The consolidation of the information age, with its exponential increase in new and
advanced technologies and its electronic sophistication, also brings a new reality
to the health área1-4, with its arsenal reaching practically all the processes involved in this area, from
management, passing to the doctor’s office - a place previously safeguarded, almost
inviolable, from the doctor-patient relationship - until the teaching process. Although
the proliferation of technologies is still criticized for threatening the traditional
doctor-patient relationship, the potential benefits derived from this relevant matrix
deserve consideration by everyone involved in this area1,2,5-8.
Telemedicine refers to providing medical services through the use of information technology
and communication between patients and service providers, separated by geographical
distances1) that may make personal encounters impractical. Given the rapid development of telecommunications
technologies, the concept of telemedicine has grown to cover a wide range of applications1. Previous studies have shown that telehealth technology improves the results in several
areas, including the management of diabetes, hypertension and chronic obstructive
pulmonary disease5,9,10. There is a description of a reduction in hospital admission rates in patients using
Plastic surgery is an especially favorable field for the application of telemedicine,
given that the visual inspection of the patient in this specialty greatly guides both
the diagnosis and the clinical monitoring of the patient2,6,12,13. Although the advantages of telemedicine are widely applied to all professionals,
recent advances in accessibility, quality and transferability of photo and video media
are of particular relevance for plastic surgeons, given the highly visual nature of
As demonstrated in this review, the new articles show that telemedicine has a special
potential in increasing the efficiency of evaluation and postoperative follow-up in
plastic surgery, both reparative2 and aesthetics7,8. It improves coordination and facilitates interprofessional collaboration in time
and space1,2, eliminates a significant number of unnecessary referrals16) and connects patients located far from large medical centers to experienced professionals1,2,14, without compromising - and even improving7) - the quality or accuracy of the care provided1,2,17,18. Besides, it can be applied to several areas of plastic surgery, such as complex
wound18,19, burns16,18) and their sequelae18, cleft lip and palate15) and pediatric plastic surgery15. Nevertheless, it must be considered that the implementation of telemedicine can
be challenging and costly20,21. Some factors can limit the broader adoption of these systems, such as the cost of
initial audio, video, network and storage installations, licensing problems with suppliers,
non-standard electronic systems for medical records, absence or poor coverage by insurance
companies and health care operators and lack of standardized legislative regulations3.
It is also important that historical observation is made during the period in which
this review was carried out. Not only geographic factors are the reason for implementing
telemedicine-based systems. On January 30, 2020, WHO declared the outbreak of COVID-19
a public health emergency of international interest and, in March 2020, began to characterize
it as a pandemic to emphasize the seriousness of the situation and urge all countries
to take action to detect infection and prevent spread22,23. In this scenario, the new coronavirus may have been a catalyst for a movement in
several spheres of products and services, including the health area, towards digital23.
Given the rapid pace of technological advances in the 21st century, associated with the possible effects of social isolation imposed by the
pandemic by COVID-1923,24, the authors considered it appropriate to publish an update of a review by Vyas et
al. (2017)4, to synthesize the new evidence available in the literature since its presentation
in June 2016.
Similarly, to the methodology described in the review by Vyas et al. (2017)4, an integrative review was carried out on articles published in telemedicine in plastic
surgery in the PubMed database, using the following MeSH terms: “telemedicine” AND
“plastic surgery”, in an advanced search. From the references obtained, those not
directly related to plastic surgery or that did not have a summary available in the
database were excluded by the title. They were excluded case reports or case series
with n <10, texts that did not relate to the guiding questions (telemedicine, plastic
surgery and assistance), review studies and those published before June 2016, date
of submission to the magazine4) of the last systematic review on the theme, which was published in June 2017, provided
that they had a citation in the references. The authors extracted data on a subspecialty
in plastic surgery, purpose, study design, intervention, results and conclusions.
The references of the included articles were scanned for additional studies.
