key: cord-0970610-uahtobuh
authors: Joji, Nikita; Patel, Nakul; Nugent, Nora; Patel, Nian; Mair, Manish; Vadodaria, Shailesh; Waterhouse, Norman; Ramakrishnan, Venkat; Sankar, Thangasamy K
title: Aesthetic Surgery Practice Resumption in the United Kingdom During the COVID-19 Pandemic
date: 2021-10-11
journal: Aesthet Surg J
DOI: 10.1093/asj/sjab364
sha: d8e0ae0cf7e3b633c3522243564496c40d7dd323
doc_id: 970610
cord_uid: uahtobuh

BACKGROUND: The global COVID-19 pandemic has significantly impacted all aspects of healthcare, including the delivery of elective aesthetic surgery practice. We carried out a national, prospective data collection of the first aesthetic plastic surgery procedures carried out during the COVID-19 pandemic in the United Kingdom. OBJECTIVES: Our aim was to explore the challenges aesthetic practice is facing and to identify if any problems or complications arose from carrying out aesthetic procedures during the COVID-19 pandemic. METHODS: Over a 6-week period from June 15 (th)-August 2 (nd), 2020, data was collected using a proforma for aesthetic plastic surgery cases. All patients had outcomes recorded for the audit period of 14 days post-surgery. RESULTS: Our results demonstrated that none of the 371 patients audited whom underwent aesthetic surgical procedures developed any symptoms of COVID-19-related illness and none required treatment for any subsequent respiratory illness. CONCLUSIONS: We found no COVID-19–related cases or complications in a cohort of patients who underwent elective aesthetic procedures under strict screening and infection control protocols in the early resumption of elective service.

A c c e p t e d M a n u s c r i p t

The global COVID-19 pandemic has significantly impacted all aspects of healthcare, including the delivery of elective aesthetic surgery practice 1 . As of June 21 st , 2021, there are now over 178 million confirmed coronavirus cases worldwide, with 3.8 million deaths as a result of COVID-19 2 . In the United Kingdom (UK), the National Health Service (NHS) has responded by adapting healthcare delivery to maximise use of resources and limit viral spread 3 . The response has been frequently amended following increased scientific understanding of the virus and the continually evolving pandemic 4 .

In the UK, the Federation of Surgical Speciality Associations classified all surgical procedures into clinical priority levels graded from 1 -4 at the onset of the pandemic 5 . The priority 4 category encompassed procedures that could be deferred more than 3 months. Since all aesthetic procedures fell into the latter group, a moratorium was imposed on elective and aesthetic surgical practice across the UK and Ireland until June 2020 5 . Due to contingency planning, the private sector was reconfigured to accommodate patients with COVID-19 infections, emergency cases and urgent oncology care from March 2020 6 . This has inevitably resulted in an increasing backlog of elective surgery and outpatient appointments 7 .

When the lockdown restrictions were lifted and aesthetic plastic surgeons in the UK contemplated resumption of activity, there were widespread concerns regarding their personal safety as well as that of their patients and colleagues 8 support practice during the COVID-19 lockdown 9-11 . However, there was no assurance that following these recommendations would be sufficient to protect patients and staff. There has also been much debate amongst plastic surgeons regarding the moral and professional dilemma of whether it is appropriate to carry out aesthetic surgery during the pandemic 12 .

Results from studies conducted during the early stages of pandemic demonstrated concerning rates of peri and post-operative mortality in patients undergoing surgical procedures 13 .

The patient cohorts and procedures undertaken in these studies were not representative of either elective plastic surgery patients or elective aesthetic procedures. There is a paucity of data examining the post-operative outcome of patients undergoing elective procedures during this crisis and the higher reported mortality results may be linked to the learning curve associated with a new disease, its treatment and outcomes as well as involving very different patient cohorts and A c c e p t e d M a n u s c r i p t procedures. A recent national audit on the effects of COVID-19 on UK free flaps, pedicled flaps and tissue replantations demonstrated significantly lower levels of morbidity and mortality in patients undergoing major reconstructive surgery when judicious infection control measures such as personal protective equipment (PPE) and COVID-19 testing were in place 14 .

By early June 2020, the UK passed the peak of infection and emerged from lockdown.

Hospitals and surgical facilities prepared to resume elective surgical procedures under strict protocols and guidelines 15 . The Cosmetic Surgery Governance Forum (CSGF) supported by BAAPS, CAPSCO and an independent aesthetic surgery provider carried out a national, prospective data collection of the first aesthetic plastic surgery procedures carried out under new regulations. Since the availability of hospital facilities for aesthetic procedures were limited, a smaller than usual number of procedures were recorded and took place in centres with allocated surgical time for aesthetic procedures.

