Role of Tranexamic Acid in Reducing Intraoperative Blood Loss and Postoperative Edema and Ecchymosis in Primary Elective Rhinoplasty: A Systematic Review and Meta-analysis

Tranexamic Acid in Patients Undergoing Rhinoplasty: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Rhinoplasty is one of the most popular aesthetic plastic surgeries worldwide. The effects of tranexamic acid (TXA) in patients undergoing rhinoplasty are still being studied to guide a better management.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) analyzing the effects of TXA in patients undergoing rhinoplasty. The outcomes evaluated were blood loss, postoperative edema, postoperative ecchymosis, surgery duration and surgeon satisfaction.

RESULTS

Eleven studies comprising 841 patients were included. Overall, TXA reduced total blood loss regardless of dose and administration route (MD = - 39.37 mL; 95% CI = - 62.70 to - 16.05 mL; p = 0.0009; I2 = 92%), using intravenous 10 mg/kg of TXA preoperatively (MD = - 16.30 mL; 95% CI = - 29.49 to - 2.57 mL; p = 0.02; I2 = 61%) and using 1 g of oral TXA preoperatively (MD = - 61.70 mL; 95% CI = - 83.02 to - 40.39 mL; p < 0.00001; I2 = 0%). TXA also decreased edema (MD = - 0.78; 95% CI = - 1.28 to - 0.27 points; p = 0.003; I2 = 80%) and ecchymosis (MD = - 1.13; 95% CI = - 1.99 to -0.28; p = 0.01; I2 = 93%) on postoperative day one (POD 1). Surgeon satisfaction was increased (SMD = 1.55; 95% CI = 0.33 to 2.77; p = 0.01; I2 = 95%). However, there was no difference in surgery duration (SMD = - 0.26; 95% CI = - 0.56 to 0.04; p = 0.09; I2 = 36%).

CONCLUSION

This study found a significant reduction in blood loss, periorbital edema and periorbital ecchymosis, along with an improvement in surgeon satisfaction. These results hold the potential to optimize the rhinoplasty management by plastic surgeons.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tranexamic acid in bleeding reduction and operative time of nasal surgeries: systematic review and meta-analysis

PURPOSE

Our study goal is to review the efficacy of tranexamic acid in reducing blood loss and operative time in nasal surgeries.

METHODS

We included randomized clinical trials using oral or intravenous tranexamic acid, excluded non-randomized studies, topic administration, coagulopathy, and using other drugs interfering in the coagulation cascade. Online databases, National Library of Medicine (MEDLINE-PubMED), Latin American and Caribbean Literature on Health Sciences (Lilacs), Cochrane Library, Embase and Google Scholar were used to perform the search. The review was registered in PROSPERO by no CRD42022310977. Two authors, independently, selected the articles meeting the inclusion criteria. They extracted the data and used RevMan 5 software to perform the meta-analysis.

RESULTS

Our search resulted in 16 RCTs that were included in the meta-analysis totalizing 1108 patients. Studies were evaluated resulting in a low risk of bias for the five domains. The use of tranexamic acid resulted in significant reduction in duration of surgery (DOS) and intraoperative blood loss (IBL) had significant reduction. The level of evidence according to GRADE System was high in all studies and variables.

CONCLUSION

Tranexamic acid has an important role in reducing intraoperative blood loss and duration of surgery. Our study has some limitations due to the low number of RCTs available in the literature.

Evaluating the Effect of Tranexamic Acid Local Injection on the Intraoperative Bleeding Amount and the Postoperative Edema and Ecchymosis in Primary Rhinoplasty Patients: A Randomized Clinical Trial

BACKGROUND AND AIMS

The purpose of this study was assessing the effect of local injection of tranexamic acid (TXA) on the amount of bleeding during the primary rhinoplasty and edema and ecchymosis following the surgery.

METHODS

In this randomized clinical trial, 50 patients applying for primary rhinoplasty were divided into two groups of intervention and observation. In the intervention group, 10 mg/kg of TXA was injected locally to the operation field. In the observation group, no medicine was injected. The same anesthesia technique was used during the operation for all the patients. Age, sex, blood pressure, bleeding amount during the operation, the amount of edema and ecchymosis on the first and seventh day after the surgery were noted. The data were analyzed by the SPSS software version 24 and using descriptive statistics of frequency and percentage of frequency and Fisher and Mann-Whitney's exact statistical tests.

