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

Abstract

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.

Takeaways

Question: What is the significance of using tranexamic acid (TXA) in aesthetic surgery, and how does it compare to other methods in terms of outcomes and complications?

Findings: We found that patients who did not receive TXA had a significantly longer operative time and length of hospital stay. However, there was no significant difference in the rate of complications between patients who received TXA and those who did not.

Meaning: The study recommends incorporating TXA as a routine component in the anesthesia protocol, but, while considering contraindications, suggests the need for a randomized controlled trial to confirm the findings.

INTRODUCTION

Aesthetic procedures have exponentially increased in the last few years. In 2020, global statistics were published by The American Society of Plastic Surgeons, showing that 15.6 million cosmetic procedures were performed around the world.¹ An important intraoperative aspect of aesthetic plastic surgery is hemostasis. An excessive amount of blood loss during an operation can lengthen operative times and increase the need for blood transfusions, both of which are associated with increased morbidity and mortality.² The majority of plastic surgical procedures do not result in significant blood loss. Nonetheless, bleeding may result in swelling, pain, bruising, frequent bandaging and drain changes, and the need for operations.³ Postoperative bleeding may also lead to wound-related complications and infections, as well as the need for allogeneic blood transfusions.^4,5 Blood products can improve hemodynamic parameters and may even be a life-saving intervention in the setting of major blood loss. However, they are associated with several noninfection-related and infection-related complications, therefore raising morbidity and mortality rates.^6,7 Many interventions have proven successful in reducing surgical bleeding, including pharmacological agents such as tranexamic acid (TXA), E-aminocaproic acid, and aprotinin, all of which work by stopping fibrinolysis and enhancing clot stability.³ TXA is a synthetic derivative of lysine. It exerts its antifibrinolytic effects by blocking lysine binding sites on plasminogen molecules, which inhibits the interaction of plasminogen with formed plasmin and fibrin. Inhibition of plasminogen activation would ultimately result in the stabilization of the preformed fibrin meshwork produced by secondary hemostasis.⁸ The need for blood transfusion during major surgery has been reduced by 32%–37% after the administration of TXA intravenously.^9,10 Although TXA has been proven to have numerous advantages and benefits in cardiac,¹¹ orthopedic,¹² and spine surgery,¹³ there is little literature on its use in aesthetic plastic surgery or body contouring other than in craniofacial¹⁴ and facial plastic,¹⁵ where it has been previously studied. A study on the use of TXA and its effectiveness in reducing perioperative blood loss during abdominoplasty, belt lipectomy, and body contouring surgery has not yet been conducted. Therefore, this retrospective chart review study aims to investigate the effects of TXA on complications and hematological outcomes after aesthetic surgery.

METHODS AND MATERIALS

Patient Selection and Study Design

This study is a retrospective chart review comparative cohort study conducted in Riyadh, Saudi Arabia. A list of patients who met the inclusion criteria was compiled. We included a list of patients who underwent aesthetic surgery performed by the senior author (O.F.N.) between January 1, 2019 and December 31, 2022. We excluded patients with missing data. For a better representation of the procedures, they were divided into abdominoplasty, breast aesthetic surgery, facial aesthetic surgery, liposuction, and belt lipectomy. Based on the surgeon’s use of TXA, patients were divided into two groups: one group did not receive any TXA, and the other group received intravenous TXA during surgery. The groups were sampled using a stratified random sampling procedure. The strata were defined by use of TXA. The sample size was calculated to achieve a power of 80% to detect a difference in the mean outcome of 0.5 units between the two groups, with an SD of 1 unit. The sample was drawn from a list of all eligible participants in the study population. In accordance with previous studies and evidence-based guidelines, the dosage of TXA ranged from 500 mg to 2 g, depending on the procedure. The primary outcomes are the rate of complications, length of hospital stay, preoperative and postoperative hemoglobin levels, blood transfusions, number of procedures, and return to the operating room. Furthermore, secondary outcomes include the effect of different patient demographics on the decision to undergo aesthetic surgery, as well as the factors that predict the decision to undergo aesthetic surgery. If intraoperative bleeding was significant, hemoglobin levels were routinely checked 6–12 hours after surgery. The decision to transfuse blood was indicated if patients had active or acute bleeding or presented symptoms related to anemia, such as tachycardia, weakness, or dyspnea on exertion, and had a hemoglobin level below 8 g/dL. These criteria for blood transfusion have been included in the article to provide a clear understanding of our transfusion practices. For DVT prophylaxis, pneumatic compression devices were used for all patients. Additionally, patients undergoing tummy tuck procedures who had comorbidities indicating the need for anticoagulation were given heparin-type blood thinners.

