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

Tranexamic Acid in Mohs Micrographic Surgery: A Systematic Review

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic that has historically been used to treat menorrhagia and bleeding disorders. Exploration of its use in procedures has grown, and it has shown promise in its ability to achieve hemostasis with low risk to patients. Analysis of its use in Mohs micrographic surgery (MMS) is warranted due to its potential superiority to traditional methods of achieving hemostasis (direct pressure, electrocoagulation, and sutures).

OBJECTIVE

To perform a systematic review of studies which evaluate the efficacy and safety profile of topical application or subcutaneous injection of TXA and analyze as it applies to MMS.

MATERIALS AND METHODS

A comprehensive literature search was conducted using the PubMed database to identify relevant studies using the search terms: "tranexamic acid" OR "TXA." The search was performed up to December 1, 2023.

RESULTS

Tranexamic acid has a strong safety profile, and its effectiveness in achieving hemostasis is well-demonstrated. Tranexamic acid has reduced risk of bleeding complications compared with traditional methods of achieving hemostasis.

CONCLUSION

An extensive review of the literature has yielded positive results, suggesting the potential of TXA in improving patient outcomes, reducing surgical time, decreasing intraoperative and postoperative bleeding, and increasing overall patient satisfaction.

Subcutaneous and Topical Tranexamic Acid Use During Rhytidectomy

OBJECTIVE

Tranexamic acid is a potential rhytidectomy adjunct; however, its route of administration, benefits, and safety remain a topic of debate. The purpose of this study is to analyze the effects of topical and subcutaneous TXA during rhytidectomy.

METHODS

This is a retrospective, 3-arm analysis of a single surgeon's practice from Aug. 2019 to Nov. 2023. 175 consecutive patients underwent rhytidectomy; 55 did not receive TXA (8/2019-12/2020), 65 received intraoperative topical 25 mg/mL TXA (1/2021-7/2022), and 55 received subcutaneous 5 mg/mL TXA (7/2022-11/2023). Measured outcomes included drain output, bruising, operative time, estimated blood loss, and complications.

RESULTS

Subcutaneous and topical TXA had similar drain outputs (11.32 mL vs. 12.98 mL, respectively) and bruising scores (20.93 vs. 22.12, respectively). These were significantly less than the control group (24.05 mL, p < 0.001 and 36.28, p < 0.001, respectively). The subcutaneous group operative time (196.13 min) was less than the topical and control groups (212.72 min, p = 0.01; 207.90 min, p = 0.037, respectively) in patients who underwent rhytidectomy with platysmaplasty. EBL and seroma formation in the subcutaneous TXA group were significantly less than the control (23.92 mL vs. 31.67 mL, p = 0.011; 3.60% vs. 18.18%, p = 0.03, respectively). Hematoma, epidermolysis, and infection rates were similar between all groups.

CONCLUSION

Both topical and subcutaneous TXA use during rhytidectomy are associated with reduced postoperative drain output and bruising without an increased risk of complications. Subcutaneous TXA has the added associated benefit of decreasing operative time, EBL, and seroma formation.

LEVEL OF EVIDENCE

III Laryngoscope, 2024.

Clinical Applications of Tranexamic Acid in Plastic and Reconstructive Surgery

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery. This study reviews the scientific evidence regarding the use of TXA in the full range of plastic and reconstructive surgery to provide clinical recommendations for safe and effective use in various plastic surgical procedures.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. An established appraisal process was used to rate the quality of articles (Grading of Recommendations Assessment, Development, and Evaluation methodology).

RESULTS

Forty-five studies describing the use of TXA in plastic surgery were included. There is moderate-certainty evidence to support the use of intravenous administration of TXA in craniofacial surgery procedures to reduce blood loss and transfusion requirements. There is high-certainty evidence to support the use of TXA in cosmetic surgery and intravenous administration in rhinoplasty procedures to reduce blood loss. Further high-level studies are needed to determine TXA's effects on hematoma rates in face-lift surgery and breast-related procedures. There is moderate-certainty evidence to support the use of TXA in burn care. Further studies are required to provide quantitative conclusions on the effects of TXA administration in microsurgery.

