Efficacy of tranexamic acid on side effects of rhinoplasty: A randomized double-blind study

A systematic review and meta-analysis of systematic and topical tranexamic acid administration in aesthetic plastic surgery

INTRODUCTION

Tranexamic acid has been widely used in plastic surgery. However, its efficacy has yet to be fully established. This meta-analysis aimed to determine its effectiveness in aesthetic plastic surgery.

METHODS

Following PRISMA guidelines, we conducted a meta-analysis of prospective randomised clinical trials that compared the effects of topical or systematic administration of tranexamic acid versus the control group in aesthetic plastic surgeries. The study was registered on the International Register of Systematic Reviews (PROSPERO) and is available online ( www.crd.york.uk/prospero , CRD42023492585).

RESULTS

Eleven studies encompassing 960 patients were included for the synthesis after critical evaluation. Systematic (MD - 18.05, 95% Cl, - 22.01, - 14.09, p < 0.00001) and topical (MD - 74.93, 95% Cl, - 88.79, - 61.07, p < 0.00001) administration of tranexamic acid reduced total blood loss. Topical tranexamic acid reduced drainage output (p < 0.0006).

CONCLUSION

Tranexamic acid reduced blood loss in aesthetic plastic surgery. More strictly defined RCTs, using high-quality methodology, are needed to evaluate the advantages and disadvantages of tranexamic acid in aesthetic plastic surgery.

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 .

Use of Intravenous Tranexamic Acid in Patients Undergoing Plastic Surgery: Implications and Recommendations per a Systematic Review and Meta-Analysis

With increasing interest in aesthetic plastic procedures, the event of blood loss has compromised patients' safety and satisfaction. Tranexamic acid (TXA) is a drug used for the reduction of blood loss during surgical procedures. This systematic review aims to evaluate the clinical efficacy and safety of TXA in aesthetic plastic surgery for the reduction of bleeding and related complications. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Electronic databases PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. The medical subject headings (MeSH) keywords used for data extraction were ("TXA," OR "tranexamic acid,") AND ("plastic surgery," OR "aesthetic surgery," OR "rhinoplasty," OR "blepharoplasty,") AND ("blood loss" OR "bleeding" OR "TBL") AND ("Edema" OR "ecchymosis"). A combination of these MeSH terms was used in the literature search. The timeline of research was set from 2015 to January 2024. A total of 7380 research articles were identified from the above-mentioned databases, and only 13 research articles met the inclusion criteria. There was a significant difference in total blood loss (TBL) among patients who had undergone plastic surgery procedures while on TXA as compared to a placebo (mean difference = -6.02; Cl: -1.07 to -0.16; p > 0.00001), and heterogeneity was found (degrees of freedom (df) = 9; I2 = 97%). Only two studies reported the average ecchymosis scores after TXA among interventions in comparison to the placebo group. This review provides evidence that TXA lowers TBL, ecchymosis, edema, and anemia during cosmetic surgery without significantly increasing thromboembolic consequences.

Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study

PURPOSE

To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty.

METHODS

A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events.

RESULTS

By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported.

CONCLUSION

In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.

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.

The Effect of Topical Tranexamic Acid on Postrhinoplasty Periorbital Ecchymosis and Eyelid Edema

BACKGROUND

This study aimed to examine the effectiveness of topical tranexamic acid application in overcoming periorbital ecchymosis and eyelid edema in patients who have undergone open-technique rhinoplasty.

METHODS

Fifty patients were included in the study and divided into two groups: those who had topical tranexamic acid applied and those who did not (controls). In the tranexamic acid group, tranexamic acid-soaked pledgets were placed under the skin flap in a way that both sides could reach the osteotomy area and left for 5 minutes. In the control group, isotonic saline-soaked pledgets were placed under the skin flap in the same manner and left for 5 minutes. Digital photographs were obtained on postoperative days 1, 3, and 7. Eyelid edema and periorbital ecchymosis were scored by two different examiners and averaged for comparison.

RESULTS

Edema that developed in the patients who had tranexamic acid applied was significantly less than in the control group on postoperative day 1. There was no difference between the two groups on postoperative day 3 or 7. Ecchymosis that developed in patients who had tranexamic acid applied was significantly less than in the control group on all days.

