INTRODUCTION

World Health Organization (WHO) declared the novel coronavirus (COVID-19) infection a global pandemic on March 11, 2020.[1] It has spread in more than 210 countries, infected over 2,501,907 people, killing more than 171,741 individuals, implying high estimated case–fatality rate.[2] Elective procedures may contribute to the spreading of the coronavirus. The safety and feasibility of continuing to perform elective surgical procedures during the COVID-19 pandemic is debatable.[3]

The Government of India has declared nationwide lockdown from March 21, 2020, where the boundaries of all the districts are sealed and public transports are shut. All nonessential surgeries are stopped. The majorly affected fields include cosmetic, aesthetic, and hair transplant (HT) surgery. Most of the HT clinics have stopped surgeries or postponed till lockdown date limit. HT surgeries make up very significant percentage of HT clinics’ revenue. Postponing surgeries will undoubtedly have financial implications for these setups. In addition to loss of revenue, clinics will face increased costs during the COVID-19 pandemic due to maintenance costs of clinic and salaries. Staff leaving the job is also a possibility. Further, it is unclear when canceled surgeries can be rescheduled, as India is still working to flatten the curve of the pandemic. We do not yet know when the curve will begin to flatten, reflecting containment of the virus. Loss of jobs and salary cuts may lead to cancelation of surgeries. Even after the peak of pandemic is over, virus may become endemic and the risk of transmission of the disease to staff is also a possibility. HT field of India is thus in an extremely challenging position.

In view of this, we wanted to study the influence of COVID-19 pandemic on the HT field of India.

SUBJECTS AND METHODS

We did a survey among the members of Association of Hair Restoration Surgeons of India (AHRS), where they had to answer multiple-choice questions (MCQs) online, which were related to the COVID-19 outbreak and its influence on their HT practice. A questionnaire of 20 MCQs was circulated through a web link. A total of 78 HT surgeons from all over India participated in the survey that was prepared using SurveyMonkey platform.

RESULTS

The questions along with their answers of the participants of the survey are given in Table 1.

Analysis: Pattern of HT practice observed among participants is as follows:

Although 36.36% of the participants were in HT surgery for more than 5 years, 12.99% were practicing for more than 15 years. Of the participants, 66.67% were dermatologists, whereas 21.79% were plastic surgeons. Of the participants, 78% practiced in metro or urban areas.

Of these surgeons, 22.08% practiced only HT surgeries, whereas 24.68% had predominant HT practice along with skin or other plastic surgeries; 43.59% were seeing 10–40 hair patients per week before COVID-19 pandemic. A large number (33.77%) were carrying out more than 10 hair-related procedures per week such as mesotherapy, platelet-rich plasma (PRP), scalp micropigmentation, and derma roller. More than half the participants performed less than 10 surgeries a month, and 25% operated more than 16 cases before this pandemic situation. Majority of them used online/video call/telephonic platform for consultation before the COVID-19 outbreak. Maximum number of HT surgeons (43.42%) said that (25%–50%) of their total practice was fulfilled by patients from another area.

Effect of corona pandemic on the participants is as follows:

Since the lockdown was declared in the country, 96.10% of doctors have stopped their HT practice. Among all these surgeons, 84.42% believed that avoiding HT surgery in pandemic situation, such as coronavirus outbreak, was needed and would help in avoiding the infection spread. It was interesting to see that 1.3% had not stopped the surgery even during the lockdown period.

Most surgeons (30.26%) were unable to predict resuming HT surgeries even after the lockdown is discontinued, whereas 28.95% said they would resume performing surgeries in 2–4 weeks post lockdown. Majority (61.84%) would screen themselves as well as their staff regularly when they would start performing HT surgeries, also majority (61.04%) would use personal protective equipment (PPE) kit for everyone post COVID-19 outbreak. Many of them (55.84%) would practice special sterilization techniques for the operation theater (OT) and OT dresses. Of the surgeons, 89.61% believed that their staff is aware of the risk of performing HT surgery in this viral outbreak. Of all, 54.67% would like to pay half salary to the staff during this no work period. However, 33% said they would pay full salary to staff.

A majority 80.26% would like to avoid HT surgery if pandemic situation worsens, and government advises to prolong the lockdown. However, 15.79% said they would perform surgeries with precautions. Almost half the population (47.37%) believed that HT practice would be affected, at least by 50% post COVID-19 outbreak, and 10.53% thought that HT practice would get affected to the extent by 100%.

DISCUSSION

Hair transplant surgery has the following special features[4]:

• It is a cosmetic surgery, and hence the risk is not acceptable.

• Duration is prolonged.[5]

• Surgeon and assistants are in close proximity to face for prolonged period of several hours—social distancing is not possible.

• Follicular unit extraction (FUE) uses drills and may produce aerosols.

• Surgery needs many assistants in the theater.

There are several conclusions that can be drawn from the survey, which are as follows:

• Participants believe that corona pandemic will significantly affect the HT practice. However, there is no uniform opinion on the duration, and the severity of this effect or when recovery will happen. There is excellent awareness of the issues involved, need for PPE, and need for avoiding the surgery during pandemic. However, it was surprising and perhaps worrying to see a very small number who said they have been performing surgery even during a pandemic and will continue doing it even if the pandemic worsens. It was heartening to see that most surgeons felt that they would pay full or at least half salary to staff to take care of them even in these times of lockdown. Many respondents were not in the opinion of using special precautions for sterilization. Also, few of the surgeon’s staff did not know the risk of performing elective surgery during pandemic outbreak, hence surgeons may need to educate their staff and adopt special precaution, which some appear not to do. In majority, the surgeons are in favor of avoiding HT surgeries if the pandemic worsens and the government prolongs the lockdown.