Viran Ranasinghe 1 MD, Leila J. Mady 1 MD PhD MPH,  Seungwon Kim 1 MD, Robert L. Ferris 1 MD PhD, Umamaheswar Duvvuri 1 MD PhD, Jonas T. Johnson 1 MD, Mario G. Solari1,2 MD, Shaum Sridharan1,2 MD, Mark Kubik1,2 MD
1 Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA USA.
2 Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA

Correspondence and/or reprint requests to:

Mark Kubik, MD
Assistant Professor
University of Pittsburgh Medical Center
Department of Otolaryngology
Suite 500 Eye and Ear Institute
200 Lothrop St.
Pittsburgh, PA 15213
E-mail: kubikmw2@upmc.edu

There are no financial conflicts or disclosures to report on behalf of the authors.

Abstract: The 2019 novel coronavirus (COVID-19) pandemic has created significant challenges to the delivery of care for patients with advanced head and neck cancer requiring multimodality therapy. Performing major head and neck ablative surgery and reconstruction is a particular concern given the extended duration and aerosolizing nature of these cases. In this manuscript, we describe our surgical approach to provide timely reconstructive care and minimize infectious risk to both the providers, patients, and families.  
Introduction
Originating in the city of Wuhan, China, the COVID-19 pandemic has swept across the globe as a true public health crisis. This highly infectious SARS-CoV-2 virus was first reported in early December 2019 in China with the first confirmed case in the United States occurring on Jan 22,20201. Since that time, the United States has seen an exponential rise in cases. Pandemic status was confirmed by the World Health Organization (WHO) on March 11,20202.
Early reports out of China suggested that otolaryngologists were at particularly high risk for nosocomial spread due to the aerosolizing nature of our procedures and our inherent proximity to the mucous membranes of the upper aerodigestive tract3.
Surgical decision making in otolaryngology and specifically head and neck surgery has thus been drastically altered. The inherent goals of these changes have been to limit infectious risk to patients, providers, trainees, and staff while continuing to provide high quality and timely care.
With regard to surgical care in the United State, most systems have transitioned to postponing procedures deemed to be elective and proceeding only with those thought be time sensitive or emergent. In head and neck oncology, we deal with a wide spectrum of pathologies with varying biology. While some cases can clearly be deferred to a later date, the determination of the true urgency of certain procedures is sometimes controversial.
Within the subset of patients requiring surgery and microvascular reconstruction for squamous cancer, however, there is little disagreement regarding the urgency of these cases. At the University of Pittsburgh, we have proceeded with surgery for squamous cell carcinoma and other advanced, high grade malignancies despite the ongoing pandemic concerns.
In this paper, we describe our institutional approach for mitigating risk while continuing to provide appropriate reconstructive care. Topics discussed include our protocols for the perioperative management of patients undergoing surgery with microvascular reconstruction. These protocols were developed through consensus among our head and neck reconstructive division based on review of the existing, but admittedly limited literature.