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

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

Tranexamic Acid as a Preventive Strategy Against Periprosthetic Joint Infection in Aseptic Revision Arthroplasty: A Comprehensive Review

Periprosthetic joint infection (PJI) is a severe complication following joint replacement surgeries, particularly in aseptic revision arthroplasty, where infection rates are higher compared to primary procedures. The extended surgical time, increased blood loss, and the presence of scar tissue contribute to the higher susceptibility to PJI in revision surgeries. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is widely used in orthopaedic surgery to reduce intraoperative and postoperative bleeding. By stabilising blood clots and reducing the need for blood transfusions, TXA improves patient outcomes and reduces complications related to excessive bleeding. Emerging evidence suggests that TXA may also play a role in reducing PJI, as minimising bleeding and haematoma formation can reduce bacterial colonisation and blood transfusions are associated with increased infection risks due to immunomodulation. This review explores the potential of TXA as a preventive strategy against PJI in aseptic revision arthroplasty, evaluating its mechanisms, clinical applications, and current evidence. While TXA's efficacy in reducing blood loss is well-established, its role in infection prevention, particularly through indirect mechanisms such as limiting haematoma formation, warrants further investigation. By incorporating TXA into multimodal strategies aimed at reducing PJI, surgeons can potentially improve patient outcomes and reduce the financial burden on healthcare systems. This review provides a comprehensive examination of the available data on TXA's role in preventing PJI in revision arthroplasty, with an emphasis on understanding its mechanisms and identifying gaps in current knowledge that require further research.

The Use of Tranexamic Acid in Breast Reduction and Abdominoplasty: A Review of a Multicenter Federated Electronic Health Record Database

Background

Tranexamic acid (TXA), a fibrinolysis inhibitor, is widely used in various surgical fields to minimize blood loss. However, its efficacy and safety in plastic surgery, especially in reduction mammaplasty and abdominoplasty, remain underexplored. This study investigates the utility of intravenous (IV) TXA in these procedures, focusing on reducing postoperative complications and evaluating its safety in the context of venous thromboembolism (VTE).

Objectives

To evaluate the efficacy and safety of TXA in reduction mammaplasty and abdominoplasty.

Methods

Using data from the TriNetX LLC (Cambridge, MA) National Health Research Network database, this retrospective study compared adult patients undergoing reduction mammaplasty or abdominoplasty who received intraoperative IV TXA against those who did not. Primary outcomes included postoperative seroma and hematoma incidences, whereas secondary outcomes assessed the necessity for procedural drainage and the occurrence of VTE within 1-year postsurgery.

Results

No significant differences in the rates or risks of hematoma, seroma, or the need for procedural drainage between patients administered IV TXA and those who were not, for both reduction mammaplasty and abdominoplasty. Additionally, IV TXA did not increase the risk of VTE in either patient group.

Conclusions

IV TXA application in reduction mammaplasty and abdominoplasty does not provide added benefits in reducing postoperative complications such as seroma, hematoma, or the necessity for procedural drainage. Furthermore, it does not alter the risk of thromboembolic events. These findings highlight the need for further research, particularly through randomized control trials, to understand TXA's efficacy in plastic surgery.

Level of Evidence 3 Therapeutic

A comparative study of the local effect of tranexamic acid and phenylephrine on the amount of bleeding in rhinoplasty: A randomized clinical trial

Background

Bleeding during nose surgery is very important, because it can cause a problem in the surgeon's field of view and lead to an increase in the probability of surgical complications. The aim of this study was to compare the local effects of tranexamic acid and phenylephrine on bleeding in rhinoplasty.

Methods

The present study is a double-blind clinical trial in which 98 patients who were candidates for rhinoplasty Shiraz were randomly divided into 49 groups of phenylephrine and tranexamic acid. In the first group, 1 cc of phenylephrine and in the second group, 1 cc of tranexamic acid was used locally and then the variables in the two groups were compared. The current study was approved by the Iranian Clinical Trial Registration Center with code IRCT20201205049602N1.

Results

The average blood pressure and heart rate in the phenylephrine group first increased and then decreased, but in the tranexamic acid group decreased from the beginning to 30 minutes. Based on the results of the test, there was a difference between the two groups in terms of the amount of bleeding, and a statistically significant relationship was observed. The average bleeding volume was lower in the phenylephrine group (p<0.0001).

