Intravenous Tranexamic Acid In Plastic Surgery Breast/chest Procedures: A Single Surgeon Experience
David M. Turer, MD, MS, James O'Brien, BS, Isaac James, MD, Katherine Hrebinko, MD, Lorelei Grunwaldt, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Goals/Purpose: Tranexamic acid (TXA) is an anti-fibrinolytic agent that reversibly binds to plasminogen, preventing its conversion to the active protease, plasmin. In recent years, TXA has demonstrated promise as an intraoperative hemostatic agent. The field of plastic surgery has begun to evaluate the use of TXA in a variety of surgical procedures. The efficacy of tranexamic acid remains unclear. This study investigates whether the use of intraoperative intravenous TXA is associated with a lower likelihood of post-operative complications in a cohort of patients undergoing breast and/or chest surgery in a plastic surgery practice.
Methods: A retrospective chart review of 271 primary and revisionary breast/chest surgeries performed by a single surgeon at a single academic center was performed. Patients either had not received TXA or had been given a bolus dose of TXA prior to incision followed by a maintenance infusion during the entirety of the case. Complication rates were analyzed and compared between the two cohorts including hematoma, seroma, hypertrophic scarring, wound dehiscence, DVT/PE formation, re-operation, and infection. Subgroup analysis was performed to evaluate if increased surgeon experience over time correlated with decreased post-operative complications.
Results: 271 charts from 2010 to 2019 were retrospectively reviewed. Mean patient age was 18.3 years and 76.4% of patients were natal females. Body mass index (BMI), mass of resected breast tissue, total operative time, ASA classification, and incidence of comorbidities were comparable between the groups. Patients in the TXA cohort were on average older and more likely to be transgender as compared to the control cohort. 195 patients did not receive TXA and 76 patients received TXA. On average, patients who were given TXA received 3163±1076 mg (42.3±12.3 mg/kg).
Indications for surgery included gender affirming female-male top surgery (n=98, 36.2%), macromastia (n=110, 40.6%), and gynecomastia (n=63, 23.2%). The patients who received TXA did not have a statistically significant lower likelihood of hematoma, seroma, hypertrophic scarring, wound dehiscence, DVT/PE formation, and reoperation when each of these complications was assessed as a separate variable. Since TXA administration began in June 2018, regression analysis revealed that increased surgeon experience did not appear to account for the observed reduction in complications for the TXA cohort.
Overall, patients who received intraoperative TXA were less likely to experience a post-operative complication compared to those patients that did not receive TXA (22% vs. 8%, RR = 0.358, 95% CI 0.16-0.80 p = 0.0132). Additionally, patients in the TXA cohort were less likely to experience a postoperative infection (12.8 vs. 2.7%, RR = 0.21, 95% CI 0.05 – 0.85, p =0.03).
Conclusion: This study suggests that administration of intravenous tranexamic acid during breast/chest surgery appears to be correlated with a lower likelihood of having any postoperative complication and specifically, a postoperative infection. This data also demonstrates that TXA administration is safe in patients undergoing breast/chest surgery
and may help surgeons choose an appropriate dose. A prospective study to evaluate the efficacy of intravenous TXA is required to corroborate these findings.
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