Role of Tranexamic Acid in Reducing Intraoperative Blood Loss and Postoperative Edema and Ecchymosis in Primary Elective Rhinoplasty

Abstract

IMPORTANCE Blood loss from surgical procedures is a major issue worldwide as the demand for blood products is increasing. Tranexamic acid is an antifibrinolytic agent commonly used to reduce intraoperative blood loss.OBJECTIVE To systematically examine the role of tranexamic acid in reducing intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.DATA SOURCES A systematic review and meta-analysis was undertaken in an academic medical setting using Medline, Embase, and Google Scholar from inception to June 30, 2018. All references of included articles were screened for potential inclusion. The search was mapped to Medical Subject Headings, and the following terms were used to identify potential articles: reconstruction or rhinoplasty and tranexamic acid or anti-fibrinolysis or antifibrinolysis and bleeding or ecchymosis or bruising or edema or complications.STUDY SELECTION The population of interest consisted of adult patients undergoing primary elective rhinoplasty. The intervention was the use of tranexamic acid. The control group was composed of patients receiving a placebo. Primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. In vitro or animal studies were excluded, and only English-language articles were included.DATA EXTRACTION AND SYNTHESIS The PRISMA guidelines were followed, and articles were assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Random-effects meta-analysis was performed to determine the overall effect size. MAIN OUTCOMES AND MEASURESThe primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis.RESULTS Five studies (comprising 332 patients) were included in the qualitative analysis, all of which were randomized clinical trials published within the past 5 years. The mean (SD) patient age was 27 ( 7) years (age range, 16-42 years), while the mean (SD) sample size was 66 (19) (range, 50-96). Meta-analysis of 4 studies (271 patients) indicated that tranexamic acid treatment resulted in a mean reduction in intraoperative blood loss of −41.6 mL (95% CI, −69.8 to −13.4 mL) compared with controls (P = .004). Three studies indicated that postoperative edema and ecchymosis were reduced with tranexamic acid treatment compared with controls; however, there was no significant difference compared with corticosteroid use. Four studies were considered of high methodological quality, with a low risk of bias. The overall quality of evidence was high.CONCLUSIONS AND RELEVANCE Tranexamic acid has the ability to significantly reduce intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.LEVEL OF EVIDENCE 4.

Tranexamic acid: a simple way to reduce drainage and bleeding in rhytidoplasty

“…We put forward that TXA due to its low cost, its safety in use, and its effectiveness in results [5,20,33] should be considered a fundamental tool in the prevention of complications in rhytidoplasty.…”

Re-Evaluating the Effect of Preoperative Tranexamic Acid on Blood Loss and Field Quality During Rhinoplasty: A Randomized Double-Blinded Controlled Trial

“…Despite various points of between-study heterogeneity, e.g., local infiltration of vasoconstrictors (infiltrated [16] vs. not infiltrated [15]), method of TXA administration (oral [15,17] vs. IV [14,16]), surgical approach (open [14,17] vs. close [16]), and performance of septoplasty (performed [16,17] vs. not mentioned [14,15]), most of the previous studies unanimously indicated TXA to be effective in reducing intraoperative blood loss. In the most recent meta-analysis of the evidence in 2019, McGuire et al stated that high-quality evidence is in support of TXA efficacy, not only in reducing intraoperative bleeding, but also in reducing postoperative edema and ecchymosis [18]. However, from a statistician's point of view, the asymmetry of the funnel plot of the included studies in this meta-analysis [14][15][16][17] (figure 2, Egger's test P = 0.071, significant at 90% level 1 ), may be pointing at possible missing results, and indicating a need for more evidence in this regard; a statement supported by the current study and a recent trial from Avci, which in line with the current study, showed a statistically insignificant decrease in blood loss during rhinoplasty following TXA administration versus controls [13].…”

“…Several meta-analyses of previous evidence have suggested TXA to be significantly effective in reducing blood loss, increasing surgical field quality, and reducing postoperative ecchymosis and edema during rhinoplasty [18][19][20]. However, most of the previously conducted studies either enrolled small sample sizes, or had a wide range of objectives, rendering them to reduced precision.…”

Tranexamic acid in otorhinolaryngology – A contemporary review

“…The potential therapeutic benefit of TXA in elective rhinoplasty has only recently been investigated. There exist 2 similar meta-analyses 28,29 evaluating the findings of five randomised control trials 30e34 (Table 3). The main outcomes assessed included intraoperative blood loss, post-operative swelling and postoperative periorbital ecchymosis.…”