CONCLUSIONS

Topical tranexamic acid applied to the surgical field immediately after osteotomy in rhinoplasty surgery reduces the development of postoperative periorbital ecchymosis. In addition, the topical tranexamic acid application also reduces the development of eyelid edema in the early postoperative period.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

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.

Intravenous Application of Tranexamic Acid in Patients Undergoing Plastic Surgery: A Systematic Review and Meta-analysis with GRADE Quality Assessment

BACKGROUND

Tranexamic acid (TXA) is a versatile antifibrinolytic agent that is widely used in modern surgeries. This review assessed the safety and efficacy of intravenous (IV) TXA in plastic surgery versus controls.

METHODS

This review selected English-language Randomized controlled trials (RCTs) evaluating IV TXA effects in plastic surgery from four electronic databases, PubMed, Web of Science, Embase, and Cochrane Library up to April 9, 2023. Primary outcomes were blood loss volume (BLV) and transfusion occurrence, with operation time and surgical field assessment as secondary outcomes. IV TXA-related complications were also important indicators. Meta-analyses and qualitative analyses were conducted and the quality of the evidence was assessed.

RESULTS

Thirty RCTs with 2150 patients were included. The total standard mean difference (SMD) of BLV and pooled relative risk of transfusion occurrence between the IV TXA and the control groups were - 1.11 (95% CI, - 1.42 to - 0.80) and 0.36 (95% CI, 0.23 to 0.55) respectively, indicating a significant blood loss reduction with IV TXA treatment, while an ambiguous outcome of operation time was observed, with an SMD of - 0.22 (95% CI, - 0.42 to - 0.02). The quality of evidence for BLV and transfusion occurrence was low and medium, respectively. A quantitative analysis of surgical field assessment was not performed because of the substantial heterogeneity in scoring methods. No IV TXA-related complications were observed.

CONCLUSIONS

In plastic surgery, IV TXA administration results in less blood loss, reduced need for transfusion and better surgical fields but probably does not increase the risk of adverse events.

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 Table of Contents or 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 .

A Systematic Review of the Efficacy and Safety of Tranexamic Acid in Facelift Surgery

Tranexamic acid (TXA) has become widely utilized in different specialities including facelift surgery. The aim of this review was to robustly evaluate the quality of available evidence on the efficacy and safety of TXA use in facelift surgery. We searched the MEDLINE (National Institutes of Health, Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), CINAHL (EBSCO Information Services, Ipswich, MA), Cochrane Central Register of Controlled Trials (CENTRAL; Wiley, Hoboken, NJ), Google Scholar (Alphabet Inc. Mountain View, CA), Science Citation Index (Clarivate, London, UK), and Latin American and Caribbean Center on Health Sciences Information (LILACS; São Paulo, Brazil) databases for randomized controlled trials (RCTs) and observational studies. Primary outcomes were blood loss, postoperative hematoma, ecchymosis, and swelling, in addition to technical considerations and complications. We assessed review quality with the AMSTAR 2 tool, study quality with Grading of Recommendations, Assessment, Development, and Evaluations approach (GRADE) tool, and the risk of bias with Cochrane's RoB 2.0 tool for RCTs and ROBINS-I for nonrandomized studies. Of the 368 articles, a total of 3 studies including 150 patients met the inclusion criteria. The RCT reported a significant reduction in postoperative serosanguineous collections in the TXA group (P < .01), and in surgeon-rated postoperative ecchymosis and bruising. The prospective cohort study reported reduced drainage output in first 24 hours in the TXA group (P < .01). The retrospective cohort study reported lower intraoperative blood loss, mean postoperative day 1 drain output, percentage of drain removal on postoperative day 1, and number of days to drain removal in the TXA group (all P < .01). The quality of studies was moderate, and this review was the highest rated compared to previous reviews, as per the AMSTAR 2 tool. Based on limited literature, TXA improves clinical outcomes regardless of the route of administration. Topical TXA is an emerging route, expediting drain removal and reducing blood loss. Future Level I high-quality studies are required.