RESULTS AND DISCUSSION
One hundred thirty-four articles were identified, all in English, in the initial search
on PubMed. Although language filters were not stipulated, all references found contained
text in English. Sixty-nine were excluded for not being directly related to plastic
surgery and telemedicine or for not having a summary available in the database. Of
the 65 remaining articles, 53 were excluded by reading the abstracts because they
are case reports or case series with n <10, have texts that are not related to the
guiding questions (telemedicine and plastic surgery), are review studies or have published
before June 2016. In this last issue of the publication date, there were two articles
with a publication date before June 2016; however, as their inclusions were not identified
in the analysis carried out in the last review of the topic, sent for publication
by Vyas et al., in 2016 and published in 20174, these were included in the present review. Therefore, 12 articles were included
and reviewed in detail. The twelve articles focused on telemedicine in plastic surgery
included: 2 in the treatment of wounds, 3 in the treatment of burns and their sequelae,
1 in trauma and emergencies in plastic surgery, 1 in cleft lip and palate, 1 in pediatric
plastic surgery, 2 in plastic surgery aesthetic and 2 in evaluation and follow-up
in reconstructive plastic surgery (Figure 1).
Figure 1 - Study selection diagram.
Figure 1 - Study selection diagram.
All twelve articles selected for this review were analyzed in detail, and their objectives,
methods, results and conclusions are described in Chart 1.
Chart 1 - Analysis of selected articles.
|Reference (Year), Country
|Douglas et al.1 (2018), United States
||Review the video teleconsultation (VTC) experience in the Connecticut VA health system
and research patients' attitudes toward telemedicine services in this context.
||Cross-sectional study through the application of qualitative and quantitative questionnaires
to assess patient satisfaction with the medical service.
||In a score scale that goes up to 10 points, patients positively evaluated the overall
quality of interaction with their physician (note: 9.2), their ability to communicate
(note: 9.3) and their overall satisfaction (note: 9.2). Patients classified video
and sound quality with grades 8.6 and 9.0, respectively. 83% stated that they would
prefer the consultation of telehealth to personal visits for future plastic surgery
problems, and 7 patients (17%) said they would prefer a personal visit.
||Live interactive telemedicine consultation with a plastic surgeon in the VA health
care system results in substantial patient satisfaction with the convenience of accessing
medical care in remote communities.
|Funderburk et al.2 (2019), Lebanon
||Develop a process of clinical efficiency improvement and offer optimal patient satisfaction,
in the postoperative scenario, through a technical health tool.
||Patients living in a predefined area were given the option of monitoring by telehealth
and follow-up for 1 year. Cosmetic surgeries were excluded.
||Preoperative studies revealed that 73% of patients preferred follow-up visits in person,
while satisfaction after the meeting by telehealth was 95%. 96% of patients said they
had their questions answered and 97% would use the service again.
||Telemedicine is associated with increased patient satisfaction and potentially improved
clinical outcomes, without prejudice to follow-up.
|Pozza et al.7 (2017), UNITED STATES
||Evaluate the effectiveness of a smartphone-based plastic surgery postoperative follow-up
||Retrospectively reviewed, during the period of 1 year, the clinical records of patients
undergoing cosmetic surgeries of the face, as well as data from questionnaires and
postoperative photographs sent by patients' smartphones.
||50 (96,2%) patients reported that the process improved the quality of their postoperative
experience. The protocol allowed the detection of early complications in 3 cases,
but complications were detected outside the deadline stipulated for early submission
||The plastic surgeon can provide virtually early postoperative patient surveillance.
