Facial Surgery

Aesthetic Surgery Journal

Preliminary Report 2020, Vol 40(6) 587–593
© 2019 The Aesthetic Society.
Reprints and permission:
Local Infiltration of Tranexamic Acid With journals.permissions@oup.com
DOI: 10.1093/asj/sjz232
www.aestheticsurgeryjournal.com
Local Anesthetic Reduces Intraoperative
Facelift Bleeding: A Preliminary Report

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Rafael A. Couto, MD; Ali Charafeddine, MD; Nicholas R. Sinclair, MD;
Laxmeesh M. Nayak, MD; and James E. Zins, MD, FACS

Abstract
Background:  Rebound bleeding as a result of loss of epinephrine effect is a common problem encountered during facelift
surgery. Tranexamic acid (TXA) is an anti-fibrinolytic agent whose safety and efficacy in reducing bleeding are well docu-
mented. We have found that local infiltration of TXA combined with a lidocaine with epinephrine solution during facelift
surgery has been effective in decreasing rebound bleeding and the time required to gain hemostasis.
Objectives:  The authors sought to share their local infiltration protocol of TXA combined with epinephrine solution in facelift.
Methods:  Patients who underwent facelift received subcutaneous injection of TXA-lidocaine 0.5% solution following the
authors’ protocol. After completing both sides of the facelift and the submental platysmaplasty, the first and second sides
were sequentially closed. The time to gain hemostasis on each side prior to closure was prospectively measured.
Results:  Twenty-seven consecutive patients who underwent facelift surgery received local infiltration of TXA-lidocaine so-
lution. In 23 of the 27 patients, the time required for hemostasis was prospectively recorded. The mean age was 62.1 years
(±9.3) and all were females. The average time spent achieving hemostasis on the right, left, and both sides of the face was
6.5 (±2.7), 6.3 (±2.1), and 12.9 (±4.2) minutes, respectively. The total surgical time saving is approximately 25 to 60 minutes.
Although primary facelift [13.6 (± 4.3)] exhibited a longer time of hemostasis compared with the secondary group [10.2 (±
2.8)], this was not statistically significant (P = 0.09).
Conclusions:  Local infiltration of TXA with local anesthetic prior to a facelift appears to decrease bleeding, operative time,
and postoperative facelift drainage output.

Level of Evidence: 4 

Editorial Decision date: August 15, 2019; online publish-ahead-of-print August 23, 2019.

Dr Couto is Chief Resident, Dr Charafeddine is an Aesthetic Fellow, Dr

Epinephrine is added to the local anesthetic during face-
lift surgery to reduce bleeding and facilitate dissection.
However, epinephrine may also have the deleterious ef-
fect of masking facelift bleeding. For the rapid facelift
surgeon, epinephrine effect is still present at the time of
closure. When residual epinephrine wears off in the re-
covery room or shortly thereafter, rebound bleeding may
occur. For those surgeons whose facelifts last longer,
Sinclair is a Resident, and Dr Zins is Chairman, Department of Plastic
Surgery, Cleveland Clinic Foundation, Cleveland, OH. Dr Zins is also
the Facial Surgery Section Editor for Aesthetic Surgery Journal. Dr
Nayak is a facial plastic surgeon in private practice in Frontenac, MO.
Corresponding Author:
Dr James E. Zins, Department of Plastic Surgery, Cleveland Clinic
Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
E-mail: zinsj@ccf.org; Twitter: @james_zins
588 Aesthetic Surgery Journal 40(6)

troublesome bleeding may result when the second side of

the facelift is completed and the first side is then closed.
This rebound phenomenon is probably the most common
cause of the postoperative facelift hematoma. Tranexamic
acid (TXA), like epinephrine, decreases bleeding but
through an entirely different mechanism. TXA is an anti-
fibrinolytic agent that reduces bleeding by inhibiting the
conversion of plasminogen to plasmin, thus preventing the
enzymatic degradation of fibrin clot.1 Furthermore, it im-
proves platelet function and inhibits plasmin-induced ac-
tivation. This preserves platelets for late clot formation.2
Inhibition of plasmin by TXA not only diminishes bleeding