Modern use of tranexamic acid in facial plastic surgery

PURPOSE OF REVIEW

Although tranexamic acid is commonly used in surgical fields such as obstetrics, orthopedics, and trauma, its utilization in facial plastic surgery is a recently emerging concept, and studies examining its potential impact have been few. This review highlights how tranexamic acid may be employed during facial plastic procedures and the promising impact it may have.

RECENT FINDINGS

Tranexamic acid is primarily being studied in rhinoplasties and rhytidectomies, with intravenous administration and local infiltration being the most common routs of application, respectively. During rhinoplasties, tranexamic acid has the potential to improve the visualization of the surgical field by decreasing blood loss and to improve postoperative edema and ecchymosis. For rhytidectomies, on the contrary, it may shorten time to attain hemostasis, lessen the rate of hematoma formation, and lead to lower surgical drain output. Its efficacy is preserved at low doses, and significant medication side effects have not been reported after facial plastic procedures.

SUMMARY

Altogether, tranexamic acid may present a valuable adjuvant to facial plastic surgery, as it could increase both surgeon and patient satisfaction while exhibiting a benign safety profile.

Reducing Postoperative Swelling, Edema, and Ecchymosis after Open Rhinoplasty Using Intranasal Drainage

Reducing postoperative strain on the patient after rhinoplasty is an important goal for the surgeon. Many strategies are described to reach that goal. One strategy is to remove blood from under the dissected soft tissue envelope by drains, before it can infiltrate the different layers causing ecchymosis, edema, and swelling. In our setting with wide degloving and using drains, we could show a significant reduction in ecchymosis on day 2 and 14 after surgery (p = 0.006 and p = 0.017). We also observed a significant effect for edema and general swelling on day 2 (p = 0.027 and p = 0.004), but this effect did not reach significance for these two parameters on day 14. And although the long-term effect needs to be assessed in the future, we found that using drains in open rhinoplasty with wide degloving is an easily applicable, cheap, and reproducible approach to reduce postoperative ecchymosis, edema, and swelling.

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 .

Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines

PURPOSE

Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.

METHODS

Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.

RESULTS/CONCLUSIONS

Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient's individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient's thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient's internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery

BACKGROUND

Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients.

OBJECTIVES

This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes.

METHODS

A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed.

RESULTS

Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001).

CONCLUSIONS

TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

LEVEL OF EVIDENCE: 4

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.

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set

SUMMARY

The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

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.

Surgical and Nonsurgical Management of the Nasal Skin-Soft Tissue Envelope

Management of the skin-soft tissue envelope (SSTE) in rhinoplasty is challenging and critical for the overall outcome. The preoperative identification of patients with thick or thin skin and with preexisting skin conditions may contribute significantly to the postsurgical result. Most publications and textbooks focus on the management of the osseocartilaginous framework, but the SSTE management is often not addressed in detail. However, nonsurgical treatments, such as skin preconditioning, topical steroid-injections, oral isotretinoin, and topical vitamin A derivatives, may provide strong benefits. In this article, we reviewed the literature to present a comprehensive review on the available surgical and nonsurgical approaches pre-, intra-, and postoperatively dealing with SSTE in rhinoplasty.

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.

Routine Postoperative Management of Blepharoplasty: A Review of Current Evidence-Based Practice

Advances in blepharoplasty have resulted in an improved understanding of preoperative risk factors, intraoperative hemostasis, and wound closure. This has reduced the risk of severe adverse events. The aim of this review is to determine the current evidence base for routine postblepharoplasty management. A literature review was performed using MEDLINE, PUBMED, and EMBASE databases. Expanded search criterion "bleph*" was combined with individual terms assessing postoperative management. Articles were assessed and qualified as per Oxford Centre of Evidence-Based Medicine levels 1 to 5 (1 = highest level of evidence). A total of 47 unique articles matched our search strategy. Most articles were a description of individual expert opinion, surveys of practice, or case series (level 4-5 evidence). Few randomized controlled trials were performed (level 2). Many articles describe the clinical experience of senior facial plastic surgeons. Our review found some evidence for postoperative cooling and preincision antisepsis to be effective. This review highlights the need for higher-quality studies to improve the evidence base for routine postoperative management.

