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

Methods

Recommendations issued by state governing bodies pertaining to elective surgery are reviewed as of April 28, 2020. We also reviewed national society and federal guidelines pertaining to elective surgeries affected by the COVID-19 outbreak. Due to the variability in enforceability and terminology used by different states, the term recommendations will be used in this article when discussing state communications about elective surgery practices during the COVID-19 outbreak.

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Table 1. CMS Tier Designation for Elective Surgery ²
Tiers	Definition	Example	Action
Tier 1a	Low-acuity surgery. Healthy patient	Outpatient surgery/non–life-threatening illness	Postpone surgery
Tier 1b	Low-acuity surgery. Unhealthy patient		Postpone surgery
Tier 2a	Intermediate-acuity surgery. Healthy patient	Non life-threatening but potential for morbidity and mortality if surgery delayed. Surgery requires inpatient stay	Consider postponing surgery
Tier 2b	Intermediate-acuity surgery. Unhealthy patient		Postpone surgery if possible
Tier 3a	High-acuity surgery. Healthy patient	Inpatient	Do not postpone
Tier 3b	High-acuity surgery	Inpatient	Do not postpone

Table 2. Summary of Recommendations Based on State, National, and Society Recommendations for Initial Delay and Resumption of Elective Surgeries
	Initial Recommendations for Delay	Recommendations for Resumption
2a. Cosmetic
	Suspend all operations except for complications requiring urgent intervention	Can resume in ambulatory surgery centers without an overnight stay
2b. Oncologic Reconstruction
Breast Reconstruction	Postpone delayed and immediate autologous reconstruction	Can resume based on complexity of operation and local and hospital resources
	Immediate implant-based reconstruction may be permissible	Must take into consideration the possibility of an immunocompromised state of oncologic patients
Head and Neck Reconstruction	May perform operations if likely to be successful, symptom-relieving, or life-saving.
2c. Trauma Reconstruction
	Postpone only those surgeries related to cosmetic concerns	Prioritize ambulatory intervention
	Do not postpone highly symptomatic patients
2d. Pediatric Craniofacial Surgery
Cleft Lip Repair	Postpone	Prioritize ambulatory intervention
Cleft Palate Repair	Ideally postpone, while taking into consideration age of patient >12 months	Those requiring inpatient hospitalization should prioritize time-sensitive procedures
Alveolar Bone Grafting	Ideally postpone, while taking into consideration timing of eruption of permanent canines
Orthognathic Surgery	Postpone
MDO and TLA	Do not postpone when performed to avoid intubation or tracheostomy
	Postpone for healthy outpatients
Craniosynostosis	Do not postpone if patient has elevated intracranial pressure
2e. Hand Surgery
Indolent Processes (carpal tunnel syndrome, trigger finger, etc.)	Postpone unless highly symptomatic	Prioritize ambulatory intervention for symptomatic patients
Traumatic Injuries	Do not postpone fixation/repair, infections, or amputations amenable to replantation