Data Collection Sheet

Based on a review of the literature related to previous studies with similar objectives, we have developed a data collection sheet with a variety of variables to collect data. The intended data were collected from the medical records database, retrospectively using an Excel sheet (Microsoft Excel, Microsoft Corp, Redmond, Wash.) with 23 variables, including the patient age, sex, marital status, having children and job or not, smoking or not, weight, height, body mass index (BMI), medical history, plastic surgery, preoperative Hgb, postoperative Hgb, type of procedure, operative time, hospital length of stay (LOS), the need for blood transfusion or not and the number of units, the use of TXA or not, the dose of TXA, number of procedures performed at once, return to operating room, and complications. For the purpose of facilitating analysis and comparison of the included data, it is necessary to properly categorize and classify the different types of aesthetic surgery.

Ethical Consideration

In accordance with the Declaration of Helsinki, patient medical records were collected after ethical approval was obtained from the institutional review board at King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia (Ref. No. 23/0167/IRB). The STROBE checklist was followed in the conduct and reporting of this retrospective cohort study.¹⁶

Statistical Analysis

Data analysis was implemented using RStudio (R version 4.1.1). We used frequencies and percentages to express categorical data, whereas continuous data were presented as mean and SD. A one-sample proportion test was used to explore the prevalence of TXA use, and the proportion was presented with the respective 95% confidence interval (CI) with continuity correction. Group-based comparisons were conducted for patients who received TXA and those who did not. These comparisons were assessed using a Pearson chi-squared test or a Fisher exact test for categorical variables. For continuous data, a Wilcoxon rank sum test was applied. The predictors of requiring TXA were investigated by incorporating the significantly associated variables from the bivariate analysis into a multivariate logistic model using the status of receiving TXA as a dependent variable. The variables were selected and entered into the model using the enter method. The outcomes were presented as odds ratio and 95% CI. Statistical significance was considered at a P value less than 0.05.

RESULTS

Demographic Characteristics

The records of 425 patients were reviewed in the current study. The mean ± SD age of patients was 37.3 ± 10.1 years. The majority of patients were women (88.5%). Current smokers represented 19.7% of patients. Moreover, 43.2% and 14.6% of patients were overweight (25.0 to <30 kg/m²) and obese (≥30 kg/m²), respectively. A positive history of a bariatric surgery was prevalent among 18.1% (Table 1).

Table 1.

Demographic Characteristics of Patients under Study

Parameter	Category	Overall, N = 425	Use of TXA			Missing
			No, N = 244	Yes, N = 181	P
Age	Year	37.3 ± 10.1	37.4 ± 10.1	37.1 ± 10.1	0.761	0 (0%)
Gender	Masculine	49 (11.5%)	28 (11.5%)	21 (11.6%)	0.968	0 (0%)
	Feminine	376 (88.5%)	216 (88.5%)	160 (88.4%)
Married	Yes	205 (54.4%)	112 (51.9%)	93 (57.8%)	0.254	48 (11%)
Having children	Yes	156 (46.7%)	81 (44.5%)	75 (49.3%)	0.378	91 (21%)
Work	Yes	196 (75.1%)	116 (79.5%)	80 (69.6%)	0.067	164 (39%)
Smoking	Yes	73 (19.7%)	46 (21.9%)	27 (16.8%)	0.218	54 (13%)
BMI	Underweight	11 (2.6%)	7 (3.0%)	4 (2.2%)	0.038	8 (1.9%)
	Healthy	165 (39.6%)	102 (43.0%)	63 (35.0%)
	Overweight	180 (43.2%)	88 (37.1%)	92 (51.1%)
	Obese	61 (14.6%)	40 (16.9%)	21 (11.7%)
Previous bariatric surgery	Yes	77 (18.1%)	33 (13.5%)	44 (24.3%)	0.004	0 (0%)
Any surgery before	Yes	211 (49.6%)	98 (40.2%)	113 (62.4%)	<0.001	0 (0%)

Values in boldface denote statistically significant differences (P < 0.05).

Use of TXA and the Associated Demographic Factors

A total of 181 patients received TXA (42.6%, 95% CI, 37.9–47.5) via the intravenous route. The majority of them received 1000 mg (95.6%), whereas 1.1% and 3.3% received 500 mg and 2000 mg, respectively. There was a significant difference between patients who received TXA and who did not in terms of their BMI levels (P = 0.038); however, other demographic characteristics did not differ significantly between groups (Table 1).

