Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS-COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management.

BACKGROUND: The worldwide spread of a novel coronavirus disease (COVID-19) has led to a near total stop of non-urgent, elective surgeries across all specialties in most affected countries. In the field of aesthetic surgery, the self-imposed moratorium for all aesthetic surgery procedures recommended by most international scientific societies has been adopted by many surgeons worldwide and resulted in a huge socioeconomic impact for most private practices and clinics. An important question still unanswered in most countries is when and how should elective/aesthetic procedures be scheduled again and what kind of organizational changes are necessary to protect patients and healthcare workers when clinics and practices reopen. Defining manageable, evidence-based protocols for testing, surgical/procedural risk mitigation and clinical flow management/contamination management will be paramount for the safety of non-urgent surgical procedures. METHODS: We conducted a MEDLINE/PubMed research for all available publications on COVID-19 and surgery and COVID-19 and anesthesia. Articles and referenced literature describing possible procedural impact factors leading to exacerbation of the clinical evolution of COVID-19-positive patients were identified to perform risk stratification for elective surgery. Based on these impact factors, considerations for patient selection, choice of procedural complexity, duration of procedure, type of anesthesia, etc., are discussed in this article and translated into algorithms for surgical/anesthesia risk management and clinical management. Current recommendations and published protocols on contamination control, avoidance of cross-contamination and procedural patient flow are reviewed. A COVID-19 testing guideline protocol for patients planning to undergo elective aesthetic surgery is presented and recommendations are made regarding adaptation of current patient information/informed consent forms and patient health questionnaires. CONCLUSION: The COVID-19 crisis has led to unprecedented challenges in the acute management of the crisis, and the wave only recently seems to flatten out in some countries. The adaptation of surgical and procedural steps for a risk-minimizing management of potential COVID-19-positive patients seeking to undergo elective aesthetic procedures in the wake of that wave will present the next big challenge for the aesthetic surgery community. We propose a clinical algorithm to enhance patient safety in elective surgery in the context of COVID-19 and to minimize cross-contamination between healthcare workers and patients. New evidence-based guidelines regarding surgical risk stratification, testing, and clinical flow management/contamination management are proposed. We believe that only the continuous development and broad implementation of guidelines like the ones proposed in this paper will allow an early reintegration of all aesthetic procedures into the scope of surgical care currently performed and to prepare the elective surgical specialties better for a possible second wave of the pandemic. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Sick cell syndrome in a burned patient.

The sick cell syndrome is a disorder of the cellular Na+/K+ pump with several causes which include hypoxia, sepsis, hypovolaemia and malnourishment. We report an example of the sick cell syndrome which occurred twice to a patient admitted to our Burn Centre, the first time due to hyponutrition and the second time septicaemia. The striking features of this syndrome were hyponatraemia (less than 130 mmol) despite an increasing sodium intake, a reduced natriuria (less than 20 mmol), a trend to hyperkalaemia and unchanged haematological parameters. Clinically the syndrome was characterized by confusion and hallucinations, and the problem was solved by appropriate treatment of the cause.

Severe electric burn of the skull.

We report a case of severe injury of the scalp and skull caused by high tension electric current. The patient developed tetraplegia. The surgical steps undertaken are also described. We used two consecutive free flaps which failed 5 days after each operation. We discuss the possible causes for flap failure, which we think was due to damaged receptor vessels. The wound was closed after expanding the adjacent scalp. Scalp expansion was an uneventful procedure, however infection of the cavity developed. We overcame this problem by an aggressive approach (cavity irrigation, daily expansion and systemic antibiotherapy). The use of a synthetic mesh to avoid cerebral herniation through the bone defect is also described.

An analysis of burn mortality: a report from a Spanish regional burn centre.

This paper reports an analysis of the mortality rates and related factors in our Burn Centre, based on 710 patients treated between 1985 and 1988. The average age of the patients was 23.8 years and the average burn size was 14 per cent of the body surface area. Burning injury affected mainly men (66 per cent), and their mortality rate was higher than that of women. The overall mortality rate was 6.6 per cent, the average age of the fatally injured patients being 54 years. We confirm that mortality in burned patients is closely related to: age (51 per cent of the patients were over 60 years of age); burn size (68 per cent of the patients had burns covering more than 30 per cent TBS); burn depth (57.4 per cent had full skin thickness burns); inhalation injury (present in 66 per cent of the fatally injured); and associated risk factors. The main cause of the burning injury was flames, chiefly from domestic accidents. The average survival time for the fatally injured patients was 10 days. Finally, our expected mortality followed a linear regression model, the LA50 for patients with only full skin thickness burns was 50 per cent.