Conclusion

Results of this study showed that the amount of bleeding in the phenylephrine group was lower than that of tranexamic acid. It is recommended to use phenylephrine in rhinoplasty surgery to reduce bleeding and improve the surgeon's vision.

Topical Tranexamic Acid on Donor Wounds in Burn Patients: A Randomized Placebo-controlled Trial

Background

Patients with major burn injuries are prone to massive blood loss owing to tangential excision of burn wounds and donor skin harvesting. In general, topical application of the antifibrinolytic drug tranexamic acid (TXA) to surgical wounds reduces bleeding; however, its effect on bleeding and re-epithelialization in superficial wounds of burns has not been explored.

Methods

This study aimed to investigate the therapeutic potential of topical TXA in reducing blood loss and its effect on wound re-epithelialization in burn surgery. Split-thickness skin graft donor wounds in burn patients were paired and randomized to topical application of either TXA (25 mg/mL) or placebo. Endpoints were postoperative bleeding as measured by dressing weight gain per cm2 wound area, blood stain area per wound area, and visual evaluation of bleeding in the dressings. Healing time was recorded to analyze the effect on wound re-epithelialization.

Results

There was no significant difference in bleeding or time to re-epithelialization between the TXA and placebo wounds. A post hoc subanalysis of wounds with dressing weight gain above the median, showed a significant difference in favor of TXA. However, use of tumescence may have influenced end points. No significant adverse events related to the study drugs were observed.

Conclusions

This study demonstrates that topical application of TXA (25 mg/mL) to split-thickness skin graft donor wounds does not delay re-epithelialization. Although a reduction in bleeding is suggested, further studies are needed to determine the role of topical TXA in reducing bleeding in burn surgery.

The Impact of Prior Obesity Surgery on Bleeding after Abdominal Body Contouring Surgery

Background

Body contouring surgery removes excess skin and fat, often after massive weight loss. Some reports suggest that patients who have previously undergone obesity (bariatric) surgery are at excess risk of subsequent bleeding, possibly due to complex nutritional and metabolic sequelae of massive weight loss.

Methods

A retrospective cohort study of intraoperative blood loss and postoperative bleeding indicators were examined for patients who had undergone abdominoplasty. Participants were categorized based on their history of previous obesity surgery, and outcome variables were compared using odds ratio, followed by subgroup comparison between a history of restrictive versus malabsorptive obesity surgery.

Results

The study included 472 patients, of which 171 (36.2 %) had a history of obesity surgery. Mean age was 40.4 years, and 402 (85.1%) participant were women. Fifty-five (11.6%) patients were smokers whereas 65 (13.7%) were hypertensive. Mean body mass index before surgery was 30.2 kg per m2, and average time between obesity and body contouring surgery (if applicable) was 35.8 months. Patients with a history of obesity surgery exhibited greater intraoperative blood loss (162.2 mL versus 132.1 mL; P = 0.001), drainage volume at 24 h (155 mL versus 135 mL; P = 0.001), and total drainage volume (300ml versus 220 mL; P = 0.001). Postoperative hematoma requiring surgical re-exploration was almost three times higher following a history of obesity surgery (4.7% versus 1.7 %; P = 0.05).

Conclusions

History of obesity surgery increases intraoperative blood loss, postoperative serosanguinous drainage volumes, and the risk of postoperative hematoma requiring surgical evacuation after abdominal body contouring procedures.

The Critical Blood-Sparing Effect of Tranexamic Acid (TXA) in Liposuction: A Systematic Review and Meta-Analysis

Introduction

Tranexamic acid (TXA) has been used to improve bleeding outcomes in many surgical procedures. However, its blood-sparing effect in liposuction is not well established.

Methods

A systematic literature search was performed using PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, ClinicalTrials.gov, and WorldWideScience.org databases from their inception to October 8, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors focused on 3 main topics: 1) TXA, 2) liposuction, and 3) complications. We included articles evaluating the potential blood-sparing effects of TXA in liposuction. Studies were excluded if they were systematic review articles or protocol papers, animal studies, conference abstracts, survey studies, or non-English publications.