Our aim was to explore the challenges aesthetic practice is facing and to identify if any problems or complications arose from carrying out category 4 aesthetic procedures during the pandemic. We also wanted to assess if healthcare workers or patients were placed under any undue risk or if any NHS (publicly funded) resources were utilised for private sector patients due to a complication of an aesthetic procedure.

Over a 6-week period from June 15 th -August 2 nd , 2020, data was collected using a proforma adopted from the COVID-19 reconstructive plastic surgery audit and adapted for aesthetic plastic surgery cases ( Figure 1 ). Surgeons were also recruited through CSGF, CAPSCO and BAAPS networks.

Because the survey did not request patient-specific information and the respondents were untraceable, institutional review board approval was not required. However, the study was registered with Ramsay healthcare and SK:N Clinics for ethical and governance oversight. The Declaration of Helsinki principles were followed for this study.

Data regarding the type of procedure, patient characteristics including co-morbidities and American Society of Anaesthesiologists (ASA) classification, the hospital or facility pre-operative protocols for self-isolation, COVID-19 testing, intraoperative PPE worn as well as outcomes such as early complications and symptoms or a positive COVID-19 test within the first two weeks after surgery were recorded. Proformas were completed by the operative surgeons and returned electronically. All patients had outcomes recorded for the audit period of 14 days post-surgery.

A c c e p t e d M a n u s c r i p t

32 plastic surgeons across the UK carried out aesthetic surgery procedures on 371 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 ASA 1-2 categories, with 83% of patients falling within ASA 1. The mean age of patients was 40.1 years and a median of 35 years ( Table 1 ). The patient population was predominantly female at 85%, with only 10% of the population being male.

71% of patients underwent procedures under a general anesthetic with the remaining 27% under a local anesthetic ( Figure 2 ). Over 50% of patients had day case procedures, followed by 27% of patients who had inpatient stays and 14% underwent outpatient procedures ( Figure 3 ).

The audit results indicated that 94% of surgical staff were provided with appropriate PPE and strict infection control protocols were followed. 75% of surgeons required 14 days of pre-operative quarantine.13% recommended 7 days pre-operatively, whilst 9% advised fewer than 7 days.

85% of all patients underwent COVID-19 testing prior to surgery. However, all patients who underwent procedures under general anesthetic had COVID-19 testing prior to surgery. Of the patients who underwent testing, 96% had a PCR test whilst the remaining 4% had antibody tests.

Aside from COVID-19 testing, patients did not undergo additional tests in relation to a preassessment compared to pre-pandemic surgical preassessment. A c c e p t e d M a n u s c r i p t

The type and frequency of procedures performed during this period is listed in Table 2 . A total of 371 patients undergoing elective aesthetic procedures were recorded in the study. Since numerous patients underwent multiple procedures in one sitting, Table 2 demonstrates the total frequency of procedures recorded during the audit period. Patients principally underwent procedures on the trunk (57%), head and neck (30%) and abdomen (8%). 91% of procedures fell under the category 4 in regard to clinical priority. The most commonly performed procedures included breast augmentation (27.8%), removal/change of implants (12.7%), breast reduction (8%) followed by rhinoplasty (7.2%) ( Table 2) . As expected, a significant reduction of the total number of surgical procedures was seen in restart of practice post-pandemic compared to the usual level of activity.

Our results demonstrated that none of the 371 patients audited whom underwent aesthetic surgical 

A total of 30 facilities were utilised. 94% of patients had their procedures undertaken in 24 independent private hospitals. The remaining 8 facilities used were corporate hospital chains.

The COVID-19 pandemic has transformed the delivery of healthcare worldwide with significant repercussions on the provision of elective aesthetic practice. It is imperative that pandemic is controlled to reduce the spread of the COVID-19 SARS-2 virus 16 . However, it is evident that we cannot indefinitely postpone elective activity. Our first duty is to 'do no harm' and as plastic surgeons, we are all aware of the myriad benefits that aesthetic surgery confers on our patients.

A c c e p t e d M a n u s c r i p t Therefore, we must advocate on their behalf, and it is incumbent on us to resume care of our patients in a timely but safe manner 17 . It is therefore necessary to critically assess how we resumed elective activity and to appraise our protocols and outcomes.

Although significant concerns were highlighted by emerging studies into the clinical impact of COVID-19 infection on surgical mortality, it was initially unclear in terms of the applicability of reported outcomes to plastic surgery patients 13 . However, it is important to note that COVD-19

illness was initially poorly understood in terms of its pathophysiology, clinical course, and its impact on surgical outcomes 18 . Several subsequent studies, in contrast to initial reports, have reported minimal risk of COVID-19 infection or complications after elective surgery [19] [20] [21] .

