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

Abstract

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.

Defining the Role for Topically Administered Tranexamic Acid in Panniculectomy Surgery

“…While the ideal delivery modality and dose continue to be investigated, the expansive body of literature on the use of TXA has demonstrated safety and efficacy across a wide range of dosages and delivery modalities within many surgical subspecialities. 40 Despite its favorable clinical properties, widespread use has yet to occur, perhaps in part due to unfamiliarity with its use, misconceptions regarding perceived untoward side effects, such as inducing thromboembolic events or seizures, and lack of prospective randomized data supporting its use in plastic surgery. Nonetheless, as evidenced in several meta-analyses, the local administration of TXA may provide sufficient drug concentrations at the wound surface with negligible risk of systemic adverse effects or increases in adverse events.…”

Topical tranexamic acid for prophylaxis of bleeding

“…Vi har publisert en systematisk li eraturgjennomgang av randomiserte kontrollerte studier på effekten av lokal traneksamsyre i bløtvevskirurgi (8). I tillegg til våre egne publikasjoner fant vi studier fra adenoidektomi, pacemakerinnleggelse, hudeksisjoner, øyelokksplastikk, lungedekortikering, prostatektomi, myomektomi og hysterektomi.…”

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

“…Alternatively, it has been observed that the use of TXA has been linked to seizure development 2 and that contact with the central nervous system should be avoided. 6 In regard to the dosage of TXA, there are currently not enough data in published literature to support a correct dosage of the drug for use. Determining the correct dose for optimal drug success would be a topic for future studies.…”

“…However, it is stated that there is no current superior dosage or means of administration when using TXA for surgical patients. 6 Similarly, in a review conducted by Elena 9 in 2021, it was determined that the use of TXA is beneficial in reducing intraoperative and postoperative blood loss and that TXA was effective when used both topically and systemically. Alternatively, it has been observed that the use of TXA has been linked to seizure development 2 and that contact with the central nervous system should be avoided.…”

“…In a review conducted by Rohrich and Cho 5 in 2018, it was demonstrated that TXA can potentially allow for decreased bleeding and positive postsurgical outcomes in plastic surgical procedures and that local use of TXA can allow for adequate hemostatic control comparable to intravenous use. 6 Although there is some evidence regarding the use of TXA as a hemostatic agent in plastic surgery, its use in hand surgery has not widely been described.…”