








key: cord-317323-wp3vh4c1
authors: Kandhari, Rajat; Kohli, Malavika; Trasi, Shrilata; Vedamurthy, Maya; Chhabra, Chiranjiv; Shetty, Kamlakar; Dhawan, Sachin; Rajan, Renita
title: The changing paradigm of an aesthetic practice during the COVID‐19 pandemic: An expert consensus
date: 2020-10-28
journal: Dermatol Ther
DOI: 10.1111/dth.14382
sha: 
doc_id: 317323
cord_uid: wp3vh4c1

Until vaccination for the SARS‐CoV‐2 becomes a reality, it appears that the infection is here to stay. With many countries lifting lockdown restrictions, aesthetic clinics have started reopening with strict standard operating procedures in place. It is pertinent that the physician today understands the infection, disinfection measures, and personal protective equipment to reduce chances of viral transmission and provide safe clinical settings for oneself, the staff and the patients. An online meeting of eight experts in the field of aesthetic dermatology was convened, which particularly focussed on PPE in detail, risk categorization of aesthetic procedures, preprocedure recommendations, and generalized and specialized SOP's for aesthetic procedures. These recommendations were aimed to bridge the gap between published guidelines and clinical practice and are by no means fully conclusive, but signify learnings over the past few months in an active clinical aesthetic practice.

The SARS-Cov-2 pandemic has changed the homeostasis of the medical world, affecting millions worldwide. Amidst the global crisis, other than the health implications, there are major consequences on the world economy. 1 In light of this massive economic slowdown, many nations have ended their lockdowns, albeit on shaky ground. With reopening of services in many countries, dermatology and aesthetic clinics, which were staring at a bleak future, have started opening up with strict standard operating procedures (SOP's) in place. In any pandemic, the need to feel good is inherent to a healthy mental-well-being, and wishing away the need for an aesthetic practice as "nonessential" may appear weak to some. While certain guidelines and expert consensus have recently been published [2] [3] [4] providing an overview of "safe" working protocols, it appears that we are evolving every day in our practices with respect to "what works" and "what does not." Our article aims to bridge the gap between guidelines and in-clinic experiences to provide a set of best practices to follow for aesthetic procedures after reopening our practices. 

An invitation to participate in the consensus group meeting along with a formulated questionnaire was sent by email by one of the moderators (RK) to seven experts in the field of dermatology and aesthetics, having experience in the working and administration of single or multiple clinics, from different parts of India, in order to avoid a regional bias. The questionnaire focused on scope of the guidelines, the preparation before resuming practice, triaging/categorization patients, PPE and general SOP's and specialized SOP's for aesthetic procedures. (Table S1 ) While analyzing the questionnaire, the response to general SOP's (cleaning, sanitization etc.) and triaging achieved over a 75% concordance in response the final meeting focussed on PPE and specialized SOP's for aesthetic procedures.

An online meeting of the group members was held on 31 May 2020, using Zoom online app. The virtual meeting was led by the moderators, via a prepared slide deck. Further, the meeting was recorded for final analysis and simultaneous notes were taken. To encourage equal participation the moderators used an open questioning style, however, few of the questions were closed ended (yes/no) to arrive at a consensus.

Analysis of the detailed discussion was divided into the following sections to provide recommendations for optimal and safe "in clinic" functioning for the physician. 

Seven out of the eight experts had reopened their clinics after overcoming initial apprehensions. All the participants agreed that they were functioning at limited capacity in terms of number of staff visiting the clinic, number of days and/or hours at work. Those with more than one center started reopening with a single/flagship center and slowly imposed similar guidelines after 2 weeks of work in other centers. All participants agreed that a "dry run" prior to reopening is crucial for staff training and creating awareness and educating oneself and the staff, as the margin for error learning on the job would be minimal. Moreover, constant updating of oneself and the staff resulted in smoother functioning and execution of new SOP's. The experts agreed upon the fact that the patients have been understanding and appreciative of clinic efforts and responsive in terms of cooperating with protocols. All experts agreed to doing and encouraging tele consultation.

While certain modes of viral transmission have been suggested, 5 in a statement issued by the WHO precautions have been laid out for droplet transmission, contact, and airborne precautions for aerosol generating procedures. 6 An aerosol is defined as a suspension of fine solid particles or liquid droplets in air or another gas, which maybe produced by either natural or anthropogenic phenomena. 7 The coronavirus has the potential to become "aerosolized" by certain procedures leading to a possible airborne transmission. The exact definition of "aerosol generating procedures" (AGP's) in the theme of aesthetic procedures seems unclear with no clear evidence regarding the same.