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but also blocks the plasminogen inflammatory cascade.3
TXA undergoes renal excretion with minimal preceding
breakdown. Following intravenous administration, the half-
life of TXA is approximately 2 to 3 hours.4
The safety and efficacy of TXA has been well studied by
our sister surgical services including cardiac, orthopedic,
dental, trauma, critical care, and dermatologic surgery.3-18
However, with the exception of craniofacial surgery,19,20
TXA is rarely used in plastic surgery. In particular, the use
of TXA in the aesthetic surgery literature is scarce and
when used has been limited to systemic or topical use.21-28
We have found TXA particularly effective in reducing re-
bound bleeding during facelift surgery when it is injected
subcutaneously. It has therefore become a routine part of
our facelift regimen, and we would like to report our pre- Video 1.  Watch now at http://academic.oup.com/asj/
liminary findings. article-lookup/doi/10.1093/asj/sjz232.

combined with 1 mg/mL TXA) was injected subcutaneously

METHODS
Approval by the Cleveland Clinic Foundation institutional
review board was obtained. In all cases, surgery was
performed under general anesthesia with orotracheal in-
tubation. Participants in this report underwent either an ex-
tended superficial musculoaponeurotic system (SMAS) or
SMAS plication facelift. In addition, all patients underwent
an anterior approach neck lift with supraplastysmal lipec-
tomy, subplastysmal lipectomy, and corset platysmaplasty.
Irrespective of the exact type of facelift, all patients re-
ceived a through and through dissection of the neck
and wide skin undermining up to but not including the
nasolabial fold. All surgeries were performed between
February 2019 and July 2019.
TXA was provided in 10-mL vials at a concentration of
100 mg/mL (Pfizer, New York, NY). We dissolved 1.5 mL of
the solution (100mg/1mL) in 150 mL of 0.5% lidocaine with
1:200,000 epinephrine (Hospira, Inc., Lake Forest, IL) for a
final concentration of 1 mg of TXA/1 mL of local anesthetic
(Video  1, available as Supplemental Material online at
www.aestheticsurgeryjournal.com). Prior to incision, 60 mL
of this solution (0.5% lidocaine 1:200,000 epinephrine
in the left face and neck. After waiting 15 to 20 minutes, we
started the facelift. When the first side of the facelift was
near completion, the second side was similarly injected.
After completing both sides of the facelift, the submental
lipectomy and platysmaplasty, the first and second sides
were sequentially closed. The time to gain hemostasis on
each side prior to closure was prospectively measured by
the circulating nurse as follows: hemostasis was obtained
on the first side and final drying up time was measured. The
first side was then closed. Hemostasis was then obtained
on the second side, and the final drying up time was meas-
ured on the second side.
RESULTS
Local infiltration of TXA with 0.5% lidocaine with 1:200,000
epinephrine was used in 27 consecutive patients. In 23 of
the 27 consecutive patients the time required for hemo-
stasis was prospectively recorded. Their mean age was
62.1 years (± 9.3; range, 37-73 years) and all were females.
Primary facelifts (77.3%) were more common than sec-
ondary (22.7%). Twenty-three patients (85%) underwent
extended SMAS facelift. Four patients (15%) underwent
Couto et al 589

Table 1.  Patient Demographics and Procedures

No. of patients 27

Mean age, y (SD) 62.1 (±9.3); range, 37–73

Female gender, n (%) 27 (100)

Facelift type

  Extended SMAS, n (%) 23 (85%)

  SMAS plication, n (%) 4 (15%)

Primary vs secondary facelift

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  Primary, n (%) 21 (78%)

  Secondary, n (%) 6 (22.%)

SD, standard deviation; SMAS, superficial musculoaponeurotic system.

