Original Article

Cosmetic
Use of Tranexamic Acid in Aesthetic Surgery:
A Retrospective Comparative Study of Outcomes
and Complications
Omar Fouda Neel, MBBS, MMgt.,
FRCSC, FACS*† Background: Bleeding is a potential complication of aesthetic surgery. Surgeons
Raghad AlKhashan, MBBS have adhered to the principle of minimizing blood loss. Tranexamic acid (TXA) is
Candidate‡ an antifibrinolytic medication capable of reducing bleeding. This study aimed to
Emad Abdulrahman AlFadhel, investigate TXA and its effect on complications and overall outcomes in aesthetic
MBBS§ surgery patients.
Reem Abdulmonem Al-Terkawi, Methods: This retrospective chart review of patients undergoing various aes-
BSIT¶ thetic procedures between 2019 and 2022 was conducted in Riyadh, Saudi Arabia.
Hatan Mortada, MBBS‖** Preoperative and postoperative hemoglobin levels, blood transfusions, and com-
plications 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 under-
went 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. (Plast Reconstr Surg Glob Open 2023;
11:e5229; doi: 10.1097/GOX.0000000000005229; Published online 1 September 2023.)

INTRODUCTION by The American Society of Plastic Surgeons, showing that

Aesthetic procedures have exponentially increased in 15.6 million cosmetic procedures were performed around
the last few years. In 2020, global statistics were published the world.1 An important intraoperative aspect of aes-
thetic plastic surgery is hemostasis. An excessive amount
of blood loss during an operation can lengthen operative
From *Division of Plastic Surgery, Department of Surgery, King
times and increase the need for blood transfusions, both
Saud University, Riyadh, Saudi Arabia; †Division of Plastic
of which are associated with increased morbidity and mor-
Surgery, Department of Surgery, McGill University, Montreal,
tality.2 The majority of plastic surgical procedures do not
Canada; ‡College of Medicine, King Saud University, Riyadh,
result in significant blood loss. Nonetheless, bleeding may
Saudi Arabia; §College of Medicine, Qassim University, Buraydah,
result in swelling, pain, bruising, frequent bandaging and
Saudi Arabia; ¶Private Practice, Riyadh, Saudi Arabia; ‖Division
drain changes, and the need for operations.3 Postoperative
of Plastic Surgery, Department of Surgery, King Saud University
bleeding may also lead to wound-related complications
Medical City, King Saud University, Riyadh, Saudi Arabia; and
and infections, as well as the need for allogeneic blood
**Department of Plastic Surgery & Burn Unit, King Saud Medical
transfusions.4,5 Blood products can improve hemodynamic
City, Riyadh, Saudi Arabia.
parameters and may even be a life-saving intervention in
Received for publication April 25, 2023; accepted July 7, 2023. the setting of major blood loss. However, they are associated
Copyright © 2023 The Authors. Published by Wolters Kluwer Health, with several noninfection-related and infection-related com-
Inc. on behalf of The American Society of Plastic Surgeons. This plications, therefore raising morbidity and mortality rates.6,7
is an open-access article distributed under the terms of the Creative Many interventions have proven successful in reducing
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
Disclosure statements are at the end of this article,
any way or used commercially without permission from the journal.
following the correspondence information.
DOI: 10.1097/GOX.0000000000005229

www.PRSGlobalOpen.com 1

surgical bleeding, including pharmacological agents such
as tranexamic acid (TXA), E-aminocaproic acid, and apro-
tinin, all of which work by stopping fibrinolysis and enhanc-
ing 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 inter-
action 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 advan-
tages and benefits in cardiac,11 orthopedic,12 and spine sur-
gery,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 periop-
erative 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 hema-
tological 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 sur-
gery, 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 sam-
pling 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 sam-
ple 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 deci-
sion to undergo aesthetic surgery, as well as the factors that
predict the decision to undergo aesthetic surgery. If intra-
operative 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
2
PRS Global Open • 2023
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 differ-
ence 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.
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 chil-
dren and job or not, smoking or not, weight, height, body
mass index (BMI), medical history, plastic surgery, preop-
erative Hgb, postoperative Hgb, type of procedure, opera-
tive 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 pro-
portion was presented with the respective 95% confidence
Neel et al • Tranexamic Acid in Aesthetic Surgery

interval (CI) with continuity correction. Group-based com-
parisons 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 mul-
tivariate 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 out-
comes 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).
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 plas-
tic surgery (54.7%). A total of 11 patients required blood
transfusion (2.6%). The mean ± SD preoperative and post-
operative 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, lipo-
suction 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).
Predictors of Using TXA
We included seven independent variables, which showed
significant associations with using TXA (BMI, surgery cat-
egory, operative time, LOS and undergoing a single or
combined surgery, and having a history of surgery or bar-
iatric 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 infla-
tion factor was <5 for all the independent variables). Based
on the results, the use of TXA was independently associ-
ated 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 proce-
dures (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

Table 1. Demographic Characteristics of Patients under Study

Use of TXA
Parameter Category Overall, N = 425 No, N = 244 Yes, N = 181 P Missing
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).