CONCLUSIONS

This is the largest study to date on the use of TXA in plastic surgery and the first to provide clinical recommendations. The literature highlights TXA's promising role in the fields of craniofacial surgery, cosmetic surgery, and burn care. Standardized, objective measurements are required to provide quantitative conclusions regarding TXA's effects on ecchymoses and edema in cosmetic surgery procedures.

Impact of Tranexamic Acid on Bleeding Outcomes and Complication Rates in Facelift: A Systematic Review and Meta-analysis

BACKGROUND

Rhytidectomy poses a significant risk of bleeding. Several studies have reported the safety profile and efficacy of tranexamic acid (TXA), an antifibrinolytic agent, in minimizing perioperative sequelae, particularly hematoma and bleeding.

OBJECTIVES

The aim of this systematic review was to analyze the effect of TXA administration in facelift surgery, its effect with different routes of administration, and to compare different administration routes in reducing intraoperative blood loss, postoperative edema, and ecchymosis in rhytidectomy.

METHODS

A systematic literature search was conducted to identify studies that reported on TXA in facelift surgery. The primary outcomes of interest were intraoperative blood loss, time to achieve hemostasis, operation duration, and postoperative hematoma, edema, ecchymosis, drain output, and major and minor complications. Meta-analyses of hematoma, operation duration, drain output, and major and minor complications were performed, and the risk of bias was assessed with ROBINS-I for nonrandomized studies, and Cochrane's RoB 2.0, a tool for randomized controlled trials.

RESULTS

In total, 104 articles were included in the initial screening. Out of 388 participants 170 patients were administered TXA, predominantly female (over 91%), with ages from the late 50s to mid-60s. TXA administration varied, with subcutaneous injection being the most common method. The meta-analysis revealed that the pooled prevalence of minor and major hematoma in TXA recipients was remarkably low, with a significant reduction in the risk of minor hematoma (odds ratio [OR] = 0.18, 95% CI 0.05-0.62, P < .001) and no significant difference in major hematoma risk. Interestingly, TXA significantly reduced postoperative drainage compared to the controls (mean difference = -25.59, 95% CI, -30.4--20.77, P < .01). Additionally, neither minor nor major complications were significantly different between the TXA recipients and controls. Specifically, the pooled odds for the incidence of major complications were not significantly different (OR = 1.47, 95% CI, 0.23-9.19, P = .68), and similar results were found for minor complications (OR = 0.59, 95% CI, 0.23-1.48, P = .26).

CONCLUSIONS

TXA significantly reduces postoperative drain output and minor hematomas in facelift surgery without increasing major complications. It also reduces edema, ecchymosis, and intraoperative blood loss. However, further studies are required to explore the efficacy of TXA with different dosages and administration routes.

LEVEL OF EVIDENCE: 3

Clearing the Smoke: The Evidence behind Risk of Electrocautery Smoke and Mitigation Strategies

Background

Electrocautery has been a useful, fundamental instrument utilized for surgical procedures since its implementation in the 1920s. However, concerns exist regarding the health hazards of the by-product smoke associated with the use of electrocautery.

Methods

A comprehensive review of articles on the composition, mitigation, and effects of smoke was conducted using the PubMed search engine and excluding articles that did not meet the predetermined inclusion criteria. From January 1963 to December 2021, a total of 264 articles resulted, and a total of 69 articles were included in this narrative review.

Results

Surgical smoke contains volatile organic compounds, polycyclic aromatic compounds, viral particles, and ultrafine particles. There has been some evidence of mutagenicity to bacterial cells during animal in vivo studies, and one human survey study has shown similar mutagenic effects. We also discuss additional hemostatic techniques that can be used, including the use of hemostatic and antithrombolytic agents, epinephrine infiltration, and the use of tourniquet when appropriate.

Conclusions

Further studies should be conducted regarding human effects, but until the data are available, we recommend precautionary measures and actions to protect operating room staff from cautery smoke exposure.

