Objectifying Priority Scoring and Shared Decision-Making in Head and Neck Cancer Reconstructive Surgery during the COVID-19 Pandemic: From Theory to Practice

The COVID-19 pandemic continues to pose unique clinical challenges to the health care industry. The current major issues in the plastic surgery service remain unresolved due to staff redeployment and subsequent system resource strain; the decrease in operating room capacity, fewer residents to assist in operations, the number of cancer patients awaiting surgery, and their disease progression have had a cumulative effect.

The American Society of Plastic Surgeons recommends that all elective and nonessential plastic surgery operations (i.e., primarily cosmetic) be deferred and only life-threatening and limb-threatening conditions be prioritized for surgery. Existing guidance on scheduling surgical procedures considers several factors, such as the nature of the case (i.e., emergent, urgent, elective nonurgent), patient comorbidities, procedural risk, likelihood of complications, prolonged operating room time, anesthesia risks, number of beds, and staffing and blood transfusion resources.¹

Physician judgment and an individualized approach to the patient’s medical and social background are required to determine the “urgency” of medical or surgical therapeutic intervention.² Although the distinction between elective and urgent/emergent cases is clear, decisions about “medically necessary time-sensitive” (MeNTS) procedures are harder to make. Thus, the objective prioritization, transparency, and accurate management of patients becomes of utmost clinical importance.

Prachand et al.³ devised an innovative scoring triage tool to help clinicians manage resource and provider risk efficiently. In light of resource scarcity, the MeNTS score is a useful method for assessing the need and timing of a procedure during the ongoing phase of the pandemic. It is applicable in all surgical specialties, including plastic and reconstructive surgery.

We applied the MeNTS score in the following case: An 80-year-old male patient, COVID-negative, fit and well otherwise, presented with a massive, exophytic, localized, biopsy-proven squamous cell carcinoma on the dorsum of the nose, partially obstructing his visual fields (Fig. 1). This case required a MeNTS procedure. Given the fact that a total or subtotal rhinectomy was warranted, after multidisciplinary team discussion and patient consultation and informed consent, a decision was made to proceed with an expedited (within 2 weeks) and aggressive surgical resection and to opt out of a microsurgical nasal reconstruction, which is typically lengthy, multistaged, and resource-demanding, requires postoperative intensive care and multiple outpatient visits, and carries increased risk of free flap failure in COVID-19 patients.⁴ The rationale was to minimize surgical and anesthetic risk, duration of operation, number of personnel, length of hospital stay, and follow-up visits. On a 1- to 5-point scale, the patient received a very low MeNTS score of 31 (procedure factors = 21, disease factors = 5, patient factors = 5), signifying decreased risk of poor perioperative outcome, COVID-19 transmission to physicians, and/or hospital resource use. Thus, the chosen procedure was reasonably, surgically, and ethically justified.

Fig. 1.

Preoperative massive exophytic tumor of the nose.

Under general anesthesia, we (S.S.) raised simultaneous double forehead flaps⁵ and conchal cartilage grafts “sandwiched” by the two flaps, followed by pedicle division under local anesthesia (Fig. 2), with excellent aesthetic and functional results. [See Figure, Supplemental Digital Content 1, which shows an intraoperative view after the complete surgical excision of the tumor. A subtotal rhinectomy defect is illustrated. Only small remnants of the columella and lateral part of the alar rims and nasal septum were preserved after resection of the tumor, http://links.lww.com/PRS/F172. See Figure, Supplemental Digital Content 2, which shows an intraoperative image of the completed reconstruction, http://links.lww.com/PRS/F173. See Figure, Supplemental Digital Content 3, which shows a postoperative photograph on day 7 after the second stage (division of pedicles), http://links.lww.com/PRS/F174.]

Fig. 2.

Intraoperative view of the first paramedian forehead flap being harvested and inset into the defect, with the skin surface providing nasal lining. Conchal cartilage grafts provided structural support to the new nose.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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