The result of this audit provides 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. Furthermore, the risk profile is considered generally lower in elective aesthetic plastic surgery due to an overall low pre-morbid status of the patients, lower ASA categories, shorter duration of surgery and the prevalent use of local anaesthetic as is demonstrated by the patient demographic of this cohort 6 . We also note a high number of rhinoplasties in our study, which is considered a high-risk operative site and an aerosol generating In the UK, 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 24 . This is due to the continued utilisation of independent hospitals by the NHS, theatre allocations and case prioritisations that have taken place since the start of the pandemic 25 .

Inevitably, a substantial period of 'catch-up' will follow with greater easing of lockdown measures, and this will require careful planning and organization. We wish to highlight that aesthetic surgery patients awaiting surgery have been placed under a substantial degree of stress due to uncertainty regarding the scheduling of their surgery. This is in addition to their original indications for surgery which alone and on their own merit confer significant patient benefits. The risk of surgery is also not higher in these patients compared to other patient groups and aesthetic patients should not be disadvantaged by the nature of the surgery that they are undertaking.

The COVID-19 pandemic has precipitated a paradigm shift in the landscape of aesthetic private practice. In the pre-pandemic era in the UK, the vast majority of private practice was undertaken by individual surgeon providers with practising privileges in corporate hospital chains.

However, it is interesting to note that that during the initial resumption of practice, 94% of cases were carried out in independent private hospitals. Although we do not have comparative data, this likely reflects increased access to independent facilities which enabled access for early resumption Results from two large vaccine trials (Pfizer-BioNTech, Moderna) indicate an efficacy of over 90% against symptomatic and severe disease [28] [29] . It is hoped that with further vaccine roll-out that the impact of future epidemic peaks, hospitalizations, and deaths will be reduced so mitigating the burden on the NHS and enabling greater resumption of elective procedures.

The study has some limitations, namely that it was reliant on personal reports of surgeons, and therefore may not be representative of all aesthetic surgeons working in the UK. Moreover, selfreported data is open to misinterpretation bias of the questions on the proforma and underreporting of COVID-19 complications due to fear of loss of confidentiality. The study period was relatively short with a relatively small dataset, thus may have missed any COVID-related infections or complications occurring outside the 2-week post-operative period. Furthermore, this audit captures a snapshot of data in time as lockdown measures were eased in the UK but stringent infection controls protocols were followed. However, this may not be representative of COVID-19 incidence and changing infection protocols in the future. Overall, this audit is intended to represent a crucial first step in reassuring hospitals, facilities, and plastic surgeons on the safety of undertaking elective aesthetic surgery in the post-pandemic era.

We found no COVID-19-related cases or complications in a cohort of over 300 patients who underwent elective aesthetic procedures under strict screening and infection control protocols in the early resumption of elective service. We also recommend routine pcr COVID-19 testing preoperatively for all aesthetic surgery patients undergoing general anaesthetic procedures or A c c e p t e d M a n u s c r i p t significant local anaesthetic procedure, eg, facial surgery while COVID-19 infections remain at pandemic levels.

Plastics surgeons have shown the ability to adapt and reinvent their practices to ensure safe delivery of aesthetic procedures during pandemic. As the aftermath of pandemic becomes clear, we must work together to advocate for our patients and the future of our specialty in an evolving landscape. The scope of aesthetic practice can be extended safely with sufficient protective measures.

M a n u s c r i p t M a n u s c r i p t M a n u s c r i p t A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t 

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United Kingdom and Ireland -multicentre national cohort study

Covid-19: UK prime minister announces relaxation of lockdown and social distancing rules

Cosmetic surgeries amidst pandemic area of COVID-19: suggested protocol

The Public's Awareness and Willingness to Undergo Plastic Surgery Procedures during the COVID-19 Pandemic

Overcoming fragmentation of health research in Europe: lessons from COVID-19

Is elective cancer surgery safe during the COVID-19 pandemic?

Evaluating Postoperative Outcomes of Patients Undergoing Elective Procedures in an Ambulatory

Can Outpatient Plastic Surgery Be Done Safely During a COVID-19 Surge? Results of a

Coronavirus Disease-19 and Rhinology/Facial Plastics

Elective surgery in the time of COVID-19

Service reconfiguration in the department of hand surgery during the UK

COVID-19 lockdown: Birmingham experience

Impact of vaccination by priority group on UK deaths, hospital admissions and intensive care admissions from COVID-19

Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in

Older Adults

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine

We would like to thank all the contributors who have kindly provided data to enable this study (Appendix, available online at www.aestheticsurgeryjournal.com). We'd also like to thank Ramsay Healthcare UK and the SK:N clinics, who were the registered leads overseeing the audit.

A c c e p t e d M a n u s c r i p t M a n u s c r i p t