RESULTS

Our results showed that there was a significant difference between the amounts of bleeding during the surgery between two groups (P-value < 0.001). Also, the postoperative edema on the first and seventh day in intervention group was less than the observation group (P-value < 0.001). There were no complications during the surgery and in the follow-up of the patients.

CONCLUSION

We revealed that local injection of TXA during the rhinoplasty procedure and decreased the intraoperative bleeding and postoperative ecchymosis and edema without any side effects and complications.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery

Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Permissive Hypotension in Rhinoplasty: A Literature Review of Therapeutics and Associated Outcomes

BACKGROUND/PURPOSE

Permissive hypotension, defined as mean arterial pressure (MAP) of 60-70 mm Hg, has been regarded as favorable among surgeons performing rhinoplasty. Furthermore, management of blood pressure has been shown to promote greater visualization of the surgical field and decrease postoperative complications, such as ecchymosis and edema. While multiple therapies have been utilized to achieve permissive hypotension, it remains unclear how modalities compare in terms of safety and efficacy. The purpose of this study was to conduct a systematic review to better understand the specific modalities and associated outcomes in managing blood pressure during rhinoplasty.

METHODS

A systematic literature review was conducted in order to identify and assess therapeutics utilized in achieving permissive hypotension during rhinoplasty. Variables collected included year of publication, journal, article title, organization of study, patient sample, treatment modality, associated outcomes (i.e., intraoperative bleeding, edema, and ecchymosis), adverse events, complications, and satisfaction. Articles were then categorized by the level of evidence as set forth by the American Society of Plastic Surgeons. Any conflicts were resolved through discussion and full-text review among co-authors. Of note, the search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No funding was required to conduct this review of the literature.

RESULTS

Initial review yielded sixty-five articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of ten studies for analysis. Articles discussed multiple therapies for management of blood pressure during rhinoplasty, including dexmedetomidine, dexamethasone, gabapentin, labetalol, nitroglycerine, remifentanil, magnesium sulfate, clonidine, and metoprolol. Overall, intraoperative bleeding, as well as postoperative ecchymosis and edema were reduced when MAP was controlled.

CONCLUSION

Given its intra- and postoperative benefits, permissive hypotension can be leveraged to improve outcomes in rhinoplasty. This study presents an updated comprehensive review of various modalities used to achieve permission hypotension in rhinoplasty. Future studies should explore how comorbidities may impact choice of treatment regimen among patients undergoing rhinoplasty.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Update: Cellulite Therapies and Optimizing Treatment Combinations

Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.

LEVEL OF EVIDENCE: 5

Reviewing the Impact of Topical and Intravenous Tranexamic Acid Use in Breast Plastic Surgery

BACKGROUND

Topical and intravenous uses of tranexamic acid (TXA) have been shown to reduce bleeding and ecchymosis in various surgical fields. However, there is a lack of data evaluating the efficacy of TXA in breast surgery. This systematic review evaluates the impact of TXA on hematoma and seroma incidence in breast plastic surgery.

METHODS

A systematic review of the literature was performed for all studies that evaluated the use of TXA in breast surgery including reduction mammoplasty, gynecomastia surgery, masculinizing chest surgery, or mastectomy. Outcomes of interest included rate of hematoma, seroma, and drain output.

RESULTS

Thirteen studies met the inclusion criteria with a total of 3297 breasts, of which 1656 were treated with any TXA, 745 with topical TXA, and 1641 were controls. There was a statistically significant decrease in hematoma formation seen in patients who received any form of TXA compared with control (odds ratio [OR], 0.37; P < 0.001), and a similar tendency toward decreased hematoma with topically treated TXA (OR, 0.42; P = 0.06). There was no significant difference in seroma formation with any TXA (OR, 0.84; P = 0.33) or topical TXA (OR, 0.91; P = 0.70). When stratified by surgery, there was a 75% decrease in the odds of hematoma formation with any TXA compared with the control for oncologic mastectomy (OR, 0.25; P = 0.003) and a 56% decrease in nononcologic breast surgery (OR, 0.44; P = 0.003).

