A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic

Abstract

Summary The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.

Oncologic Head and Neck Reconstructive Microsurgery during the COVID-19 Pandemic in Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia

“…The balance between hospital supply of limited resources such as PPE, intensive care unit (ICU), and HCWs for COVID-19 cases and elective surgery must be reached because the allocation of these resources is prioritized for managing COVID-19 cases in the larger public health context. 22 The surgical management for head and neck cancer has become a clinical dilemma during this pandemic. Therefore, a careful risk-benefit assessment for each patient is necessary, particularly in head and neck reconstructive surgery procedures that were considered as a high risk of disease transmission.…”

“…15,28 However, several centers reported that the head and neck reconstructive microsurgery still can be successfully performed during this pandemic by applying the protocol to reduce the risk of COVID-19 transmission. [17][18][19] Our protocols have been adapted from various sources, including those of the World Health Organization, 21 Pittsburgh, 6 Irish Microsurgery Special Interest Group Guideline, 7 Baylor Scott & White's head and neck protocol, 22 American College of Surgeons, 16 and a few other guidelines. [17][18][19] The Dharmais Cancer Hospital-National Cancer Center has adopted a protocol to safely continue the head and neck reconstructive microsurgery, including preoperative, intraoperative, and postoperative COVID-19 protocols.…”

“…The protocol may vary from one center to another center, but the main principle was COVID-19-positive patients requiring operation will be treated appropriately, but not during the active viral infection to spare both risk and morbidity to the patient and surgical team. 22 The limitation of our hospital is there is not yet a negativepressure operating room to operate for COVID-19 patients. Patients with COVID-19 infections will be at increased risk for adverse outcomes, including perioperative mortality rates of up to 16.7% in those with COVID-19 compared with 1.4% in non-COVID-19 patients.…”

Reconstructive Microsurgery in the COVID-19 Environment

“…As in the influenza pandemic of 1918, social distancing and quarantine remained the main focus for reducing viral spread. 6 Although modern technology undoubtedly assisted in managing patients with COVID-19, the sparsity of knowledge on patient outcomes in previous pandemics 7 precluded comparisons of strategies to resist viral spread.…”

“…Additionally, in patients after resection of head and neck cancer, wounds were covered with local flaps instead of free flaps (the preferred method) to both shorten operative time and minimize the need for follow-up. 6 After surgery, patients were transferred directly from the OR to the ward, bypassing the recovery room. 9 Importantly, before surgery, patients were counseled regarding possible prolonged anesthesia time and the potential repercussions of newly instituted measures on postoperative management.…”