Assessment of Tranexamic Acid in Reducing Intraoperative Blood Loss During Rhytidectomy

Intraoperative and postoperative bleeding are common risks in rhytidectomy, with hematoma complications identified in 1–15% of cases1 and approximately 90% occurring within the first 24 hours after surgery.2 Optimizing blood loss during facelift surgery and preventing hematoma and ecchymosis are thus of utmost importance as these complications have the potential to lead to cutaneous vascular compromise, permanent pigmentation changes, and extended recovery.3 In an effort to reduce hematoma risk during rhytidectomy, epinephrine is routinely added to local anesthetic to form tumescent solution that reduces bleeding and facilitates dissection. Though useful, prolonged effects of epinephrine present at the time of closure may mask bleeding and predispose to “rebound bleeding,” which is described as the most common cause of postoperative hematoma following rhytidectomy.2 Recently the use of preoperative antifibrinolytic agents in various facial plastic and reconstructive surgeries has been described, but their use in rhytidectomy remains a topic of ongoing discussion. tranexamic acid (TXA) is an antifibrinolytic agent that inhibits clot breakdown and is well described in the literature to reduce intraoperative blood loss in craniofacial, cardiac, trauma, dermatologic, and orthopedic surgeries.2-5 Despite the potential for TXA to decrease intraoperative blood loss in facelift, no formal guidelines exist for this use. This review covers pertinent literature to elucidate whether the use of TXA in rhytidectomy confers intraoperative and postoperative benefits (Table I). In 2016, Butz and Geldner1 were the first to report the use of TXA soaked-pledgets in their series of 57 patients undergoing a full face and neck rhytidectomy. They described the novel intraoperative placement of TXA soaked pledgets after SMAS plication. Subjective findings of reduced edema, ecchymosis, and recovery time were reported that were not prospectively analyzed. Overall, one postoperative hematoma occurred that required evacuation (1.7%) and no patients experienced venous thromboembolic events (VTE) or other systemic complications related to TXA use. The authors went on to advocate for topical TXA use in all rhytidectomy cases due to its potential to minimize hematoma-related complications and reduce inflammation. Though they presented a novel use for TXA in rhytidectomy, the authors failed to objectively assess topical TXA and the dosing used. A prospective, randomized double-blinded case control series by Cohen et al.4 was the first to investigate the utility of intravenous (IV) TXA in extended deep plane facelift. This study included 44 patients and patients in the treatment group received 1 g of IV TXA preoperatively and postoperatively while the control group received IV saline. Evaluations on days one, six, and nine evaluated lower facial/neck bruising and swelling on a scale of 1 (mild), 2 (moderate), or 3 (severe). Patients were scored by a blinded surgeon and asked to self-rate their ecchymosis and edema. The treatment group was found to have decreased intraoperative bleeding; however, this was not statistically significant (P = .54). When comparing outcomes of mean ecchymosis scores, a significant difference was noted in the surgeon scores of patients receiving TXA (P = .03). All other scores, while all lower in the TXA group, failed to achieve statistical significance. In this series, 4% of patients in the TXA group experienced a submental fluid collection, compared to 29% in the control group (P < .01). No patients experienced frank hematoma, infection, or VTE. To further explore whether local TXA infiltration is effective in decreasing rebound bleeding and hemostasis time, Couto et al.2 investigated 27 patients prospectively who underwent rhytidectomy with anterior approach neck lift. All patients received local infiltration of 60 mL/side of TXA-lidocaine-epinephrine solution (1 mg TXA/1 mL of local anesthetic) into the face and neck. The authors hypothesized that hemostasis on the first operative side would take longer since the effects of epinephrine would be more likely to have worn off by the time of closure. However, the authors did not see a difference in rebound bleeding on the first side and the time to hemostasis between sides was not significant. The authors did, however, report a subjective reduction in bleeding compared to prior patients not receiving TXA infiltration, but this was not prospectively analyzed. In this series, there were no postoperative hematomas, seromas, or VTE. Despite these findings, the authors acknowledged their findings as preliminary, subjective, and underpowered. As a follow-up to this study, a prospective, single-surgeon case–control study from the same institution was conducted by Kochuba et al.5 This study included 39 patients undergoing facelift surgery alone or in combination with other facial rejuvenation procedures. All patients in the study received a subcutaneous injection of 1 or 2 mg/mL TXA + lidocaine-epinephrine solution prior to dissection (60 mL/side). No significant difference was noted in total time to hemostasis between administration of 1 mg or 2 mg of TXA (P = .93). In the cohort receiving 2 mg TXA, mean time required for hemostasis on the left (first side) vs. right side was found to be significant (P < .03). The authors concluded that higher doses of TXA resulted in decreased time to hemostasis, though this was not statistically significant. No patients experienced postoperative hematoma, seroma, or clinical VTE. Schroder and Langsdon3 continued investigating local infiltration of TXA in a retrospective cohort study of 76 patients undergoing deep plane rhytidectomy with platysmaplasty. Here the authors reported the use of 1 cc (100 mg) of TXA in every 10 cc of lidocaine-epinephrine solution compared to a control group without TXA. The authors reported reduced drain output on postoperative day 1 (P < .001), decreased duration of drains (P < .001), and decreased intraoperative blood loss (P < .001) in the TXA cohort. No statistically significant differences in hematoma or VTE were found between cohorts. Of note, one patient (2.3%) receiving TXA experienced both a major hematoma event and a thromboembolic event (compared to 0%, 0% in the control group, respectively). The preoperative administration of TXA in rhytidectomy is poorly defined in the literature and various methods of delivery including IV, topical, and local infiltration in tumescent solution are described. The literature is currently sparse, often subjective, and underpowered, and although preliminary trends signal a possible benefit in decreased intraoperative time to achieve hemostasis, intraoperative blood loss, and drain duration, there is no meaningful advantage to justify using TXA as a best practice measure in rhytidectomy. Further research involving prospective, case–controlled multi institutional studies comparing routes of delivery are needed before a formal recommendation can be made. While risks of TXA administration are rare, risk factors for hypercoagulability should be discussed and administration is cautioned in patients who take oral contraception or hormone replacement therapy.4 The existing literature is lacking. Two prospective cohort studies (level II),4, 5 one retrospective cohort study (level III),3 and two case series (level IV)1, 2 were evaluated.