CONCLUSIONS

This review suggests that TXA may significantly reduce hematoma formation in breast surgery and may also decrease seroma and drain output. Future high-quality prospective studies are required to evaluate the utility of topical and intravenous TXA in decreasing hematoma, seroma, and drain output in breast surgery patients.

[Role of Tranexamic Acid in Plastic Surgery: a Systematic Review]

BACKGROUND

Bleeding events in surgery are a problem and can lead to revision surgery and bleeding anaemia, which sometimes must be treated by blood transfusion. Tranexamic acid is an antifibrinolytic agent and is already known for its role in the prevention and treatment of perioperative bleeding in the fields of orthopaedics, cardiovascular surgery and gynaecology. In plastic surgery, the use of tranexamic acid is increasing in popularity and has already been described in individual studies.

METHODS

A literature search was performed using the database MEDLINE from the United States National Library of Medicine (NLM). The keywords "tranexamic acid in plastic surgery", "intravenous tranexamic acid in plastic surgery", "topical tranexamic acid in plastic surgery" and "subcutaneous tranexamic acid in plastic surgery" were used. The search was limited to the period from 2010 to 2023. The studies were analysed according to the level of evidence, validity and availability and divided into three groups for the topical, intravenous or subcutaneous application of tranexamic acid. Randomised controlled trials and non-randomised prospective and retrospective cohort studies were included in the systematic review. Studies from other disciplines, review articles, technical notes, experimental studies, letters to the editor, comments and case reports were excluded.

RESULTS

The literature search resulted in a total of 135 papers. Of these, 56 papers were assessed as relevant to plastic surgery. After further analysis, 41 papers were excluded using the exclusion criteria described above. Fifteen studies were finally included in the present work and recommendations for possible applications such as intravenous, topical and subcutaneous application of tranexamic acid, including the indications, contraindications and dosage formulas were developed.

DISCUSSION

Although the current study situation on the use of tranexamic acid is limited, the results show more advantages than disadvantages for perioperative use. Establishing the use of tranexamic acid in plastic surgery could facilitate the reduction of perioperative bleeding and lead to more precision in surgery, and it could enable a rapid removal of drains. However, following the analysis of benefit and risk factors, further randomised controlled trials are required for use in plastic surgery.

Reducing Surgical Risks in the Rhinoplasty Patient

Reducing complications after rhinoplasty is critical to ensuring optimal functional, aesthetic, and patient satisfaction outcomes. Many of the most frequent complications of rhinoplasty are technical in nature and can be prevented with meticulous attention to detail and preservation of critical nasal support structures. In this article, the authors review many of the common pitfalls of rhinoplasty and discuss preventative measures that can be used by the competent rhinoplasty surgeon.

Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis

Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.

Local Application of Tranexamic Acid in Plastic Surgery Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

According to recent evidence, the use of local tranexamic acid (TXA) during plastic surgery may lessen blood loss.

OBJECTIVES

To comprehensively assess the use of local TXA during plastic surgery through a systematic review and meta-analysis of randomized controlled trials addressing these issues.

METHODS

Four electronic databases, including PubMed, Web of Science, Embase and the Cochrane Library, were searched until December 12, 2022. Following meta-analyses, the mean difference (MD) or standardized mean difference (SMD) for blood loss volume (BLV), ΔHct, ΔHb and operation time were calculated when appropriate.

RESULTS

Eleven randomized controlled trials were included in the qualitative synthesis, while 8 studies were included in the meta-analysis. Compared with the control group, the local TXA group showed a reduction in blood loss volume of -1.05 (p < 0.00001; 95% CI, -1.72 to -0.38). However, local TXA had a limited effect on reducing ΔHct, ΔHb and operation time. A meta-analysis was not performed because of heterogeneity in other outcomes; however, except for 1 study in which no significant difference was observed on POD 1, all studies showed significantly lower rates of postoperative ecchymosis after surgery, 2 studies showed statistically significant reductions in transfusion risk or volume, and 3 studies reported significantly better surgical field quality in operations with local TXA. In the 2 included studies, the researchers concluded that local treatment does not play a role in relieving postoperative pain.

CONCLUSIONS

Local TXA is associated with less blood loss, less ecchymosis and better surgical field in plastic surgery patients.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of bruising after injection to reduce cellulite

BACKGROUND

Cellulite 80%-98% of post-pubertal women and results in cutaneous dimples in the affected area.

