Effect of Tranexamic Acid in Bleeding Control in Liposuction:

Outpatient-Based High-Volume Liposuction: A Retrospective Review of 310 Consecutive Patients

BACKGROUND

Currently, the definition of large-volume liposuction is the removal of 5 L or more of total aspirate. Higher volumes of lipoaspirate come into consideration with higher BMIs, because more than 5 L is often required to achieve a satisfactory aesthetic result. The boundaries of what lipoaspirate volume is considered safe are based on historical opinion and are constantly in question.

OBJECTIVES

Because to date there have been no scientific data available to support a specific safe maximum volume of lipoaspirate, the authors discuss necessary conditions for safe high-volume lipoaspirate extraction.

METHODS

This retrospective study included 310 patients who had liposuction of ≥5 L over a 30-month period. All patients had 360° liposuction alone or in combination with other procedures.

RESULTS

Patient ages ranged from 20 to 66 with a mean age of 38.5 (SD = 9.3). Average operative time was 202 minutes (SD = 83.1). Mean total aspirate was 7.5 L (SD = 1.9). An average of 1.84 L (SD = 0.69) of intravenous fluids and 8.99 L (SD = 1.47) of tumescent fluid were administered. Urine output was maintained above 0.5 mL/kg/hr. There were no major cardiopulmonary complications or cases requiring blood transfusion.

CONCLUSIONS

High-volume liposuction is safe if proper preoperative, intraoperative, and postoperative protocols and techniques are employed. The authors believe that this bias should be modified and that sharing their experience with high-volume liposuction may help guide other surgeons to incorporate this practice with confidence and safety for better patient outcomes.

LEVEL OF EVIDENCE: 3

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 Combined Effect of Intravenous and Topical Tranexamic Acid in Liposuction: A Randomized Double-Blinded Controlled Trial

Background

Tranexamic acid (TXA) use in surgical procedures due to its hemostatic effects has been gaining an increased interest. In plastic surgery, the effects of TXA have been studied intravenously (IV), and there have been some reports regarding local use.

Objectives

A comparative study examining the combined effect of IV and local TXA was conducted.

Methods

A randomized double-blinded controlled trial was performed for patients undergoing breast reduction treatment with liposuction and resection following the power-assisted liposuction mammaplasty (PALM) technique. All patients received 5 mL IV of 0.5 g/5 mL TXA on induction. Before installation, one researcher prepared two solutions of 1 L normal saline: one with 5 mL of 0.5 g/5 mL TXA associated with epinephrine 1:100,000 and the other with only epinephrine 1:100,000. These were randomly infiltrated in either the left or right breast. Clinical dermal bleeding was assessed for both breasts after deepithelialization. The lipoaspirate from these breasts was then compared with each other. A postoperative evaluation at 24 hours was performed to compare the ecchymosis rate.

Results

Ratios of decanted volume to total lipoaspirate was measured in bottles and compared between breasts. There was a statistical difference (P = 0.0002) in the ratio of decanted to lipoaspirated volume when comparing the control group (ratio: 0.21) with the treatment group (0.13). Video analysis revealed decreased dermal bleeding in the TXA group and postoperative evaluation less ecchymosis.

Conclusions

The combined use of IV and local TXA can help reducing blood loss in liposuction as measured by decantation in separate drain bottles and as assessed clinically preoperatively and postoperatively.

Level of Evidence 2

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.

Use of Tranexamic Acid to Reduce Blood Loss in Liposuction

BACKGROUND

The use of tranexamic acid for blood loss prevention has gained popularity in many specialties, including plastic surgery. However, its use in liposuction has not been studied. The authors present a prospective, double-blind, nonrandomized study evaluating the efficacy of tranexamic acid in reducing perioperative blood loss during liposuction.

METHODS

Twenty women undergoing liposuction were divided into two cohorts. Group 1 (n = 10) received a standard dose of 10 mg/kg of tranexamic acid intravenously in the preoperative and postoperative periods, whereas group 2 (n = 10) received a placebo. Patient hematocrit levels were evaluated preoperatively and postoperatively. Blood volume in the infranatant of the lipoaspirate was also measured; t tests were used for statistical analysis.

RESULTS

Age, body mass index, and volume of lipoaspirate were comparable between the two cohorts. The volume of blood loss for every liter of lipoaspirate was 56.2 percent less in the tranexamic group compared with the control group (p < 0.001). Hematocrit levels at day 7 postoperatively were 48 percent less in group 1 compared with group 2 (p = 0.001). Furthermore, a 1 percent drop in the hematocrit level was found after liposuction of 812 ± 432 ml in group 1 and 379 ± 204 ml in group 2. Thus, the use of tranexamic acid could allow for aspiration of 114 percent more fat, with comparable variation in hematocrit levels.

CONCLUSIONS

Tranexamic acid has been shown to be effective for minimizing perioperative blood loss in liposuction. Further large randomized controlled studies are required to corroborate this effect.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.