SMAS plication (Table 1). The mean length of follow-up was

3.6 months (range, 1–6 months).
The most impressive finding was a subjective dra-
matic reduction in bleeding compared with our previous
experience with patients who received 0.5% lidocaine
with 1:200,000 epinephrine without TXA. Instead of re-
bound bleeding, the field is surprisingly dry (Video  2,
available as Supplemental Material online at www.
aestheticsurgeryjournal.com). The average time spent
achieving hemostasis on the right, left, and the 2 sides Video 2.  Watch now at http://academic.oup.com/asj/
of the face combined was 6.5 minutes (±2.7; range 1–15 article-lookup/doi/10.1093/asj/sjz232.
minutes), 6.3 minutes (±2.1; range, 3–13 minutes), and 12.9
minutes (±4.2; range, 7–28 minutes), respectively (Table 2).
includes quilting sutures, fibrin glue, platelet rich plasma,
Previously, the senior author would spend 20–30 minutes
facelift drains, tumescent fluid, and the elimination of
gaining hemostasis on each side. Therefore, the total sur-
epinephrine from the local anesthetic.29-36 The initiating
gical time saved was approximately 25 to 60 minutes.
factor in many facelift hematomas is rebound bleeding,
Although the overall time to gain hemostasis in the pri-
which is the loss of epinephrine effect and the unmasking
mary facelift group [13.6 (±4.3)] was greater than secondary
of bleeding postoperatively.30,31 Ninety percent of facelift
[10.2 (±2.8)], this was not statistically significant (P  =  0.1)
hematomas occur within the first 24 hours of surgery.37
(Table 3). The extended SMAS facelift group [13.1 (±4.1)] re-
Whereas epinephrine reduces intraoperative bleeding
quired a longer period of time to gain hemostasis than the
through its vasoconstrictive effect, TXA’s mechanism of ac-
SMAS plication group [7.5 (±0.7)]. However, this finding did
tion is quite different. TXA is a lysine analogue and gains
not reach statistical significance (P = 0.07) (Table 4).
its efficacy by altering the fibrinolytic portion of the clotting
With regards to complications, there were no
cascade and preventing the conversion of plasminogen to
intraoperative or postoperative hematomas or seromas.
plasmin.1-3 The safety and efficacy of TXA has been dem-
Two patients (7.4%) developed minor delayed post-
onstrated in a wide variety of operative procedures per-
auricular skin healing, which was treated conservatively
formed by our sister surgical services.3-18 However, the
in the office. One patient (3.7%) had a temporary unilat-
most of these specialties have used TXA either topically or
eral marginal mandibular neuropraxia, which resolved in 2
intravenously.3-18,27
weeks. There were no clinically apparent deep vein throm-
The value of TXA in facelift surgery was first docu-
boses or pulmonary emboli.
mented by Butz and Geldner.25 Their experience
employing TXA-soaked pledgets under facial skin flaps in
DISCUSSION 57 patients demonstrated 1 hematoma (1.7%), and no sys-
temic complications were reported.25 They did not, how-
A variety of techniques has been investigated in an attempt ever, include the concentration of TXA utilized. Reduced
to reduce facelift drainage, seromas, and hematomas. This edema, ecchymosis, and recovery time were subjectively
590 Aesthetic Surgery Journal 40(6)

Table 2.  Average Time in Minutes Taken to Gain Hemostasis Table 3.  Primary vs Secondary Facelift: Average Time in Min-
on Right, Left, and Both Sides of the Facelift Prior to Closure utes Taken to Gain Hemostasis on Right, Left, and Both Sides
of the Face Prior to Closure
Patients Time for
hemostasis (min) Primary facelift Secondary P
facelift valuea
Right side Left side Total time
(n = 17) (n = 5)
1 7 7 14
Average hemostasis time (SD)
2 15 13 28
Right side 7.1 (± 2.6) 6.6 (± 2.2) 0.07
3 8 7 15
Left side 6.6 (± 2.2) 5.6 (± 1.5) 0.31
4 8 9 17
Total time 13.6 (± 4.3) 10.2 (± 2.8) 0.11

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5 7 7 14
SD, standard deviation. aStatistically significant P < 0.05.
6 7 8 15

7 7 7 14

8 5 6 11
Table 4.  Extended SMAS vs SMAS Plication Facelift: Average
9 7 7 14 Time in Minutes Taken to Gain Hemostasis on Right, Left, and
Both Sides of the Face Prior to Closure
10 5 6 11
Extended SMAS SMAS P
11 6 7 13 plication valuea

12 5 5 10 (n = 21) (n = 2)

13 5 6 11 Average hemostasis time (SD)

14 7 8 15 Right side 6.8 (± 2.4) 3.0 (± 2.8) 0.07

15 5 5 10 Left side 6.4 (± 2.2) 4.5 (± 2.1) 0.22

16 1 6 7 Total time 13.1 (± 4.1) 7.5 (± 0.7) 0.07

17 7 5 12 aStatistically
significant P < 0.05. SD, standard deviation; SMAS, superficial
musculoaponeurotic system.
18 6 5 11

