Palliative Reconstructive Surgery for Advanced Maxillofacial Osteosarcoma in the Peak of COVID-19 Pandemic: A Matter of Ethical Decision-making

Summary: The coronavirus disease 2019 posed an unprecedented strain to plastic surgery services. The scarcity of validated guidelines - at the beginning of this healthcare crisis - to direct clinical, ethical, transparent decision-making for head and neck cancer patients requiring palliative reconstructive surgery was a difficult situation. We report a 15-year-old girl with an advanced chemoresistant rare radiotherapy-induced mandibular osteosarcoma during the early phase of the pandemic in the United States in mid-March 2020, when official recommendations for triage were still developing. Local guidelines suggested canceling all elective procedures, and allowed operating emergency and/or nonelective cases only. Many surgeons declined surgery due to patient's poor prognosis and high perioperative risk, but her mother pursued different professional opinions elsewhere. However, upon Beaumont hospital approval, the patient underwent radical en bloc resection of the tumor, hemimandibulectomy, zygomatic resection, maxillectomy, and hemipalate resection followed by reconstruction with free fibula osteocutaneous and anterolateral thigh flaps. The challenging decision to proceed with surgery was based on evidence-based and objective risk-stratifying scores, available at the time, and ethical recommendations from emerging reliable published literature. Despite a favorable postoperative outcome, the patient expired due to cardiac complications of the disease. Our patient taught us that ethical decision-making, sound clinical judgment, and a patient-centered individualized approach remain pivotal aspects of the medical profession. Although the surgery will not provide a cure for the disease, we have found that palliative reconstructive surgery can greatly improve patient's quality of life, and help family cope with the advancing stages of disease.