Systemic Tranexamic Acid for Reduced Postoperative Blood Loss and Less Bleeding Complications in Fleur-de-lis Abdominoplasty and Apronectomy

BACKGROUND

Strategies minimizing surgical bleeding, including the antifibrinolytic agent tranexamic acid, play a crucial role in clinical practice to optimize overall surgical outcomes. Despite its proven efficacy in various clinical fields, there is a limited understanding regarding the use of tranexamic acid in plastic and aesthetic procedures. This study is the first investigating the effects of systemically administered tranexamic acid on postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies.

METHODS

Patients who received 1 g tranexamic acid (n = 44) during fleur-de-lis abdominoplasty or apronectomy were retrospectively compared with those who did not (n = 44). In this context, the outcome parameters 24-h and total drain fluid production, drain time, hospital stay, absolute and relative drop in hemoglobin and hematocrit level as well as bleeding complications such as blood transfusion, hematoma puncture and evacuation were evaluated.

RESULTS

Tranexamic acid significantly decreased both drainage volume in 24 h (40.5%, p = 0.0046) and total drain fluid production (42.5%, p = 0.0017). Moreover, a shorter drainage time (19.4%, p = 0.0028) and hospital stay (21.4%, p = 0.0009) were observed. The administration of tranexamic acid was also associated with a reduced postoperative decline in hemoglobin and hematocrit levels. Notably, no bleeding complications were observed in patients who received tranexamic acid, while 6 events occurred in patients without (p = 0.0262).

CONCLUSION

Systemic administration of tranexamic acid effectively reduced postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies.

LEVEL OF EVIDENCE IV

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 .

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process.

METHODS

Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021.

RESULTS

Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001).

CONCLUSIONS

A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time.

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 .

Safety and Outcomes in Multiplane Facial Rejuvenation with Tranexamic Acid: A Cohort Study

Background

Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and complications among patients undergoing facial surgical procedures.

Methods

A retrospective cohort study of patients who underwent multiplane facial rhytidectomy from January 2018 to September 2022 at the Clinica Ziegler, Lima, Peru. Patients were divided into two groups according to the use of intravenous plus local infiltration of TXA. We performed the chi square test to assess associations among categorical variables, the Student t test and Mann-Whitney U test for categorical with continuous variables, and Pearson correlation for quantitative variables.

Results

A total of 100 patients were included with 50 patients in each group. The median age was 59.5 years and the majority were women (88%). The median operative time was 288.5 minutes. The TXA group presented less intraoperative bleeding (40 versus 90 mL, P < 0.05) and shorter operative time (237 versus 353 minutes, P < 0.05); no differences in the development of hematoma (2% versus 12%, P = 0.11), less ecchymosis (2% versus 36%, P < 0.05), edema (2% versus 100%, P < 0.05), and time to drain removal (3 versus 6 days, P < 0.05).

Conclusions

TXA improves the short- and long-term outcomes of patients who undergo multiplane facial rhytidectomy. It also decreases intraoperative bleeding by more than half and reduces the operative time by one third. Moreover, patients receiving TXA presented significantly less ecchymosis, edema, and time to drain removal.

Tranexamic Acid in Tumescence for Cervicofacial Rhytidectomies

Background

Cervicofacial rhytidectomies are one of the most common procedures in the United States. There are many different methods and techniques involved, but all aim to minimize blood loss and procedure time. In our study, we investigated the addition of tranexamic acid (TXA) to tumescent anesthesia during rhytidectomy procedures. Our objective was to analyze the difference in mean procedure time and estimated blood loss in patients undergoing both general and other anesthesia types, with and without the addition of TXA, while maintaining patient safety.

Methods

Seventy-four patients underwent a standard superficial musculoaponeurotic system plication technique rhytidectomy, with 60 patients undergoing general anesthesia and the remaining 14 undergoing other anesthesia types. Forty patients were treated without TXA, whereas the remaining 34 were treated with TXA.

Results

Although the difference was not statistically significant, the addition of TXA resulted in a lower procedure time and estimated blood loss. Within anesthesia type, there was also a slight difference that TXA decreased blood loss and procedure time. We did find that general anesthesia type does significantly impact procedure time and estimated blood loss, when compared with other anesthesia types, independent of TXA use.