19 3 5 8

20 7 7 14 assess postoperative swelling or ecchymosis, because

currently there is no validated instrument to accurately as-
21 5 3 8
sess this parameter.
22 11 3 14 Little information exists regarding subcutaneous injec-
tion of TXA. Zilinski et al performed a double-blinded, ran-
23 6 4 10
domized, placebo-controlled prospective study evaluating
Average (SD) 6.5 (±2.7) 6.3 (±2.1) 12.9 (±4.2) the efficacy of subcutaneous TXA injection in 131 patients
who underwent dermatological procedures.14 They found
SD, standard deviation. that this drug delivery modality was safe and effective in
reducing bleeding, especially in individuals treated with
anticoagulants.14 However, when the same research team,
noted. Recently, Rohrich et  al published a review article employing a similar experimental design, examined subcu-
presenting their preliminary experience with topical TXA taneous TXA injection in upper blepharoplasty patients,15
in 150 cosmetic surgery patients (blepharoplasty, facelift, patients treated with TXA did not differ in terms of bleeding,
rhinoplasty, abdominoplasty, breast augmentation).27 The operative time, and degree of ecchymosis compared with
TXA was diluted to a 3% concentration and applied to the placebo group. This study could be criticized, because
the wound bed for 3 to 5 minutes utilizing gauze, neuro- it appeared to be underpowered with only 34 patients in-
pledgets, or irrigants. The authors observed reduced cluded in the trial.15
intraoperative bleeding and a decrease in postoperative We found local infiltration of TXA particularly effective in
ecchymosis and swelling.27 Of note, our study did not reducing the time from completion of the facelift dissection
Couto et al
to closure, significantly shortening overall operative time.
The average wholesale price of TXA is also reasonably in-
expensive. One 10-mL vial costs approximately between
$10.75 and $88.68. Therefore, TXA represents a cost-ef-
fective tool to decrease operative time.
TXA also appears to reduce postoperative drainage.
Ausen et al investigated the efficacy of topical TXA (25 mg/
mL) in breast reduction patients and demonstrated that
breasts treated with topical TXA exhibited a 39% reduction
in postoperative drainage compared with those of a control
group.26 In our facelift group, the combination of bipolar
cautery, TXA, and raising the blood pressure to preopera-
tive levels or higher at the time of closure has anecdotally
minimized postoperative drainage and hematoma.
Whether local infiltration of TXA is superior to topical or
systemic use is unclear. However, there are perhaps the-
oretic benefits to subcutaneous injection compared with
systemic use. Borrowing from concepts developed util-
izing tumescent techniques in liposuction,38 where large
volumes of dilute lidocaine achieve prolonged local anes-
thesia with delayed and minimal systemic peak lidocaine
levels, infiltrating large volumes of dilute TXA directly to the
surgical field might achieve longer lasting anti-fibrinolytic
effect in the area while minimizing systemic levels. Further,
by injecting the product subcutaneously, no product is lost
to the gauze or irrigation. Finally, by injecting the TXA at
the beginning of the surgery rather than applying it topi-
cally at the end, the surgeon may be provided a drier field
throughout the case, facilitating a more rapid dissection.
Unlike systemic use, the optimal dosage of topical and
local infiltration of TXA has not been established.27 Topical
TXA has been studied in multiple surgical situations at
a wide range of dosages (0.7–100  mg/mL).27,38,39 The 2
available studies examining subcutaneous injections em-
ployed a TXA concentration of 50 mg/mL diluted in 2% li-
docaine.14,15 Because it has been shown that lidocaine and
epinephrine do not change the effects of TXA on fibrinol-
ysis, we dilute the TXA in local anesthetic (lidocaine 0.5%)