Perioperative Characteristics of Patients

More than half of patients underwent their first plastic surgery (54.7%). A total of 11 patients required blood transfusion (2.6%). The mean ± SD preoperative and postoperative hemoglobin (Hb) values were 13.3 ± 1.1 and 10.8 ± 1.7, respectively. The mean ± SD operative time was 194.9 ± 71.3 minutes, and it was significantly longer among patients who did not receive TXA (214.0 ± 62.8 minutes versus 180.6 ± 73.9 minutes, P < 0.001). The mean ± SD length of hospital stay was 1.5 ± 1.0 days, with a significant difference between patients who did not receive TXA and those who did (1.8 ± 1.1 versus 1.3 ± 0.9 days, P < 0.001). A larger proportion of patients who were administered TXA underwent aesthetic surgery on the trunk (49.7%) as compared to those who were not (20.9%), a difference that was statistically significant (P < 0.001). Similarly, liposuction was more commonly performed on patients in the TXA group (12.2%) than in the non-TXA group (7.4%), a finding that was also statistically significant (P < 0.001, see Fig. 1). Lastly, patients who received TXA tended to have combined procedures more often (65.7%) than those who did not receive TXA (40.6%), a difference that was again statistically significant (P < 0.001). Furthermore, patients who received TXA had a history of any surgery (62.4% versus 40.2%, respectively, P < 0.001) or bariatric surgery (24.3% versus 13.5%, respectively, P = 0.004) more frequently, compared with the non-TXA group (Table 2).

Fig. 1.

The proportions of procedures performed for patients who received TXA and those who did not.

Table 2.

Perioperative Characteristics and Outcomes of Patients under Study

Parameter	Category	Overall, N = 425	Use of TXA			Missing
			No, N = 244	Yes, N = 181	P
Plastic surgery	First	177 (55.5%)	104 (61.2%)	73 (49.0%)	0.077	106 (25%)
	Second	126 (39.5%)	60 (35.3%)	66 (44.3%)
	Third	15 (4.7%)	6 (3.5%)	9 (6.0%)
	More	1 (0.3%)	0 (0.0%)	1 (0.7%)
Surgery category	Breast aesthetic surgery	124 (29.2%)	99 (40.6%)	25 (13.8%)	<0.001	0 (0%)
	Facial aesthetic surgery	78 (18.4%)	52 (21.3%)	26 (14.4%)
	Trunk aesthetic surgery	141 (33.2%)	51 (20.9%)	90 (49.7%)
	Liposuction	40 (9.4%)	18 (7.4%)	22 (12.2%)
	Extremities aesthetic surgery	42 (9.9%)	24 (9.8%)	18 (9.9%)
Single or combined	Single	207 (48.7%)	145 (59.4%)	62 (34.3%)	<0.001	0 (0%)
	Combined	218 (51.3%)	99 (40.6%)	119 (65.7%)
Preoperative Hb	Mean ± SD	13.3 ± 1.1	13.3 ± 1.2	13.3 ± 1.0	0.661	44 (10%)
Postoperative Hb	Mean ± SD	10.8 ± 1.7	10.7 ± 1.7	10.9 ± 1.6	0.697	371 (87%)
Operative time (min)	Mean ± SD	194.9 ± 71.3	214.0 ± 62.8	180.6 ± 73.9	<0.001	4 (0.9%)
LOS (d)	Mean ± SD	1.5 ± 1.0	1.8 ± 1.1	1.3 ± 0.9	<0.001	83 (20%)
Blood transfusion	Yes	11 (2.6%)	7 (2.9%)	4 (2.2%)	0.766	2 (0.5%)
B-Units (units)	1	1 (9.1%)	0 (0.0%)	1 (25.0%)	0.475	0 (0%)
	2	7 (63.6%)	5 (71.4%)	2 (50.0%)
	3	1 (9.1%)	1 (14.3%)	0 (0.0%)
	4	1 (9.1%)	1 (14.3%)	0 (0.0%)
	6	1 (9.1%)	0 (0.0%)	1 (25.0%)
Return to operating room	Yes	2 (0.5%)	1 (0.4%)	1 (0.6%)	>0.999	0 (0%)
Complications	Yes	1 (0.2%)	1 (0.4%)	0 (0.0%)	>0.999	4 (0.9%)

*An asterisk indicates that descriptive statistics are based on 11 patients who required blood transfusion.