Although early photography failed to identify complications, they were detected by
|Westra et al.8 (2015), Netherlands
||Investigate whether online consultation is a satisfactory alternative to traditional
face-to-face consultation in the postoperative period of face-to-face plastic surgery.
||Randomized clinical trial with inclusion of eligible patients in two 6-week postoperative
evaluation arms: face-to-face consultation or video consultation, with subsequent
completion of scientifically validated questionnaires (PSQ-18, PEQ and TSQ) of satisfaction
and evaluation of doctor-patient communication
||31 patients participated. Overall satisfaction was the same in both groups, but there
was a significant difference in the dimensions "general satisfaction" (online most
satisfied consultation group, P=0.02) and "accessibility and convenience" (less satisfied
online consultation group, P=0.01) in the PSQ-18 questionnaire.
||Patients were also satisfied with traditional or real-time video consultation in plastic
surgery. Online consultation is considered a time-saving alternative to traditional
consultation, although it may be perceived by some patients as a negative influence
on communication with the doctor.
|Rimal et al.14 (2017), Australia
||Share the experience of authors using technology for the provision of services and
care in a geographically challenging environment
||Retrospective study of data from patients' medical records for a period of 1 year,
including all patients registered in the plastic surgery technical service.
||194 rural patients (66 men and 128 women), 26 of whom were elective cases and 358
follow-up visits in telehealth. 10 patients were treated only via telehealth; 24 patients
had their first face-to-face clinical review and additional follow-up via telehealth,
and 99 patients were postoperative. The etiology of cases ranged from skin lacerations
to complex soft tissue and bone lesions, as well as elective cases of postoperative
craniofacial follow-up of the hands.
||Telemedicine in plastic surgery can also be used in the pediatric population, especially
in remote locations, with minimal access to specialists.
|Sood et al.17 (2016), France
||Analysis of the wound treatment system by telemedicine.
||Review of data from the CICAT network (Home Hospital Healing Network), including 5,794
patients, between January 2005 and October 2015. Clinical efficacy and medical-economic
results were analyzed.
||In the experience of the CICAT wound network, the results showed that 75% of the wounds
improved or healed, a 72% reduction in the number of hospitalizations and a 56% reduction
in ambulance transfers to healing centers.
||Telemedicine can be beneficial in the treatment of wounds, although it is important
to note that in some countries legal restrictions can make telemedicine extremely
|Rennekampff et al.19 (2015), Germany
||Examine the intra- and inter-examiner variability of remote photographic wound closure
analysis, as well as the reliability of remote photographic wound analysis with direct
||Blind analysis by panel of high-resolution image evaluators from two randomized clinical
trials. The validity of the photographic image analysis was correlated with clinical
evaluations of the time for recovery.
||The mean intraclass correlation coefficient of the four examiners was excellent (r
= 0.79; 95% confidence interval (CI), 0.61, 1.00). The correlation coefficient between
evaluators was good (r = 0.67; 95%, 0.57, 1.00)). The agreement between remote visual
evaluation and clinical evaluation at the time of healing was good (r = 0.64; 95%,
||Remote photographic analysis of skin wounds is a viable tool in clinical studies to
assess the time to wound closure.
|Hughes et al.15 (2017), USA and Ecuador
||To evaluate the reliability of remote digital video in the preoperative diagnosis
of cleft lip and palate in environments with few resources in rural Ecuador, as well
as to evaluate the possible economic gains generated with the adoption of this technology.
||Retrospective analysis of video data during preoperative evaluations by a craniofacial
surgeon in patients in February 2015, with classification of each patient with the
same objective criteria. Analysis of the percentage of agreement between the two groups
and the reliability among evaluators.
||A 95.7% agreement was found among the observers for cleft lip, with substantial reliability
(k = 0.78, P< 0.01). There was agreement of 82.6% among the observers for cleft palate,
with moderate reliability (k=0.55, P< 0.01). We found agreement of 47.8% among the
observers for alveolar cleft, with a weak and non-significant kappa agreement.
||Remote digital evaluations are a reliable way to diagnose labial and palatine cleft
preoperatively in the context of interventions in plastic surgeries in low- and middle-income
|Martinez et al.16 (2017), South Africa
||Evaluate the WhatsApp application to facilitate burn treatment and resource allocation.
||Review of all queries that used WhatsApp for 18 months, received by two senior doctors
from a burn center
||833 communications and 1562 clinical doubts were evaluated. 486 interactions (58%)
from inside the hospital. There was no change in the number of surgical interventions,
but they reduced outpatient consultations.
