Establishing the New Normal: Best Practice Recommendations in response to the COVID-19 Pandemic

Realself - Back in March, as governors, one by one, issued stay-at-home orders to flatten the curve, and suspended elective surgeries in anticipation of COVID-19 surges, countless dermatologists, plastic surgeons, facial plastic surgeons, oculoplastic surgeons, and physicians from other “nonessential” specialties closed their doors for what many hoped would be a two-week hiatus. As the pandemic swiftly escalated, any tentative plans for re-openings were quickly scrapped. Doctors wiped clean their spring calendars and pivoted to telemedicine, seeing in person only true medical emergencies.

Daily confirmed new cases (5-day moving average) - Outbreak evolution for the current 10 most affected countries - Johns Hopkins (updated June 22, 2020)

Now, as doctors and patients move into month three of quarantine, our collective focus has shifted from navigating its many complexities—working from home while schooling kids, sourcing and sanitizing food, and mastering the art of mask-making—to preparing for yet another new normal: life after lockdown. Initiating the earliest phase of reentry, several states have begun easing hospital restrictions on elective surgeries.

To that end, dermatology and plastic surgery societies are formulating guidelines for reopening. Separately, physicians are banding together, convening independent task forces and consensus groups, to brainstorm best practices and universal precautions. Here, doctors reveal what we can expect at our next visit—while allowing for one big caveat: these carefully devised protocols may change as they track the progress of COVID-19 testing and the trajectory of the pandemic. 

Procedures will be prioritized by medical necessity.

“Not all elective cases are of equivalent medical necessity,” explains Dr. Steven Teitelbaum, a board-certified plastic surgeon in Santa Monica, California. “We need to look at both the benefit from the procedure as well as the price that’s paid for delaying—we need to be thoughtful about how we move forward.”

“There will be a clear hierarchy of cases,” notes Dr. Jennifer Levine, a board-certified facial plastic surgeon in New York City. Hospitals will tend to the most critical pending cases first—tumor resections, organ transplants, heart valve and hip replacements—surgeries performed to halt the progression of disease, relieve pain, save lives. In the plastics realm, “cases such as breast reconstructions after mastectomies that have been put on hold will take priority—there’s been talk of running ORs 24 hours a day to address this issue,” says Dr. Steve Fallek, a board-certified plastic surgeon in Englewood Cliffs, New Jersey. Doctors will likely lean on surgical centers in the short term, he notes, to avoid overwhelming hospitals and exposing healthy patients to COVID-19.

Though surgeons with office-based ORs aren’t subject to institutional rules, most will follow the standards set by local hospitals to protect both patients’ interests as well as their own reputations. “You don’t want to be that guy jumping the gun and doing things found to be distasteful,” says Dr. Jonathan Kaplan, a board-certified plastic surgeon in San Francisco.

There’s also the chance that “private facilities and surgery centers may lag slightly behind hospitals [in reopening], especially since their access to tests may be more limited,” points out Dr. Levine. Generally speaking, “you can assume that there will be some type of testing required before any surgery,” adds Dr. Fallek.

Dermatologists will also be tasked with prioritizing a slew of canceled patients. “We’ll be starting with the most urgent cases—patients awaiting skin-cancer diagnoses and treatments; those on systemic medications who require monitoring; anyone needing blood work, imaging, or biopsies,” says Dr. Heidi Goodarzi, a board-certified dermatologist in Newport Beach, California.

As for cosmetic interventions, like injectables and devices, some derms plan to get right back to them—in a limited and modified way—while others hesitate to resume such services too soon. “Aesthetic medicine should be one of the last things to come back—and I say this with a little ache in my heart, because I enjoy these procedures and they’re a huge part of my income,” Dr. Goodarzi says. “In my opinion, there’s just no place for this during a pandemic.”

It may be weeks before your doctor can see you.

Doctors are confronting waitlists of previously scheduled patients, plus volumes more clamouring for overdue skin checks and cosmetic touch-ups—they simply won’t be able to accommodate everyone on day one. “From a practical standpoint, we’ll be seeing far fewer patients each day, because we don’t want people crossing paths in the office, and our decontamination protocols between patients will take longer,” so offices will be running at a slower pace, says Dr. Heidi Waldorf, a board-certified dermatologist in Nanuet, New York.

In bracing for reentry, some physicians foresee curtailing their hours. “We could start back in mid-May or June, but it’s not going to be a full start—it may be one or two days a week to take care of just the high-risk cases,” says Dr. Tiffany Libby, a board-certified dermatologist in Providence, Rhode Island, who specializes in Mohs surgery. “Even then, I’ll be very selective about who I’m treating and careful to weigh each patient’s risks and benefits”—particularly if they’re immunosuppressed and at heightened risk for contracting COVID-19. Several of the skin-cancer patients she’s checked in with recently have said they’re not yet comfortable leaving the house for treatment.