Gunpowder-related burns.

Gunpowder misuse is a frequent cause of burn injury in our area. The injuries are mostly minor lesions which may be treated on an outpatient basis, the more serious injuries need surgical treatment. Experience of the management of these burns is reported by reviewing 123 clinical charts of patients admitted between 1983 and 1990. The most frequent victims are teenage males who are involved mainly in accidents in the street. The most serious burns followed work-related accidents, with a fatal outcome in 47 per cent of the patients. The serious burns are usually deep dermal or full skin thickness. A common pattern affects groins, genitalia, hypogastrium and hands, and are produced when fireworks ignite in the pockets of the patient's trousers. The management of these lesions does not differ from burns caused by other agents, although attention should be paid to the presence of associated lesions, chiefly to eyes, ears and hands, due to the shockwave and shrapnel.

Male chest enhancement: pectoral implants.

The authors present their experience with the pectoral muscle implant for male chest enhancement in 21 patients. The markings and technique are thoroughly described. The implants used were manufactured and custom made. The candidates for implants comprised three groups: group 1 (18 patients seeking chest enhancement), group 2 (1 patient with muscular atrophy), and group 3 (2 patients with muscular injuries). Because of the satisfying results obtained, including significant enhancement of the chest contour and no major complications, this technique is used for an increasing number of male cosmetic surgeries.

Hip and buttock implants to enhance the feminine contour for patients with HIV.

The antiretroviral therapy for patients with human immunodeficiency virus (HIV) causes lipodystrophy, or a change in the distribution of body. Treatment for the facial changes is well addressed and covered in the recent literature, but female patients also report changes in their buttocks and lower limbs. There is no treatment for the lower limb deformity, but plastic surgeons can do something for the buttock. The authors propose a classification for the deformities of these patients and a new solution to improve the contour of this area and to reduce the social impact of deformity on women with HIV. This consists of placing two silicone implants, in the buttock and on the hip, to give a rounder appearance. The authors think that hip implants may be indicated also for gender reassignment surgery and for women with masculine features.

Our algorithm for nasal reconstruction.

Nasal reconstruction is always challenging for plastic surgeons. Its midfacial localisation and the relationship between convexities and concavities of nasal subunits make impossible to hide any sort of deformity without a proper reconstruction. Nasal tissue defects can be caused by tumor removal, trauma or by any other insult to the nasal pyramid, like cocaine abuse, developing an irreversible sequela. Due to the special characteristics of the nasal pyramid surface, the removal of the lesion or the debridement must be performed according to nasal subunits as introduced by Burget. Afterwards, the reconstructive technique or a combination of them must be selected according to the size and the localisation of the defect created, and tissue availability to fulfil the procedure. An anatomical reconstruction must be completed as far as possible, trying to restore the nasal lining, the osteocartilaginous framework and the skin cover. In our department, 35 patients were operated on between 2000 and 2002: three bilobed flaps, five nasolabial flaps, two V-Y advancement flaps from the sidewall, three dorsonasal flaps modified by Ohsumi, 19 paramedian forehead flaps, three cheek advancement flaps, three costocondral grafts, two full-thickness skin grafts and two auricular helix free flaps for alar reconstruction. All flaps but one free flap survived with no postoperative complications. After 12-24 months of follow-up, all reconstructions remained stable from cosmetic and functional point of view. Our aim is to present our choice for nasal reconstruction according to the size and localization of the defect, and donor tissue availability.

A complicated trochanteric pressure sore: what is the best surgical management? Case report.