Conclusion

The use of tumescent TXA may allow for a faster procedure with less blood loss, although further studies with a larger sample size are needed.

Topical Tranexamic Acid in Primary Breast Augmentation Surgery: Short- and Long-term Outcomes

BACKGROUND

Breast augmentation mammaplasty (BAM) remains the most popular cosmetic procedure done worldwide. Bleeding in this procedure increases the chance of capsular contracture. Tranexamic acid (TXA), an antifibrinolytic, has been widely used by other surgical specialties to reduce bleeding.

OBJECTIVES

We aimed to evaluate the use of TXA in BAM surgery.

METHODS

This was a single-surgeon case series of all patients who underwent primary BAM from March 2017 to March 2018 and received topical TXA spray to the implant pocket before implant insertion. Early postoperative complications and long-term outcomes, such as capsular contracture and revisional surgery, were recorded and described.

RESULTS

Two hundred and eighty-eight patients were included in the study with an overall complication rate of 2.8% over 5 years. No patients had postoperative bleeding or hematoma formation. One patient had a seroma, managed with ultrasound drainage. Complications requiring reoperation included rippling (3, 1.0%), pocket revision (2, 0.7%), capsule contracture (1, 0.3%) and rupture (1, 0.3%).

CONCLUSIONS

This study highlights the safety and potential benefits of the use of topical TXA in breast augmentation, with low bleeding and capsular contracture rates.

LEVEL OF EVIDENCE: 4

Wound Healing Complications With Tranexamic Acid: Not the Silver Bullet After All

Tranexamic acid (TXA) has been popularized as an adjunct to decrease the risk of bleeding and subsequent bruising and edema in aesthetic surgery. The most notable risks of TXA are thrombus and seizures, which are associated with higher plasma concentrations of the acid. In an effort to mitigate these risks, surgeons have begun using TXA locally, either as a topical irrigation or mixed into the local anesthetic. Although local use is thought to be safer from a side-effect standpoint, because there is decreased systemic absorption, its use is not without risk. We present 4 patients who developed wound healing complications thought to be related to locally administered TXA. One patient had TXA delivered topically, and 3 patients had TXA mixed into their local anesthetic. These adverse events have not been published in the literature previously. This case report serves as a warning to other surgeons about using locally administered TXA.

LEVEL OF EVIDENCE: 4

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.

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.

Tranexamic acid in rhytidectomy: a scoping review

Background

Intraoperative and postoperative bleeding is considered one of the most common risks in rhytidectomy. Recently, the use of antifibrinolytic agents in facial plastic and reconstructive surgeries has been evaluated, but their use in rhytidectomy remains a topic of ongoing discussion. Tranexamic acid (TXA) is an antifibrinolytic agent that prevents enzymatic degradation of the fibrin clot by blocking the conversion of plasminogen to plasmin, improves platelet function, and has a direct anti-inflammatory effect. This review covers pertinent literature to elucidate whether the use of TXA in rhytidectomy confers intraoperative and postoperative benefits.

Methods

A systematic literature search was conducted in online databases: PubMed, Google Scholar, Cochrane, Scopus, and Web of Science for all articles on the topic of TXA in facelift published up to and including June, 2023 using the following terms: "TXA," "tranexamic acid," "plastic surgery," "aesthetic surgery," "facelift," "rhytidectomy". They were either searched individually or in combination. All relevant original research articles, of any study design were included and narratively discussed in this review. Studies not carried out in humans and studies centred on the use of TXA in other specialties were excluded. English Language was included.

Results

Eight articles were reviewed in this paper. Through these articles, the authors provided in detail the possible beneficial effects of TXA in facelift patients in evaluating several clinical outcomes: intraoperative blood loss, postoperative drain output, postoperative oedema, ecchymosis, operative time, and surgical field quality.

Conclusion

Although there is still a lack of information on TXA in facelift patients, we are not able to deny the beneficial effects of TXA on this topic. Therefore, further investigations including prospective, case-controlled multi-institutional studies comparing routes of delivery should be performed until reaching, at the end, an evidence-based guideline providing a clear protocol in terms of the administration and dosage of TXA in facelift.

