The spread of the severe acute respiratory syndrome-associated coronavirus, commonly referred to as COVID-19, has significantly affected the global community and the landscape of health care. At the time of this writing, the global case number was greater than 87 million, with more than 1.8 million deaths attributed to the disease. The United States has been particularly affected, with approximately 21 million cases and more than 362,000 deaths, despite attempts at quarantine and social isolation.1 Because of initial concerns that infected individuals may overwhelm the capacity of the health care system to provide personal protective equipment, ventilators, and appropriate care, a mandate to halt all elective surgical procedures was instituted in anticipation of the surge. Fortunately, by spring of 2020, the volume and rate of symptomatic patients did not exceed the capabilities of most health care systems. Although interest in facial plastic surgical procedures decreased during the initial phases of COVID-19 in March and April of 2020, it rebounded to higher than prepandemic levels.2 By November and December of 2021, vaccines from Pfizer (New York, N.Y.)–BioNTech (Mainz, Germany) and Moderna (Cambridge, Mass.), with greater than 94 percent efficacy against COVID-19, had been approved for emergency use.3 Because of holiday travel (in November and December) and large group gatherings, there was a notable resurgence in cases, which strained some health care systems.
The primary methods of transmission are through aerosolization and droplets, although the disease can be acquired through contact and fomites as well.4,5 Health care providers who are exposed to the nasopharynx and oropharynx of patients are at higher risk for infection because of mechanisms of transmission and higher viral loads in these locations.6 Multiple protocols have been established by different specialties at increased risk for exposure.7–9 In this article, we discuss the practice changes at an ambulatory surgical center and a systematic approach to safety when performing rhinoplasty during the COVID-19 era, with particular focus on how to minimize the risk of disease transmission.
The risks for disease transmission to patients are highest when they are in close proximity to other individuals (such as medical staff and visitors) and when their face is exposed during examination or intervention. These risks are minimized by ensuring a healthy staff, limiting patient waiting areas, requiring masks at all times, maintaining preoperative social isolation precautions, and using prophylactic maneuvers in the perioperative period.
The risks for disease transmission to the staff are similarly highest when in close proximity to other individuals (such as medical staff), especially unmasked patients during physical examination, surgery, or manipulation of the airway (intubation and extubation). These risks are minimized by ensuring appropriate screening of patients, requiring prophylactic maneuvers in the perioperative period, limiting personnel in the operating room (especially during intubation and extubation), and ensuring adequate operating room air exchange cycles are used. Employee break rooms should have limited capacity and seating should allow for adequate distance between employees. In addition, the medical team should routinely follow precautions of social distancing, mask wearing, and hand hygiene in their professional and personal lives.
The increased utilization of video telecommunications in routine health care decreases in-person interactions but evaluation of surgical candidacy requires direct patient contact. The benefits of a controlled clinical setting include the ability to limit the number of individuals in a given location, prescreen patients before contact or intervention, and minimize contact between the health care team and patients. However, high traffic zones are not always monitored, risking exposure of the patient while waiting in a public location.
Surgical practices must have well-established protocols in place to minimize the risk of disease transmission, with clear expectations for both staff and patients. The patient should understand that although the risk is minimized, there is still the possibility of acquiring COVID-19. If the patient is concerned and unwilling to continue the clinical evaluation, the procedure should be rescheduled until such time as the patient is agreeable to the risk or the risk has been eliminated.
The screening process must at minimum follow the best practices guidelines from the Centers for Disease Control and Prevention, which provides regular updates to their recommendations.10 All individuals (staff and patients) undergo the screening process, which includes a questionnaire for possible viral infection symptoms and a temperature check (Table 1). Screening questions inquire into exposure to recently infected individuals and travel to high-risk regions. If there is concern, a virtual consultation can be offered to patients who are interested in surgical intervention. When scheduling the in-person appointment, patients should be instructed to arrive with a mask, avoid waiting in a common area, and avoid bringing additional people to the appointment. In certain cases, such as for minors or patients with anxiety, exceptions can be made to accommodate the need to have a support person present.
Strategies for COVID-19 Disease Prevention in the Perioperative Setting
|• COVID-19 symptom questionnaire|
|• High-risk exposure questionnaire|
|• Temperature check (excluding patients with temperature greater than 99.6°F or 37.56°C)|
|• No or limited number of visitors (one visitor)|
|• Social distancing at all times among visitors (6 feet)|
|• Mask wearing at all times except during examination|
|• No waiting rooms to limit group formation|
|• RT-PCR testing for COVID-19 within 3 to 5 days|
|• Questionnaire screening the day before surgery|
|• Screening and isolation precautions (same as initial assessment) upon arrival to day surgery center|
|• Application of 2% PVP-I nasal spray and 15 seconds gargling with 2% PVP-I solution (mix of 10% PVP-I with mouthwash diluted 1:4)|
|• Limiting personnel in operating room during induction and intubation|
|• N95 and personal protective equipment worn by anesthesiologist|
|• Insertion of 2% PVP-I nasal pledget and throat pack|
|• Standard preparation of face with 10% PVP-I|
|• Application of Tegaderm dressing to cover oral cavity and endotracheal tube|
|• Keeping throat pack in place until end of case|
|• Minimizing personnel in operating room during extubation|
|• Limiting manipulation of anterior neck to decrease cough reflex from irritation|
|• Providing individual recovery areas (no pooled locations)|
|• Recommending social isolation for the patient in the acute postoperative period|
PVP-I, povidone-iodine; RT-PCR, reverse transcription polymerase chain reaction.