Efficacy of Topical Tranexamic Acid (Cyclokapron) in "Wet" Field Infiltration with Dilute Local Anaesthetic Solutions in Plastic Surgery

BACKGROUND

Surgical bleeding may lead to the need for blood transfusion and minimizing blood loss has been a basic principle followed by surgeons for generations. Antifibrinolytic agents are widely used to reduce perioperative haemorrhage. The present study sought to assess the efficacy of directly infiltrated tranexamic acid in ameliorating bruising in participants undergoing cosmetic plastic surgery (liposuction).

MATERIALS AND METHODS

The study employed a blinded, prospective, randomized, case control design. Thirty-three patients were studied. Tranexamic acid free infiltration tumescent solution (saline, bupivacaine lignocaine and adrenalin) was infiltrated to one flank of patients undergoing liposuction of flanks. The other flank was infiltrated with the same tumescent solution (saline, bupivacaine lignocaine and adrenalin) mixed with tranexamic acid (0.1%). Bruises were photographed one and seven days after surgery and measured for size. The surface area of the bruises was calculated using ImageJ software. We compared the bruised surface are between the tranexamic acid infiltrated flank and non-tranexamic acid infiltrated flank in the same patient. The model employed involved measuring the bruises on each flank of the same patient, with surgery by a single surgeon using the same infiltration and surgical techniques for both sides. The only variable was the difference in tranexamic acid concentration between study and control flanks.

RESULTS

We found that use of tranexamic acid consistently resulted in a smaller bruise area on days one and seven after liposuction of flanks. Results were statistically significant.

CONCLUSIONS

This is the first study examining addition of tranexamic acid to a tumescent infiltration solution-to produce a predictable local concentration of tranexamic acid-in order to maximize surgical site effect and minimize systemic effect. The authors recommend incorporation of tranexamic acid as a routine component along with adrenaline and local anaesthetics in tumescent field infiltration solution 10-15 min before commencement of the cosmetic surgery.

LEVEL OF EVIDENCE II

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 effect of a single 75 mg preoperative dose of pregabalin on postoperative pain in rhinoplasty: A double-blinded, placebo-controlled randomized clinical trial

The goal of this study was to evaluate the effect of a single preoperative dose of 75 mg of pregabalin on postoperative pain in rhinoplasty. Volunteers with a physical status of ASA I were included in our study after informed written consent. This was a randomized, double-blinded, placebo-controlled clinical trial. All pregabalin and placebo capsules were given to patients orally 1 h prior to surgery. A standard open rhinoplasty procedure was performed on all patients. All patients underwent the same general anesthesia and postoperative analgesic protocol, with the only difference between the two studied groups being the use of a single dose of pregabalin prior to surgery. Finally, pain intensity was measured at 2, 4, 6, 12, and 24 h after surgery, using a horizontal visual analogue scale (VAS), and was analyzed statistically. 128 volunteers - 33 men (25.8%) and 95 women (74.2%) - with a mean age of 26.23 ± 7.16 were included in this study. Pain intensity scores were consistently lower in patients who received pregabalin preoperatively (p = 0.002); however, the incidence of nausea, drowsiness, difficulty in concentrating, dry mouth, and constipation showed no differences between the two study groups (p > 0.05). In conclusion, the administration of pregabalin should be added to the perioperative protocol whenever appropriate.

Tranexamic Acid in Aesthetic Facial Plastic Surgery: A Systematic Review of Evidence, Applications, and Outcomes

Background

Tranexamic acid (TXA) is an antifibrinolytic that has become widely used in aesthetic facial plastic surgery, although its efficacy has not been well investigated.

Objectives

To evaluate the existing evidence for use of TXA in aesthetic facial plastic surgery, highlighting routes of administration, dosing, surgical applications, and clinical outcomes.

Methods

Systematic review of primary literature evaluating TXA in aesthetic facial plastic surgery.

Results

Eleven studies met inclusion criteria: 8 prospective randomized controlled trials, 2 retrospective case series/cohort studies, and 1 clinical opinion. Six studies evaluated TXA in rhinoplasty, 4 in rhytidectomy, and 1 in blepharoplasty. Significant reductions in intraoperative blood loss were found in 5 rhinoplasty studies. Three rhinoplasty and 2 rhytidectomy studies found significantly reduced postoperative edema and ecchymosis. One rhinoplasty and 1 rhytidectomy study reported reduced operative time and time to achieve hemostasis. One rhytidectomy study reported reduced postoperative drain output and faster time to drain removal. No studies reported an adverse outcome directly related to TXA.