Pressure sores are a common complication after spinal cord injury. But great advances in their management (nursing care, prevention and surgery) have been made in the last four decades. Neglected pressure ulcers may affect the adjacent joint, leading to septic arthritis. We report a paraplegic patient with a large trochanteric sore with hip arthritis, in whom we performed an upper femoral resection and acetabular curettage (Girdlestone's technique) and coverage with the homolateral vastus lateralis muscle flap in one stage. Some questions pertaining to this operation are discussed and there is a comparison with other ways of management described in the literature. We conclude that a successful outcome with the management of such large sores depends on a radical, aggressive operation to remove all of the affected tissue, and ensure a safe coverage with a reliable, viable muscle flap. The collaboration and the positive attitude of the patient towards the procedure and the result obtained are decisive in preventing recurrences.

Forehead flag flap.

We present a modification of the Okada and Maruyama's flap for forehead reconstruction, based solely on the supratrochlear vessels. The flap is raised extra-periosteally but in the area of the pedicle the periosteum is included in the flap to protect the vessels. The flap is advanced and rotated to cover full thickness defects on the contralateral hemi-forehead, like a flag on its flagpole. We have treated six patients with large malignant tumours of the forehead which required excision including the periosteum. The flap survived in all cases and no necrosis was observed in any. The main advantage of this flap is that it is relatively straightforward to raise, being a good solution in selected cases (elderly patients). The main disadvantages of this flap are that the supraorbital nerve is sacrificed and some distortion of the eyebrows occurs.

Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps.

Soft tissue heel defects reconstruction represents a challenge for plastic surgeons because of the poor availability of regional tissue to perform the reconstruction. We divide the heel on the anterior or weight-bearing heel and the posterior or non-weight-bearing heel. Our preferences are the fasciocutaneous instep flap for anterior heel defects and the reverse sural flap for posterior heel defects. We have performed 11 reconstructions of the heel. The complications were total necrosis of 1 instep flap in a previously irradiated patient and 1 case of partial tip necrosis in a reverse sural flap. Functional recovery has been very satisfactory for both procedures. Regional island flaps are for us the first therapeutic option because the skin is similar to the lost one and less time consuming than a free-flap reconstruction.

Invaginated vein graft as nerve conduit: an experimental study.

Vein grafts have been used for nerve repair in experimental and clinical studies. However, some concerns about their collapsability and the presence of valves which could block axonal growth have been put forth. We propose a modification to eliminate these potential problems by turning the vein inside out, obtaining an "invaginated" vein graft. We performed an experimental study on 61 adult Wistar rats, divided into 3 groups: control (non-operated) (n = 11); immediate repair, with 3 subgroups: invaginated vein graft (n = 10), vein graft (n = 10), and nerve graft (n = 10); and delayed repair, with 2 subgroups: invaginated vein graft (n = 10) and nerve graft (n = 10). Delayed repair was performed 3 to 4 weeks following division of the nerve. Electromyographical (EMG) assessment was performed in all operated animals at 2, 4, and 6 months after immediate reconstruction, and at 1 and 4 months after delayed repair. At the end of the study, all nerves were excised and a morphometric analysis was performed. We conclude that vein grafts are as useful as nerve grafts in immediate and delayed nerve repair, as there were no significant functional or histologic differences. We found no significant differences between invaginated vein grafts and non-invaginated vein grafts. However, electrophysiological results were slightly superior in the former. Regenerated axons were small, grouped in minifascicles with thin myelin sheaths. The venous adventitia did not interfere with axonal growth.

[Tumors of Vater's ampulla. Review of 25 cases]. / Tumores de la ampolla de Vater. Revisión de 25 casos.

Cancer of ampulla of Vater is a infrequent tumor which was a much better prognosis after radical treatment than cancer of the pancreas. In this paper, 25 patients were studied, with a mean age of 59 years and a slight male predominance. The most frequent symptoms were related to jaundice and weight loss. The correct preoperative diagnosis was only reached in 54.16% of the patients, endoscopic retrograde cholangiopancreatography being the best diagnostic method, together with ?CTPH. We emphasize the difficulty of reaching a diagnosis and the variable results of both pre- and peroperative biopsy. The results of surgical treatment (9 Whipple operations, 7 ampullectomies and 7 bypass operations) are evaluated, showing that duodenopancreatectomy is the most effective therapy, although we had only one 5-year survival, 11.1% versus 0% for ampullectomy, which is an operation that carriers an elevated recurrence rate (greater than 50%). The mortality derived from Whipple's operation was 22.2%, and from local excision, 14.3%. The rate of complications was 55.5% after cephalic duodenopancreatectomy and null after ampullectomy. In view of these results, we think that the most appropriate therapeutic approach to ampulloma is the Whipple operation, and that ampullectomy should be reserved for those patients in poor general condition with small tumors, and that bypass operations should be used when the tumor is not resectable.