Results

A total of 711 articles were identified, with 1 retrospective and 4 prospective (3 randomized) studies meeting our inclusion criteria. TXA was used in various forms: administered intravenously either on induction or after the procedure, mixed into the tumescent solution, or infiltrated into the liposuction sites after lipoaspiration. A significantly smaller reduction in hematocrit was noted in the TXA group compared with that in the non-TXA group (p<0.001) despite a significantly greater amount of lipoaspirate removed in the TXA group (p<0.001). Patients in non-TXA cohorts experienced adverse effects (such as seroma and need for transfusion) that were not seen in TXA cohorts.

Conclusion

TXA use in patients undergoing liposuction seems to be associated with a beneficial blood-sparing effect, which may enhance safety in this population. Future studies should aim to determine the optimal route and dosing for TXA in liposuction.

Evidence Based Medicine

Level IV.

Does tranexamic acid effectively minimise blood loss in cleft palate repair? A rigorous assessment through comprehensive systematic review and meta-analysis

Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during various surgical procedures, but its effectiveness in cleft palate repair remains unclear. This systematic review and meta-analysis aimed to assess the effectiveness of TXA to reduce postoperative blood loss. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across multiple databases, including PubMed, Cochrane, and Web of Science, to identify relevant studies published up to September 2023. Only randomised controlled trials (RCTs) were included. Primary outcomes measured were total blood loss, transfusion rates, and postoperative complications. We identified four relevant RCTs, which included 275 cleft palate patients with a mean (range) age of 28.7 (6-65) months. The pooled analysis found no significant difference in duration of surgery (MD -18.40 minutes, p = 0.09), preoperative haemoglobin (MD 0.46 g/dl, p = 0.27), or postoperative haemoglobin (MD 0.07 g/dl, p = 0.86) between TXA and control groups. Intraoperative blood loss was lower with TXA, but with TXA, the difference was not statistically significant (MD -16.63 ml, p = 0.15). TXA significantly improved surgical field visibility (p = 0.004). No adverse events occurred with its use. While no significant differences were found in surgical outcomes with TXA, surgical field visibility significantly improved, and TXA showed a promising safety profile. Larger and higher-quality RCTs are still needed to validate these preliminary findings before TXA can be considered as a standard treatment.

Use of Tranexamic Acid in Gender-Affirming Mastectomy Reduces Rates of Postoperative Hematoma and Seroma

BACKGROUND

The established safety and efficacy of tranexamic acid (TXA) in minimizing perioperative blood loss has led to increased interest within plastic surgery. Prior studies have demonstrated decreased edema and ecchymosis and reduced rates of postoperative collection with administration of TXA; however, its use has not been reported in gender-affirming mastectomy. This represents the first study to evaluate the effects of TXA on postoperative outcomes in patients undergoing gender-affirming mastectomy.

METHODS

A single-center cohort study was performed analyzing all consecutive patients undergoing gender-affirming mastectomy with the senior author (R.B.-L.) between February of 2017 and October of 2022. Beginning in June of 2021, all patients received 1000 mg of TXA intravenously before incision and 1000 mg at the conclusion of the procedure. Patients were stratified according to intraoperative administration of TXA, with demographic characteristics, surgical characteristics, and postoperative outcomes compared between groups.

RESULTS

A total of 851 patients underwent gender-affirming mastectomy. Of these, 646 cases were performed without TXA, and 205 patients received intravenous TXA intraoperatively, as described previously. Patients who received TXA had significantly lower rates of seroma (20.5% versus 33.0%; P < 0.001) and hematoma (0.5% versus 5.7%; P = 0.002). There was no difference in rates of surgical-site infection ( P = 0.74). TXA use was not associated with increased rates of venous thromboembolism ( P = 0.42).

CONCLUSIONS

Intraoperative administration of TXA in patients undergoing gender-affirming mastectomy may safely reduce the risk of postoperative seroma and hematoma without increased risk of thromboembolic events. Additional data collection and prospective studies are warranted to corroborate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Evidence of Hematoma Prevention After Facelift