but also add epinephrine (1:200,000).30 Although our TXA
concentration (1  mg/mL) is lower than what is described
in the literature (4–50 mg/mL)14,15 a dramatic reduction in
intraoperative bleeding is consistently observed. The ex-
tent to which the combination of TXA and epinephrine
contribute to intraoperative hemostasis needs to be further
investigated. Whether epinephrine could be totally elimin-
ated from the solution and similar hemostatic effect main-
tained is unclear. Jones and Grover have demonstrated
that the elimination of epinephrine from infiltrating solu-
tion significantly reduced the facelift hematoma rate.30,31
It is quite possible that TXA mixed with local anesthesia
without epinephrine will offer similar benefits. Although the
consensus in the literature is that intravenous TXA does
not increase the risk of deep vein thrombosis, having the
591
lowest system at levels possible, without compromising
wound levels, is most desirable.17,40
During our facelift technique, we complete both the dis-
section and the underlying SMAS repositioning on both
sides as well as the submental work before proceeding
to sequentially close the first and second sides of the
face. We prefer this sequence because it maximizes the
time prior to closure of the first side, allowing the vasocon-
strictive effect of epinephrine to subside and any rebound
bleeding to be controlled. Because the time period from
injection of local anesthetic to closure on the first side is
longer than on the second side, one would expect less epi-
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nephrine effect and a greater amount of rebound bleeding
on the first side. In spite of this, the time to gain hemostasis
did not differ between the first and the second side when
TXA was added to the local anesthesia solution. It appears
that the rebound bleeding seen with epinephrine is pos-
sibly negated by the addition of TXA through a different
mechanism of action: the inhibition of the conversion of
plasminogen to plasmin.
The subcutaneous use of TXA at the beginning of face-
lift surgery appears to reduce the amount of bleeding at
the time of closure. However, as with any retrospective
case series, there are inherent limitations to our study.
Neither comparative group nor historic control has been
established. Therefore, our results are subjective, and
this is a weakness of our preliminary report. Other impor-
tant parameters were not assessed in our study including
intraoperative blood loss, drain output, and degree of
postoperative swelling and ecchymosis. Furthermore, our
sample size was small and thus too underpowered to iden-
tify a reduction in complications such as hematoma.
Although we are encouraged by our experience with
subcutaneous TXA administration in facelift surgery, we
perhaps pose more questions than we answer. Is subcuta-
neous TXA more effective in reducing bleeding than top-
ical or systemic administration? Is postoperative drainage
reduced? Perhaps most importantly, can epinephrine be
eliminated from facelift local anesthetic and, by inference,
facelift hematoma rates reduced? Answers to these impor-
tant questions will have to wait for another day.
CONCLUSIONS
Local infiltration of TXA with local anesthetic prior to a
facelift appears to decrease bleeding. The use of local in-
filtration TXA in the field of aesthetic surgery needs to be
investigated. The preliminary findings in this report may
stimulate further interest in this promising area.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
592
Disclosures
The authors declared no potential conflicts of interest with re-
spect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in sur-
gery and other indications. Drugs. 1999;57(6):1005-1032.
2. Ervin  AL, Peerschke  EI. Platelet activation by sustained
exposure to low-dose plasmin. Blood Coagul Fibrinolysis.
2001;12(6):415-425.
3. Jimenez JJ, Iribarren JL, Lorente L, et al. Tranexamic acid
