key: cord-298967-vjyh1xvh authors: Bertossi, Dario; Mohsahebi, Ash; Philippe Dormstrom,; Heidenrich, Izolda; Pirayesh, Ali; D’Souza, Alwyn; Saleh, Hesham; Yavuzer, Rezha; Fakih, Nabil; Vent, Julia; Rahman, Eqram; Kapoor, Krishan Mohan title: Safety guidelines for non‐surgical facial procedures during covid‐19 outbreak date: 2020-06-07 journal: J Cosmet Dermatol DOI: 10.1111/jocd.13530 sha: doc_id: 298967 cord_uid: vjyh1xvh BACKGROUND: The novel coronavirus (COVID‐19) pandemic is expected to last for an extended time, making strict safety precautions for office procedures unavoidable. The lockdown is going to be lifted in many areas, and strict guidelines detailing the infection control measures for aesthetic clinics are going to be of particular importance. METHODS: A virtual meeting was conducted with the members (n=12) of the European Academy of Facial Plastic Surgery Focus Group to outline the safety protocol for the non‐surgical facial aesthetic procedures for aesthetic practices in order to protect the clinic staff and the patients from SARS‐CoV‐2 infection. The data analysis was undertaken by thematic and iterative approach. RESULTS: Consensus guidelines for non‐surgical facial aesthetic procedures based on current knowledge are provided for three levels: precautions before visiting the clinic, precautions during the clinic visit, and precautions after the clinic visit. CONCLUSIONS: Sound infection control measures are mandatory for non‐surgical aesthetic practices all around the world. These may vary from country to country, but this logical approach can be customized according to the respective country laws and guidelines. The COVID19 outbreak, caused by the SARS-Cov2 virus, has had an unprecedented impact on global health systems [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] . The economic burden induced by lockdowns will need to be carefully mitigated by "next phase" responses, which will vary with country and viral burden. While many medical Accepted Article practices are being run with online consultations 10 , some countries have recently decided to allow the opening of practices requiring one-on-one contact like dental, physiotherapy, for emergencies provided they strictly follow the guidelines detailing the infection control measures [12] [13] . Facial aesthetic non-surgical procedures, although having a well-documented impact on quality of life, are not considered essential medical services and conscious efforts should made to minimize infection in this sector. The nature of our work carries a very high inherent risk of contagion for both patient and practitioner. Due to the primary involvement of the face and neck, specifically the perioral and nasal regions, and our field is at a particular occupational hazard due to the risk of aerosol generating procedures [13] [14] . Strict global measures are constantly evolving, and discrete guidelines need to be instituted and kept current. In our largely elective field, both staff and resources should ideally be allocated through careful protocols in order to prevent COVID-19 infection. The FG members have discussed recommendations for resuming elective nonsurgical facial aesthetic work using a topic guide. The virtual meeting was led by a facilitator (DB) and contemporaneous notes were recorded by another author (ER). The facilitator used a topic guide to ask the group members to explore the problem in question and factors for mitigation. The topic guide was developed by the lead author after thorough literature review and cross checking with available guidelines in different specialties. To minimize the number of the prompts and equal participation, the facilitator used an open questioning style. The transcriptions of the discussion were subsequently analyzed by a multidisciplinary research team in form of iterative and thematic approach. During this process data was verified systematically, discussion was made around the interpretive analysis and exploring the potential research bias. Various steps were recommended in order to deliver a safe elective service, with inputs from the public and private health systems of many countries. In addition to the respective country recommendations, these guidelines hope to guide the "next phase" after the lockdown ends. The recommendation was divided into three phases for both the patients and HCPs. and avoidance of hospital visits or contact with COVID19 positive cases. Two days before the appointment, patients should receive an e-mail with a protocol on the office routes, they will have to follow (Scheme 1-2) and some forms to This article is protected by copyright. All rights reserved be filled and returned 12 hours before the appointment (Scheme 3). Vital information relates to Covid-19 contact, quarantine or symptoms during the preceding 15 days. One primary information that is essential to obtain is a declaration that the patient has not been in quarantine and has not had coronavirus symptoms in the last 15 days. If the answer to any of this is definite, the doctor must order a Covid-19 test for the patient. Another option is to postpone the procedure for at least two weeks. People coming before or after a given time will be asked to wait outside the office or in their cars . A series of pre-determined in-office routes must be decided, and patients should get access only by following these routes. These pre-determined in office routes must be decided with patients having access to only these . Temperature testing (Tympanic or infrared device) (Figure 1c) should be completed before access to waiting areas where a minimum of 2m Accepted Article between patients and 10 square meters per person, should be maintained ( Figure 2a) . As soon they get to the waiting area, they will be then requested to follow a healthcare professional (HCP) who guides them to a room where they wash their hands and face (Figure 2b ), they may be supplied with a labeled tshirt (cost is 10 euros or 12 US dollars which we give them as a gift) which they may keep after the treatment ( Figure 6 ). After disinfecting hands and applying a headband, they progress to photography (Figure 2c ) (povidone-iodine 10%). Plastic/Acrylic windows panels or glass partitions should be used to decrease staff and HCP exposure 22 . In order to avoid contamination in any area of the office all unnecessary material should be removed (leaflets, magazines, covers, water fountains, dresses etc.). In order to avoid contamination by walking frequently between different areas, it is recommended that hand sanitizers and hand-washing facilities are readily available in all patient and staff areas and clinic staff which is encouraged to use it with high frequency making the rule of 1 glove which is the "new skin" and a second glove which is patient related and is going to be changes at every procedure. The same rule applies to water bottles and disposable glasses. conditions. This is assessed in a week again, and further follow up is arranged as appropriate. HCP AND STAFF: Following every procedure, t he HCP removes her/his shield, surgical masks and double gloves. Whenever possible, the window is opened for 10 minutes while a professional cleans and disinfects all devices and room with 1% sodium hypochlorite or a phenolic detergent three to four times a day. They should be well trained in hand hygiene protocols [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] . This is ideally done while another patient is having photographs taken . Air disinfection can be further achieved with UV or O3 devices 41 . A minimum of 10 minutes for HCP to relax is recommended. All routine post-operative care ought to be completed via video consultation which is done between noon and 1 pm or 7 pm to 8 pm at scheduled days. During the current Covid-19 pandemic, at the very first weeks all non-essential procedures were provisionally suspended worldwide, with reallocation of resources in many public and private hospitals . In-office consultations and procedures were thus not possible. Closure of surgical theatres constituted a further preventive measure for the wide viral spread and peak particularly in China, Europe and the USA. Currently, preliminary epidemiological experience even in high risk areas shows that spread is mitigated by wearing appropriate mask as a personal preventive device as well as correct hand sanitizing . Furthermore, every Medical specialty has started to develop protocols to protect staff and patients. In response to this pandemic, our focus group has developed a process to stratify procedures and clinical levels with protocols that aim to minimize the risk of contagion and the diffusion of COVID-19 infection. The present study has several limitations. Although the author has utilized widely accepted method of Expert focus group discussion, it is often mentioned that they act as 'Expert and Judge' 42 . Also, because of the qualitative nature of the interpretation, to address the reflexivity and Hawthorne effect, the analysis was based strictly on the transcription, critical appraisal of the literature and multidisciplinary research analysis 43 to minimise bias. Although, finding an optimal guideline in limited timeframe remains elusive, Nonetheless, the present first ever clinical safety guideline for the non-surgical facial aesthetic procedures can help designing conceptual framework for the COVID-19 safety guidelines in aesthetic practices across the globe. 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