3

Fig. 1. The proportions of procedures performed for patients who received TXA and those who did not.
potential correlation between the dose or timing of TXA
and postoperative hemoglobin levels. However, no signifi-
cant associations were found. Therefore, no specific correla-
tion between the dose or timing of TXA administration and
postoperative hemoglobin levels could be identified.
Outcomes of Patients
In general, five patients (1.1%) developed postopera-
tive 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 over-
all 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 return-
ing 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
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bleeding and bruising, which can negatively impact patient
satisfaction and recovery.2 A number of studies have investi-
gated 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 poten-
tial benefits and risks of TXA should be carefully consid-
ered 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 find-
ings align with the currently available literature that TXA
elicits a potent anti-inflammatory response with a decrease
Neel et al • Tranexamic Acid in Aesthetic Surgery

Table 2. Perioperative Characteristics and Outcomes of Patients under Study

Use of TXA
Parameter Category Overall, N = 425 No, N = 244 Yes, N = 181 P Missing
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).

Table 3. Predictors of Using TXA in Plastic Surgery In terms of complications, although no significant
Parameter Category OR 95% CI P difference was observed between the cohorts, this could
BMI Healthy — —
be attributed to a number of discrepancies between the
Underweight 0.90 0.19–4.00 0.89
two groups. For instance, significantly more trunk aes-
Overweight 1.55 0.87–2.76 0.134 thetic surgery patients were given TXA than not. One of
Obese 0.51 0.23–1.11 0.096 the trunk aesthetic procedures is abdominoplasty, which
Surgery Breast aesthetic — — is a major procedure with a significant risk of complica-
category surgery tions. De Paep et al found that the overall complication
Facial aesthetic 2.05 0.93–4.53 0.074 rate of abdominoplasty reaches up to 29.8%, and the
surgery rate of major complications requiring medical interven-
Trunk aesthetic 4.93 2.56–9.71 <0.001 tion is 10%.19 On the other hand, significantly fewer
surgery
patients undergoing breast aesthetic surgery were given
Liposuction 5.52 2.05–15.1 <0.001
TXA compared with the control group. Aesthetic breast
Extremities 2.60 1.02–6.68 0.044
aesthetic surgery surgery documents much lower complication rates in
Single or Single — — the literature compared with abdominoplasty. Gupta et
combined Combined 2.70 1.55–4.78 <0.001 al have found in their study of 73,608 aesthetic breast
Any surgery No — — surgery cases that the incidence of major complications
before Yes 2.19 1.25–3.89 0.007 after the surgery is low at 1.46%.20 In our study, we did
Previous No — — not find a significant difference in postoperative bleeding
bariatric Yes 0.81 0.41–1.63 0.562 rates between the group that received TXA and the group
surgery that did not. Although patients who received TXA had
Operation Minutes 1.00 0.99–1.01 0.917 a lower mean preoperative hemoglobin value, indicating
time a potential effect on reducing blood loss, other factors
LOS Days 1.40 1.06–1.90 0.023
may have influenced the lack of significant differences.
OR, odds ratio.
Further research, including randomized controlled trials,
Values in boldface denote statistically significant differences (P < 0.05).
is needed to explore the impact of TXA on bleeding out-
comes in cosmetic surgery.
in postoperative edema and ecchymosis, which improves The type of aesthetic procedure the patient is under-
recovery time.5 Laikhter et al also found in a recent sys- going might influence the choice to use TXA. Procedures
tematic review and meta-analysis that the use of TXA can like trunk aesthetic surgery and liposuction had statisti-
potentially increase patient satisfaction with postoperative cally significantly higher use of TXA. Factors such as the
recovery and decrease costs associated with complications surgeon experience, surgery complexity, and higher fre-
in aesthetic surgery.18 quency of postoperative complications may have been