To ensure complete compliance, masks should be available or provided by the facility at the check-in location. Signage to stress the importance of social distancing (6 feet) and wearing a mask should be clearly visible and placed in high-traffic areas. Patients who refuse to follow appropriate protocols should be reinstructed or asked to leave and reschedule for a later date. As the protocol is updated by the Centers for Disease Control and Prevention, the clinical team can adjust the screening process accordingly.
In addition to being candidates for rhinoplasty, patients should undergo comprehensive evaluation for surgical candidacy, with particular attention paid to high-risk factors for disease transmission or for disease acuity that might result in a critical condition. We do not currently offer operative intervention to patients who are not in general good health, including those who have poorly controlled chronic obstructive pulmonary disease, actively use nicotine, or have obstructive sleep apnea.
Several features of the COVID-19 virus have contributed to its rapid spread and today’s persistent pandemic: the period of symptomatic latency (5 to 6 days), the highly infectious asymptomatic phase, and the varying degrees of symptoms.11,12 Viral loads in symptomatic and asymptomatic patients are similar and therefore any infected individual can spread the virus.4 Multiple testing modalities exist to screen patients objectively; however, none is without limitations.
Nucleic acid amplification through reverse transcription polymerase chain reaction (RT-PCR) allows for examination of nasopharyngeal specimens and has emerged as the standard objective screening process in our clinical practice. The accuracy of the testing can vary (with a sensitivity of 63 to 78 percent) and therefore should be considered an adjunct to the questionnaire.13 If a patient tests positive, current Centers for Disease Control and Prevention recommendations must be taken into consideration for the duration of quarantine before medical intervention or return to work.14 During the early periods of recovery, it is possible to receive a positive result with the RT-PCR test even when no longer contagious because of the presence of residual viral nucleic acid.
Antibody testing (immunoglobulin M and immunoglobulin G) can provide additional details regarding the phase of the disease. However, its utility in clinical practice is limited given the additional cost and complexity in interpretation of clinical information (with limited specificity and sensitivity).15,16 We typically require a negative nasopharyngeal RT-PCR result 72 to 110 hours before surgery in addition to absence of symptoms concerning for COVID-19. No practice recommendations have been made regarding vaccination status; however, it is likely that COVID-19 RT-PCR testing would be required preoperatively regardless of vaccination status, given the risk of asymptomatic carrier status in vaccinated individuals.
All patients are asked to follow social isolation precautions in the immediate preoperative period. The day before the planned surgery, the patient is screened over the phone for possible symptoms, including fever (>99.6°F or 37.56°C), dyspnea, cough, respiratory changes, unexplained muscle aches, gastrointestinal symptoms, loss of taste or smell, conjunctivitis, chills, extreme fatigue, and exposure to individuals with COVID-19. If the patient is older than 70 years, additional information regarding confusion, dizziness, unexplained weight loss, and mental status changes are obtained.
PERIOPERATIVE RHINOPLASTY PROTOCOL
Upon arrival to the surgical center, patients are again screened with a temperature check and standardized symptom questionnaire. Patients and staff are masked throughout the encounter, except for when the patient’s nose or mouth is being evaluated by the surgical or anesthesiology team. No visitors are allowed into the preoperative suite with the patient and the family waiting rooms are closed to prevent congregation.