Hematoma is a common complication after facelift procedures. Multiple factors have been shown to increase the risk of hematoma formation, such as male gender, anticoagulant medication use, perioperative hypertension, increased intrathoracic pressure, and operative technique. The purpose of this manuscript is to provide an overview of existing literature to provide surgeons with evidence-based recommendations on how to minimize hematoma risk during facelift surgery. A literature search for hematoma and facelift surgery was performed that identified 478 unique manuscripts. Abstracts were reviewed, excluding articles not describing facelift surgery, those written before 1970, studies with a sample size of fewer than 5 patients, non-English studies, and those that did not provide postoperative hematoma rates. Forty-five articles were included in this text, with their recommendations. Measures such as the prophylactic management of pain, nausea, and hypertension, the use of fibrin glue tissue sealants, the use of local anesthesia rather than general anesthesia, and strict blood pressure control of at least <140 mmHg were found to significantly reduce hematoma formation. Quilting sutures has shown benefit in some high-risk patients. Measures such as drains, compression dressings, perioperative use of selective serotonin reuptake inhibitors, and perioperative steroids had no significant effect on hematoma formation. In addition to appropriate patient selection and careful intraoperative hemostasis, many adjunct measures have been shown to reduce postoperative hematoma formation in facelift procedures.

LEVEL OF EVIDENCE: 3

Contemporary Prophylactic Antibiotic Practices and Adjunct Therapies in Autologous Fat Grafting Procedures: A Survey of The Aesthetic Society Members

Background

Autologous fat grafting (AFG) is a widely used surgical technique that involves extracting a patient's own adipose tissue and transferring it to different areas of the body. This practice is still evolving. Guidelines for antibiotic prophylaxis and use of adjuncts in plastic surgery are currently limited, with a notable absence of standardized guidelines for AFG.

Objectives

In this survey, we assess contemporary antibiotic practices and adjuncts in AFG procedures.

Methods

A 52-question survey was emailed to 3106 active members of The Aesthetic Society. Two hundred and ninety-three responses were recorded, representing a 9% response rate.

Results

We analyzed 288 responses. The most common AFG procedures were facial (38%), gluteal (34%), and breast (27%) augmentation. Preoperative antibiotics were used by 84.0% overall, with rates of 74.3%, 88.0%, and 92.7% in face, breast, and gluteal AFG, respectively. Lipoaspirate-antibiotic mixing was reported by 19.8%, mainly during gluteal AFG (46.9%), and less so in face (2.8%) and breast (8%) AFG. Notably, 46.9% of surgeons administered prolonged prophylaxis for 72 h or more. Tranexamic acid was utilized by 39.9% of the surveyed surgeons. Platelet-rich plasma was used by 5.6%. Doppler ultrasound was incorporated by 16.7% in AFG, with 21.5% in gluteal AFG, 14% in the face, and 19% in breast procedures.

Conclusions

In this survey, we offer insights into antibiotic practices and adjunct therapies in AFG, especially intraoperative antibiotic mixing. Practices among members of The Aesthetic Society vary from guidelines. It is crucial to standardize practices and conduct further research to pave the way for evidence-based guidelines in AFG.

Level of Evidence 5

British Society for Dermatological Surgery guidance on antithrombotics and skin surgery 2023

Our letter highlights some of the key changes and updates to the British Society for Dermatological Surgery antithrombotic and skin surgery guidance in 2023. An updated flowchart advises clinicians on assessing bleeding risk and when discontinuation of antithrombotics can be considered.

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

Tranexamic Acid Irrigation in Liposuction: A Double-Blind, Half-Body, Randomized, Placebo-Controlled Trial

BACKGROUND

Hematomas are common complications following plastic and esthetic surgeries. Large and complex hematomas might result in prolonged hospitalization, further interventions, additional expenses, and poor esthetic outcome. Tranexamic acid (TXA), an antifibrinolytic agent, has long been used to reduce blood loss. Its use in the field of plastic surgery has gained popularity recently. Several studies have presented the ability of TXA to reduce blood loss, hematomas, and ecchymoses after liposuctions. However, the proper dose and the route of administration remained controversial.

OBJECTIVE

The objective of the study was to quantify the effect of a low dose of TXA in an irrigation method in reducing hematomas and ecchymoses following liposuction.

METHODS

A prospective randomized controlled trial was conducted. Following liposuction, 400 mg of TXA were administered in an irrigation protocol to one side of the body in each patient, while the other side was administered with saline. The patients were photographed on 1, 2, 4, and 11 post-operative days. Ecchymosis and hematoma were measured and rated.