Conclusions

Existing literature investigating TXA in aesthetic facial plastic surgery is sparse with varying levels of evidence and heterogeneous data. Literature suggests systemic TXA reduces intraoperative blood loss during rhinoplasty, although the clinical significance of this blood loss reduction is unclear. TXA may also reduce postoperative edema and/or ecchymosis in rhytidectomy and rhinoplasty, although the lack of validated grading scales yields insufficient evidence to support this claim. Topical and subcutaneously injected TXA are emerging administration routes in rhytidectomy, with evidence suggesting TXA mixed with tumescent may reduce postoperative drain output, thereby expediting drain removal.

Level of Evidence: 2

Local Infiltration of Tranexamic Acid With Local Anesthetic Reduces Intraoperative Facelift Bleeding: A Preliminary Report

BACKGROUND

Rebound bleeding as a result of loss of epinephrine effect is a common problem encountered during facelift surgery. Tranexamic acid (TXA) is an anti-fibrinolytic agent whose safety and efficacy in reducing bleeding are well documented. We have found that local infiltration of TXA combined with a lidocaine with epinephrine solution during facelift surgery has been effective in decreasing rebound bleeding and the time required to gain hemostasis.

OBJECTIVES

The authors sought to share their local infiltration protocol of TXA combined with epinephrine solution in facelift.

METHODS

Patients who underwent facelift received subcutaneous injection of TXA-lidocaine 0.5% solution following the authors' protocol. After completing both sides of the facelift and the submental platysmaplasty, the first and second sides were sequentially closed. The time to gain hemostasis on each side prior to closure was prospectively measured.

RESULTS

Twenty-seven consecutive patients who underwent facelift surgery received local infiltration of TXA-lidocaine solution. In 23 of the 27 patients, the time required for hemostasis was prospectively recorded. The mean age was 62.1 years (±9.3) and all were females. The average time spent achieving hemostasis on the right, left, and both sides of the face was 6.5 (±2.7), 6.3 (±2.1), and 12.9 (±4.2) minutes, respectively. The total surgical time saving is approximately 25 to 60 minutes. Although primary facelift [13.6 (± 4.3)] exhibited a longer time of hemostasis compared with the secondary group [10.2 (± 2.8)], this was not statistically significant (P = 0.09).

CONCLUSIONS

Local infiltration of TXA with local anesthetic prior to a facelift appears to decrease bleeding, operative time, and postoperative facelift drainage output.

Level of Evidence: 4.

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.

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

Importance

Blood loss from surgical procedures is a major issue worldwide as the demand for blood products is increasing. Tranexamic acid is an antifibrinolytic agent commonly used to reduce intraoperative blood loss.

Objective

To systematically examine the role of tranexamic acid in reducing intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.

Data Sources

A systematic review and meta-analysis was undertaken in an academic medical setting using Medline, Embase, and Google Scholar from inception to June 30, 2018. All references of included articles were screened for potential inclusion. The search was mapped to Medical Subject Headings, and the following terms were used to identify potential articles: reconstruction or rhinoplasty and tranexamic acid or anti-fibrinolysis or antifibrinolysis and bleeding or ecchymosis or bruising or edema or complications.

Study Selection

The population of interest consisted of adult patients undergoing primary elective rhinoplasty. The intervention was the use of tranexamic acid. The control group was composed of patients receiving a placebo. Primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. In vitro or animal studies were excluded, and only English-language articles were included.

Data Extraction and Synthesis

The PRISMA guidelines were followed, and articles were assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Random-effects meta-analysis was performed to determine the overall effect size.

Main Outcomes and Measures

The primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis.

Results

Five studies (comprising 332 patients) were included in the qualitative analysis, all of which were randomized clinical trials published within the past 5 years. The mean (SD) patient age was 27 (7) years (age range, 16-42 years), while the mean (SD) sample size was 66 (19) (range, 50-96). Meta-analysis of 4 studies (271 patients) indicated that tranexamic acid treatment resulted in a mean reduction in intraoperative blood loss of -41.6 mL (95% CI, -69.8 to -13.4 mL) compared with controls (P = .004). Three studies indicated that postoperative edema and ecchymosis were reduced with tranexamic acid treatment compared with controls; however, there was no significant difference compared with corticosteroid use. Four studies were considered of high methodological quality, with a low risk of bias. The overall quality of evidence was high.