||WhatsApp has contributed to the reduction of unnecessary referrals and outpatient
|Cai et al.18 (2016), Nepal and USA
||Test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using
||Prospective study conducted with three independent observers. They evaluated 85 burn
scars from 17 individuals.
||Reliability for single evaluator was acceptable (ICC> 0.70). The reliability of the
mean of the three evaluators was acceptable (ICC> 0.70). In the general opinion score,
patients consistently reported worse opinion.
||Evaluation of burn scars using the POSAS scale can be accurately performed through
|Boccara et al.26 (2018), France
||Evaluate the quality of method for telemedicine.
||Retrospective study with 323 patients. The purpose of using telemedicine was to evaluate
the need for surgery.
||Correct initial diagnosis in 94.4% (305/323) of cases. Eleven patients (3.4%) were
transferred unnecessarily and seven patients (2.2%) were not transferred, despite
the need for surgery.
||The results encourage the development of telemedicine based on digital photography,
although it never replaces clinical examination.
|Paik et al.25 (2016), UNITED STATES
||Evaluate the response of telehealth through an application for consultations related
to plastic surgeries.
||Quality Assurance/Improvement Study of a trauma center. The study used an application
to send images and brief history to plastic surgery teachers.
||42 consultations performed. The agreement between teachers and consultants was 85.7%
for face-to-face consultations and 100% for telephone consultations. In four cases
of telephone consultations, emergency department providers incorrectly placed splints
on injured patients.
||The results show that telehealth consultations were able to produce timely and accurate
responses in an emergency care unit.
Chart 1 - Analysis of selected articles.
The pandemic underway for the new SARS-CoV-2 has accelerated the search for the use
of medical services at a distance. In this scenario, it is imperative to look for
what is in the scientific literature about advances in telemedicine in plastic surgery
to promote improvements, exclude failures, and implement innovations, seeking a better
adaptive response to the current challenge.
Vyas et al. in 20174) an excellent review of 23 articles focused on telemedicine in plastic surgery. They
used the following Terms MeSH: “surgery, plastic; general surgery; surgical procedures, operative; surgery; burns;
wounds and injuries; soft tissue injuries; dermatology; teledermatology; teledermatological;
maxillofacial injuries; hand; hand injuries; microsurgery; breast; cell phones; orthopedics;
telesurgery; remote consultation”. Since then, advances in this area have been notorious, either by the exponential
expansion of mobile technology or by the growing familiarity and accessibility to
the average consumer. In this context, new articles have emerged and are not included
in the review by Vyas et al. (2017)4.
The articles found in this review demonstrated benefits in the use of telemedicine
applied to plastic surgery. They were more pronounced in the postoperative follow-up
of patients2,7,8,14, reduction or extinction of the need for face-to-face visits1,14,16-19, satisfaction of patients in telemedicine consultations1,2,8, reduction of financial costs1, reduction of response time for referrals25, diagnostic accuracy similar to face-to-face assessment15,17-19,25,26) and improvement in access to specialized care in remote places, both geographically
and socially unfavorable1,2,14,15,25. Despite the vast majority of studies showing significant patient satisfaction, it
is worth highlighting the selection bias present in these studies. The method of attracting
volunteers, willing to be consulted by telemedicine, favors patients’ selection more
receptive to this approach1,2,8,25.
In 2015, Westra and Niessen8 conducted a randomized clinical trial comparing the assessment
of patient and physician satisfaction in a postoperative follow-up consultation through
a real-time video connection and traditional personal consultation, using validated
questionnaires of measures of different aspects of health care doctor-patient communication
and satisfaction with telemedicine. The results showed that, in general, patients
are equally satisfied with traditional consultation or video conferencing. However,
online consultation was perceived by some patients as a negative influence on the
doctor-patient relationship. Still, even in a study with higher statistical robustness,
a small sample size was observed, which was potentiated by the loss of 30% of the
initial sample of eligible patients, which may have generated attrition bias.