Although, it is clear that an aerosol generating procedure increases the risk of viral transmission in healthcare workers (HCW) and should only be undertaken when necessary, this is primarily suggested for respiratory and surgical procedures generating aerosols. The different types of aerosol comprise:

1. Respiratory aerosol: Respiratory or upper airway secretions, containing a higher viral content and a greater risk of viral transmission.

2. Surgical or nonrespiratory aerosol: Aerosolisation of blood and tissue fluids leading to relatively lower risk of viral transmission.

The WHO defines "droplets" as >5 μm in diameter and "airborne particles" as <5 μm in diameter. 8 Droplet transmission is the result of larger particles, which have the tendency to settle on the ground and on nearby surfaces. This type of transmission occurs due to proximity of the HCW with the patient. In contrast, the occurrence of airborne transmission is due to smaller particles, which maybe suspended in the air for long periods and can infect people distant from the source (eg, AGP's)PPE consists of protective apparel and/or equipment designed for providing protection against infectious agents to HCW's and their patients. The appropriate use of PPE is crucial, and the decision regarding the PPE to be used is based on the setting between the HCW and the patient, the procedure being carried out, the secretions produced. The panel recommendations for PPE are discussed below.

Globally, recommendations for protection of HCW's against COVID-19 for nonaerosol-generating procedures (nonAGP's) are conflicting. [9] [10] [11] [12] With the barrage of masks available, choosing the right one becomes crucial. The expert panels recommendation and the differing types of masks have been elaborated ( Table 1 ). The panel felt that while the role of the staff and the type of procedure would be key factors defining the type of mask used, the space in the clinic would also be a defining factor, as certain clinics would be smaller wherein maintaining an "ideal social distance" (6 ft apart/2 arm's length) maybe a challenge. 13 In such scenarios, an N95 respirator maybe used by the support staff as well ( Figure 1 ).

Use of N95 facial facepiece respirator (FFR) 1. All the experts unanimously agreed upon the use of N95 respirators for themselves, particularly when involved in non-AGP's close contact procedures or AGP's. 3. Beard hair:It is recommended for one to be clean shaven, however, beard styles such as soul patch, side whiskers, pencil, toothbrush, lampshade, zorro, zappa, walrus, painter's brush, chevron, and handlebar maybe considered. 17 The recommendations are to make sure that the N95 FFRis well fitted on face.

4. Use of N95 FFR in Sikhs: The religious beliefs in the Sikh population, leads to an inability to trim or cut the beard hair leading to difficulty in achieving a tight fit of the respirator. In such cases, either a Powered Air-Purifying Respirators (PAPR) maybe used, which provides facial coverage despite the facial hair or any facial irregularity. 18 PAPRs are more expensive than N95 FFR's. Else, the individual in question can make use of a "cotton cloth" or "thatha" around the beard and tie a knot on the top of the turban. This allows for coverage and a smooth surface over the facial hair for the respirator to sit on and achieve a tight fit.

• Use of paper bags: While only considered single use masks, all panel members agreed to reuse of their masks. A 5-mask set maybe used by each individual, along with four brown paper, breathable bags, which are marked 1 to 5. After use of first mask, it should be placed in the paper bag and allowed to dry for 4 days. It should be reused on day 6. The masks maybe used sequentially in such a manner and once all masks have been used five times, they should be discarded. Use of a disposable, surgical three ply mask/face shield on top of the respirator will further prevent it's contamination. 19 This was being followed by three of the panelists and has been suggested as an additional safe practice. The physiological burden (heart rate, oxygen saturation, tidal volume, respiratory rate, etc.) of using a surgical mask over an N95 respirator has been a matter of concern and while using it for short durations appears to have no significant physiological burden, studies with usage over longer periods are suggested in order to consider this as a routine practice or recommendation in daily practice. 20 • UVC (254 nm) at the appropriate dosing 21 or vaporous hydrogen peroxide 22 if available can be used for decontamination of the N95 mask. • Negative seal check: on inspiration face piece should collapse.

• Fogging: While minimal fogging of glasses is inevitable, due to water vapor released via the edge of the mask, it may suggest that the FFR may not be air tight. It is recommended to squeeze the metal frame on the upper edge of the mask in such cases and re-assess the fit of the mask. 

