A Summary of Recommendations for Plastic Surgeons During the Coronavirus Disease 2019 Outbreak

Anna R. Schoenbrunner, MD; Benjamin A. Sarac, BS; Jeffrey E. Janis, MD


Plast Reconstr Surg Glob Open. 2020;8(7):e3039 

In This Article

Abstract and Introduction


Background: The coronavirus disease 2019 outbreak presents unique challenges to the healthcare system. The lack of unified guidelines on what constitutes elective surgery left plastic surgeons without a clear framework to guide their practices. More urgently, the ambiguity in defining elective surgery leaves plastic surgeons without clear guidance as states begin to phase in these procedures.

Methods: Recommendations issued by state governing bodies as of April 28, 2020, were reviewed. National society and federal guidelines pertaining to postponement and resumption of elective surgeries affected by the coronavirus disease 2019 outbreak were also reviewed. Recommendations based on the above are collated for plastic surgeons.

Results: Thirty-six states and the District of Columbia provide recommendations regarding elective surgery. Cosmetic surgery is considered an elective surgery and should be postponed; this may be among the first elective surgeries to safely resume. Societal guidelines provide disease-specific recommendations for cancer-related surgery and breast reconstruction. Trauma, other cancer-related reconstruction, and hand surgeries are considered nonelective if postponement threatens life or limb or if a patient is highly symptomatic. Postponement and resumption of oncology, trauma, and hand surgery cases depend on disease stage and complexity of reconstruction. Pediatric craniofacial surgery presents unique challenges due to the time-sensitive nature of the interventions.

Conclusions: Guidance on elective surgery is vague for plastic surgeons. Government recommendations and societal guidelines provide a framework for plastic surgeons to assess the elective nature of a surgical intervention and safety of resumption; however, a nuanced assessment must be made on local disease transmission, supply availability, and hospital capacity.


The coronavirus disease 2019 (COVID-19) outbreak caused by the SARS-CoV-2 virus was declared a pandemic by the World Health Organization on March 11, 2020. Following this announcement, the American College of Surgeons (ACS) issued guidance for triaging nonemergent cases based on an Elective Surgery Acuity Scale.[1] The ACS announcement was closely followed by the announcement by Centers for Medicare and Medicaid Services (CMS) recommending that "all elective, nonessential medical, surgical, and dental procedures be delayed" during the COVID-19 outbreak to minimize spread of the virus and preserve personal protective equipment (PPE).[2] Similar statements by The American Society of Plastic Surgeons (ASPS)[3] and individual states soon followed. Despite the plethora of guidelines, the criteria of what constitutes an elective procedure remain elusive. As states begin to control local outbreaks of the novel coronavirus, public health officials and societies have issued guidance on the resumption of elective procedures.[3–5]

The lack of clearly defined criteria regarding what constitutes an elective procedure has resulted in haphazard implementation within practices and between providers. More urgently, this lack of clearly defined criteria portends a disordered resumption to normalcy. Plastic surgeons must be apprised of the most current state and society guidelines on the status of elective procedures and be amenable to adapt in the event of a second COVID-19 surge.[6]

In this report, we present recommendations issued by federal and state governing bodies concerning the cessation and resumption of elective surgeries. These recommendations, in conjunction with national society guidelines, are collated to provide guidance regarding elective surgery practices to plastic surgeons during the COVID-19 outbreak.