key: cord-0801072-smylaett authors: Joji, Ms Nikita; Nugent, Ms Nora; Vadodaria, Mr Shailesh; Sankar, Mr Thangasamy K title: Impact of COVID-19 on Aesthetic Plastic Surgery Practice in the United Kingdom date: 2021-06-06 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2021.05.020 sha: 7bb58d3533446559a7e1e008ad5d29857eb3ce08 doc_id: 801072 cord_uid: smylaett BACKGROUND: The COVID-19 pandemic has transformed the delivery of medical and surgical services globally. Subsequently, all elective and aesthetic procedures have been cancelled or deferred as per government-mandated quarantine measures. The Cosmetic Surgery Governance Forum (CSGF) is a network of aesthetic plastic surgery consultants which has enabled a sharing of expertise during challenging times. We conducted a cross-sectional survey to assess the impact of the COVID-19 outbreak on aesthetic plastic surgeons and their practice in the UK. METHODS: On 15(th) June 2020, 131 respondents from the CSGF and wider aesthetic plastic surgeons in the UK were invited to respond to an online survey. An anonymised questionnaire was created using SmartSurvey(TM) and distributed towards the end of the quarantine period. Questions regarding their current scope of practice, willingness to recommence face-to-face consultations, financial loss and psychological impact were asked. RESULTS: A total of 101 Consultant Plastic surgeons (76%) completed the questionnaire. If strict protocols and adequate personal protective equipment were available, 50-55% of respondents would consider offering non-surgical treatments as soon as the private clinic was open. 51% would consider procedures under general anaesthetic whilst 89% of respondents would offer local anaesthetic only in the initial phase. 66% reported experiencing a psychological impact and 100% of respondents reported a significant financial impact. CONCLUSIONS: This survey aims to give an account of the current state (May-July 2020) of aesthetic plastic surgery in the UK. There is ongoing uncertainty and deliberation regarding the timing and organisational changes required for aesthetic practice to restart. The COVID-19 pandemic has transformed the delivery of medical and surgical services globally. Subsequently, all elective and aesthetic procedures have been cancelled or deferred as per government-mandated quarantine measures. The Cosmetic Surgery Governance Forum (CSGF) is a network of aesthetic plastic surgery consultants which has enabled a sharing of expertise during challenging times. We conducted a cross-sectional survey to assess the impact of the COVID-19 outbreak on aesthetic plastic surgeons and their practice in the UK. On 15 th June 2020, 131 respondents from the CSGF and wider aesthetic plastic surgeons in the UK were invited to respond to an online survey. An anonymised questionnaire was created using SmartSurvey TM and distributed towards the end of the quarantine period. Questions regarding their current scope of practice, willingness to recommence face-to-face consultations, financial loss and psychological impact were asked. A total of 101 Consultant Plastic surgeons (76%) completed the questionnaire. If strict protocols and adequate personal protective equipment were available, 50-55% of respondents would consider offering non-surgical treatments as soon as the private clinic was open. 51% would consider procedures under general anaesthetic whilst 89% of respondents would offer local anaesthetic only in the initial phase. 66% reported experiencing a psychological impact and 100% of respondents reported a significant financial impact. This survey aims to give an account of the current state (May-July 2020) of aesthetic plastic surgery in the UK. There is ongoing uncertainty and deliberation regarding the timing and organisational changes required for aesthetic practice to restart. A novel coronavirus termed "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" was first reported in December 2019 in Wuhan, China [1] December 2020 [2] . The World Health Organisation declared a global pandemic on 11 th March 2020 [3] . The risk of viral transmission from minimally symptomatic and even asymptomatic patients has posed a significant challenge in regards to contact tracing and isolation strategies [4] . The primary mechanisms of transmission are through respiratory droplets and direct human contact but there is also a risk of spread through aerosolgenerating procedures [5] . The first phase of COVID-19 vaccination has commenced in the UK and we await the potential effect on infection and transmission rate [6] [7] . The Confederation of British Surgery echoed governmental recommendations to cease and defer all non-essential procedures on 22 nd March 2020 in the United Kingdom [8] . As a result, almost all surgical disciplines including the plastic surgery community have instituted a self-imposed mortarium on elective practice, in an attempt to unburden the NHS, minimize viral spread and preserve resources [10] . With imminent relaxation of physical distancing measures and the resumption of elective aesthetic surgery, surgeons are challenged with adapting their clinical and surgical workflow to minimize risk and safeguard patients and the clinic staff in the post-pandemic era [11] . We created a cross-sectional survey to assess the consequences of the COVID-19 pandemic on aesthetic surgeons and their practice in the UK. The Cosmetic Surgery Governance Forum (CSGF) is a network of aesthetic plastic surgery consultants who communicate on a social media platform, which was set up by the senior author (TKS) in 2014. The network has enabled a collaborative approach to complex cases and a sharing of expertise. This has been particularly valuable to overcome common issues faced during quarantine and to give plastic surgeons a user friendly, supportive, and confidential environment to express their concerns and to share their solutions in these challenging