Use of Tranexamic Acid in Liposculpture: A Double-Blind, Multicenter, Randomized Clinical Trial

Topical Tranexamic Acid Does Not Reduce Hematoma in Reduction Mammaplasty: A Double-Blind Randomized Controlled Trial

BACKGROUND

Breast reduction mammaplasty is among the most common procedures in plastic surgery, with a 1% to 7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but it remains underused in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following breast reduction mammaplasty.

METHODS

A double-blind randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammaplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000 mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and the patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts.

RESULTS

The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma ( P = 0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study period (1.5% versus 2.4%; P = 0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use ( P = 0.799). No adverse effects or thromboembolic events from TXA were observed.

CONCLUSION

Topical application of TXA does not decrease the incidence of hematoma following reduction mammaplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Von Willebrand's disease in breast surgery: case report

Von Willebrand disease is an inherited disorder characterized by deficiency of von Willebrand factor, which contributes to platelet adhesion to the endothelium. Patients with coagulation disorders present a challenge at the time of surgery due to the high risk of presenting heavy bleeding within the procedure or postoperative hematomas. We present a case of a 56-year-old woman with Type 1 von Willebrand's disease who was scheduled for breast explantation with autologous reconstruction, due to the presence of long-standing breast implants. The case was satisfactorily managed by a multidisciplinary team formed by plastic surgery, hematology, and anesthesiology, individualizing the management for the patient's case, obtaining good results and a safe procedure.

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.

Deep Back Liposuction: Ultrasound-Guided Deep Fat Liposuction of the Subiliac Crest

In the past 5 years, aesthetic surgery of the buttock has changed a lot with the use of technologies like imaging ultrasound to get safer and more beautiful results. These techniques are not only used to make a safer fat infiltration in the buttock, but also for modeling it. The aim of this study was to describe ultrasound-guided subiliac crest deep fat liposuction for contouring the buttock-back region. This area is often overlooked in gluteal frame management because of the depth at which it is located. Healthy patients were chosen for whom this deep back ultrasound technique was performed to improve the gluteal frame. The technique involved making a small incision in the iliac crest of the ilium, followed by identification of the area of deep posterior fat below the iliac crest under ultrasonographic control. A cannula was positioned to deliver static tumescent infiltration and liposuction was performed. This study included 16 female patients aged 20 to 45 years old who underwent this procedure. The area was infiltrated with 150 to 200 mL of tumescent solution per side, and 175 to 200 mL of fat was obtained. The depth of the study area varied but was observed to be generally located between 3 and 5 cm from the skin. This study indicates that this technique is safe and effective in achieving aspiration of the subiliac crest deep fat, which enhances the frame for buttock-back contouring. Ultrasound was indispensable for locating the fat and infiltrating the area for subsequent liposuction.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, Chinese, and Taiwanese online here: https://doi.org/10.1093/asj/sjad236.

LEVEL OF EVIDENCE: 4

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE I

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

Ultrasonic- and Ultrasound-assisted Improvement of Silhouette of the Torso: Bone Structure High-definition Remodeling (Part I)

Background

High-definition liposculpture allowed plastic surgeons to achieve better aesthetic results by carving the underlying muscles and contours in a new way. Several authors have improved the original technique by adding other procedures and new technologies. We designed a new improvement by incorporating bone transformation surgery to overcome the lack of silhouette at the waist and, as a result, optimize the breast-waist-hip ratios.

Methods

We carried out a prospective multicenter study, with five different surgeons performing the same rib remodeling technique for waist definition. We used an ultrasonic piece for costal corticotomy and real-time ultrasound imaging to perform green-stick fractures over the last two or three floating ribs. Ours is a new technique based on the prior one described by Kudzaev.

Results

We reported 131 consecutive patients who were enrolled in this study. Waistline diameter decreased an average of 8 cm after surgery (P < 0.05). Most patients were women (n = 125, 95.4%). No major complications were reported. Most common complication was prolonged pain, with only three cases of contour asymmetry, all of which were attributable to noncompliance of constantly wearing the corset + compressive garments. Patients reported a high satisfaction rate and fast recovery (Body-QoL survey).

Conclusions

Ultrasonic- and ultrasound- assisted indentation surgery of the thorax is a safe and reliable technique for waistline definition, with a high satisfaction rate, almost-invisible scars, and minimal risk for complications. Incorporation of high-definition liposculpture to rib remodeling opens up a new horizon for bone structure modification surgery (S-high-definition remodeling) that can be safely performed for patients who seek better aesthetic outcomes in body contouring.

Lipoplasty in the Overweight Patient

The practice of large volume liposuction, when executed by board-certified plastic surgeons using a variety of energy-assisted liposuction devices, has been substantiated as a secure procedure, yielding enhanced aesthetic results and minimal complications. Techniques including the superwet technique and ultrasonic-assisted liposuction are utilized to diminish blood loss, while also maintaining a keen awareness of the maximum volume of infiltration fluid permissible for safe infusion. Adherence to evidence-based protocols is of paramount importance to reduce the risk of postoperative complications. These protocols encompass hypothermia prevention, deep vein thrombosis (DVT) prophylaxis, and perioperative antibiotic prophylaxis. To ensure the highest quality of care, it is recommended that large volume liposuction procedures be performed in accredited hospitals or certified ambulatory surgery centers. Postoperative procedures should include overnight admission of patients to facilitate proper hemodynamic monitoring. While the employment of multiple devices such as VASERLipo and Renuvion has been noted to augment skin and soft tissue contraction, it is worth noting that there may be a heightened risk of seroma formation (at 2.27%) and subcutaneous emphysema (at 1.47%). Consequently, prudent use of these advanced medical devices is essential to avoid any potential adverse events.