We have been using preoperative povidone-iodine nasal spray and gargle to decrease risk of viral transmission. Povidone-iodine has been shown to have significant virucidal properties, in particular to the severe acute respiratory syndrome and Middle East respiratory syndrome pathogens.17–22 Multiple practices and studies have demonstrated successful viral suppression with varying dilutions of povidone-iodine. Eggers et al.17 demonstrated a greater than 99.99 percent reduction in Middle East respiratory syndrome–associated coronavirus in “dirty conditions” with 1% povidone-iodine for 30 seconds (0.5% povidone-iodine irrigation). Bidra et al.22 demonstrated inactivation of the virus at 0.5%, 1%, and 1.5% after 15 seconds of contact (0.5% povidone-iodine irrigation) and Frank et al.23 found similar efficacy of nasal antiseptic solution of povidone-iodine at concentrations of 0.5%, 1.25%, and 2.5% after 15 to 30 seconds of contact. Although data are limited for in vivo studies, there is evidence that povidone-iodine mouth rinse (15 ml of 1% povidone-iodine for 1 minute) can result in sustained decrease in nasopharyngeal viral loads for up to 2 hours after treatment.24
We use a dilute 2% povidone-iodine nasal spray and a 1:4 dilution of 10% povidone-iodine with Crest Pro-Health Rinse (Procter & Gamble; Cincinnati, Ohio) for a 2% povidone-iodine concentration. The spray is applied for 15 seconds, and the mouthwash is gargled for 15 seconds (Table 2). The dilution of 10% povidone-iodine with the mouthwash results in a more palatable gargle. Chlorhexidine is inferior to povidone-iodine for virucidal properties against Middle East respiratory syndrome–associated coronavirus and therefore should not be considered the first line in exposure prophylaxis.25,26
Perioperative Interventions to Decrease Potential Viral Load
|Dilute 1:4 of 10% PVP-I nasal spray: 15-second application|
|Dilute 1:4 of 10% PVP-I with Crest Pro-Health Rinse: 15-second gargle|
|Insertion of three nasal pledgets moistened with 1:4 of 10% PVP-I with oxymetazoline|
|Insertion of throat pack moistened with 2% PVP-I|
|Standard preparation of face with 10% PVP-I|
The induction and intubation period is a high-risk scenario given the manipulation of oral mucosa. Providers in proximity to the face during intubation, including the anesthesiologist, assisting nurses, and so on, must wear appropriate personal protective equipment to ensure safety. In general, anesthesiology staff will wear N95 masks, face shields, and gowns and are double-gloved to protect themselves from any inadvertent exposure. Operating room air exchange cycles are 20 to 25 exchanges per hour, resulting in 99 percent particle clearance within 8 to 14 minutes.
After the airway has been secured, the senior surgeon places three oxymetazoline (Afrin; Bayer, Leverkusen, Germany) plus 2% povidone-iodine–soaked nasal pledgets in each nostril and a 2% povidone-iodine–moistened throat pack. Patients who do not have a secure airway (local or sedation) are not candidates for throat pack insertion. The face is sterile-prepped with 10% povidone-iodine and, after 30 to 60 seconds, is cleaned with 0.9% normal saline solution. The mouth and endotracheal tube are covered with a Tegaderm (3M; Saint Paul, Minn.) dressing (a semi-occlusive dressing) to decrease open exposure of the oral cavity when the patient has a secure airway (Table 2). [See Video 1 (online), which shows a demonstration of intraoperative surgical precautions in prepping and draping for a rhinoplasty procedure to decrease risk for COVID-19 transmission.] The surgeon wears an N95 mask in addition to standard personal protective equipment. The nasal pledgets are removed after elevation of the nasal skin envelope, before outfracturing of the inferior turbinates is performed, but the throat pack is kept in place throughout the entirety of the case. The nasopharynx is suctioned as needed throughout the procedure.
After application of the dressings, including the internal and external splints, the number of staff in the room is minimized to limit exposure during extubation. Similar personal protective equipment is donned by the anesthesiologist as during intubation. Particular care must be taken to avoid cleaning or stimulating the area around the anterior neck aggressively, as this can initiate a cough reflex. The patient is masked after extubation and taken to an individually sectioned setting to minimize pooled locations of postoperative patients. Because of limited access to visitors, specific efforts must be made toward providing frequent updates to family members and companions of the patient to maintain a line of communication and assuage any concerns. After the patient has recovered sufficiently to ambulate, the patient is escorted into the care of his or her chaperone. We routinely instruct patients to socially isolate and follow standard precautions for 4 weeks postoperatively because of the hypothetical increased risk of disease susceptibility of recently operated or manipulated mucosa.
Since the resumption of elective surgery, the volume of rhinoplasty surgery has returned to pre–COVID-19 volumes. Executing a well-strategized plan to minimize transmission risks has resulted in zero cases of COVID-19 transmission to patients or staff in more than 250 surgical encounters (150 or more rhinoplasties). Early lessons learned have been to dilute the concentration of povidone-iodine of the throat pack, as a 10% solution can cause mucosal irritation of the throat, which can take 7 to 10 days to resolve. The current dilution of povidone-iodine to 2% has been well-tolerated, without any allergic reactions or mucositis. The solution can be diluted further to 0.5% and still be effective in decreasing the viral load in the nasopharynx and oropharynx. To maintain a safe working environment, patients, visitors, and health care team members need to abide by established protocols and Centers for Disease Control and Prevention recommendations and accept the risk that disease transmission remains possible.
The resumption of elective surgical procedures, particularly rhinoplasty, has been approached with trepidation because of COVID-19. However, with a multistep process of screening and prophylaxis, safe surgical services can be provided with minimal increase in patient inconvenience or surgical time. In this era of masks, rhinoplasty continues to be a sought-after procedure despite the pandemic. With a well-prepared staff and well-informed patient, rhinoplasty can be performed safely.