Preliminary Report of a National Audit of Aesthetic Surgery Practice in the United Kingdom During the COVID-19 Pandemic

The global COVID-19 pandemic has significantly impacted all aspects of healthcare both in terms of its function and delivery.1 Many countries in Europe have faced substantial disruptions due to the high incidence of infection and associated mortality.2 In the United Kingdom, we are in the midst of a national quarantine due to a second wave of increasing COVID-19 infection, hospitalizations, and deaths since November 3, 2020, subsequent to the first full lockdown implemented by the UK government on March 23, 2020. All elective surgical procedures were suspended across the National Health Service (NHS).3 Furthermore, the private sector was reconfigured to accommodate patients with COVID-19 infections as well as emergency cases and urgent oncology care in March 2020.4 A moratorium was imposed on aesthetic surgical practice across the United Kingdom and Ireland until June 2020.3 As the lockdown restrictions were lifted, there was significant anxiety among aesthetic plastic surgeons in the United Kingdom. There were widespread fears regarding their personal safety as well as that of their patients and colleagues.5 The risk of perioperative and postoperative mortality during the early stages of the pandemic appeared to be high in the early studies released, and this was combined with the learning curve associated with a new disease, its treatment, and outcomes.6 However, results from a national audit on the effects of COVID-19 on UK free flaps, major pedicled flaps, and replantations demonstrated much lower levels of morbidity and mortality in major reconstructive surgery when protective measures such as personal protective equipment (PPE) and COVID-19 testing were in place.7 There has been also been much debate among plastic surgeons regarding the moral and professional dilemma of whether it is appropriate to carry out aesthetic surgery amid the pandemic.8 As the United Kingdom emerged from lockdown, hospitals and surgical facilities prepared to resume elective surgical procedures under strict protocols and guidelines.9 The Cosmetic Surgery Governance Forum supported by British Association of Aesthetic Plastic Surgeons, the Consortium of Aesthetic Plastic Surgery Clinic Owners, and an independent cosmetic surgery provider carried out a national, prospective data collection of the first aesthetic plastic surgery procedures performed under new regulations. Because the availability of hospital facilities for aesthetic procedures was limited, a smaller than usual number of procedures was recorded and took place in centers with allocated surgical time for aesthetic procedures. Over a 2-month period from July 15, 2020, data were collected prospectively utilizing a proforma adopted from the COVID-19 reconstructive plastic surgery audit and adapted for aesthetic plastic surgery cases. Data regarding the type of case, patient characteristics including co-morbidities and American Society of Anaesthesiologists classification, the hospital or facility preoperative protocols for self-isolation, COVID-19 testing, intraoperative PPE worn, and outcomes such as early complications and symptoms or a positive COVID-19 test within the first 2 weeks after surgery were recorded. The audit results showed that all surgical staff were provided with appropriate PPE, and strict infection control protocols were followed. A total of 32 plastic surgeons across the United Kingdom carried out aesthetic surgery procedures on 370 patients during this period. Patients were followed-up as per the responsible surgeon’s protocol with outcomes up to 14 days post-surgery recorded in the audit. All patients fell within the American Society of Anaesthesiologists 1–2 categories. Patient age ranged between 18 and 65 years. All patients had outcomes recorded for the audit period of 14 days post-surgery. Our preliminary results demonstrated that none of the 370 patients audited who underwent aesthetic surgical procedures developed any symptoms of COVID-19–related illness and none required treatment for any subsequent respiratory illness. Three patients in the study group were readmitted and returned to theatre for non-COVID-19–related surgical complications (hematomas). There were no deaths, nor were any significant complications reported in the patient group. No patients required transfer to or treatment in a public health (NHS) facility. COVID-19 is a novel disease that has had and continues to have a massive global impact. It is imperative that the pandemic is controlled to reduce the spread of the COVID-19 SARS-2 virus.9 However, normal life and activity cannot be indefinitely postponed. Our first duty is to “do no harm,” and as plastic surgeons, we all aware of the myriad benefits that aesthetic surgery confers on our patients. We have a duty of care to our patients, and it is incumbent on us to resume care of our patients in a timely but safe manner.10 It was therefore necessary to critically assess how we resumed elective activity and to appraise our protocols and outcomes. Our prospective and national audit has shown that aesthetic surgical procedures can be performed safely when stringent protocols and policies are followed. Teitelbaum et al carried out a similar survey-based study on the safety of outpatient plastic surgery in Los Angeles County looking at the first 2 months of elective plastic surgery resumption (May to July 2020) after the moratorium on elective surgery due to the COVID-19 pandemic.11 This study had a good response rate, and data from 5663 surgeries were reported. It is reassuring to see that a similar safe resumption of plastic surgery occurred in this large study as well. Interestingly, of the 7 (0.13%) patients who had positive COVID-19 tests in the 2 weeks following surgery, all had a mild clinical course with no hospitalization required. An earlier time period of March and April 2020 was examined by Couto et al in a Texas ambulatory surgery center.12 Approximately 300 consecutive elective cases were strictly screened (but not tested) prior to their procedure for symptoms that could be suggestive of COVID-19. Forty-two of this group underwent plastic surgery procedures, and 75 plastic surgery procedures in total carried out. With this screening in place, no documented COVID-19 diagnoses or COVID-19–related symptoms were recorded post-procedure for any of the patients. The study does not state how many patients were asked to self-isolate and postpone their procedures due to the screening process. Nevertheless, it provides additional evidence that elective surgery can be carried out safely with screening and infection control protocols in place. In the United Kingdom, many plastic surgeons have amassed long waiting lists and are unable to offer or are only able to offer limited numbers of aesthetic surgical procedures due to lack of theatre capacity.13 This is due to the continued utilization of independent hospitals by the NHS, theatre allocations, and case prioritizations that have taken place since the start of the pandemic.14 We wish to highlight that aesthetic surgical patients awaiting surgery have been placed under a substantial degree of stress due to uncertainty regarding the scheduling of their surgery.15 This is in addition to their original indications for surgery, which alone and on their own merit confer significant patient benefits. Our data provide reassurance and evidence to the surgical hospitals, facilities, and plastic surgeons that aesthetic plastic surgery procedures can take place safely akin to other electives surgeries during this pandemic. Preliminary Audit Results PPE, personal protective equipment. Dr Sankar is chief medical officer (clinical governance lead) for The Harley Medical Group, 34 Harborne Road, Edgbaston, Birmingham, B15 3AA, UK. The other authors have conflicts of interest to declare for this audit. The authors received no financial support for the research, authorship, and publication of this article.

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