Values in boldface denote statistically significant differences (P < 0.05).

Predictors of Using TXA

We included seven independent variables, which showed significant associations with using TXA (BMI, surgery category, operative time, LOS and undergoing a single or combined surgery, and having a history of surgery or bariatric surgery). However, due to data missingness in the independent variables, the multiple logistic regression model included records of 334 patients. The model was fitted with no risk of multicollinearity (the variance inflation factor was <5 for all the independent variables). Based on the results, the use of TXA was independently associated with having a positive history of any surgery (OR = 2.2, 95% CI, 1.3–3.9, P = 0.007) and undergoing trunk aesthetic surgery (OR = 4.9, 95% CI, 2.6–9.7, P < 0.001), liposuction (OR = 5.5, 95% CI, 2.1–15.1, P < 0.001), and extremity aesthetic surgery (OR = 2.6, 95% CI, 1.0–6.7, P = 0.044), as well as undergoing combined procedures (OR = 2.7, 95% CI, 1.6–4.8, P < 0.001). A prolonged length of hospital stay was also associated with an increased likelihood of receiving TXA (OR = 1.4, 95% CI, 1.1–1.9, P = 0.016; Table 3). We reviewed our data to investigate any potential correlation between the dose or timing of TXA and postoperative hemoglobin levels. However, no significant associations were found. Therefore, no specific correlation between the dose or timing of TXA administration and postoperative hemoglobin levels could be identified.

Table 3.

Predictors of Using TXA in Plastic Surgery

Parameter	Category	OR	95% CI	P
BMI	Healthy	—	—
	Underweight	0.90	0.19–4.00	0.89
	Overweight	1.55	0.87–2.76	0.134
	Obese	0.51	0.23–1.11	0.096
Surgery category	Breast aesthetic surgery	—	—
	Facial aesthetic surgery	2.05	0.93–4.53	0.074
	Trunk aesthetic surgery	4.93	2.56–9.71	<0.001
	Liposuction	5.52	2.05–15.1	<0.001
	Extremities aesthetic surgery	2.60	1.02–6.68	0.044
Single or combined	Single	—	—
	Combined	2.70	1.55–4.78	<0.001
Any surgery before	No	—	—
	Yes	2.19	1.25–3.89	0.007
Previous bariatric surgery	No	—	—
	Yes	0.81	0.41–1.63	0.562
Operation time	Minutes	1.00	0.99–1.01	0.917
LOS	Days	1.40	1.06–1.90	0.023

OR, odds ratio.

Values in boldface denote statistically significant differences (P < 0.05).

Outcomes of Patients

In general, five patients (1.1%) developed postoperative complications, of whom the types of complications were available for four patients. These included anesthesia-related complications in one patient, infection for 10 days in one patient, and intraoperative hypoxemia in two patients. The complications occurred in four patients among those who received TXA (2.2%) and one patient who did not receive the medication, with no significant difference in the proportions of complications (P = 0.165). Out of the overall cohort, two patients (0.5%) returned to the operating room. One of these patients received TXA. There was no significant difference in patient groups in terms of returning to the operating room (P > 0.999, Table 2).

DISCUSSION

Cosmetic surgery has become increasingly popular in recent years.¹ However, these procedures carry a risk of bleeding and bruising, which can negatively impact patient satisfaction and recovery.² A number of studies have investigated the effect of TXA on the length of hospital stay, and the results have been somewhat mixed.^5,14,15 Some studies have found that TXA can significantly reduce the length of hospital stay, particularly in patients undergoing total knee or hip replacement surgery.¹² However, other studies have not found a significant effect of TXA on the length of hospital stay.^14,15 Overall, although the evidence on the effect of TXA on length of hospital stay and postoperative recovery is not entirely consistent, there is some evidence to suggest that TXA can have a beneficial effect in certain surgical contexts. However, it is important to note that TXA is not appropriate for all patients and can carry some risks, particularly in patients with a history of blood clots. As with any medication or surgical intervention, the potential benefits and risks of TXA should be carefully considered and discussed with a healthcare provider.¹⁷ According to our results, compared with the control group, patients receiving TXA had a significant decrease in intraoperative time and overall length of hospitalization. This implies an enhanced postoperative recovery in patients receiving TXA and less need for postoperative monitoring. These findings align with the currently available literature that TXA elicits a potent anti-inflammatory response with a decrease in postoperative edema and ecchymosis, which improves recovery time.⁵ Laikhter et al also found in a recent systematic review and meta-analysis that the use of TXA can potentially increase patient satisfaction with postoperative recovery and decrease costs associated with complications in aesthetic surgery.¹⁸

