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Clinical Updates

Update from the ACS Advisory Council for Plastic and Maxillofacial Surgery: Craniomaxillofacial Surgery during the COVID-19 Pandemic

By Jesse A. Taylor, MD, FACS, and Peter J. Taub MD, MS, FACS, Chair of the ACS Advisory Council for Plastic and Maxillofacial Surgery

The rapid global spread of COVID-19 has had numerous effects on the delivery of health care. Despite the significant risk of health care workers contracting the disease, there is an obligation to care for patients with other health concerns. While truly elective procedures can be delayed, others require urgent or semi-urgent care to avoid negative sequalae. 

Craniomaxillofacial surgery has unique concerns that span across the spectrum of care. Surgery around the oropharynx has a high viral concentration in the mucosa and an increased risk of droplet and aerosol production from manipulation of this tissue. Surgeons and anesthesiologists are placed at increased risk when operating in this area. While an orbital floor fracture with globe entrapment is certainly an emergency, a congenital malocclusion is not. However, there are many cases within our subspecialty that are less obvious. Should cleft palate repair in an 18-month-old infant be delayed, cognizant of the risk of developing hypernasal speech that may be difficult to overcome? 

Surgeons at the Children’s Hospital of Philadelphia developed a system of decision-making guidelines that may serve as a guide for others. Tier 1 cases are “urgent or emergent,” where harm may result if the procedure is not performed within 48 hours. Tier 2 cases are “high priority,” where harm may result if the procedure is not performed within three weeks. Tier 3 cases are “moderate priority,” where harm may result if the procedure is not performed within three to six weeks. And Tier 4 cases are “low priority,” where the patient can safely wait longer than six weeks to have surgery. Within this framework, some diagnoses are split between tiers on account of patients approaching the age limits of existing safety and efficacy guidelines. For example, patients with craniosynostosis and documented signs of intracranial pressure are considered “high priority,” whereas those without are considered “moderate” or “low priority.” It is hoped that a model of prioritization will create valuable discourse and aid surgeons debating the merits of proceeding during a pandemic.