AIMS

Therapies that target collagenous fibrous septae often provide successful outcomes.

MATERIALS & METHODS

Collagenase clostridium histolyticum-aaes (CCH) for injection consists of two collagenases which, under physiologic conditions, disrupt collagen structures by hydrolyzing Type I and III collagen.

RESULTS

Subcutaneous CCH was approved in the United States in 2020 for the treatment of moderate-to-severe cellulite in the buttocks of adult women. Although bruising is primarily an aesthetic concern, a conspicuous procedure-induced bruise may limit a patient's social activities and result in hesitation to undergo a similar cosmetic procedure in the future.

CONCLUSION

The purpose of this review is to describe the available techniques for hastening bruise resolution and how they apply to resolving bruises associated with a CCH injectable.

Local Infiltration of Tranexamic Acid During Facelift Improves Operating Room Efficiency: A Matched Patient Study

BACKGROUND

Tranexamic acid (TXA) has rapidly gained popularity in aesthetic surgery. Previous reports have suggested that TXA provides a dry surgical field and significantly reduces operating time during facelift surgery.

OBJECTIVES

The aim of this study was to build upon earlier findings by providing a large cohort matched alongside historic controls and more clearly document time saved when performing facelift surgery.

METHODS

A retrospective, single-surgeon case-control study was undertaken between July 2016 and October 2021. All patients underwent facelift surgery alone or in combination with fat transfer and perioral chemical peel. All patients received subcutaneous infiltration of 0.5% lidocaine/1:200,000 epinephrine with or without 1 or 2 mg/mL TXA. Patient demographics, TXA dose, surgical time, and minor and major complications were examined.

RESULTS

In total 145 consecutive patients were identified: 73 in Group 1 (no-TXA) and 72 in Group 2 (TXA). No differences in terms of gender distribution (P = 0.75), age (P = 0.54), BMI (P = 0.18), frequency of secondary rhytidectomy (P = 0.08), rate of ancillary lipografting (P = 0.44), TXA dose (P = 0.238), and minor complication rate (P = 0.56) were observed. However, mean surgical time in the no-TXA group was 21 minutes longer than in the TXA group (P = 0.016). Six patients (8%) in the no-TXA group experienced minor complications vs 8 patients (11%) in the TXA group. No patients experienced major complications.

CONCLUSIONS

Although previous studies have highlighted the potential benefits of TXA in aesthetic surgery, most of the data remain subjective and non-validated. This report adds to the objective body of evidence supporting TXA in facial aesthetic surgery by documenting time saved in the operating room without additional surgical morbidity.

LEVEL OF EVIDENCE: 4

The effects of 5-degree, 10-degree and 20-degree reverse Trendelenburg positions on intraoperative bleeding and postoperative Edemea and ecchymosis around the eye in open rhinoplasty

PURPOSE

In this study, we investigated the effect of reverse Trendelenburg position (RTP), with five, ten, and twenty degrees, on intraoperative bleeding and postoperative edema and ecchymosis around the eye in open rhinoplasty operations.

MATERIALS AND METHODS

Ninety patients undergoing open rhinoplasty were divided into three groups, 5° angle RTP (Group 5; n = 30), 10° angle RTP (Group 10; n = 30), and 20° angle RTP (Group 20; n = 30). After 3 min of preoxygenation, anesthesia was induced with 3 mg.kg^-1 propofol, 1 μg.kg^-1 fentanyl, and 0.6 mg/kg rocuronium for muscle relaxation. Maintenance of anesthesia was provided with a minimum alveolar concentration of 1-1.5 with sevoflurane, 1:1 O2/N2O. Hemodynamic variables, intraoperational bleeding, postoperative 1st, 3rd and 7th days ecchymosis and edema around the eyes of the patients were compared between the groups.

RESULTS

Edema changes on postoperative 1st, 3rd and 7th days and ecchymosis changes around the eyes on postoperative 1st and 3rd days in Group 20 were found significantly lower than Group 5 (p < 0.017). Besides, the change of ecchymosis on the postoperative 1st day was found significantly lower in Group 20 compared to Group 10 (p < 0.017). The amount of intraoperative bleeding and surgical field evaluation score were found to be significantly lower in Group 10 and Group 20 compared to Group 5 (p < 0.017).

