reported on over 5600 surgeries by over 110 surgeons. Future investigators should be inspired by what these authors showed to be possible. But they should strive to balance attaining the highest-quality prospective data with the need to adequately power the study. The authors estimated that the prevalence of COVID-19 was 1:345 during the time of the study, and therefore including just 368 patients was not enough to perform any quantitative statistical analysis; and indeed any qualitative conclusion must be made with great caution. But given the need to promptly disseminate this information, limiting the case collection period—and hence the number of enrolled patients—was entirely understandable. A second lesson is just how rapidly these authors responded to the crisis by organizing a complex study and promptly writing it up for ASJ, where it appeared online in December 2020. Furthermore, the alacrity with which ASJ has published articles on COVID-19 ahead of print during the emergence of this new disease rapidly brought important research to surgeons. We can no longer stay current by merely waiting for our issue of ASJ to arrive in our mailboxes; rather, the ASJ website should be checked regularly for articles published ahead of print as well as for excellent articles only published online in the ASJ Open Forum. The value of these data for patient safety cannot be overstated. But regulatory agencies and local governments did specifically discuss curtailing plastic surgery. Had those talks continued, given the public’s schizophrenic and sometimes hostile attitude towards plastic surgery—simultaneously praising it and condemning it—this study would have provided much-needed data so that public policy could be informed by fact and not emotion. The decision of The Aesthetic Society presidents Charles Thorne MD and Herluf Lund MD to create and support a COVID-19 Safety Task Force was valuable insofar as the Task Force described the framework by which patients could safely undergo plastic surgery. Those recommendations were followed by the surgeons in this article, and ultimate congratulations therefore should go to Task Force chairman James Fernau MD for the daunting task of assembling those protocols.3 Most interesting, however, is that a detailed analysis of the authors’ concluding sentence provides reminders about how to read medical papers. We are all susceptible to remembering those key words without the critical and limiting factors. In this case the authors stated, “With appropriate screening and safety precautions, elective aesthetic plastic surgery can be performed in a manner that is safe for patients and healthcare providers and with a very low risk for accelerating virus transmission within the community.” The screening precautions included: a polymerase chain reaction nasopharyngeal swab taken 3 to 4 days preoperatively and isolation until the date of surgery; a questionnaire administered 24 hours before surgery; a second questionnaire given upon arrival; and a temperature check. Safety precautions at the facility included: changes in traffic flow; cleaning of surfaces; adjustments to heating and ventilation systems; air purification; new instruments for airway management; training of employees and staff; training in proper use of personal protective equipment; and employing only board-certified plastic surgeons and anesthesiologists in accredited facilities. Patient demographics may have been critical; they were all self-pay (and presumably affluent and not living or working in high-risk situations); age <65 years; ASA I or II; young (average age, 39 years), predominantly female (92.7%), and were mostly thin (average BMI, 24.4 kg/m2). That is a long list of potentially relevant circumstances, and because they were studied together it is not known which were the critical factors; perhaps the elimination of one or more might result in a failure to replicate the same level of safety. If one is to cite the conclusion of this paper to justify the safety of their own practice, one must also embrace the entirety of these measures. And as the incidence of the virus increases, so does the possibility that screening fails to identify a case. The authors stated that daily case rates in Ontario, Canada were about 250 per day during the case collection period. In January 2021, daily cases in Ontario increased to nearly 8000.4 This does not mean that there was actually a 32-fold increase because testing also increased. But it serves as a reminder that deficiencies in screening and safety that were not observed at a lower prevalence might be observed when prevalence rises. Were the authors justified in writing that “appropriate screening and safety precautions” made plastic surgery safe? To the extent they did not catch any confirmed COVID-19 patients with screening and testing, the authors are not justified in writing that screening made plastic surgery safe. And with no presumed COVID-19 patients slipping through screening and into the operating room, neither can the authors conclude that the appropriate safety precautions helped to make it safe. It is entirely plausible that the complication-free outcome was a result of no patients with COVID-19 being scheduled for surgery during the period. Indeed, with no preoperative cases identified, the authors might have argued that screening was not even necessary. But such a conclusion cannot be made when studying 368 patients for a 1:345 occurrence. (The 1:345 figure was based on an estimate that only 10% of cases were identified; the official rate was 10-fold lower, and therefore it is possible that the rate was not nearly that high.) Consider that if the screening had been perfect, then the safety precautions would not have been necessary; everything done in the office only matters to the extent that COVID-19 patients or staff enter the operating room, and there is no suggestion that happened in this study. No study would allow SARS-CoV-2–positive patients or staff to enter an operating room, but if enough were caught with screening, one could infer that some positive individuals ended up in the operating room due to false-negative screens. Fundamentally the incidence of COVID-19 was too low in Ontario at the time of the study for a robust conclusion to be made about the efficacy of the safety and screening methods they employed. Ordinarily this would be a prodigious number of patients for a study in a surgical journal. But this is not a technique paper; it is an epidemiologic paper which requires a greater number of patients. I again must emphasize that their decision to get the best possible data and to publish it quickly was undeniably preferable to including more centers where screening and safety methods may not have been standardized, or to collect data for a longer period of time and thereby fail to convey this important information when it was much needed. It is only relevant insofar as these limitations must be understood. They also concluded that there was low risk for accelerating virus transmission within the community, but because they did not trace or test the community, such a conclusion cannot be drawn. Presumably if patients did not become sick after surgery they were not likely to have passed it on, but asymptomatic transfer is a well-known aspect of this virus. Furthermore, the word “low” implies a nonzero level of risk, yet zero risk was observed in this trial. A more appropriate conclusion might have been, “While the occurrence of Covid-19 complications in this study was zero, conclusions about the risk were limited by the community rate and the number of patients in the study.” Some of the most vigorous debates among plastic surgeons have concerned the issue of routine preoperative polymerase chain reaction testing.5 I have a strong opinion on that issue today, but because circumstances with the pandemic will undoubtedly change it is not a matter worthy of discussion in an article that should be relevant in the future. What should endure is the principle that plastic surgeons operating in settings where they set the rules should be just as fastidious as hospitals and surgicenters in their community. Our patients deserve that for safety. Far less important, but relevant to this discussion, is that the specialty of plastic surgery is always susceptible to bad press from the outcomes of an individual surgeon. A single patient suffering from a bad case of COVID-19 after a breast augmentation might have been a widely publicized story, bringing with it widespread condemnation to our specialty and possibly restrictions. But just as a single surgeon on the fringe can bring disrespect to our entire specialty, a few surgeons conducting excellent research can elevate it. The quality of this study and the promptness with which it was written and published represents the finest in our specialty. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.