key: cord-1013169-u0rzxw7o
authors: Hart, Andrew
title: Cover Illustration: “Lockdown” mural, Bath Street, Glasgow, by the.rebel.bearUnshackling Plastic Surgery from COVID-19
date: 2020-06-14
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.05.082
sha: 394ab8c661ceda904ad4e80e92174d75e46e0a36
doc_id: 1013169
cord_uid: u0rzxw7o

nan

colleagues who were doing so, and reduce activity during the exponentially rising phase of the epidemic. It is also right that as incidence plateaus and falls we now advocate the rapid restoration of broader healthcare, in order to limit further avoidable death and disability that can only worsen the health, economic, and moral impact of COVID-19 upon our communities.

In this advocacy we are promoting the care that we can deliver primarily against restricted healthcare provision, and less against that given by other specialties and services. The risks of providing normal treatments while COVID-19 remains prevalent must be compassionately balanced against the undoubted risks of not providing those treatments. Considerable supportive evidence exists for the positive impact of plastic and reconstructive surgery upon quality of life, patient reported outcomes, return to work, and longterm healthcare costs, but to most effectively advocate Plastic surgery to policy makers focused upon the risks and resource requirements of COVID-19, more, scientifically robust, data is urgently needed. National / international evidence of the impact of plastic surgery service disruption upon patient welfare is also required.

The clearest immediate argument for rapid resumption of elective surgery is based on our role in cancer care. Amongst evidence that cancer care is being compromised by both a public perception that healthcare services should be avoided, and by structural disruption of those services, is elegant modelling published on the 19th May 5 . This illustrates the considerable impact on 5-year survival for surgical cancers of treatment delays of only 3 / 6 months. A 6-month delay in delivering surgical cancer treatment results in 43% of the life years, and 59% of the resource adjusted life years, saved by treating COVID-19 cases being lost to increased cancer mortality. The effect is greater for more aggressive cancers, and lesser for more indolent ones, but cumulative loss of years of life remains sizeable for common, low risk malignancies. Cancer surgery must recommence urgently, with initial supranormal throughput if delays in delivering definitive surgical care are not to be perpetuated, and the increased mortality and healthcare cost made permanent. That will require novel solutions and facilities, overcoming difficulties around social distancing and patient education since symptom-screening and PCR-testing continue to have an undesirably high false negative rate. It also requires considered thought about major reconstruction, for which we urgently need specific safety data in COVID infected patients (U.K. data currently being sought by the BAPRAS microsurgical special interest group 6 ). It is unlikely that the 44.1% rate of ICU admission and 20.5% risk of death recently shown for major surgery 7 will directly transfer to flap procedures, but the association between more severe peri-operative morbidity and increased mortality with more prolonged general anaesthesia, age, and identified patient factors may.

Where major reconstruction enables curative resection (as with chest wall sarcoma) the decision seems simple. Reconstruction for limb salvage is not essential for curative intent resection, but merited as the one opportunity to preserve function and body image. The same argument can be extended to immediate breast reconstruction, but this is a more nuanced debate given the range of cancer subtypes, oncoplastic and reconstructive options, each with differing resource requirements and outcomes / complication profiles. The undoubted benefit of immediate reconstruction for a sizeable cohort of women is being considered against the greater apparent safety and lesser shortterm resource requirement of mastectomy and delayed reconstruction, and guidance from the Association of Breast Surgery (U.K.) is under review. Women will have to wait an extended period for delayed reconstruction in a time of greater healthcare stringencies, and delay carries harm in itself. It will be specifically addressed in the next issue, but the solution may be to develop capacity to provide equitable access to safe, effective reconstruction, with a low complication profile, in a governanced setting where the risk of operating during COVID infection can be minimised, and detailed consent provided that includes known and unknown risks, along with the implications of awaiting delayed reconstruction.

As Plastic Surgeons we deliver a continuum of outcomes from functional restitution that restores independent living or occupational capacity, through optimisation of holistic and psychological welfare (e.g. through breast reconstruction), to pain reduction and curative oncological surgery; treating neonates to centenarians. This generates a complex surgical prioritisation matrix for assessing plastic surgery service provision against service restriction while COVID-19 remains prevalent. Various bodies have produced prioritisation guidance, including the joint Royal Colleges 8 , and U.K. Federation of Surgical Specialty Associations (in preparation 9 ), but rationalisation may best be finalised at the local level in reflection of actual risks (COVID-19 alert level 10 , local prevalence and epidemiology), healthcare capacity (anaesthetic and surgical consumables, bed occupancy, HDU / ICU / theatre capacity, adjuvant therapy pro-vision), staffing levels (including that for all post-operative care, occupational and physiotherapy), and supply levels of PPE (reflecting anaesthetic guidance 11 ). Prioritisation must reflect both the individual care needs of the patient and their individualised risk from receiving that care in the COVID era, when outcomes may differ from historical ones due to altered structures and processes, with new known and unknown risks to account for. Consent legally requires a new and detailed conversation specifically cogniscent of the impact of COVID-19. This supports the benefit of separating care streams / facilities into those naive to COVID status (e.g. for acute trauma), and those based around stringent measures to exclude COVID infection during elective interventions. It also provides a framework within which ethically secure decisions can be made around the resumption of appropriate aesthetic surgery. Given the different clinical picture for COVID in the paediatric population, children's services will merit focused attention to ensure that key age-related windows of opportunity for intervention are not missed, in order to avoid permanent impacts upon growth trajectory, development, or lifelong functional outcomes.

Many of these complexities are being addressed in the BAPRAS COVID webinar series 12 , supported by JPRAS. The series also seeks positives from the current situation, including ways to provide better services in the longer term, and to enhance education and training. The use of webinars, social media, and virtual platforms for education and meetings has become universally accepted within a month, and now challenges the traditional models for professional associations and surgical education that relied upon physical presence. Individual units, including the Canniesburn Unit, are providing webinar teaching that is freely open to participants from around the world, while others deliver virtual courses. We are witnessing the democratisation of education in a manner that facilitates international collaboration in ways that could also actually solve longstanding research or clinical problems, and provide previously unachievable levels of equity in access to expert opinion and high quality educational resources. Professional associations should consider changing their meetings into social and networking events, with scientific presentations and education delivered online, since these may become the only reason to physically bring people together. Without the restriction of travel, a shrinking pool of highly available international experts may come to dominate global educational output, but they, like those setting programmes, should take care to support the development of their successors, and provide space for dissent and evidence based argument in preference to eminence-based didactic instruction. JPRAS supports this global drive (for example through the ICOPLAST journal club 13 that will feature the free-to-access Editor's choice paper each month), and celebrates the millennial approach to consolidating our specialty, our international community, and the evidence base that will drive international consensus and strengthen Plastic Surgery's voice in these challenging times.

World Bank global poverty projection

Lockdown

Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Federation of Surgical Specialty Associations guidance on surgi

aesthetic guidance on recommencing elective surgery