Conclusions and Relevance

Tranexamic acid has the ability to significantly reduce intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.

Level of Evidence

4.

Reporting Outcomes and Outcome Measures in Open Rhinoplasty: A Systematic Review

BACKGROUND

Comparative studies have shown little statistical difference in outcomes following rhinoplasty, demonstrating near equivalent results across all surgical techniques. Cross-study comparisons of these trials are difficult because variation in outcome reporting prevents statistical pooling and analysis.

OBJECTIVES

The authors sought to identify all outcomes and outcome measures used to evaluate postoperative results in rhinoplasty.

METHODS

An extensive computerized database search of MEDLINE and EMBASE was performed; all trials involving n ≥ 20 patients, aged 18 years and older undergoing a primary, open rhinoplasty procedure, were included for review.

RESULTS

Of the 3235 citations initially screened, 72 studies met the stated inclusion criteria. A total of 53 unique outcomes and 55 postoperative outcome measures were identified. Outcomes were divided into 6 unique domains: objective signs, subjective symptom severity, physical function related to activities of daily living, patient satisfaction, surgeon satisfaction, and quality of life. The identified outcome measures consisted of 5 nasal-specific, author-reported instruments; 5 nasal specific, patient-reported instruments; 5 patient-reported, generic instruments; and 40 author-generated instruments. Of the outcome measures identified, the Rhinoplasty Outcomes Evaluation, Sino-Nasal Outcome Test-22, and FACE-Q were the only instruments to demonstrate adequate validity, reliability, and responsiveness to change in patients who underwent a rhinoplasty procedure.

CONCLUSIONS

There is heterogeneity in the outcomes and outcome measures employed to assess postsurgical outcomes following rhinoplasty. A standardized core outcome set is urgently needed to make it possible for future investigators to compare results of various techniques in rhinoplasty surgery.

LEVEL OF EVIDENCE: 2

Preoperative Tranexamic Acid for Treatment of Bleeding, Edema, and Ecchymosis in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Evidence has emerged on the efficacy of tranexamic acid to control blood loss and postoperative complications after rhinoplasty.

Objective

To investigate the results of tranexamic acid use to reduce intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty.

Data Sources and Study Selection

For this systematic review of randomized clinical trials, searches were performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, Science Direct, Google Scholar, OpenThesis, and ClinicalTrials.gov from inception to December 23, 2017. Key words included tranexamic acid, rhinoplasty, and nasal surgical procedures. The following elements were used to define eligibility criteria: (1) population: patients undergoing rhinoplasty surgery; (2) intervention and controls: tranexamic acid vs placebo solution or no-treatment control group; (3) outcomes: intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis, and thromboembolic events; and (4) study type: randomized clinical trials.

Data Extraction and Synthesis

Two reviewers extracted data and assessed study quality according to the Cochrane guidelines for randomized clinical trials. Treatment effects were defined as weighted mean difference (WMD) and 95% CIs. The strength of evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation rating system.

Main Outcomes and Measures

Intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis. To calculate the effect sizes, means and SDs were obtained for each study group and outcome of interest.

Results

Five studies comprising 276 patients were included in the systematic review: 177 patients (64.1%) were women, and mean age was 26.8 (range, 16-42) years. Four studies comprising 246 patients estimated the amount in intraoperative bleeding as a primary outcome and were included in the meta-analysis. Eyelid edema and ecchymosis were evaluated as outcomes in 2 studies. Tranexamic acid was associated with reduced bleeding during rhinoplasty was found (WMD, -42.28 mL; 95% CI, -70.36 to -14.21 mL), with differences (P = .01) between oral (WMD, -61.70 mL; 95% CI, -83.02 to -40.39 mL; I2 = 0%) and intravenous (WMD, -23.88 mL; 95% CI, -45.19 to -2.58 mL; I2 = 56%) administration. Eyelid edema and ecchymosis scores in patients receiving tranexamic acid were significantly lower compared with the control group within the first postoperative week: lower eyelid edema, WMD, -0.76; 95% CI, -1.04 to -0.49 and lower eyelid ecchymosis, WMD, -0.94; 95% CI, -1.80 to -0.08. No cases of thromboembolic events were reported.