RESULTS

No statistical difference was observed between the intervention and control groups in terms of RBC in liposuction area (p = 0.11), RBC in lipoaspirate (p = 0.79), bruising size on days 1, 2, 4, and 11 (p = 0.68, 0.21, 0.42, and 0.75), and average ecchymosis score on the same days (p = 0.34, 0.72, 0.09, and 1) CONCLUSIONS: The use of a low-dose TXA irrigation solution did not demonstrate a statistically significant difference in post-operative hematoma formations rates and subsequent ecchymosis size and scale.

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 .

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.

Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial

BACKGROUND

Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications.

METHODS

This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded.

RESULTS

Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18).

CONCLUSIONS

Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Use of Tranexamic Acid in Aesthetic Surgery: A Retrospective Comparative Study of Outcomes and Complications

Background

Bleeding is a potential complication of aesthetic surgery. Surgeons have adhered to the principle of minimizing blood loss. Tranexamic acid (TXA) is an antifibrinolytic medication capable of reducing bleeding. This study aimed to investigate TXA and its effect on complications and overall outcomes in aesthetic surgery patients.

Methods

This retrospective chart review of patients undergoing various aesthetic procedures between 2019 and 2022 was conducted in Riyadh, Saudi Arabia. Preoperative and postoperative hemoglobin levels, blood transfusions, and complications were the primary outcomes. Furthermore, the predictors of giving TXA were studied.

Results

In total, 435 patients were included in the study. TXA was administered to 181 patients (41.6%). Significantly higher proportions of patients who received TXA underwent trunk aesthetic surgery (P < 0.001), and those who received TXA underwent combined procedures more frequently than non-users (P < 0.001). The mean operative time and length of hospital stay were significantly longer among patients who did not receive TXA (P < 0.001, and P < 0.001, respectively). Most predictors for using TXA were significantly associated with performing liposuction (OR = 5.5), trunk aesthetic surgery (OR = 4.9), and undergoing combined procedures (OR = 2.7). No significant difference was noted in the rate of complications between the two cohorts.

Conclusions

Although our data show improvement in patient outcomes in multiple aspects, the heterogeneity of our cohort makes us unable to draw definite conclusions to recommend the use of TXA in aesthetic surgery. Thus, a randomized controlled trial is necessary to support the findings of this study.

Safe Reproducible Breast Reduction

Breast reduction is a common operation performed by plastic surgeons. Patients can have significant improvement in physical symptoms in addition to increased self-esteem, body image, and quality of life as a result. The authors describe common techniques for breast reduction and provide representative photographs and videos of these techniques. An evidence-based review is provided for patient selection criteria, common surgical techniques, and methods to avoid and treat complications. Information is also provided on patient education about breast reduction. In most cases, breast reduction is safe to perform in the outpatient setting. The Wise pattern and vertical pattern are among the most common techniques for skin incisions, and the inferior and superomedial pedicles are two of the most common pedicles used in breast reduction. Enhanced Recovery After Surgery protocols are helpful to effectively control pain and reduce narcotic use postoperatively. Patient satisfaction after breast reduction surgery is typically high. Multiple techniques are available to successfully perform breast reduction. The plastic surgeon needs to select patients carefully and determine the appropriate technique to use. Patient education about the operation, recovery, expected result, and risks is an important component of achieving an optimal result.

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.

Breast Augmentation: A Cross-Sectional Survey of UK and Irish Aesthetic Surgeons

Background

Breast augmentation surgery is the most frequently performed aesthetic surgical procedure within the United Kingdom year on year. However, many variations exist among surgeons regarding various aspects of implant usage and technique.

Objectives

The aim of this study was to evaluate current trends and practices in breast augmentation, within the United Kingdom and correlate them to evidence-based literature.

Methods

An electronic survey of 41 questions was sent to 201 surgeons performing breast augmentation within the United Kingdom and Republic of Ireland. The survey inquired about the surgeons themselves, their practice, implant choice, surgical technique, post-op care, revision surgery, and impact of breast implant-associated anaplastic large cell lymphoma among several other questions.

Results

There were a total of 166 respondents, with 146 completing the survey fully, equaling a response rate of approximately 73%. Overall, there were specific trends in certain aspects such as type of practice, number of augmentations performed per surgeon per year, preferred implant manufacturer, and implant characteristics. That said, there has been a change in other aspects such as implant texture with an increase in the use of smooth implants. The United Kingdom and Ireland concur with certain internationally dominant practice preferences, including the use of inframammary incisions and post-op bra use.