Following strict hand hygiene along with use of nonpowdered, latex gloves are adequate for examination of patients and/or consultation room. The recommendations for hand hygiene include use of an alcohol-based hand sanitizer (60% ethanol or 70% isopropanol) or hand wash for at least 20s with soap and water. 25 • Nitrile gloves are preferable over, latex gloves in the procedure rooms, as they are resistant to damage by chemicals or disinfectants, and are hypoallergenic.

• Housekeeping staff may use nitrile or rubber gloves which cover above the wrists.

• While donning of gloves one must make sure the gloves extend to cover above the wrist of the isolation gown.

A. Face shield and goggles:

• The panel agreed upon the use of a face shield as a routine measure in current circumstances, during all consultations and procedures as it not only provides protection to the mucosal surfaces but also prevents inadvertent touch to the face, eyes, nose or mouth with a contaminated hand.

• Face shield and/or goggles are a must in AGP's.

• Use of face shield/goggles may result in fogging at times due to expired air escaping from the mask, in such circumstances one may reassess the fit of the mask or seek the use of well fitted antifogging goggles ( Figure 5 ). 26 B. Coverall or gowns

• Disposable, below knee, SpunbondMeltblownSpunbond (SMS) material, breathable gowns are adequate for consulting and examination. An autoclavable, below knee, surgical cloth gown for routine consultations was suggested by three of the experts, however, the panel did not arrive at a consensus for this. practice. If a coverall is used, one coverall should be used per patient and these maybe reserved for AGP's. One may use a 60-70 gsm, coverall, as extrapolated from data during the Ebola outbreak.

• A plastic apron maybe used over the gown, in procedures involving body fluid splatter or splash.

• The panel agreed upon the use of head caps during "close contact" procedures and these should be worn by the patient and the doctor/therapist. If wearing a coverall, that itself would provide head coverage, else a surgical head cap should be used.

• Experts felt that that if regular cleaning and sanitation of the premises is being carried out, the use of shoe covers is not mandatory.

• If shoe covers are used they should be made ideally be impermeable, for example, plastic

• One of the experts on the panel suggested the use of washable rubber slippers for patients and staff in place of shoe covers.

• The common principles regarding use of PPE, including hand hygiene prior donning and during doffing of PPE, protocols of donning/doffing and correct disposal should be repeatedly discussed with the clinic staff.

• A room with a mirror is ideal for donning and doffing of PPE.Developing a "buddy system" may help, that is, a team member who may observe the donning and doffing process. 28 

and/or use of zinc ointment before donning and after doffing the PPE. 31 4. Make sure the FFR is "well fit" and not "overtight". The lips touching the front of the mask is suggestive of a tight fit and can become uncomfortable for the user. A mix of "natural" and "mechanical ventilation" is ideal for a clinical premises, which allows the air to flow from areas where there is a suspected source, towards the areas free of susceptible individuals. 

The use of laser and EBD's, requiring contact of the skin with the laser tip, particularly need to be handled with caution. The cases for laser procedures maybe divided into low, medium or high risk (Table 4 ). Further, certain points regarding the procedures maybe taken into consideration.

Certain laser systems, (ablative CO2, erbium YAG) lead to "plume" 

The panel categorized the risk involved with injectable procedures in the following manner: (Table 5) a. Low risk: The mask of the patient can remain on.

b. Medium risk: The mask of the patient is off.

c. High risk: The mask of the patient is off and the procedure involves the oral or nasal mucosa.

Certain procedures for example, periorbital enhancement even though carried out on the upper face, are often done with cannulas and ideally require the mask be off, so that the injector can carry out the procedure comfortably and look out for vascular events.

Further, a tight fitting mask during and postprocedure may lead to external compression and/or make evaluation of a unexpected vascular event challenging. The risk categorization for chemical peels is below:

• Low risk: Body peels, spot peels on face with mask, peels for nails and periorbital area. • Low risk: PRP therapy for scalp and body areas, mesotherapy for scalp and body (stretch marks)

• Moderate risk: PRP and mesotherapy for face

Numerous other procedures carried out in an aesthetic clinic have been categorized below (Table 6 ).

The above recommendations do not necessarily signify a "cook book" approach but are learnings over the past few months in an active clinical aesthetic practice during the ongoing pandemic. While one must adapt fast to the "new norms", the real challenge would lie in the strength of the practitioner to balance one's own and our staffs mental health, to attain equilibrium of financial setbacks with concerns over self, staff, and patient safety, and to conduct practices in a just manner. The well-known adage to "lead as an example" is the best reinforcer of safe practices and general wellbeing.

The authors declare no conflict of interest. 

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The changing paradigm of an aesthetic practice during the COVID-19 pandemic: An expert consensus