Conclusions and Relevance

Current available evidence suggests that preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding as well as postoperative eyelid edema and ecchymosis in patients undergoing rhinoplasty.

Role of tranexamic acid in nasal surgery: A systemic review and meta-analysis of randomized control trial

OBJECTIVE

Nasal surgeries (such as Functional Endoscopic Sinus Surgery, Rhinoplasty, and Septorhinoplasty) are popular procedures. But perioperative bleeding, eyelid edema, and periorbital ecchymosis remain problems. Tranexamic acid (TXA) is an antifibrinolytic, and it was used to reduce the perioperative bleeding. However, there is no enough evidence judging its safety and efficiency. Therefore, a meta-analysis is conducted by us to evaluate the role of TXA in patients undergoing nasal surgeries.

METHOD

A search of the literature was performed until June 2018; the PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for related articles using search strategy. Two authors independently assessed the methodological quality of the included studies and extracted data. Surgical information and postoperative outcomes were analyzed. Only randomized controlled trial (RCT) articles were included, and subgroup analysis was established to deal with heterogeneity. RevMan 5.3 software was selected to conduct the meta-analysis.

RESULT

Eleven RCTs were included in our meta-analysis. There were significant differences in blood loss (P < .001), surgical field quality (P < .001), edema rating of upper (P < .001) and lower (P < .001) eyelid, ecchymosis rating of upper (P < .001) and lower eyelid (P < .001) when comparing the TXA group to the placebo group. However, the difference in operation time (P = .57) was not significant between the two groups.

CONCLUSION

Perioperative TXA could reduce the blood loss and improve the quality of surgery field during nasal surgery, and it was helpful for reducing the edema and ecchymosis after nasal surgeries, but it has little influence in reducing the operation time.

The Role of Antifibrinolytics in Reducing Blood Loss During Craniofacial or Orthognathic Surgical Procedures: A Meta-Analysis

PURPOSE

Use of antifibrinolytic drugs in craniofacial and orthognathic surgery seems quite promising and has strong advocates. However, supporting evidence is controversial and limited by a small sample of individual studies. We sought to systematically review and meta-analyze the available data regarding the role of preoperative or intraoperative antifibrinolytic drugs (eg, tranexamic acid, aprotinin, or aminocaproic acid) in craniofacial and orthognathic surgery.

MATERIALS AND METHODS

We searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science through April 19, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included the volume of blood loss, volume of transfusions, and operative time. A meta-analysis was performed with a random-effects model using Review Manager (RevMan) software (The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

We identified 32 eligible studies with 749 patients undergoing craniofacial surgery and 546 undergoing orthognathic surgery. Meta-analysis showed that antifibrinolytic use led to statistically significant decreases in blood loss and blood transfusions for craniofacial procedures in adult or pediatric patients and to significantly less blood loss during orthognathic surgical procedures. Operative time did not significantly differ for either type of surgery.

CONCLUSIONS

Antifibrinolytics can significantly reduce blood loss in craniofacial surgical procedures including pediatric craniosynostosis and adult rhinoplasties and in orthognathic surgical procedures, as well as transfusion requirements in pediatric craniofacial surgical procedures. However, the clinical significance of the medications is still questionable because of the relative paucity of information on adverse effects and the usual small volume loss during those operations.

Tranexamic acid for patients with nasal haemorrhage (epistaxis)

BACKGROUND

Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention.

OBJECTIVES

To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re-bleeding (as measured by the proportion of patients re-bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re-bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults.Tranexamic acid versus placeboFor our primary outcome, control of epistaxis: re-bleeding (proportion re-bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re-bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate-quality evidence).When we compared the effects of oral and topical tranexamic acid separately the risk of re-bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate-quality evidence) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low, therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10-day period after a single application.No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events).The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low-quality evidence).No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation).One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low-quality evidence).Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) -1.60 days, 95% CI -2.49 to -0.71; 68 participants). The other study found no evidence of a difference between the groups.Tranexamic acid versus other haemostatic agentsWhen we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) (moderate-quality evidence).Adverse effects across all studiesFive studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No "other serious adverse effect" was reported in any study.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that there is probably a reduction in the risk of re-bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10-day period after a single application. We found moderate-quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes.There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials.