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 .

Effectiveness of Tranexamic Acid in the Postoperative Period in Body Contour Surgery: Randomized Clinical Trial

Background

Tranexamic acid (TXA) is used to reduce bleeding in body contouring procedures; however, there are no studies that show the effectiveness of TXA when it is also used in the immediate postoperative period.

Methods

A controlled, randomized, parallel, and open-label clinical trial was carried out in adult patients undergoing liposculpture and/or abdominoplasty. A control group administering presurgical TXA and a study group with presurgical and postsurgical TXA were formed. The decrease in hemoglobin and the incidence of blood transfusions between both groups were compared as well as the possible adverse effects of TXA.

Results

Four hundred twenty-seven subjects were included, 208 (48.7%) in the control group and 219 (51.3%) in the study group. The median age was 34 years (interquartile range 28-42). Median postoperative hemoglobin levels at 24 hours were similar in both groups (study 11.3 g/dL versus control 11.1 g/dL, P = 0.07); however, at 72 hours, postoperative hemoglobin was higher in the study group versus control (10.8 versus 10.0 g/dL, P ≤ 0.001). The incidence of transfusions at 72 hours was 1.8% in the study group and 8.6% in the control group, for a risk ratio of 0.21 (95% confidence interval 0.07-0.61). There were no adverse or thromboembolic events.

Conclusion

TXA proved to be more effective in reducing intra- and postsurgical bleeding and the need for transfusions, when used preoperatively and continued for 48 hours after surgery, than when used only preoperatively, without reporting adverse or thromboembolic effects.

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

Postpartum Hemorrhage and Tranexamic Acid: A Literature Review

This review aims to explore the postpartum hemorrhage (PPH) burden and the efficacy of prophylactic tranexamic acid (TXA) in PPH and recent indications of TXA. A comprehensive review of the literature was conducted using a combination of Medical Subject Headings keywords including "Postpartum haemorrhage," "Tranexamic acid," and "Cesarean section." PPH has been explored for epidemiology, risk factors, and pathophysiology in the first part of the article. Recent indications of TXA, obstetric indications, and the role of TXA as prophylaxis for PPH are discussed in the second part of this article. TXA has many indications apart from obstetric indications and shows a significant effect in controlling bleeding. Furthermore, TXA is more efficient in preventing PPH if administered during the final stage of labor and is a valuable option for managing obstetric bleeding.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE I

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

Fluid Balance After Tumescent Infiltration: A Practical Guideline to Avoid Dilution Anemia in Circumferential Liposuction Based on a Prospective Single Center Study

BACKGROUND

Circumferential liposuction may cause a dilution anemia due to a high volume of infiltrated tumescent. Studies analyzing the percentage of absorbed tumescent as well as the safe limit of tumescent infiltration are currently lacking.

OBJECTIVES

The objective was to calculate the average volume uptake of administered fluids in power-assisted liposuction. Furthermore, we sought to calculate a practical formula to determine the amount of fluid that can safely be administered without inducing symptomatic dilution anemia or hypervolemia.

METHODS

Patients undergoing circumferential liposuction with power-assisted tumescent infiltration were included in a prospective clinical study. All relevant administered and excreted volumes during and after the operation were collected. Preoperative versus postoperative hemogram results were compared and the hemodynamic parameters were followed for 24 hours. The average volume uptake was calculated based on the measured volumes, as well as the ratio between administered volumes and the patient's blood volume.

RESULTS

30 patients were included during September 2021. The average volume uptake was 58% for a calculated 1.11 to 1 infiltration to aspiration ratio. There was a mean drop of 1.9 g/dl and 4.6% for the postoperative Hb and Hct, respectively, with a stable Red Blood Cell level. All patients remained hemodynamically stable without the need for blood transfusion or prolonged oxygen need. The average tumescent versus blood volume ratio was 85.0%.

CONCLUSIONS

In circumferential liposuction with power-assisted infiltration, the infiltrated tumescent volume should remain below 85% of the patient's blood volume to minimize the risk of a symptomatic dilution anemia or hypervolemia.

The British Association of Aesthetic Plastic Surgeons (BAAPS) Gluteal Fat Grafting Safety Review -and Recommendations

Superficial gluteal lipofilling (SGL) is a fat grafting procedure that is performed to correct a trochanteric depression and buttock deflation. Brazilian Butt Lift (BBL) is gluteal lipofilling procedure traditionally associated with exaggerated appearance and intramuscular fat transfer. The risk of mortality from fat embolism in Brazilian Butt Lift (BBL) was previously reported as being 1:2500. The actual risk was later estimated to be nearer 1:15,000, which is similar to the mortality risk in abdominoplasty. There is increasing evidence regarding the safety of subcutaneous gluteal lipofilling. This has principally been related to new technologies, surgical techniques and training being developed to avoid intramuscular injection of fat. The efficacy and benefits of using intraoperative ultrasound scan has been demonstrated in guiding the subcutaneous placement of fat and avoiding inadvertent deep lipofilling. Other serious risks and complications must be considered in addition to mortality. These include hypothermia, sepsis, skin necrosis, and poor aesthetic results, as well as the much-publicised risk of fat embolism. Complications are better controlled and managed in strictly regulated healthcare settings. Patients seeking surgery at unregulated facilities or via medical tourism are deemed to be at higher risk of being exposed to these serious complications and/or inadequate subsequent management.