CONCLUSION

We concluded that in open rhinoplasty surgeries, 20° degree RTP reduces intraoperative blood loss and provides a more bloodless surgical field, as well as reducing edema and ecchymoses around the eyes in the postoperative period.

Safety and Efficacy of Local Tranexamic Acid for the Prevention of Surgical Bleeding in Soft-Tissue Surgery: A Review of the Literature and Recommendations for Plastic Surgery

Background:

Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery.

Methods:

A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors’ own research.

Results:

Fourteen randomized controlled trials, including 1923 patients, were included in the systematic review on local use of tranexamic acid in soft-tissue surgery.

Conclusions:

Local use of tranexamic acid may reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects, but high-quality randomized controlled trials are few. Prolonged exposure to high local concentrations is discouraged, and direct contact with the central nervous system may cause seizures. No single superior means of administration or dosage is supported in the literature, and lowest effective dose is unknown. There may not be one single ideal dosing regimen, but rather many possibilities adaptable for different surgical situations.

Complications in Rhinoplasty

Rhinoplasty is widely regarded as one of the more technically challenging surgeries, owing in part to the many possible short- and long-term complications that can arise. Although severe complications are uncommon, unforeseen complications can lead to esthetic and functional compromise, patient dissatisfaction, and need for revision surgery. The rhinoplasty surgeon must be prepared to counsel patients and identify and manage the range of complications that may result from this procedure. This article reviews some of the most frequently encountered complications related to rhinoplasty and their management approaches.

Tranexamic acid in otorhinolaryngology - A contemporary review

Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.

Re-Evaluating the Effect of Preoperative Tranexamic Acid on Blood Loss and Field Quality During Rhinoplasty: A Randomized Double-Blinded Controlled Trial

BACKGROUND

Nowadays, minimizing the surgical complications of rhinoplasty has gained more importance. Results from previous trials show that Tranexamic acid (TXA) reduces intraoperative bleeding, one of the major complicating factors during rhinoplasty.

OBJECTIVE

To contribute to previous evidence by re-evaluating the efficacy of TXA, specifically in reducing intraoperative blood loss and increasing surgical field quality in rhinoplasty.

STUDY DESIGN AND METHODS

A randomized placebo-controlled trial was conducted (IRCT20111219008458N2). The outcomes included total intraoperative blood loss, measured by the total volume of fluid collected by suction and gauzes, subtracted by volume of used irrigation fluids, and the quality of surgical field, measured by surgeon's satisfaction on a 5-point Likert scale. Demographics, blood coagulation measures, and clinical data were also collected and were held as covariates in analysis. After blinding, randomization, and group allocations, the intervention group received TXA 10mg/kg and the placebo group normal saline in equal volumes.

RESULTS

Data of a total of 80 patients were gathered and analyzed. The total intraoperative blood loss was insignificantly lower (mean difference [95% CI]:  - 3.6 ( - 19.19, 11.99), P = 0.65) and surgeon's satisfaction was insignificantly higher (mean difference [95% CI]: 0.18 ( - 0.11, 0.46), P = 0.22) in TXA group. Results were confirmed by multivariable analysis.

CONCLUSION

In contrast to most of the previous studies, this study showed only a statistically insignificant decrease in total intraoperative blood loss in patients receiving TXA compared to placebo. Further studies are required to more precisely estimate the efficacy of TXA in reducing blood loss during rhinoplasty.

LEVEL OF EVIDENCE

LEVEL I, RANDOMIZED CONTROLLED TRIAL.: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effects of Intraoperative Local Tranexamic Acid on Periorbital Edema and Ecchymosis in Septorhinoplasty

INTRODUCTION

The aim of the present study is to examine the effect of local administration of tranexamic acid (TXA) through lateral osteotomy line on postoperative periorbital edema and ecchymosis.

MATERIALMETHOD

Thirty patients underwent open technical septorhinoplasty were included. Before lateral osteotomies, the surgeon opened narrow subperiosteal tunnels on the both sides. After lateral osteotomies, the surgeon irrigated TXA into the right tunnel with the broken tip of the injection and the same amount of saline into the left tunnel. The patient's photographs were taken on the first, third, and seventh postoperative days. Periorbital edema and ecchymoses were evaluated by the blinded author. The statistical differences between the 2 sides were analyzed.