Conclusions

This survey suggests that many aspects of breast augmentation surgery in the United Kingdom are approaching standardization. There are, however, some variations in practice and controversies remaining as expected. It is our belief that further standardizing this very common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes for patients.

Local Infiltration of Tranexamic Acid in Breast Reduction for Symptomatic Macromastia

BACKGROUND

With a surge of tranexamic acid (TXA) use in the plastic surgery community and a constant demand for breast reduction for symptomatic macromastia, questions about the benefits and risks emerge. The aims of this study are to evaluate and compare outcomes of patients undergoing breast reduction while receiving local TXA as opposed to standard procedure without TXA and to assess intraoperative bleeding and operative time.

METHODS

A retrospective review of breast reductions at a single institution from June 2020 to December 2021 was performed. The breast was infiltrated with tumescent solution at the time of surgery, with or without TXA. The population was divided into 2 groups: the TXA receiving group and tumescent only group. Demographics, intraoperative bleeding, operative time, complications, and drain duration were compared between groups. T test and χ 2 test analyses were performed on IBM SPSS.TM.

RESULTS

A total of 81 patients and 162 breasts were included. Mean age among patients was 30 ± 13.44 years. Mean SN-N distance was 32.80 ± 3.62 cm. Average resected breast specimen weight was 903.21 ± 336.50 g. Mean operating room time was 159 minutes. Intraoperative blood loss and operative time were not statistically different between groups ( P = 0.583 and P = 0.549, respectively). T-junction dehiscence was lower in the TXA group ( P = 0.016). Incidence of suture granulomas was lower in the TXA group ( P = 0.05). Drain duration was statistically significantly higher in the TXA group ( P = 0.033).

CONCLUSIONS

No decreases in intraoperative blood loss, operative time, or hematoma were seen after local administration of TXA during breast reduction. The rate of overall complications was not increased by using TXA, and incidence of T-junction dehiscence was lower in the TXA group lending to TXA's relatively safe profile. More research is necessary to further elucidate the TXA-related benefits in standard breast reductions.

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.

Topical tranexamic acid reduces postoperative hematomas in reduction mammaplasties

BACKGROUND

Postoperative bleeding requiring reoperation is an untoward event in breast surgery. Topical tranexamic acid (TXA) has been routinely used to reduce the risk of postoperative bleeding in some surgical fields. In breast surgery, it is not routinely used owing to scarce information. We investigated whether the intraoperatively applied topical TXA reduces the incidence of postoperative hematoma in reduction mammaplasty surgeries.

METHODS

This retrospective, single-center cohort study comprises of 415 consecutive patients who underwent reduction mammaplasty between 2019 and 2021. The prophylactic use of topically applied TXA (20 mg/ml) was implemented as a part of the hospital protocol in November 2020. The patients who were rinsed with TXA before the wound closure were compared with those who were not rinsed. The results were analyzed using statistical tests, two-sided Pearson's Chi-Square and Fisher's exact tests.

RESULTS

Topical TXA significantly reduced the number of postoperative hematomas requiring evacuation (p = 0.008). In the non-TXA control group, 12 (5.8%) hematomas were observed out of 208 patients. In the topical TXA group, only one (0.6%) hematoma occurred among the 168 patients. A tendency towards fewer wound infections, seromas, and other minor wound-healing problems can also be seen in the topical TXA group (ns). No adverse events of topical TXA were detected.

CONCLUSIONS

The incidence of postoperative hematomas decreased to a tenth after the introduction of topical TXA in reduction mammaplasty surgeries. This simple procedure may save patients from reoperations owing to bleeding. Randomized controlled trials are warranted.

The Potential of Transexamic Acid Use for Wide Awake Local Anesthesia No Tourniquet

Tranexamic acid (TXA) is a drug commonly used to decrease intraoperative bleeding. Its use in various types of surgery is well defined; however, its use in plastic surgery and even more so, hand surgery is not as well researched. Concurrently, the use of wide-awake local anesthesia no tourniquet (WALANT) procedures has increased in popularity. As the use of WALANT increases, it comes to question whether TXA could be used as an alternative to epinephrine during WALANT procedures. This case involves a 33-year-old woman status-post motor vehicle collision. On examination, the patient sustained transection of the flexor digitorum profundus on both her left middle and ring fingers along with absent sensation to her left middle finger. Due to the surgical preference for vascular monitoring, TXA was used alternatively to epinephrine to control intraoperative bleeding during the tendon repairs. It was observed that TXA allowed for controlled bleeding, preservation of the surgical visual field, successful tendon repair, and postoperative success. The successful use of TXA in this case prompts further investigation as to whether TXA could be used as an alternative to epinephrine in WALANT procedures.