Other providers predict adjusting their schedules in different ways. “Sixty patients a day used to go through my office—and I’d sometimes have 25 staff members running around,” says New York dermatologist Dr. Paul Jarrod Frank. When he returns to work, the headcount will be drastically reduced. “Maybe we’ll see 10–15 patients a day, possibly seven days a week, carefully spacing everyone out and rotating in staff for a few hours a day or whatever they’re comfortable with,” he says. “And that’s assuming the curve stays low and we get increased access to testing.”

Across the board, the new normal will be slow, methodical, and not without hiccups. Show patience and understanding as your doctor and their team get up and running.

Consultations may remain virtual until a vaccine is available.

If you’re looking to get a professional opinion, discuss a future surgery, follow up on a past procedure, or address an issue that can be diagnosed and treated visually, your doctor will probably insist on a contact-free visit. The majority of derms and surgeons, having sharpened their virtual skills during quarantine, are making online consults de rigueur going forward to limit the potential vectors entering the office. (And they say this with love.)
You’ll be screened before your appointment and upon arrival.

The COVID-19 checklist is now a thing. As is the COVID-19 consent form.

Standard questionnaires will inquire about your current health, recent symptoms, previous COVID-19 exposure or diagnoses, sick family members, travel history, and so forth. Medical buildings and individual doctor’s offices will also be taking temperatures before allowing patients inside. “There are an enormous amount of people walking around with 99.5 degree fevers who don’t know it,” says Dr. Frank. “We’ll be doing a laser-pointer temperature test on everyone—this is an easy way to detect potential asymptomatic shedders.”

According to Dr. Waldorf, “If there’s any question as to whether someone presents a risk, they’ll be asked to reschedule.”
Doctors will require testing before certain procedures.

Allow me to preface all forthcoming talk of testing with this understatement: it’s complicated.

(And also this spoiler: no test is infallible.)

Widespread testing, you’ve no doubt read, is key to reopening the economy. “And on a more microcosmic level, it’s the one thing that can save our individual practices,” says Dr. Teitelbaum. But there’s a catch: “There is a lot we don’t know about the quality and availability of testing—and the facts change every few days.”

At the moment, though, it seems that hospital-based outpatient surgeries will generally require a pre-operative COVID-19 diagnostic lab test (or PCR)—this is the deep nasal swab that detects active viral particles. This particular test has to be performed and processed in a sophisticated manner at a government-regulated lab. Results take hours to days to procure.

“Testing may need to be done twice—24–48 hours prior to a procedure and perhaps again at the time of admission—to ensure that [the original result] was not a false negative,” says Dr. Levine, who’s on staff at Manhattan’s Lenox Hill Hospital.

Emulating hospital policy—and optimistic that diagnostic testing will ramp up in the coming weeks—certain plastic surgery societies are advising members not to operate without a negative pre-op COVID-19 PCR test.

Currently, though, since the diagnostic swab tests are, in certain parts of the country, “a very limited resource,” notes Dr. Teitelbaum, many physicians who provide office-based treatments, or operate in private ORs, are relying on antibody blood tests—the rapid finger-prick kind most commonly—to flag patients (both surgical and nonsurgical) who’ve been exposed to the virus.

Doctors also plan on antibody testing themselves and their staff regularly.

Regardless, the implications of having antibodies—and their real-world significance—are still fuzzy, as evidence linking antibodies to immunity is lacking. Confounding matters, “not all COVID-19 patients develop antibodies—and [in those who do], we don’t know how long they last,” Dr. Waldorf notes. Moreover, both antibody tests and PCR tests can fail to pick up the virus in its earliest stages, when folks are highly contagious but perhaps not yet showing signs of infection. “This is why it’s critically important to combine testing with talking to patients and getting a history of symptoms and exposures,” Dr. Kaplan says.

The bulk of antibody tests on the market, it’s worth noting, are not formally FDA approved. Manufacturers of certain kits have applied for an EUA or emergency use authorization —“meaning doctors can use the tests while the FDA vets them,” Dr. Kaplan explains. The particular test he’s chosen for his surgical patients is on the EUA list. “I’ve reviewed the company’s clinical data,” he says, “and I know the sensitivities and specificities of the test.”

Doctors are investing in tests that look for two types of antibodies: an initial wave called immunoglobulin M (IgM), which the body produces within a week to ten days of being infected with the coronavirus, and immunoglobulin G (IgG), a secondary cascade thought to maybe confer some yet-to-be-substantiated element of immunity.

Beyond their varying degrees of validity, antibody tests pose another challenge—how to interpret and act upon the results. In Beverly Hills board-certified facial plastic surgeon Dr. Sagar Patel’s practice, “any patient who shows a positive result, even if it’s IgG, will have their surgery delayed for two weeks. “More likely than not, that result means the person is no longer infectious, but we plan on playing it extra safe.”

An IgM positive result indicates an active or recent infection, suggesting patients isolate and push off procedures. An IgG positive/IgM negative reading implies the patient had the virus, “but is likely no longer contagious, because it takes a while for the IgM antibody to go away,” says Dr. Adam Rubinstein, a board-certified plastic surgeon in Miami.