times. Our aim was not to only to collect and analyse data, but also to explore the challenges aesthetic practice is facing, record current trends in working and to highlight the repercussion on aesthetic surgeons in industry. As the pandemic started to decline on 15 th June 2020, 131 members of CSGF were In total, 27% of respondents were clinic owners and in full time private practice. Prior to the COVID-19 pandemic, 67% of respondents performed non-surgical cosmetic treatments and Lasers. All respondents had voluntarily closed their clinic and ceased elective aesthetic practice due to the COVID-19 pandemic. When respondents were asked whether they felt ready to re-commence consultations, 57% felt appropriate to commence with virtually prior to face-to-face consultations ( Figure 1 ). However, 7% stated that they were not willing to restart consultations in the current circumstances, whilst 8% would opt for exclusively video or virtual consultations. Regarding non-surgical cosmetic treatments, 55% of respondents would consider offering muscle relaxing injections as soon as their private clinic was open and if strict protocols and adequate provision of PPE were available. Similarly, 50% would consider offering facial fillers. However only 37% would consider offering lip fillers whilst 21% would wait for private corporate hospitals to start offering the treatment first. At the time of the survey, 89% of respondents would offer local anaesthetic (LA) only for aesthetic surgical procedures whilst 72% would offer LA and sedation ( Figure 2 ). 51% would consider cosmetic procedures under general anaesthetic. 55% of respondents reported that they would consider offering minor cosmetic procedures (up to 60 minutes) under LA as soon as their hospital/clinic re-opened. 35% preferred to wait until the corporate groups of private hospitals resumed their service. Table 1 delineates types of minor cosmetic procedures and percentage of respondents who would undertake them. (Figure 3 ). All aesthetic consultants sustained a significant financial impact ranging from 60-100% reduction of their prior income. In contrast, full time private consultant plastic surgeons who are business owners encountered a 100% reduction of their income. 66% of respondents reported a experiencing a psychological impact in response to the consequences of COVID-19. 27% reported anxiety with the remaining respondents experiencing stress (25%), depression (8%) and insomnia (6%) ( Figure 4 ). The study aimed to provide an account Aesthetic surgeons, many of whom also work the public sector, face significant uncertainty in regards to the future of their aesthetic practice [11] . The mandatory and rational suspension of all elective and aesthetic plastic surgery has inevitably resulted in detrimental financial consequences on the plastic surgery community, especially those whose livelihood depend on a practice which is purely in the private sector. The substantial impact on the aesthetic sector cannot be underestimated, with a reported reduction in income ranging from 60-100% resulting from the closure of clinics. A pandemic often culminates in a global recession and economic analysts have predicted that enforced social distancing protocols during a pandemic, such as the country-wide quarantines and travel prohibitions, will contribute to a decline in consumer and business spending until the end of 2020 [12] . The effect is exacerbated by the reduction in disposable income as the public attempt to recuperate from a prolonged period of lost earnings [13] . The significant economic downturn imposed by the social-distancing measures will inevitably lead to long-term repercussions enduring well past the ban being lifted on elective surgery [14, 15] . The NHS has undergone significant reconfiguration to create new space for critically ill patients. Consequently, 33 000 hospital beds and 1200 ventilators have been provided by private hospitals [16] . Despite currently declining rates of COVID-19 and easing of the UK Government lockdown restrictions into a phased period of relaxation, aesthetic plastic surgery procedures are classified as non-urgent (Category 4) [17] . The deferral of non-urgent elective procedures will exacerbate the already growing backlog of cases [10] . Therefore, with an increasing demand for surgical services as elective surgery recommences, combined with finite facility resources available, it is unlikely that elective aesthetic plastic surgery will take place in the near future in private hospitals, especially in those that provide a broad range of speciality services [19] . However, focused aesthetic plastic surgery units may be in a different position but will have to comply with stringent UK Government regulations and local healthcare provider recommendations regarding patient testing, procedure triage, decontamination as well as reconfiguring facilities to comply with social distancing measures [19] . The long terms effects of COVID-19 outbreak on individual businesses and the cosmetic industry is unclear. However, it is apparent that aesthetic surgeons share similar concerns regarding the on-going and potential consequences on their business, client base and long-term prospects. Due to the uncertainty regarding availability of operating facilities within the private-corporate sector, it is feasible that aesthetic surgery may have to be delivered from small independent operating facilities primarily owned and run by consultant plastic surgeons. CAPSCO is currently undertaking a survey to ascertain the feasibility of this model in the UK. The unprecedented nature of the COVID-19 pandemic has forced businesses to adapt rapidly over a short period. Many aesthetic practices were understandably unprepared for disruption to such an extent, and many surgeons have reported that their standard contingency plans were ill-equipped for the situation of being unable to carry out aesthetic procedures