This work was sponsored by Merz Aesthetics. All authors were consultants and/or investigators for Merz Aesthetics. This work includes consensus recommendations of the round table participants. In determining when to re-open aesthetics practices and how to best mitigate risk, aesthetics professionals should consult guidance from resources such as the World Health Organization, the Centers for Disease Control, and other similar national and local authorities, and use their own professional judgment.

In the midst of the ongoing COVID-19 pandemic, many aesthetic practices have closed or made significant changes to their usual operating procedures. As a result, many aesthetic practitioners are asking themselves when and how they may reopen their practices and move towards establishing a sense of “new normal” in these far from normal times. To address these questions from a global perspective, an international group of thought leaders in the aesthetic field convened for a virtual roundtable discussion. This white paper outlines their insights, recommendations, and best practices for reopening aesthetic practice while mitigating risks to practitioners, their patients, staff, and the general public.

Maintaining a Bespoke Culture

A shift has occurred from the binary physician-patient relationship. Aesthetic professionals may no longer focus solely on the patient; they must also factor public safety concerns into the equation.

The first step towards reopening an aesthetic practice is to understand the prevalence and incidence of COVID-19 in the community, keeping up-to-date with the latest information from the World Health Organization (WHO) and national/local health authorities. It is also important not to forget that aesthetic practice is by nature, a bespoke specialty where the individual needs of the patient are paramount.

How do we maintain a bespoke culture commensurate with our specialty?

We must continue to optimize both the patient experience and outcomes despite the host of challenges facing our practices that come in the form of many dichotomies: a streamlined experience but not rushed; attentive care by staff but maintaining social distance as much as possible; a comfortable patient environment but isolated and sequestered; abundant safety measures but no touch-point amenities; maximum connectivity with minimum contact; and the need to establish rapport and trust while concealed behind a mask.

As far as possible, a fluid transition from our former routines, with focus on patient education and understanding, should be instituted. Modifications to the routine should not be overly complex and should be reasonable and justifiable to the patient while respectful of cultural sensitivities. Broad implementation of complex new rules and boundaries should be avoided as this may cause undue stress, anxiety and confusion for patients. Some significant changes to the practice routine may be required, and recommendations for how to do so are perhaps best considered in terms of the patient journey.

The Patient Journey BEFORE THE CLINIC APPOINTMENT

Step 1. Patient Screening

Prior to scheduling an appointment, health status screening by the practice manager or nursing staff should be conducted for each patient according to a simplified algorithm (Figure 1). This can be offered virtually, via telemedicine, video calling, phone call or email. Video calling should be considered as the preferred medium, to give patients the opportunity to meet the staff who are involved in their aesthetic journey. In this fashion, the call can be leveraged to produce more personal one-on-one relationships between patients and medical staff, which results in increased loyalty and trust.

Figure 1. Flowchart for pre-appointment patient screening.

Patients at high risk for COVID-19 should also be identified (according to comorbidities, age, gender, etc.) using an appropriate scoring system. We recommend postponing appointments for patients deemed high-risk until either clarity is gained on disease seasonality, herd immunity has been attained, or a vaccine becomes available. Where COVID-19 testing is available, a polymerase chain reaction (PCR) test is recommended. Where testing is not available, it is prudent to take the same precautions with all patients as you would if they had tested positive.

Once deemed a candidate for a Video TPC with the physician, patients can also be briefed on any changes they can expect to their usual appointment routine. For this purpose, it may be useful to develop a code of conduct for patients arriving at the clinic. An example is provided in an Appendix to this document available from your Merz Aesthetics Representative. A follow-up call one day prior to the scheduled appointment is recommended to confirm there is no change in the patient’s health status.

Step 2. The Video TPC (Telemedicine Preliminary Consult)

Physicians should ideally consider incorporating the Video TPC into their pre-clinic processing of potential patients. The advantages are mostly two-fold in providing a streamlining of the in-clinic consultation as well as increasing the practice efficiency. Limiting exposure time to patients in the clinic is self-evident in the new normal, with more time devoted to proper environment disinfection pre- and post-visit.

The video TPC permits more precise scheduling within the practice while minimizing patient wait times and is reassuring for patients regarding the availability of their treating physician. It is also convenient for both patient and physician, extending flexible hours for leisurely video conferencing. Most platforms allow for easy recording and managing of data during the preliminary consult, including preliminary photographs, and provide a reviewable record of the consultation encounter. Most importantly, the video TPC enables the physician to triage patients with unrealistic expectations or health and mental issues, all the while reducing subsequent no-shows.

Disadvantages of video TPCs revolve around technical equipment training of clinic staff (minor), proper internet connection, and most importantly privacy protection. It is advisable to inform the patient at the outset of the video TPC regarding the efforts made to preserve confidentiality, privacy, and security of information. Physicians should consult with their medical corporations and malpractice carriers regarding prevailing regional healthcare laws and legal exposure to on-line video conferencing. Finally, although this represents a preliminary consultation, the physician must schedule more time than usual to spend on facial assessment, as the setting is not ideal but will accelerate the in-clinic live consultation.

Preparing The Clinic Environment

Some changes to the practice space will undoubtedly be necessary in order to ensure the safest possible environment for patients and staff; the aim being to keep the clinic experience pleasant for patients without putting them at risk. The following modifications are recommended:

  • Clean and disinfect the practice according to WHO standards.
  • Place hand sanitizer and wipe dispensers at the main entrance to the clinic and at every interior room entrance with a door handle.
  • Make contactless temperature-monitoring equipment available at the clinic entrance.
  • Post a sign at the entrance reminding patients not to enter if they have experienced any illness or flu-like symptoms in the past two weeks.
  • Remove all non-essential items that comprise touch points (e.g., magazines, brochures, product samples/testers, self-serve drinks station, etc.)
  • Install contactless dispensers for hand sanitizer, soap, paper towels, etc. in bathrooms.
  • Install physical barriers (e.g., acrylic sneeze guards) at the reception desk.
  • Install equipment to facilitate contactless payment if not already available.
  • Use covers for any tablets/smartphones needed for electronic signatures, so these may be disinfected after each use.
  • Consider asking patients to wait in their car until called/texted or setting up a waiting area for a single patient outside of the clinic entrance. An electronic waiting list may be helpful.
  • If using a waiting room, adjust the seating to ensure minimal safe physical distancing between patients.

