International roundtable: COVID-19 and plastic surgery viewpoints from around the world

Although the United States now leads the world in both confirmed cases of COVID-19 and deaths as a result of the coronavirus, the pandemic has affected the entire world since the virus infected its first patient in late 2019.

The coronavirus taxed international health systems, the global economy and patients' decisions whether to pursue plastic surgery everywhere. Some of the Society's International Members provided their insights to PSN in mid-May on how COVID-19 affected the specialty in their respective countries and how reopening might unfold. Taking part in this discussion are Horacio F. Mayer, MD (Argentina); Nigel Mercer, MD (United Kingdom); Jianxing Song, MD, PhD (China); Tormod Westvik, MD (Norway); and Kotaro Yoshimura, MD (Japan).

PSN: How has the COVID-19 pandemic affected plastic surgery in your country in terms of elective procedures and plastic surgeons volunteering, or being called to help in overtaxed hospitals?

Dr. Mayer (Argentina): All elective procedures were cancelled following a resolution handed down by the National Ministry of Health. The situation is still controlled over here with few cases requiring ICU care. There has been no need for plastic surgeons to volunteer thus far.

Dr. Mercer (UK): Emergency and cancer surgery continues, but everything else has stopped. National Health Service (NHS) plastic surgeons have bene redeployed to other tasks, including running COVID-19 wards.

Dr. Song (China): The epidemic has a profound impact on the plastic surgery industry in China. Many plastic surgeons cannot afford to pay rent, utilities, resales, closings, etc. Due to the necessity of preventing the spread of the virus and isolation, medical and plastic surgery institutions have to be closed for a period of time. As a result, the owner has no income. Our national economy has also been affected by the epidemic, and as our citizens' income decreases, the decision to have cosmetic surgery becomes more difficult. Cosmetic procedures are similar to luxury goods – consumption is based on income. There's still a significant fear of the virus here, so most patients dare not go to medical and cosmetic clinics for surgery or treatment. However, a few private hospital or clinics are experiencing a rebound in consumption. Some clients are typically too busy with work in normal circumstances and are taking advantage of the "down time" to complete cosmetic procedures.

China is the world's largest exporter, and our international trade must be impacted by the epidemic, which will in turn affect employment and the income of the Chinese people. Most of the recent international declines in the stock market reflect investors' concerns about international economic development, and this directly affects China's plastic surgery industry. Only a few plastic surgeons directly participated in the fight against the epidemic in Wuhan – more of them helped raise funds to support controlling the epidemic.

Dr. Westvik (Norway): As of March 12, all elective, non-essential cases were put on hold based on government regulations. Many plastic surgeons have made themselves available for other tasks within the health system, but very few (if any) have been needed to manage the pandemic. Our system has not been overwhelmed, and ICUs have been adequately staffed by intensivists and nurses.

Dr. Yoshimura (Japan): Elective surgeries have been cancelled or postponed in some hospitals in big cities because of the need to provide more resources to patients hospitalized with COVID-19. In other areas, surgeries are being done as they were before. We're going to start COVID testing as a routine before all surgeries under general anesthesia. In general, the number of patients we've seen has reduced from mid-April, when we started a non-strict lockdown in big cities.

PSN: How are plastic surgeons in private practice dealing with the downturn in people seeking elective surgery?

Dr. Mayer: Plastic surgeons are offering virtual and in-person consultations with increased safety measures. Although all procedures are currently forbidden, they are trying to keep the connection with prospective patients.

Dr. Mercer: As private surgery has stopped, all private beds have been bought by the NHS for six months.

Dr. Song: There are efforts to maintain contact with patients and potential clients through marketing channels, and I think there's an eye on how to secure new clients once the epidemic has ended. This is being handled through follow-up and other communications with existing patients, fortifying an online presence with educational videos, providing discounts for certain procedures and other ways to encourage a rebound in business.

Dr. Westvik: First of all, private practice in Norway means aesthetic only – except for a few groups having agreements with the government to provide certain procedures on behalf of the public hospitals due to capacity challenges. All private clinics closed down on March 12, and only necessary postoperative visits were conducted for the first weeks. The Norwegian government made guarantees to all employees temporarily being furloughed that salary would be covered 100 percent (to a maximum) for the first 20 days, with 63 percent coverage thereafter for prolonged "unemployment." All planned consultations and operations were notified, and people were very understanding and understood that they would have to wait – very few cancelled.

Dr. Yoshimura: Private practice plastic surgeons are still doing surgery – it's just that some patients have become more hesitant about having procedures done.

PSN: What surprised you most about plastic surgery's response to COVID-19 in your country?

Dr. Mayer: Both plastic surgeons and patients understood the severity of the pandemic and there has been strict adherence to the quarantine. Plastic surgery services have been restricted to urgent and emergent care.

Dr. Mercer: Not a great deal has. There are heroes, and there are those who are more worried.

Dr. Song: The big surprise was the negative impact on the economic and social psychology of the COVID-19 pandemic.

Dr. Westvik: The uniform acceptance that we were all in this together. Everyone closed down simultaneously based on the guidelines from the government.

Dr. Yoshimura: We were optimistic; we didn't expect such a downturn in the number of cosmetic surgery procedures. The number of patients seeking treatment has definitely decreased since April.

PSN: What kind of timetable are you looking at for resuming elective and aesthetic surgery (or are you already doing so)?

Dr. Mayer: Resumption of elective surgeries is expected between September and December.

Dr. Mercer: As of May 11, elective surgery is starting again, but there's a wait-and-see approach with aesthetic procedures.

Dr. Song: On Jan. 23, the city of Wuhan closed. On Jan. 24, which is the Chinese New Year, all hospitals were closed according to government regulations. About 10 percent of hospitals and clinics opened on March 1, and by March 20, 90 percent of our industries gained government approval to reopen. Nearly 100 percent of our clinics reopened for business in April, and at present, the plastic surgery industry in China has returned to about 70-80 percent of its pre-pandemic total.

Dr. Westvik: As of April 20, we were able to reopen and clinics have been booked to the limit. Strict PPE and distancing have been instituted, and all consultations are done with gloves, masks, distance and no hand-shaking. There's also an increased focus on routines in the O.R., with N95 masks being used for certain procedures such as rhinoplasty, and during intubation/extubation.

Dr. Yoshimura: Except for some hospitals in our larger cities, elective aesthetic surgery is still being done. The reduction in the number of procedures is a reflection of patient concerns rather than any actual regulations.