RESULTS

Lower Eyelid Edema values were significantly lower in the TXA(+) group than the TXA(-) group on the third day (P = 0.001). There was no statistically significant difference between the sides in terms of lower eyelid edema values on the first and seventh days (P = 0.065, P = 0.317). Upper and lower eyelid ecchymosis values were significantly lower in TXA(+) group than TXA(-) group on the first, third, and seventh days (P < 0.05). Upper eyelid edema values were found to be significantly lower in the TXA(+) group than the TXA(-) group on the first and third days (P = 0.002, P = 0.005). There was no statistically significant between the sides in terms of upper eyelid edema (P = 0.315) on the seventh day.

CONCLUSIONS

It was observed in the present study that local administration of TXA in septorhinoplasty was effective in reducing postoperative periorbital edema and ecchymosis.Level of evidence: 2c.

Effect of Tranexamic Acid Administration on Postoperative Ecchymosis and Edema in Excision of Lipomas

BACKGROUND

Previous studies have shown that systemic tranexamic acid reduces bleeding during soft tissue surgeries and reduces postoperative ecchymosis and edema experienced by surgical patients.

OBJECTIVE

To evaluate the effect of postoperative tranexamic acid administration on the reduction of ecchymosis and edema after lipoma surgery.

MATERIALS AND METHODS

A total of 40 patients who underwent lipoma excision were included in the comparative analysis. In the tranexamic acid group (n = 20), 1 g of tranexamic acid was administered daily for 5 consecutive postoperative days. Tranexamic acid was not administered to the control group (n = 20). The severity of ecchymosis and edema at the first visit after surgery was rated on a 4-point scale by 2 blinded dermatologists.

RESULTS

The mean interval of the initial visit after surgery was 1.1 ± 0.5 (range: 1-4) days. Mean ecchymosis scores were significantly lower in the tranexamic acid group (0.5 ± 0.8) than in the control group (1.2 ± 1.0) (p < .05). No statistical difference was seen in mean edema scores between groups (0.5 ± 0.6 in tranexamic acid vs 0.7 ± 0.8 in control).

CONCLUSION

We observed that postoperative administration of tranexamic acid significantly decreased ecchymosis in lipoma excision.

Quantitative Analysis of Tranexamic Acid Effects on Ecchymosis in Rhinoplasty

Background: Many methods have been described to reduce postoperative ecchymosis in rhinoplasty with tranexamic acid (TXA) remaining controversial. TXA remains a consideration for surgeons, however, may have serious side effects, including seizures, blood clots, and vision changes. Methods: A prospective study of primary rhinoplasty patients was performed from March 2019 to June 2019. TXA was used in 50 patients and postoperative ecchymosis was compared with 50 control patients. Adobe Photoshop was used to quantitate postoperative ecchymosis using multiple objective color scales. Results: One hundred subjects were enrolled in the study. Eighty-four females and 16 males were included. Photographs were taken on postoperative day 7. There were no significant differences among any of the Red, Green, Blue (RGB) and L*a*b* color subgroups with p > 0.05. There were no adverse events with TXA. Conclusions: In this study, TXA did not reduce postoperative ecchymosis in rhinoplasty when used both through intravenous and intraoperative injections.

Transconjunctival Lower Lid Blepharoplasty with and Without Fat Preservation and Skin Resurfacing

Transconjunctival lower lid blepharoplasty is a safe and effective procedure with a low complication rate. Success with this procedure depends on proper patient analysis and selection. The lower lid periorbital fat can be resected, or preserved, and draped over the orbital rim or used as free fat grafts, depending on the clinical presentation. The lower lid skin can be resurfaced with a peel, with a laser, or by skin pinch depending on surgeon preference.

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding

BACKGROUND

Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery.

OBJECTIVES

The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage.

METHODS

This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded.

RESULTS

The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications.