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.

[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.

The Usage of Intravenous Tranexamic Acid in Reduction Mammaplasty Safely Reduces Hematoma Rates

BACKGROUND

Bleeding complications are not uncommon after breast reduction surgery, and recently, tranexamic acid (TXA) as an antifibrinolytic agent has been used in various surgical specialties as a way to minimizes such adverse outcomes. We elected to evaluate the effectiveness of intravenous (IV) intraoperative TXA in reduction mammoplasty patients.

METHODS

This is a retrospective chart review of clinical charts of all patients who received reduction mammoplasty by a single surgeon at Emory University Hospital or its affiliated Aesthetic Center from January 1, 2020, to March 1, 2022. Seventy-four consecutive breast reduction patients received 1-g IV TXA intraoperatively compared with 117 consecutive controls. The outcome of interest included 30-day postoperative bleeding complications.

RESULTS

There was no significant difference in age ( P = 0.92), body mass index ( P = 0.98), percentage of smokers ( P = 0.56), operating time ( P = 0.87), estimated blood loss ( P = 0.90), or weight removed ( P = 0.98) between patients in each arm. There were 19 bleeding events (16.2%) in the non-TXA arm compared with 1 bleeding event (1.4%) in the TXA arm ( P = 0.0143). Of the 19, 6 (5.1%) were major events, and 13 were minor events (11.1%); the only bleeding event in the TXA arm was minor. Number needed to treat all bleeding events with use of TXA was 7, and the number needed to treat minor hematomas was 11. There was no significant difference in the rate of seroma, wound healing complications, infection, or nipple necrosis between the 2 arms ( P > 0.05).

CONCLUSIONS

The use of IV TXA is a safe and effective way to reduce hematoma rates in patients receiving reduction mammoplasty.

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

BACKGROUND

In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.

METHODS

A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.

RESULTS

A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.

CONCLUSIONS

The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery.

OBJECTIVES

The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty.

METHODS

A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort.

RESULTS

A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration.

CONCLUSIONS

This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

LEVEL OF EVIDENCE: 3

Defining the Role for Topically Administered Tranexamic Acid in Panniculectomy Surgery

Background

Abdominal panniculectomy after weight loss is a commonly performed procedure with high patient satisfaction yet continues to have a high post-operative complication profile. Several risk-reducing surgical approaches, such as preservation of Scarpa’s fascia, use of tissue adhesives, and progressive tension suture techniques have been described. However, the use of tranexamic acid (TXA) has not been previously reported in panniculectomy surgery.

Objectives

To improve the safety and predictability of this procedure, the authors investigate whether the use of topically administered TXA during panniculectomy surgery reduces seroma, hematoma, and drain duration.

Methods

Consecutive patients who underwent panniculectomy (January 2010 to January 2022) were retrospectively reviewed. Outcome measures included hematoma requiring surgical evacuation, seroma requiring percutaneous aspiration, and drain duration. Patients with thromboembolic diseases and those taking anticoagulation/antiplatelet medications were excluded. Patients who had received TXA were compared with a historical control group who had not received TXA.

Results

A total of 288 consecutive patients were included. Topical TXA was administered in 56 (19.4%) cases. The mean (standard deviation [SD]) follow-up was 43.9 (37.4) months (3.7 years). The median (range) resection weight was 2.6 kg (0.15-19.96 kg). Regarding seroma and hematoma formation, the use of TXA did not reduce the likelihood of developing seroma or hematoma (odds ratio [OR] = 1.7, 95% CI [0.56- 4.8], P = 0.38 and OR = 2.1, 95% CI [0.4-11.8], P = 0.42), respectively. The mean (SD) duration of drains was slightly lower in the TXA group (18.1 [12.1] days vs 19.8 [13.9] days); however, this difference was not statistically significant, albeit clinically significant.

Conclusions

As the use of TXA in plastic surgical procedures continues to expand, the utility of TXA in panniculectomy and abdominoplasty has not been elucidated. Although previous studies report hematoma and seroma risk reduction, the use of TXA was not associated with a statistically significant reduction in seroma, hematoma, or drain duration following panniculectomy surgery. Prospective, randomized controlled studies on the use of TXA in body contouring are needed.