Doctors are using the best information available to decipher results, weigh the odds, and steer patients to safe outcomes—well aware that a wrong call could have catastrophic consequences. “Our biggest concern is unwittingly operating on patients who are in the incubation period,” Dr. Teitelbaum says. “If we give them anesthesia or shock their immune system by doing surgery, is it theoretically possible that we might trigger a worse infection than they otherwise would have had? That’s totally unknown at this point.”

Of course, with many surgeons still a month or more out from operating, the hope is that better tests will come to market. “A more reliable test is supposedly pending,” notes Dr. Steven Pearlman, a board-certified facial plastic surgeon in New York City. He expects to need both types of tests—swab and finger prick—for his patients. As an additional safeguard, he’s considering having out-of-towners quarantine in New York for two weeks before surgery.

Offices are eliminating waiting rooms to uphold social distancing.

There will be no perusing pamphlets, skimming magazines, or enjoying complimentary refreshments—because there will be no waiting rooms. “We’ll ask patients to come on time for their appointments,” says Dr. Pearlman. “If they’re early, they’ll wait outside or in their cars.”

If you’re cleared to enter—normal temperature, no red flags on your checklist—you’ll be immediately outfitted with a mandatory mask, gloves, and shoe covers, and then escorted (at an acceptable distance) directly back to a sterile exam room. Your doctor and their team will also be wearing masks (N95s if available or copper-treated cloth masks), gloves, and other PPE, including goggles or face shields. The hand sanitizer will be flowing.

All the usual front-end paperwork will be handled digitally in advance of your visit. “We have a HIPAA-compliant messaging system through which people can safely share their insurance card, driver’s license, and medical forms,” adds Dr. Goodarzi. “There’s absolutely no reason to check in in person.”

Guests of patients will not be allowed into the office, so you’ll need to cue up FaceTime for the emotional support or second opinions you’d normally seek from friends or partners.

After checking out—in the exam room rather than at reception—you’ll exit via a different door than the one you entered through to skirt other patients.

You may not be able to get the procedure you want right away.

Providers will reboot aesthetics treatments in their own time. Some will focus exclusively on medical cases to start: “I’m not even thinking about cosmetics right now,” admits Dr. Libby.

Others will offer a limited menu of in-office treatments in the early goings. “I’ll only do mask-on procedures to start,” says Beverly Hills board-certified plastic surgeon Dr. Sheila NazarianBotox your forehead and glabella? Sure thing. Fill your nose and lips? No, ma’am.

(Most practitioners will be antibody testing nonsurgical patients before office-based procedures, but remember: no test is foolproof and a negative result isn’t entirely trustworthy.)

There are doctors who oppose the mask-on treatment approach. Assessing and altering only part of the face “is a disservice to patients,” Dr. Waldorf believes. “We need to treat based on how the face looks in full.”

That said, having patients remove masks for injectables, lasers, facials, and microdermabrasion—“the things people are really jonesing for after being holed up,” says Dr. Rubinstein—means taking a calculated risk. Dr. Rubinstein and his staff will be deciding together how to handle such cases when patients are asymptomatic with no known exposures to the virus. He’s also factoring in the incidence of coronavirus in his state of Florida, which he estimates to be around .1%—a figure that’s “pretty low, but still needs to be respected,” he says.

Laser treatments have been a hot topic because certain types of devices—deep-reaching CO2 lasershair removal lasersfractional resurfacing lasers—can produce a plume or “aerosol of skin cells, potential virus, and other dangerous particulates that can be inhaled,” explains Dr. Waldorf. “Given the circumstances, I’m going to wait to restart FraxelClear + Brilliant, laser hair removal, and tattoo removal until I have special air-circulating units with HEPA filters and UVC in those treatment rooms.”

In the surgical arena, “facial cases will demand more precautions than body cases,” says Dr. Fallek—the particulars of which will vary by surgeon. Rhinoplasties and oral surgeries, like buccal fat removal, are thought to be especially dicey due to the high viral load in these areas—and some surgeons may choose not to perform such operations for a time.

Doctors and hospitals are implementing new strategies for surgeries performed under general anesthesia. The process of inserting and removing breathing tubes—intubating and extubating, respectively—endangers the anesthesiologists who are putting patients under, because such airway maneuvers can aerosolize the virus. Certain hospitals are ordering anesthesiologists to be alone in the OR during intubation/extubation, and requiring others to wait 15–20 minutes before entering to allow for sufficient ventilation.

“The need to do that is a function of the possibility that the patient could be in the incubation period at the time of surgery despite having gone through pre-operative COVID-19 testing,” notes Dr. Teitelbaum.

These measures will, of course, increase anesthesia and OR time—and time is money—so be sure to discuss COVID-19-related price hikes with your plastic surgeon.

Rest assured, reputable physicians are “in no way being cavalier or rushing to reopen,” adds Dr. Rubinstein. “We’ll do it once it’s deemed safe by the government—and regardless of perceived safety, we’ll be taking every precaution possible to protect our patients.”




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