Changes to Staffing

Alterations to working schedules and responsibilities of staff members are recommended to accommodate the necessary precautions and safeguard the health of the clinic’s staff:

  • Rotate the practice staff, if possible, so that not all staff are present in the clinic at the same time.
  • Ensure only healthy staff with symptom-free household members are allowed to work in the clinic; if possible, test staff for COVID-19.
  • Assign responsibility to a staff member(s) or consider hiring a cleaning professional for disinfection of all contact points during office hours between each patient: exam tabletops, exam beds/chairs, door handles, exam light buttons/handles.

Appointment Scheduling

With additional precautions in place, plan for more time per patient than usual. A reasonable starting point may be to have no more than one patient per treatment room, with no additional patients waiting. Rotating examining rooms may carry the advantage of allowing for a reasonable one-half hour non-occupancy ventilation air exchange for most clinics. Staff availability and appropriate social distancing measures must also be taken into account (see Treatment Protocols and Personal Protective Equipment). Additionally, digitization of patient records is strongly recommended, if this has not already been accomplished.

During the Clinic Appointment

Processing the Patient on Arrival

  • Ask patients to remain in their car/wait in the lobby or outdoors until called/texted.
  • Leave front door open so patients will not have to touch handles.
  • Greet patients (and staff) with a nod, smile, or wave; no handshakes or hugs.
  • Monitor the patient’s temperature on entry to the clinic using a non-contact thermometer. If the patient’s temperature is above 37°C/98.6°F, the appointment should be postponed until the individual is two weeks symptom-free or has a negative COVID-19 swab test.
  • Testing patients using rapid antibody fingerstick screening, if available, may provide a further layer of protection for clinic staff. If opting for this tactic, only proceed with treatment for those patients who test IgM-/IgG- or IgM-/IgG+. Patients testing IgM+/IgG+ or IgM+/IgG- theoretically may be in the viral shedding stage of the disease and should not be treated according to the latest FDA guidance.
  • Patients should be given a surgical mask before entering the clinic if they do not bring their own. Shoe covers may also be given, if available.

Streamlining Patient Exposure

  • Patients should be exposed to as few rooms as possible within the clinic. The patient should be taken directly to the treatment room on arrival. Ideally, pre- and post-treatment activities should take place in the treatment room (e.g., consent, post-treatment photographs, payment).
  • Minimize contact points and proximity to staff and other patients.
  • Only the patient should be present for the visit—no family, friends, pets or any person not being seen by the doctor unless the patient is a minor.

Treatment Protocols and Personal Protective Equipment

  • A Level 2 surgical mask (at a minimum), face shield, gown (optional), and gloves should be worn when performing procedures on all patients.
  • The patient should remove their mask for assessment and treatment of facial areas only; otherwise it should be worn at all other times.
  • Hands should be cleaned with soap and water or an alcohol-based hand sanitizer between each patient and upon entering and exiting the exam room.
  • Consider Povidone Iodine mouthwash and nasal spray prior to treatment of the nasal or perioral region or if extended contact with the face is required
  • Ensure proper cleaning and ventilation of the treatment room after each patient: leave the window open (for 10-15 minutes) or ventilation on and thoroughly disinfect all contact points.
  • Practice social distancing: have no more than three persons present in the treatment room at any one time.

After the Clinic Appointment

  • At the completion of the visit, the names of all staff in contact with the patient should be recorded in the patient’s chart.
  • Patient follow-up should be done via telemedicine within reason. Patients should be asked during follow-up if they have developed symptoms since attending the clinic.
  • It is important to communicate with your patients through social media, your practice website, or other channels to keep them informed about the measures you are taking to ensure their safety and developments in your practice.
  • Finally, be prepared to take the necessary measures if there is a case of COVID-19 in your clinic once you have reopened. Consult your local health authority for guidance.

Conclusion

With appropriate planning and precautions in place, a safe return to practice that instills confidence in both patients and staff is possible. The guidance given here is based on insights from aesthetic healthcare providers who have successfully reopened their practices and those who were able to keep their practices open with reduced patient intake. The authors hope these recommendations will prove valuable to aesthetic physicians coping with the uncertainties brought on by COVID-19 and assist them in returning to practice. The importance of a gradual and cautious approach should not be underestimated, and patients should feel completely assured that every possible measure has been taken to ensure their experience in your practice is as safe as possible.

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ADDITIONAL RESOURCES

World Health Organization Country & Technical Guidance: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/technical-guidance

Centers for Disease Control and Prevention: Information for Healthcare Professionals about Coronavirus (COVID-19) https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

AAD Coronavirus Resource Centre https://www.aad.org/member/practice/coronavirus

COVID-19 Resources for AACS Members https://www.cosmeticsurgery.org/page/COVID19

ASDS COVID-19 Member Resources https://www.asds.net/medical-professionals/covid-19

ASPS COVID-19 Risk Informed Consent Form https://www.plasticsurgery.org/documents/ medical-professionals/COVID19-Informed-Consent.pdf

ISPAN Position Statement on Resumption of Practice https://ispan.org/multimedia/files/ position-statements/Resumption-Practice.pdf