[Breast carcinoma in men: a review of 21 cases]. / Carcinoma mamario en el varón: revisión de 21 casos.

Male breast carcinoma is a truly rare tumor the treatment and prognosis of which have been recently considered similar to female cancer. In this work we reviewed the clinical histories of 21 patients with breast cancer attended in our hospital over a period of fifteen years. Mean age was 60 years. The main cause of consult was the presence of painless nodules most frequently localized in the left breast. We have found a great latency period between the detection of the first symptoms and medical consult (almost 20 months) which by itself justifies that almost fifty percent of patients were either in stage III or IV. Global surveillance was 60% after 5 years excluding other causes of death that were not directly related with the tumor. Statistic analysis did not reveal any significant relationship, probably due to the small number of patients, between the prognosis of the disease and the presence of factors such as cutaneous involvement, duration of symptoms, thelorrhagia, patient age, lymph node [correction of ganglionar] involvement, or deep plane involvement, although a significant relationship (p less than 0.05) was found with TNM stage.

[Benefits of splenectomy in the treatment of chronic leukemia]. / Beneficio de la esplenectomía en el tratamiento de las leucemias crónicas.

Both chronic myeloid leukemias (CML) and lymphoid chronic leukemias (LCL) affect the spleen provoking the appearance of symptoms due to the size of the spleen or the sequestration of blood cells. Splenectomy has been utilized to prevent these conditions. We have a series of 12 patients suffering (CML) and 7 suffering LCL with a mean age of 34.4 and 60.14 respectively. All our patients underwent surgery since their splenomegaly did not respond to chemotherapy on radiotherapy with a general worsening of the patients condition. The postsurgery morbidity was greater in patients suffering CML than in those suffering LCL. The most important complications were pulmonary, followed by hemorrhages in the LCL group, and by the presence of fever of unknown origin in the splenectomized LCL patients. There were no fatalities in our series. Clinical and hematological improvement was evident in LCL patients, with increasing hematocrit and platelet number (100% of the cases). The CML results, however, are not so satisfactory, with a complete remission rate of 16.6%. Mortality was very high (83.3%) after a two year follow up, versus 14.3% in LCL, which, could be due to the natural course of the disease. In summary, we believe that splenectomy is a therapeutical approach to consider in all those cases with splenic symptoms improving their quality of life.

[Primary retroperitoneal tumors. Review of 34 cases]. / Tumores retroperitoneales primarios. Revisión de 34 casos.

Thirty four cases of primary retroperitoneal tumors treated in our hospital during a period of thirteen years are presented. The predominant clinical picture consisted of abdominal pain (57%) and paraneoplasic syndrome (42.8%) with palpable abdominal mass in 79.4% of patients. We highlight the diagnostic value of TAC and ultrasound in these lesions. Surgical treatment was performed in 33 patients, 19 patients underwent radical resection, 3 partial resection and a biopsy was performed in 12 patients. The relapse index after radical surgery was 68.4%. Chemotherapy and/or radiotherapy was given to 70.5% of the patients. The five year survival for solid tumors was 10%.

[Primary tumors of the small intestine]. / Tumores primarios del intestino delgado.

We made a retrospective analysis of 43 cases of primary tumor of the small intestine, 28 benign and 15 malignant, diagnosed and treated in our hospital over a period of 18 years. A preoperative diagnosis was reached in 13 cases (30%), while in 37.2% the tumor was a casual finding during operation by other methods. The remaining 32.5% debuted as acute abdomen and were an emergency surgical indication. Simple tumoral resection was practiced in 19 cases (44.1%) of benign tumor, intestinal resection with end-to-end anastomosis in 22 cases (51%) and only biopsy in two cases (4.6%). Coadjuvant chemotherapy was given to five patients (11.5%) and radiotherapy to one (2.3%). The one-year survival for malignant tumors was 73%, and only 18% (2 cases) survived more than 5 years after the operation).