Level of Evidence: 3

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.

Hematoma After Non-Oncologic Breast Procedures: A Comprehensive Review of the Evidence

BACKGROUND

Hematoma after non-oncologic breast surgery is a common concern requiring expeditious treatment. The purpose of this study is to perform an evidence-based review of perioperative factors that may contribute to hematoma in non-oncologic breast procedures.

METHODS

A comprehensive literature review was performed of non-oncologic breast procedures: breast augmentation, single-stage augmentation-mastopexy, mastopexy, and reduction. In total, 28 studies highlighting incidence and potential risk factors for hematoma were included; overall level of evidence was established regarding each perioperative factor examined and hematoma rate.

RESULTS

The hematoma rate in breast augmentation ranges from 0.2 to 5.7%. There is inconclusive evidence to support an association between pocket choice or incision location and hematoma rate (Level III) and no evidence of an association between implant type and hematoma (Level V). Single-stage augmentation-mastopexy may have a lower hematoma rate than augmentation alone (Level II). Hematoma may increase the risk of capsular contracture (Level III). In breast reduction, the hematoma rate ranges from 1.0 to 9.3%. Evidence of an association between incision choice and hematoma rate is inconclusive (Level III). Use of epinephrine-containing solution, pedicle choice, and resection weight do not appear to affect hematoma rate (Level V, II, and II, respectively). The use of postoperative drains and ketorolac do not affect the incidence of hematoma (Level I and III, respectively). Intraoperative hypotension may increase the risk of hematoma after breast reduction (Level III).

CONCLUSIONS

Breast hematomas are not uncommon complications. Current literature lacks ample evidence for risk factors for hematoma after non-oncologic breast procedures, warranting further, high-powered investigations.

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 .

Methods for Minimizing Bleeding in Facelift Surgery: An Evidence-based Review

INTRODUCTION

Bleeding and hematoma remain leading causes of postoperative complications and unsatisfactory patient outcomes in facelift surgery. Several methods have been implemented, and continue to be developed, to minimize bleeding in facelift surgery. These methods include perioperative blood pressure management, compression dressings, drains, tissue sealants, wetting solution infiltrate, and tranexamic acid.

METHODS

An evidence-based review of methods used to minimize bleeding in facelift surgery was conducted using the PubMed database according to PRISMA guidelines. Included studies were evaluated for the effects of implemented methods on bleeding outcomes in facelift surgery. Recommendations for each method evaluated were determined based on the amount, level, and heterogeneity of included studies.

RESULTS

Thirty-six studies were included in the evidence-based review. Effective strategies to reduce the time to hemostasis, postoperative drainage volume, and hematoma rate included perioperative blood pressure management, tissue sealants, and tranexamic acid. While the use of drains or wetting solution infiltrate did not demonstrate to significantly influence bleeding outcome measures, these methods may provide other advantages to facelift surgery. Compression dressings have not demonstrated a significant effect on facelift outcome measures.

CONCLUSIONS

Perioperative medical management of blood pressure, tissue sealants, and tranexamic acid are most effective in facilitating hemostasis and preventing postoperative hematoma in facelift surgery.

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

OBJECTIVES

The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

METHODS

A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

RESULTS

Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

CONCLUSIONS

Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

LEVEL OF EVIDENCE: 4

The Use of Tranexamic Acid in Facial Cosmetic Surgery Procedures: A Technical Note

Tranexamic acid (TXA) has been widely used as an antifibrinolytic in dentoalveolar surgery and only recently has its effects been explored in facial procedures. Multiple studies have reported the use of TXA in facial cosmetic surgery; and to date, only a limited number of them utilized TXA as a local infiltrative technique for rhytidectomy procedures. We present a technical note to using lower concentrations of TXA in tumescent anesthesia for an array of facial cosmetic procedures. Our experience thus far has shown improved hemostasis, reduction of intraoperative bleeding and a more profound reduction in postoperative ecchymosis, edema and seroma formation.

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.

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.