STUDY DESIGN AND METHODS

A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis.

RESULTS

A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not.

CONCLUSION

Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.

Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions

BACKGROUND

Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations.

METHODS

A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications.

RESULTS

Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495).

CONCLUSIONS

Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.

Tranexamic Acid Decreases Visible and Hidden Blood Loss Without Affecting Prethrombotic State Molecular Markers in Transforaminal Thoracic Interbody Fusion for Treatment of Thoracolumbar Fracture-Dislocation

STUDY DESIGN

A randomized, double-blind, placebo-controlled clinical trial.

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) administered during the surgical correction of thoracolumbar fracture-dislocation.

SUMMARY OF BACKGROUND DATA

Thoracolumbar fracture-dislocation surgery is generally associated with substantial blood loss and a high risk of deep vein thrombosis. TXA has been shown to improve hemostasis in surgical procedures.

METHODS

We investigated 80 patients with thoracolumbar fracture-dislocation who underwent transforaminal thoracic interbody fusion between March 2014 and December 2016. The patients were randomized into the TXA (n = 39) and Placebo (n = 41) groups, according to whether they did or did not receive pre- and intraoperative TXA treatment. The two groups were compared for demographic characteristics as well as pre- and postoperative levels of prethrombosis-state molecular markers and visible and hidden blood loss volumes. Additionally, the prevalence of TXA-related complications was determined.

RESULTS

The two groups did not differ significantly in demographic characteristics. The visible blood loss (intra- and postoperative bleeding during the first 24 h), hidden blood loss, and true total blood loss during surgery in the TXA group were significantly lower than those in the Placebo group (835 ± 180.3 mL, 351 ± 82.3 mL, 1385 ± 102.3 mL vs. 1155 ± 175.3 mL, 564 ± 170.5 mL, 1683 ± 121.0 mL, respectively; P < 0.01). Furthermore, the levels of the prethrombosis-state molecular markers GMP-140, fibrinogen, fibrin degradation products, and D-dimer were higher in the TXA group than in the Placebo group, although the differences were not significant (P > 0.05). No significant intergroup differences were noted in the prevalence of deep venous thrombosis and pulmonary embolus during the study period.

CONCLUSION

TXA significantly reduced visible and hidden blood loss without affecting the prethrombosis-state molecular markers in transforaminal thoracic interbody fusion or causing any notable adverse effects.

LEVEL OF EVIDENCE

3.

Comparison of the Effect of Dexamethasone and Tranexamic Acid, Separately or in Combination on Post-Rhinoplasty Edema and Ecchymosis

BACKGROUND

Dexamethasone and tranexamic acid are used to decrease post-rhinoplasty periorbital edema and ecchymosis. We compared the impact of each medication separately or in combination in this regard.

METHODS

A prospective, randomized triple-blinded study was undertaken on 60 patients who underwent primary open rhinoplasty. They were divided into four groups: Group D (n = 15) received 8 mg dexamethasone, group T (n = 15) received 10 mg/kg tranexamic acid, group DT (n = 15) received both 8 mg dexamethasone and 10 mg/kg tranexamic acid, and group P (n = 15) received neither medication and served as the placebo control group. The medications were given intravenously (IV) 1 h before and three doses every 8 h postoperatively. Digital photographs were taken on the first, third and seventh postoperative days. One expert examiner blinded to the study evaluated the periorbital edema and ecchymosis on a scale of 0-4. Periorbital edema and ecchymosis were examined in all groups.

RESULTS

In group D, group T and group DT, periorbital edema and ecchymosis ratings were significantly lower compared with the control group (p < 0.01). No statistically significant difference was seen in preventing or decreasing both periorbital edema and ecchymosis among group D, group T and group DT.

CONCLUSION

Tranexamic acid and dexamethasone, separately or in combination, had similar effects in reducing periorbital edema and ecchymosis in open rhinoplasty. Combined application did not show a significantly higher beneficial effect in this regard.

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 .