key: cord-0789778-80ln5oxd
authors: Sharp, O.; Masud, D.
title: Breast reconstruction with immediate autologous free tissue transfer in a peri-operative COVID-19 positive patient: a case report illustrating feasibility of aftercare
date: 2020-11-07
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.10.088
sha: 7d40b11aa62fba5436d17346dcb236156c880932
doc_id: 789778
cord_uid: 80ln5oxd

Globally, there has been a measured response to rationalise elective operating during the Coronavirus disease 2019 (COVID-19) pandemic. In terms of breast cancer care, this has led to a restricted provision of reconstruction with autologous free tissue transfer. A primary concern is the risk of mortality in elective surgery patients who develop COVID-19. The aim of this report is to describe the observed physiological impact of the virus on our patient, and to address how outpatient care after autologous free tissue transfer can be delivered to COVID-19 positive patients. In March 2020, we performed a bilateral breast reconstruction with a deep inferior epigastric perforator flap and a superficial inferior epigastric perforator flap. The patient became symptomatic on day three post-operatively, tested positive for COVID-19 and was discharged home. Drain and dressing management was continued through the use of telemedicine. Two weeks following the operation, a breast seroma formed that was drained semi-electively in the COVID-19 positive area of the Emergency Department. The patient visited the dressing clinic twice in total and healed after three weeks. Despite undergoing complex surgery and having pre-operative chemotherapy, our patient suffered a mild form of the virus limited to upper respiratory symptoms. Physiologically we did not see any significant difference to that of the normal post-operative course. This case demonstrates the possibility of managing autologous breast reconstruction patients using telemedicine. Although COVID-19 can complicate, or even be fatal, in the perioperative course, our patient thankfully suffered no discernable negative outcome from her infection.

This paper has not previously been presented.

Globally, there has been a measured response to rationalise elective operating during the Coronavirus disease 2019 (COVID-19) pandemic. In terms of breast cancer care, this has led to a restricted provision of reconstruction with autologous free tissue transfer. A primary concern is the risk of mortality in elective surgery patients who develop COVID-19. The aim of this report is to describe the observed physiological impact of the virus on our patient, and to address how outpatient care after autologous free tissue transfer can be delivered to COVID-19 positive patients.

In March 2020, we performed a bilateral breast reconstruction with a deep inferior epigastric perforator flap and a superficial inferior epigastric perforator flap. The patient became symptomatic on day three post-operatively, tested positive for COVID-19 and was discharged home. Drain and dressing management was continued through the use of telemedicine. Two weeks following the operation, a breast seroma formed that was drained semi-electively in the COVID-19 positive area of the Emergency Department. The patient visited the dressing clinic twice in total and healed after three weeks.

Despite undergoing complex surgery and having pre-operative chemotherapy, our patient suffered a mild form of the virus limited to upper respiratory symptoms. Physiologically we did not see any significant difference to that of the normal post-operative course. This case demonstrates the possibility of managing autologous breast reconstruction patients using telemedicine. Although COVID-19 can complicate, or even be fatal, in the perioperative course, our patient thankfully suffered no discernable negative outcome from her infection. On the first day post-operatively, the patient's daughter visited from London. The same day, the patient had a temperature and pleuritic chest pain. Two litres of oxygen per minute were required 5 during the first 24 hours to maintain oxygen saturations >94%. A chest radiograph was performed as shown in Figure 1 .

On day two post-operatively, the patient's physiologic observations were normal, with no oxygen requirement. On day three, the patient had reached the standard clinical and physiotherapy goals for discharge. It was noted the patient developed a cough, sore throat and a temperature.

In view of the patient feeling well with normal cardiovascular observations, discharge planning continued. A COVID-19 test was sent and the patient was advised to self-isolate. The left breast drain was removed prior to discharge after draining less than 50mls over 24 hours. The right breast and abdominal drains remained.

The patient was subsequently found to be COVID-19 positive and continued to have fever (38.5-39°C) at home for two weeks. There was no shortness of breath. The patient was monitored with telephone consultations and photographs almost daily for two weeks.

Multiple factors were taken into consideration with the patient's post-operative care. These included limited availability of personal protective equipment and the risk of infection to staff.

Additionally, the patient did not feel comfortable attending the hospital under the circumstances.

We provided drain removal and wound management advice using emails, telephones and photographs. Two weeks following the operation a seroma of the right breast was diagnosed.

As this was symptomatic, the seroma was drained in the COVID-19 positive area within the Emergency Department. The patient's partner collected dressings in the hospital car park to limit hospital exposure. The patient visited the dressing clinic twice in total and healed after three weeks.

This case was at the start of the UK pandemic. Since the average incubation period of the virus is 5.2 days, the patient was most likely an asymptomatic carrier prior to admission 2 . Of note, the medical staff whom managed the patient did not develop symptoms. Clinically and physiologically, we did not see any significant difference to that of a normal post-operative bilateral DIEP patient, as demonstrated in Table 1 3,4 . This case demonstrated the possibility of managing patients using virtual technology. As a result of this experience, and COVID-19 more broadly, we have transitioned to telemedicine based consultations wherever feasible.

Despite the uneventful recovery of our patient, we appreciate we were likely to have been fortunate with our outcome. We have significantly modified our breast reconstruction protocol.

We select low risk patients, fully informed of the risk of COVID-19. and have two senior surgeons operating synchronously to maximise efficiency. Patients are not permitted visitors and are discharged on day two.

As the epidemiology of COVID-19 and resultant impact on hospital resources changes over time,

we will continue to adapt our pathway. If COVID-19 is contracted peri-operatively, this report aims to illustrate that high-quality patient care can still be delivered. Although COVID-19 can complicate, or even be fatal in the perioperative course, our patient thankfully suffered no discernible negative outcome.

Ethical Approval: N/A Conflict of Interest: None Funding: None 

Guide to surgical prioritisation 2020

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. The New England journal of medicine

Surgery during the COVID-19 pandemic: A comprehensive overview and perioperative care

Coronaviruses and the cardiovascular system: acute and long-term implications