Investigating the Effect of Tranexamic Acid on the Treatment of Subdural Hematoma: A Systematic Review Study

Context: Tranexamic acid (TXA) belongs to the family of lysine-derived antifibrinolytics. TXA requires a simple molecular breakdown in the liver to be metabolized and has a high renal excretion. Objectives: This study aimed to determine the effect of TXA on subdural hematoma (SDH) treatment using the SR method. Methods: Following a systematic review design, this study aimed to evaluate the effect of TXA on SDH treatment using studies published from 2000 to 2020. The search was performed by two researchers who were dominant in various types of SR studies and specialized discussion of neurosurgery. A checklist that contained the following items was used to collect the data: surname, year of study, year of publication, population, sample size, age, intervention, and outcomes. Data were also classified and reported using Word software. Results: Initially, 178 articles were identified, out of which 118 were removed due to the relevance of the title and method, 44 due to duplication, six due to following the SR method, and three due to having a case report design. Seven studies were found as eligible, as follows: the study by Wakabayashi et al. with a sample of 199 patients, Kageyama et al.’s study with 21 patients, Wan et al.’s study with 90 patients, Kutty et al.’ study with 27 patients, Tanweer et al.’s study with 14 patients, Yamada et al.’s study with 193 patients, and Lodewijkx et al.’s study with 7 patients. All articles showed that TXA could reduce SH. Conclusions: Regarding the positive effect of TXA on reducing SDH, administration of this medicine is recommended in the treatment of patients with CSDH.

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

Tranexamic Acid Use During Surgery Associated with Extension of Acute Perioperative Type 1 Myocardial Infarction: A Case Report

CASE PRESENTATION

A 70-year-old women presented to a regional hospital after a fall, resulting in a periprosthetic femoral fracture. Preoperative echocardiogram was ordered to investigate a cardiac murmur, and unexpectedly, a significant regional wall abnormality was found. Further repeat electrocardiograph and troponin blood biomarker analysis demonstrated the patient had suffered an acute type 1 myocardial infarction after admission to the ward, without exhibiting classical ischemic cardiac symptoms. A multidisciplinary decision was made for the patient to proceed to surgery, and at that time, she received tranexamic acid (TXA). Postoperatively, there was notable echocardiographic extension of the infarction, which required transfer to a tertiary center for management with complex coronary artery stenting. The patient once discharged was followed up by cardiology at the 3-month interval.

CONCLUSION

The use of TXA in arterial thromboembolic disease requires thorough consideration because it may contribute to further myocardial damage. A patient-specific approach should be adopted with the risk of thrombosis extension being considered.

Validation of the Developed Zero-Order Infrared Spectrophotometry Method for Qualitative and Quantitative Analyses of Tranexamic Acid in Marketed Tablets

(1) Background: The functional groups present in tranexamic acid allow direct infrared detection analysis. This study aimed to develop, apply, and validate an infrared spectrophotometry method used for qualitative and quantitative analyses of tranexamic acid in marketed tablets. (2) Methods: This was a descriptive observational study that consisted of several stages: determining the specific wavenumber for analysis, obtaining a simple linear regression equation, analyzing tranexamic acid both qualitatively and quantitatively, and validating the developed method for routine analysis. (3) Results: The peak analysis obtained a range of baseline wavenumbers from 1679.17 to 1295.25 cm⁻¹. The regression equation obtained was Y = 310.8527 × X + 0.9718, and the coefficient of determination (R²) obtained was 0.9994. The tranexamic acids in marketed tablets overall have a similarity index value of more than 0.90 and overall have levels ranging between 97.0% and 103.0%. The infrared spectrophotometry method that was successfully developed, applied, and validated for qualitative and quantitative analyses of tranexamic acid in marketed tablets meets the requirements both qualitatively and quantitatively of the tablet monograph. (4) Conclusions: The infrared spectrophotometry method has been validated and meets the requirements for accuracy, precision, detection limit, quantitation limit, linearity, range, and specificity.