In terms of complications, although no significant difference was observed between the cohorts, this could be attributed to a number of discrepancies between the two groups. For instance, significantly more trunk aesthetic surgery patients were given TXA than not. One of the trunk aesthetic procedures is abdominoplasty, which is a major procedure with a significant risk of complications. De Paep et al found that the overall complication rate of abdominoplasty reaches up to 29.8%, and the rate of major complications requiring medical intervention is 10%.¹⁹ On the other hand, significantly fewer patients undergoing breast aesthetic surgery were given TXA compared with the control group. Aesthetic breast surgery documents much lower complication rates in the literature compared with abdominoplasty. Gupta et al have found in their study of 73,608 aesthetic breast surgery cases that the incidence of major complications after the surgery is low at 1.46%.²⁰ In our study, we did not find a significant difference in postoperative bleeding rates between the group that received TXA and the group that did not. Although patients who received TXA had a lower mean preoperative hemoglobin value, indicating a potential effect on reducing blood loss, other factors may have influenced the lack of significant differences. Further research, including randomized controlled trials, is needed to explore the impact of TXA on bleeding outcomes in cosmetic surgery.

The type of aesthetic procedure the patient is undergoing might influence the choice to use TXA. Procedures like trunk aesthetic surgery and liposuction had statistically significantly higher use of TXA. Factors such as the surgeon experience, surgery complexity, and higher frequency of postoperative complications may have been deciding factors in the surgeon’s choice to prefer the use of TXA in these procedures.^9,20

Limitations and Future Directions

Our study showed excellent demographic similarities between the two cohorts, with only their BMI showing significant difference. This ensures that no demographic differences have influenced the results of our study. The study has several limitations that should be noted regarding the interpretation of its results. Firstly, the study is a retrospective comparative study, which has inherent limitations, such as selection bias and confounding factors. Secondly, the study only included patients who received TXA from a single surgeon, which limits the generalizability of the findings to other surgeons or surgical settings. Thirdly, the study did not have a standardized protocol for the use of TXA, and the decision to use TXA was left to the discretion of the surgeon. This may have led to variability in the dose and timing of TXA administration, which could have affected the results. In addition, one limitation of our study is the lack of explicit documentation regarding the indications for patients returning to the operating room. Although the senior author’s knowledge and experience indicated that a significant proportion of the cases involved patients returning to the operating room due to bleeding, this information was not systematically recorded or analyzed. As a result, we were unable to provide a comprehensive evaluation of the specific indications and timing of the return to the operating time in relation to the use of TXA. Further studies with detailed documentation of indications for returning to the operating room and a comparison of outcomes between patients who received TXA and those who did not would be beneficial in exploring the potential impact of TXA on the rate of return to the operating room in aesthetic surgery. One important limitation of our study is the absence of specific inclusion criteria for TXA and the rationale behind these decisions. This lack of defined criteria introduces the potential for selection bias, making the study less robust and its findings less generalizable. As a retrospective analysis, the decision to use TXA was based on the surgeon’s expertise, considering factors such as the complexity of the surgery and the patient’s risks (eg, high BMI). To address this limitation, a potential future study should be undertaken with a more rigorous design, such as a randomized and blinded trial, specifically focused on a single operation. This would allow for unbiased allocation of patients to receive TXA or placebo, minimizing the influence of confounding factors and providing more meaningful results to the readers.

We acknowledge that the presence of selection bias is a limitation in our study, and we emphasize the importance of future research efforts to incorporate rigorous study designs that can overcome this limitation and provide stronger evidence in the field of TXA use in aesthetic surgery. Lastly, the study did not control for all potentially confounding variables, such as the use of other medications, medical comorbidities, and surgeon experience. These variables may have influenced the outcomes of the study and limited the ability to draw definitive conclusions. The quality and reliability of our findings would be improved if we conducted a prospective, multicenter study with a larger sample size and standardized protocol for the use of TXA.

CONCLUSIONS

In conclusion, our retrospective comparative study on the use of TXA in aesthetic surgery showed that TXA is associated with a significant decrease in the overall length of hospital stay and intraoperative time, implying an enhanced postoperative recovery in patients receiving TXA, and less need for postoperative monitoring. Although our data suggest potential improvements in patient outcomes across various measures, it is important to acknowledge the limitations of our study, including the heterogeneity of our cohort and the retrospective design.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.