Slowing the Spread and Minimizing the Impact of COVID-19

Lessons From the Past and Recommendations for the Plastic Surgeon

Ethan L. MacKenzie, M.D.; Samuel O. Poore, M.D., Ph.D.


Plast Reconstr Surg. 2020;146(3):681-689. 

In This Article

Abstract and Introduction


Background: Coronavirus disease 2019 (COVID-19), a novel coronavirus originating in December of 2019 in Wuhan, People's Republic of China, has spread rapidly throughout the globe over 3 months. On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. COVID-19 represents a nearly unprecedented threat to both the public health and the durability of our health care systems and will profoundly affect the field of plastic and reconstructive surgery. The objective of this article is to provide a natural history of COVID-19—including virology, epidemiology, and transmission patterns—and a guide for plastic surgeons regarding patient and resource management.

Methods: The authors reviewed existing literature regarding COVID-19, both primary research and secondary reviews, by means of PubMed queries, and recommendations from relevant professional organizations (e.g., American College of Surgeons and American Society of Plastic Surgeons). The literature and recommendations were summarized to provide a specific guide for plastic surgeons.

Results: Internationally, over 5.7 million cases and 357,000 deaths from COVID-19 have been reported at the time of writing. No pharmacologic treatments have been identified, but epidemiologic strategies were identified to prevent viral spread, preserve health care resources, and protect patients and surgeons globally. Specific recommendations for plastic and reconstructive surgeons include postponing elective cases and transitioning to telecommunication platforms for patient consultations and education.

Conclusions: COVID-19 represents a nearly unprecedented threat to the public health and the durability of health care systems in the contemporary era. Although plastic and reconstructive surgery may seem relatively remote from the pandemic in direct patient care and exposure, our field can significantly enhance health care resource management.


Starting in December of 2019, a series of cases of viral pneumonia emerged in Wuhan, China, and quickly propagated within Wuhan and wider China within weeks. The causal agent was isolated in early January of 2020 and identified as a β-coronavirus.[1] This newly isolated virus was termed coronavirus disease 19 (COVID-19) by the World Health Organization. Coronaviruses are enveloped single-stranded RNA viruses that cause a variety of animal diseases.[2] Coronavirus can be divided into four genera, α, β, γ, and δ, all causing animal disease. There are only six previously known coronaviruses that infect humans, all of which fall into the α and β genera. Two of these, SARS-CoV and MERS-CoV, cause severe acute respiratory syndrome and Middle Eastern respiratory syndrome, which are associated with high rates of mortality.[3] Similar to SARS-CoV, COVID-19 uses the angiotensin-converting enzyme 2 receptor as its portal of entry into human cells. As high proportions of type I and II lung alveolar cells express angiotensin-converting enzyme 2, respiratory tissues are particularly susceptible to infection.[4] Further genetic analysis of COVID-19 has identified bats as the likely host of origin, although several intermediate hosts have been suggested, including pangolins and snakes.[1,5]

The symptomatology of COVID-19 mimics that of other respiratory illnesses. COVID-19 spreads through respiratory contacts; however, the virus has been isolated from blood and fecal samples, making transmission through multiple routes a possibility.[6,7] Once exposed, the time to symptom presentation ranges from 1 to 14 days, with the average being 3 to 7 days.[8] During this time, the infected individual is contagious despite being asymptomatic.[9,10] The most common symptoms observed are cough, fevers, shortness of breath, and fatigue. Smaller numbers of patients develop headache, diarrhea, and hemoptysis.[11–13] Approximately 20 percent of patients develop more severe disease requiring hospitalization, with subsets of patients developing acute respiratory distress syndrome, acute kidney injury, elevated cardiac enzymes, and liver injury. Patients older than 65 years or with multiple comorbidities are more likely to develop severe disease.[13–15]

Although several drugs are currently undergoing testing as antivirals for COVID-19, data supporting their use are premature.[16] The U.S. Food and Drug Administration recently granted emergency authorization for use of hydroxychloroquine for treatment of COVID-19.[17] This authorization has been controversial, as the drug remains under investigation for this indication. There are ongoing clinical trials investigating multiple medications and vaccines for the treatment of COVID-19, although deployment of these into the general population is likely months away (Table 1).