attenuates inflammatory response in cardiopulmonary
bypass surgery through blockade of fibrinolysis: a case
control study followed by a randomized double-blind con-
trolled trial. Crit Care. 2007;11(6):R117.
4. Pilbrant  A, Schannong  M, Vessman  J. Pharmacokinetics
and bioavailability of tranexamic acid. Eur J Clin
Pharmacol. 1981;20(1):65-72.
5. Ramström  G, Sindet-Pedersen  S, Hall  G, Blombäck  M,
Alander  U. Prevention of postsurgical bleeding in oral
surgery using tranexamic acid without dose modifi-
cation of oral anticoagulants. J Oral Maxillofac Surg.
1993;51(11):1211-1216.
6. Lee JH, Park JG, Lim SH, et al. Localized intradermal micro-
injection of tranexamic acid for treatment of melasma in
Asian patients: a preliminary clinical trial. Dermatol Surg.
2006;32(5):626-631.
7. Fawzy H, Elmistekawy E, Bonneau D, Latter D, Errett L. Can
local application of tranexamic acid reduce post-coronary
bypass surgery blood loss? A randomized controlled trial.
J Cardiothorac Surg. 2009;4:25.
8. Wong J, Abrishami A, El Beheiry H, et al. Topical applica-
tion of tranexamic acid reduces postoperative blood loss
in total knee arthroplasty: a randomized, controlled trial. J
Bone Joint Surg Am. 2010;92(15):2503-2513.
9. Wang H, Shen B, Zeng Y. Comparison of topical vs intra-
venous tranexamic acid in primary total knee arthroplasty:
a meta-analysis of randomized controlled and prospective
cohort trials. Knee. 2014;21(6):987-993.
10. Queiroz  SIML, Silvestre  VD, Soares  RM, Campos  GBP,
Germano  AR, da  Silva  JSP. Tranexamic acid as a local
hemostasis method after dental extraction in patients on
warfarin: a randomized controlled clinical study. Clin Oral
Investig. 2018;22(6):2281-2289.
11. Sharma R, Mahajan VK, Mehta KS, Chauhan PS, Rawat R,
Shiny TN. Therapeutic efficacy and safety of oral tranex-
amic acid and that of tranexamic acid local infiltration with
microinjections in patients with melasma: a comparative
study. Clin Exp Dermatol. 2017;42(7):728-734.
12. Liu Y, Meng F, Yang G, et al. Comparison of intra-articular
vs intravenous application of tranexamic acid in total knee
arthroplasty: a meta-analysis of randomized controlled
trials. Arch Med Sci. 2017;3:534-539.
Aesthetic Surgery Journal 40(6)
13. Zhang  YM, Yang  B, Sun  XD, Zhang  Z. Combined intra-
venous and intra-articular tranexamic acid administration
in total knee arthroplasty for preventing blood loss and
hyperfibrinolysis: a randomized controlled trial. Medicine
(Baltimore). 2019;98(7):e14458.
14. Zilinsky I, Barazani TB, Visentin D, Ahuja K, Martinowitz U,
Haik  J. Subcutaneous injection of tranexamic acid
to reduce bleeding during dermatologic surgery: a
double-blind, placebo-controlled, randomized clinical
trial. Dermatol Surg. 2019;45(6):759-767.
15. Sagiv  O, Rosenfeld  E, Kalderon  E, et  al. Subcutaneous
tranexamic acid in upper eyelid blepharoplasty: a pro-
spective randomized pilot study. Can J Ophthalmol.
Downloaded from https://academic.oup.com/asj/article/40/6/587/5554079 by guest on 21 February 2021
2018;53(6):600-604.
16. Pazyar  N, Yaghoobi  R, Zeynalie  M, Vala  S. Comparison
of the efficacy of intradermal injected tranexamic acid vs
hydroquinone cream in the treatment of melasma. Clin
Cosmet Investig Dermatol. 2019;12:115-122.
17. CRASH-2 trial collaborators. Effects of tranexamic acid on
death, vascular occlusive events, and blood transfusion
in trauma patients with significant haemorrhage (CRASH-
2): a randomized, placebo-controlled trial. Lancet.
2010;376(9734):23-32.
18. Ker  K, Edwards  P, Perel  P, Shakur  H, Roberts  I. Effect of
tranexamic acid on surgical bleeding: systematic review
and cumulative meta-analysis. BMJ. 2012;344:e3054.
19. Goobie  SM, Cladis  FP, Glover  CD, et  al.; the Pediatric
Craniofacial Collaborative Group. Safety of antifibrinolytics
in cranial vault reconstructive surgery: a report from
the pediatric craniofacial collaborative group. Paediatr