Four articles discussed barriers and limitations, observed or potential, to the use
of telemedicine in plastic surgery, which were: data security, with the need for sophisticated
and protected software and hardware so that patient data storage can be free from
fraud1,7; regulation and legislation, both in the governmental sphere and in the sphere of
private health, for wider adoption of telemedicine in the propaedeutic arsenal1,17; initial financial costs, which can be high, of installing audio, video, data transmission
and storage equipment1, perception of negative influence on doctor-patient communication and the probable
need for specific training dedicated to doctors and other health professionals in
the improvement of their online communication skills8.
Some studies show that the technology present in current smartphones is sufficient
to allow an accurate assessment of various pathologies in the field of plastic surgery2,7,8,16,17,25,26. Even apps for routine use can be used as demonstrated by Martinez et al. in 201816, who used the WhatsApp app for communication between various burn patients’ treatment
levels. Pozza et al., in 20177, using smartphones, preferred to employ a very specific and protected network for
data transmission called HIPPA. This is a sophisticated network with great data security.
The use of smartphones reduces the cost of implementing the system and facilitates
real-time communication with specialists7,16,25. Specifically in the work of Paik et al., in 201725, the time of face-to-face response and the time of response through virtual communication
between emergency services and specialists was measured, finding a significant difference
in time, with a great advantage for virtual consultation. Time and cost savings are
critical to patient satisfaction and hospital financing.
Douglas et al. (2018)1, Sood et al. (2016)17 and Rennekampff et al. (2015)19, on the other hand, used complex communication networks associated with their own
technologies with specific software in the development of telemedicine in their work.
These authors were able to find excellent results regarding the reliability of the
method, reliability of information, satisfactory clinical judgment, population coverage
and reduction of costs with hospitalization and transportation. Further studies would
be needed in order to determine the best tool for performing telemedicine, whether
through smartphones or some other specific technology for this purpose.
The analyzed studies demonstrate the significant gain in knowledge about telemedicine
applied to plastic surgery in recent years. The technological incorporation has the
power to reduce distances, facilitate the interaction of the doctor-patient binomial
without prejudice to care, even in areas where interaction is as fundamental as the
The focus is not to have these technologies as substitutes for face-to-face care,
but as tools to expand and improve care for patients who need evaluation with the
Such tools have become more relevant in the pandemic scenario by COVID-19, where social
distance has proved to be the most effective measure to slow down contagion due to
its potential to prevent direct physical contact, provide continuous service to the
community and, possibly, reduce morbidity and mortality due to the disease27.
Much of what has been developed in studies is not yet fully implemented in the different
health systems. The challenge of a non-exclusive technological development persists,
which is accessible to anyone who needs this care. It is expected that in the adversities
caused by the coronavirus, it will be possible to improve the ability to care, either
in person or mediated by technologies.
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Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/32738884
1. Universidade Federal de Sergipe, Programa de Pós-Graduação de Gestão e Inovação
em Saúde, Aracaju, SE, Brasil.
2. Universidade Federal de Sergipe, Programa de Pós-Graduação de Ciências da Saúde,
Aracaju, SE, Brasil.
Kênya de Souza Borges Avenida Doutor José Machado de Souza, 220, Sala 304, Ed. Neo Office, Jardins, Aracaju,
SE, Brazil. Zip Code: 49025-740. E-mail: email@example.com
Article received: August 25, 2020.
Article accepted: November 10, 2021.
Conflicts of interest: none
KSB Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Methodology, Project Administration, Writing
- Original Draft Preparation, Writing - Review & Editing
VOBO Analysis and/or data interpretation, Conception and design study, Data Curation,
Final manuscript approval, Methodology, Project Administration, Writing - Original
Draft Preparation, Writing - Review & Editing
JBCF Analysis and/or data interpretation, Conception and design study, Data Curation,
Final manuscript approval, Methodology, Project Administration, Writing - Original
Draft Preparation, Writing - Review & Editing
SMS Conception and design study, Final manuscript approval, Supervision
AAO Conception and design study, Final manuscript approval, Supervision
CAL Conception and design study, Final manuscript approval, Supervision