for an extended period. The mandatory reshaping of treatment priorities will transform the delivery of aesthetic practice and will certainly not return to "business as usual" in the near future. The COVID-19 crisis presents a unique opportunity to embed the positive changes adopted during the pandemic such as the greater use of telemedicine, increased efficiency and digital outpatient services. A large number of participants introduced telemedicine (audio and video calls), which had often not been embraced as extensively as during the pandemic and can be considered as a "silver lining" or a "lesson learned" from the pandemic. It confers numerous advantages including maintaining relationships with patients virtually and reassuring patients regarding continuation of their care, instead of cancelling or rescheduling appointments [18] . A key restriction is the inability to perform a full physical examination and assessment [19] . As a result, virtual consultations are usually costed based on time spent with the patient, including counselling and coordination of care [20] . Furthermore, live teleconsultation also requires synchronisation of the schedules of both the patient and surgeon, availability of audio-visual equipment with the capacity to stream seamlessly with high speed internet, to which patients may not always have access. Therefore it is important to emphasise that digital consultations are not a replacement for face-to-face consultations, but an adjunct to mitigate exposure to potential contagions by facilitating compliance to social distancing protocols and reduced travel costs [19] . Telemedicine can also enable a greater frequency of follow up appointments during aftercare by eliminating the need for patients to travel to attend consultations, whilst also providing reassurance in otherwise lengthy intervals between appointments. The loss of educational opportunities including conferences has also catalysed the widespread adoption of virtual training through webinars [21] . We believe creating a platform such as the Cosmetic Surgery Governance Forum is an accessible means to create solidarity and share innovation within the speciality. The study has some limitations, namely that it was reliant on personal reports of respondents, and therefore may not be representative of all aesthetic surgeons working in the UK. However, CSGF has members with diverse affiliations, backgrounds and geographical locations across all four nations of the United Kingdom backgrounds and geographical locations across all four nations of the United Kingdom. Since the questionnaires were distributed by respondents to consultant colleagues, the overall survey population is undefined. However, the authors specifically requested the questionnaires to be distributed to fellow consultants in the aesthetic surgery field in the UK, thus enabling greater representation of aesthetic surgeons in the UK as opposed to exclusively members of the CSGF. The survey was conducted in the midst of the pandemic, and therefore represents a snapshot of the mood and opinions of respondents during the COVID-19 pandemic, which is dynamic and evolving. Conversely, its timely collection is likely to garner current opinions with less recollection bias as responses were not collected retrospectively. As the pandemic evolves and hopefully declines, the scope of aesthetic practice can be extended safely with sufficient protective measures. The prioritisation and adaptation of aesthetic procedures with a risk-minimizing approach in the postpandemic era will present likely represent the next challenge for the aesthetic surgery community. The Cosmetic Surgery Governance Forum is a network of aesthetic plastic surgery consultants which has enabled a collaborative approach to discuss complex cases and a sharing of expertise during challenging times. Solidarity with the exchange of ideas and innovations in an open forum will ensure that the speciality can overcome challenges with evidence-based measures. Not required None No funding received Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes Daily Update of Coronavirus (COVID-19) in the United Kigndom Covid-19: WHO declares pandemic because of "alarming levels" of spread, severity, and inaction Presumed Asymptomatic Carrier Transmission of COVID-19 SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients COVID-19: The race for a vaccine COVID-19 vaccines: a race against time in the middle of death and devastation Plastic Surgery and the Covid-19 Pandemic: A Review of Clinical Guidelines Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS-COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management Covid-19: UK prime minister announces relaxation of lockdown and social distancing rules The COVID-19 Pandemic and its Impact on Plastic Surgery in Europe -An ESPRAS Survey Is the lockdown important to prevent the COVID-9 pandemic? Effects on psychology, environment and economy-perspective Impact of the Coronavirus (COVID-19) pandemic on surgical practice-part 1". Impact of the Coronavirus (COVID-19) pandemic on surgical practice: Time to embrace telehealth in surgery COVID-19's impact on private practice and academic dentistry in North America Impact of the Coronavirus (COVID-19) pandemic on surgical practice -Part 1 Impact of the Coronavirus (COVID-19) pandemic on surgical practice -Part 2 (surgical prioritisation) Federation of Surgical Speciality Associations: Clinical Guide to Surgical Prioritisation during the Coronavirus Pandemic Telemedicine in the Era of the COVID-19 Pandemic: Implications in Facial Plastic Surgery Telemedicine in plastic surgery: E-consult the attending surgeon Telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls Webinars in plastic and reconstructive surgery training -a review of the current landscape during the COVID-19 pandemic COVID-19 outbreak situation and its psychological impact among surgeons in training in France