Anaesth. 2017;27(3):271-281.
20. Nishijima DK, Monuteaux MC, Faraoni D, et al. Tranexamic
acid use in United States children’s hospitals. J Emerg
Med. 2016;50(6):868-874.e1.
21. Beikaei M, Ghazipour A, Derakhshande V, et al. Evaluating
the effect of intravenous tranexamic acid on intraoperative
bleeding during elective rhinoplasty. Biomed Pharm J.
2015;8:753-759.
22. Eftekharian HR, Rajabzadeh Z. The efficacy of preopera-
tive oral tranexamic acid on intraoperative bleeding
during rhinoplasty. J Craniofac Surg. 2016;27(1):97-100.
23.
Ghavimi  MA, Taheri  Talesh  K, Ghoreishizadeh  A,
Chavoshzadeh MA, Zarandi A. Efficacy of tranexamic acid
on side effects of rhinoplasty: a randomized double-blind
study. J Craniomaxillofac Surg. 2017;45(6):897-902.
24. Sakallioğlu Ö, Polat C, Soylu E, Düzer S, Orhan İ, Akyiğit A.
The efficacy of tranexamic acid and corticosteroid on
edema and ecchymosis in septorhinoplasty. Ann Plast
Surg. 2015;74(4):392-396.
25. Butz  DR, Geldner  PD. The use of tranexamic acid in
rhytidectomy patients. Plast Reconstr Surg Glob Open.
2016;4(5):e716.
26. Ausen  K, Fossmark  R, Spigset  O, Pleym  H. Randomized
clinical trial of topical tranexamic acid after reduction
mammoplasty. Br J Surg. 2015;102(11):1348-1353.
27. Rohrich  RJ, Cho  MJ. The Role of tranexamic acid in
plastic surgery: review and technical considerations. Plast
Reconstr Surg. 2018;141(2):507-515.
Couto et al
28. Cansancao AL, Condé-Green A, David JA, Cansancao B,
Vidigal RA. Use of tranexamic acid to reduce blood loss in
liposuction. Plast Reconstr Surg. 2018;141(5):1132-1135.
29. Man D, Plosker H, Winland-Brown JE. The use of autolo-
gous platelet-rich plasma (platelet gel) and autologous
platelet-poor plasma (fibrin glue) in cosmetic surgery.
Plast Reconstr Surg. 2001;107(1):229-237; discussion 238.
30. Grover  R, Jones  BM, Waterhouse  N. The prevention of
haematoma following rhytidectomy: a review of 1078 con-
secutive facelifts. Br J Plast Surg. 2001;54(6):481-486.
31. Jones BM, Grover R. Avoiding hematoma in cervicofacial
rhytidectomy: a personal 8-year quest. Reviewing 910 pa-
tients. Plast Reconstr Surg. 2004;113(1):381-387; discus-
sion 388.
32. Jones BM, Grover R, Hamilton S. The efficacy of surgical
drainage in cervicofacial rhytidectomy: a prospective,
randomized, controlled trial. Plast Reconstr Surg.
2007;120(1):263-270.
33. Por YC, Shi L, Samuel M, Song C, Yeow VK. Use of tissue
sealants in face-lifts: a meta analysis. Aesthetic Plast Surg.
2009;33(3):336-339.
34. Hester  TR Jr, Gerut  ZE, Shire  JR, et  al. Exploratory, ran-
domized, controlled, phase 2 study to evaluate the safety
and efficacy of adjuvant fibrin sealant VH S/D 4 S-Apr
593
(ARTISS) in patients undergoing rhytidectomy. Aesthet
Surg J. 2013;33(3):323-333.
35. Cabas Neto J, Rodriguez Fernandez DE, Boles MM. A new
technique of external quilting sutures: their importance in
preventing hematomas in cervicofacial rhytidectomies.
Plast Reconstr Surg. 2013;131(1):121e.
36.
Auersvald  A, Auersvald  LA. Hemostatic net in
rhytidoplasty: an efficient and safe method for preventing
hematoma in 405 consecutive patients. Aesthetic Plast
Surg. 2014;38(1):1-9.
37. Beale EW, Rasko Y, Rohrich RJ. A 20-year experience with
secondary rhytidectomy: a review of technique, longevity,
and outcomes. Plast Reconstr Surg. 2013;131(3):625-634.
Downloaded from https://academic.oup.com/asj/article/40/6/587/5554079 by guest on 21 February 2021
38.
Klein  JA. The tumescent technique. Anesthesia
and modified liposuction technique. Dermatol Clin.
1990;8(3):425-437.
39. De  Bonis  M, Cavaliere  F, Alessandrini  F, et  al. Topical
use of tranexamic acid in coronary artery bypass op-
erations: a double-blind, prospective, randomized,
placebo-controlled study. J Thorac Cardiovasc Surg.
2000;119(3):575-580.
40. Ker  K, Beecher  D, Roberts  I. Topical application of tran-
examic acid for the reduction of bleeding. Cochrane
Database Syst Rev. 2013;7:CD010562.