Timing of COVID-19 Vaccination in Relation to Elective Surgery.

Abstract

With the outbreak of the COVID-19 pandemic, the medical profession has had to adapt and transform in order to ensure comprehensive and safe patient care. This has affected the way surgeons triage patients and book and perform operations. The introduction of COVID-19 vaccines was an exciting advancement in disease prevention, but their long-term efficacy and effects remain unknown. We are often asked by patients when we would recommend they receive a COVID-19 vaccine in relation to undergoing surgery. Our goal was to investigate current recommendations regarding timing of COVID-19 vaccination in patients who are undergoing or have recently undergone surgery in an attempt to better inform our plastic surgery patient population. Centers for Disease Control and Prevention recommendations surrounding vaccinations suggest that “current, recent or upcoming anesthesia/surgery/hospitalization” is not a contraindication to receiving any vaccine.1 If patients are acutely ill during the perioperative period, it has been recommended that they wait to receive vaccines as soon as possible once they have improved clinically.1 It is not unusual for patients to exhibit a myriad of acute symptoms related to receiving a vaccine that may confuse the picture of a perioperative illness or infection. Recent phase III trials have shown a significant incidence of side effects following COVID-19 vaccination. The majority appear to be self-limiting and a few days in duration. Such symptoms include flu-like symptoms and reactions restricted to the injection site (Table 1), but severe effects, such as anaphylaxis, although rare, may occur.1,2 These symptoms overlap with those observed in the setting of systemic illness, infection, or adverse drug reaction, all of which are a concern in the acute perioperative period. For example, if a patient presents with a concern for illness preoperatively, we are likely to delay surgery, and in the postoperative setting we may have a heightened suspicion for a surgically related pathogenesis. Table 1. - Side Effects Associated with Various COVID-19 Vaccinations Common Side Effects Uncommon Side Effects Fatigue Anaphylaxis Headache Death Fever and/or chills Nausea and/or vomiting Pain, swelling, or redness at injection site Enlarged lymph nodes Recently there have been reports of facial or lip swelling following receipt of the Moderna (Cambridge, Mass.) COVID-19 vaccine in patients who have a history of facial filler. This appears to be a relatively rare delayed hypersensitivity reaction that resolves when treated with oral steroids and antihistamines. It has been postulated this may result from a vaccine-driven immune response provoking a local inflammatory reaction targeting tissue containing filler.3,4 At this time, there is not enough information to determine with certainty whether this was the cause or how many people with a history of facial filler are likely to have a similar reaction. The Centers for Disease Control and Prevention currently states that people with a history of dermal fillers who have no contraindications to vaccines should proceed with vaccination.1 This is important for plastic surgeons to be aware of and disclose when counseling patients with a history of facial filler or who are considering facial filler in adjunct with the COVID-19 vaccine and may consider delaying such elective procedures until the final vaccine has been received. There is currently no uniform recommendation regarding COVID-19 vaccination timing in respect to elective surgery. Surgery results in a generalized state of immunosuppression and we do not yet have a full understanding of the potential for immunocompromise after COVID-19 vaccination.5 We have therefore taken Centers for Disease Control and Prevention guidelines, available literature, as well as risk factors of surgical procedures into consideration when determining how to most safely and appropriately counsel our patients who are undergoing or have recently undergone surgery. For patients who are undergoing minor elective procedures without prolonged anesthesia and are at lower risk for postoperative complications (e.g., cutaneous oncologic excision and reconstruction, scar revision), we recommend they receive the vaccination at the earliest date possible without any limitation. For patients undergoing more extensive procedures (e.g., autologous and implant-based breast reconstruction, abdominal reconstruction, abdominal or lower body contouring), we recommend patients do not receive the vaccine within a week before or after the operation. We believe this may help prevent misinterpretation of any vaccine-related side effects as perioperative infection that may prompt an extensive workup or intervention. At this time, we have limited available data with which to guide our vaccine recommendations in regard to elective surgery, and our priority is, first and foremost, the safety of our patients. In discussion with our institutions and after reviewing current recommendations and literature, we believe this is a safe and effective way to counsel our patients. We are prepared to make adjustments as we learn more about the impact of COVID-19 vaccination. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.