The addition of tranexamic acid (TXA) to local anesthetic and epinephrine before facelift surgery correlates with decreased bleeding and operative time as well as postoperative drainage, according to a study published in Aesthetic Surgery Journal. While the use of TXA is common in other surgical specialties, this Cleveland Clinic study offers some of the earliest evidence supporting its use in aesthetic surgery.
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TXA’s mechanism of action
The vascularity of the face often presents bleeding challenges intra- and postoperatively. Current protocols utilize epinephrine added to local anesthetic to minimize bleeding and allow greater visibility during dissection. But when the vasoconstrictive effects of epinephrine dissipate, rebound bleeding can occur. If this occurs during surgery, it can create problematic bleeding during surgical completion. After surgery, it can cause postoperative facelift hematoma.
TXA decreases bleeding by a different mechanism, reducing bleeding by inhibiting plasminogen conversion to plasmin, thus stabilizing fibrin clot and preventing the plasminogen inflammatory cascade. Studies in cardiac, trauma, dental, orthopedic and dermatologic surgeries have repeatedly demonstrated the safety of intravenous and topical TXA, but its use in aesthetic surgery is not well documented.
A dramatic reduction in dry-up time
Researchers enrolled 27 patients undergoing superficial musculoaponeurotic system (SMAS) or SMAS plication facelift; all patients also underwent neck lift with supraplastysmal lipectomy, subplastysmal lipectomy and corset platysmaplasty.
All patients received subcutaneous injections of 100 mg of TXA dissolved in 150 mL of 0.5% lidocaine with 1:200,000 epinephrine. “Our sister surgical services are using much higher doses intravenously, but even at this very low concentration of 1-to-1 TXA to local anesthetic, we saw a dramatic impact,” says James Zins, MD, Chairman of the Department of Plastic Surgery in Cleveland Clinic’s Dermatology & Plastic Surgery Institute and senior author of the study.
After both sides of the facelift were completed, researchers measured the time to gain hemostasis on each side. The average dry-up time was 6.5 minutes on the right, 6.3 minutes on the left and 12.9 minutes total. “With epinephrine alone, I would spend 20 to 30 minutes closing each side,” says Dr. Zins. “This is a very profound reduction that saves the patient time under anesthesia and creates time and cost efficiencies.” Notice the dryness of the field in the video below:
While there were no intraoperative or postoperative hematomas or seromas in the study group, the study was not powered to demonstrate a reduction in hematoma or complications. “The incidence of this complication is low, and we’d need a very large group of patients to show a decrease in rebound bleeding,” notes Dr. Zins.
Eliminating epinephrine entirely
The current study demonstrates the efficacy of TXA in reducing intraoperative bleeding and time, but rebound bleeding remains an issue. The next step, according to Dr. Zins, is to remove epinephrine from the equation entirely. “Can we get rid of vasoconstriction entirely as a method of reducing bleeding in facelift surgery, and thus avoid the rebound effect once vasoconstriction diminishes? That’s the next big question and our next avenue for research,” he says.