5

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 regard-
ing the interpretation of its results. Firstly, the study is a
retrospective comparative study, which has inherent limi-
tations, such as selection bias and confounding factors.
Secondly, the study only included patients who received
TXA from a single surgeon, which limits the generalizabil-
ity 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 documen-
tation 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 spe-
cific indications and timing of the return to the operat-
ing 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 aes-
thetic 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 cri-
teria 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 alloca-
tion 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 evi-
dence in the field of TXA use in aesthetic surgery. Lastly, the
study did not control for all potentially confounding vari-
ables, such as the use of other medications, medical comor-
bidities, 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
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PRS Global Open • 2023
our findings would be improved if we conducted a prospec-
tive, multicenter study with a larger sample size and stan-
dardized 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 receiv-
ing 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.
Hatan Mortada, MBBS
Division of Plastic Surgery
Department of Surgery
King Saud University Medical City, King Saud University; and
Department of Plastic Surgery & Burn Unit
King Saud Medical City
Riyadh, Saudi Arabia
E-mail: hatanmortada@gmail.com
Twitter: HatanMortada
Instagram: HatanMortada
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.
REFERENCES
1. American Society of Plastic Surgeons. Plastic surgery statis-
tics report 2020. Available at https://www.plasticsurgery.org/
documents/news/statistics/2020/plastic-surgery-statistics-full-
report-2020.pdf. Published 2020. Accessed February 16, 2023.
2. Marlino S, Cagli B, Vitale A, et al. Bleeding in plastic-aesthetic
surgery: a prognostic pathway with clinical application. Aesthetic
Plast Surg. 2020;44:201–206.
3. Neel OF, Mortada H, Qasim SS, et al. Current practices and
guidelines for perioperative blood management in post-bariatric
body contouring surgery: a comprehensive review of literature.
Aesthetic Plast Surg. 2022 [E-pub ahead of print].
4. Ausen K, Fossmark R, Spigset O, et al. 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. Plast Reconstr Surg. 2022;149:774–787.
5. Elena Scarafoni E. A systematic review of tranexamic acid in plas-
tic surgery: what’s new? Plast Reconstr Surg Glob Open. 2021;9:e3172.
6. Johnson DJ, Scott AV, Barodka VM, et al. Morbidity and mortality
after high-dose transfusion. Anesthesiology. 2016;124:387–395.
7. Busch MP, Kleinman SH, Nemo GJ. Current and emerging infec-
tious risks of blood transfusions. JAMA. 2003;289:959–962.
8. Cai J, Ribkoff J, Olson S, et al. The many roles of tranexamic acid:
an overview of the clinical indications for TXA in medical and
surgical patients. Eur J Haematol. 2020;104:79–87.
Neel et al • Tranexamic Acid in Aesthetic Surgery
9. Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analy-
sis and meta-regression of the effect of tranexamic acid on surgi-
cal blood loss. Br J Surg. 2013;100:1271–1279.
10. Ker K, Edwards P, Perel P, et al. Effect of tranexamic acid on sur-
gical bleeding: systematic review and cumulative meta-analysis.
BMJ. 2012;344:e3054.
11. Schouten ES, van de Pol AC, Schouten AN, et al. The effect of
aprotinin, tranexamic acid, and aminocaproic acid on blood loss
and use of blood products in major pediatric surgery: a meta-
analysis. Pediatr Crit Care Med. 2009;10:182–190.
12. Kim TK, Chang CB, Koh IJ. Practical issues for the use of
tranexamic acid in total knee arthroplasty: a systematic review.
Knee Surg Sports Traumatol Arthrosc. 2014;22:1849–1858.
13. Elgafy H, Bransford RJ, McGuire RA, et al. Blood loss in major
spine surgery: are there effective measures to decrease massive
hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976).
2010;35:S47–S56.
14. Varidel A, Marucci D. Tranexamic acid in craniosynostosis sur-
gery: a systematic review and meta-analysis. J Craniofac Surg.
2022;33:146–150.
15. Locketz GD, Lozada KN, Bloom JD. Tranexamic acid in aes-
thetic facial plastic surgery: a systematic review of evidence,
applications, and outcomes. Aesthet Surg J Open Forum.
2020;2:ojaa029.
16. Von Elm E, Altman DG, Egger M, et al; STROBE Initiative. The
strengthening the reporting of observational studies in epidemi-
ology (STROBE) statement: guidelines for reporting observa-
tional studies. Lancet. 2007;370:1453–1457.
17. Ng WC, Jerath A, Wasowicz M. Tranexamic acid: a clinical review.
Anaesthesiol Intensive Ther. 2015;47:339–350.
18. Laikhter E, Comer CD, Shiah E, et al. A systematic review
and meta-analysis evaluating the impact of tranexamic acid
administration in aesthetic plastic surgery. Aesthet Surg J. 2022;
42:548–558.
19. De Paep K, Van Campenhout I, Van Cauwenberge S, et al. Post-
bariatric abdominoplasty: identification of risk factors for com-
plications. Obes Surg. 2021;31:3203–3209.
20. Gupta V, Yeslev M, Winocour J, et al. Aesthetic breast surgery and
concomitant procedures: incidence and risk factors for major
complications in 73,608 cases. Aesthet Surg J. 2017;37:515–527.