CONCLUSIONS

TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

LEVEL OF EVIDENCE: 2

Tranexamic Acid in Craniomaxillofacial Surgery: A Meta-Analysis and Systematic Review

Objective: To compare the effectiveness of tranexamic acid (TXA) in reducing blood loss and decreasing surgery duration in craniomaxillofacial surgery. Methods: The literature was searched systematically for all comparative studies of the effect of TXA on craniomaxillofacial surgery with placebo to evaluate the efficacy of TXA in craniomaxillofacial surgery. The primary outcome was intraoperative blood loss, and secondary outcomes were postoperative hematocrit, postoperative hemoglobin, and operation duration. Results: This systematic review included 16 studies consisting of 958 patients. Meta-analysis revealed that compared with the placebo group, the TXA group showed a significant reduction in intraoperative blood loss of 139.81 mL (95% confidence interval, CI: -179.66 to -99.96 mL; p < 0.01), a shortening of the maxillary surgery duration of 15.48 min (95% CI: -21.03 to -9.92 min; p < 0.01), an elevation of the postoperative hemoglobin level of 0.74 mg/dL (95% CI: 0.42 to 1.07 mg/dL; p < 0.01), and a limited effect on increasing the postoperative hematocrit level of 1.77% (95% CI: 0.17 to 3.36; p = 0.03). Conclusion: The use of TXA in craniomaxillofacial surgery can effectively reduce intraoperative blood loss, maintain elevate postoperative hemoglobin and hematocrit levels, and reduce the operation duration.

A Systematic Review of Tranexamic Acid in Plastic Surgery: What's New?

BACKGROUND

Blood loss associated with surgical interventions can lead to several complications. Therefore, minimizing perioperative bleeding is critical to improve overall survival. Several interventions have been found to successfully reduce surgical bleeding, including the antifibrinolytic agent. After aprotinin was withdrawn from the market in 2008, TXA remained the most commonly used medication. The safety and efficacy of TXA has been well studied in other specialties. TXA has been rarely used in plastic surgery, except in craniofacial procedures. Since the last review, the number of articles examining the use of TXA has doubled; so the aim of this systematic review is to update the readers on the current knowledge and clinical recommendations regarding the efficacy of TXA in plastic surgical procedures.

METHODS

A systematic literature search was conducted in Medline, SciELO, Cochrane, and Google Scholar to evaluate all articles that discussed the use of TXA in plastic surgery in the fields of aesthetic surgery, burn care, and reconstructive microsurgery.

RESULTS

A total of 233 publications were identified using the search criteria defined above. After examination of titles and abstracts, and exclusion of duplicates, a total of 23 articles were selected for analysis.

CONCLUSIONS

The literature shows a clear benefit of using TXA to decrease blood loss regardless of the administration route, with no risk of thrombosis events. Also, TXA elicits a potent anti-inflammatory response with a decrease in postoperative edema and ecchymosis, which improves recovery time. Further investigations are needed to standardize the optimal administration route and dosage of TXA.

Effects of Intravenous Tranexamic Acid During Rhytidectomy: A Randomized, Controlled, Double-Blind Pilot Study

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent shown to decrease intraoperative bleeding, reduce transfusions, and improve outcomes across multiple specialties. Within plastic surgery, initial reports are encouraging but formal studies are lacking.

OBJECTIVES

The aim of this study was to determine whether intravenous (IV) TXA has any effect on intraoperative bleeding or postoperative sequelae in patients undergoing a deep-plane facelift.

METHODS

This is a prospective, randomized, double-blind, case series in a private practice surgery center. The participants were 44 patients undergoing rhytidectomy with the senior authors (R.A.G. or M.J.G). The treatment group received a 1-g dose of IV TXA prior to skin incision and the same dose 4 hours later (vs saline). Bleeding was rated mild, moderate, or severe. Postoperative ecchymosis and edema were subjectively evaluated by patient and surgeon and scores were aggregated for analysis.

RESULTS

The TXA group showed decreased intraoperative bleeding but this difference did not reach statistical significance. Postoperative ecchymosis/edema ratings were lower for patients who received TXA, including a statistically significant decrease in surgeon-rated bruising. TXA resulted in a statistically significant decrease in postoperative collections in this study and no major complications occurred.

CONCLUSIONS

TXA is a safe, low-cost addition to any existing surgical protocol and may lead to fewer surgical sequelae and improved satisfaction. Although we did not observe a dramatically different intraoperative experience, postoperative bruising and collections were significantly reduced. TXA acid may have great value in the management of patients undergoing rhytidectomy and its use warrants further study.

LEVEL OF EVIDENCE: 2