Tranexamic acid as a local hemostasis method after dental extraction in patients on warfarin: a randomized controlled clinical study

Role of tranexamic acid (TXA) in plastic and reconstructive surgery: A national perspective

PURPOSE

Despite the widespread use of tranexamic acid (TXA) in plastic surgery, guidelines for the safe and effective administration have yet to be established. The present study reports the current practices of TXA usage in plastic and reconstructive surgery procedures among members of the American Society of Plastic Surgeons (ASPS).

METHODS

An online survey was distributed to all active members of the ASPS. The survey was organized into three general parts: (1) demographic data and practice profiles; (2) familiarity, perceptions, and experience with TXA in various plastic surgery fields including craniofacial surgery, aesthetic surgery, burn care, microsurgery, and Mohs surgery; and (3) TXA dosage, mode, and time of administration.

RESULTS

Five hundred two ASPS members completed the survey (21% response rate). Among the respondents, TXA use was most common in aesthetic surgery (90.3%), craniofacial surgery (78.2%), and breast reconstruction (61.8%). The most common procedures performed under TXA were facial procedures, including facelift (83.6%), neck lift (77.1%), forehead and browlift (54.8%), and rhinoplasty (55.0%). TXA administration protocols in aesthetic procedures included IV bolus (52.3%) and topical administration (50.5%). The most common IV bolus dose was 1 g (43.2%) and the most common TXA solution concentration was 3% (36.0). A total of 92.4% of respondents reported that they had never observed any TXA-related complications.

CONCLUSIONS

The results reflect the widespread use of TXA among ASPS members, the preferred administration protocols in plastic surgery, and TXA's efficacy and favorable safety profile across a wide range of procedures.

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Clinical Applications of Tranexamic Acid in Plastic and Reconstructive Surgery

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery. This study reviews the scientific evidence regarding the use of TXA in the full range of plastic and reconstructive surgery to provide clinical recommendations for safe and effective use in various plastic surgical procedures.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. An established appraisal process was used to rate the quality of articles (Grading of Recommendations Assessment, Development, and Evaluation methodology).

RESULTS

Forty-five studies describing the use of TXA in plastic surgery were included. There is moderate-certainty evidence to support the use of intravenous administration of TXA in craniofacial surgery procedures to reduce blood loss and transfusion requirements. There is high-certainty evidence to support the use of TXA in cosmetic surgery and intravenous administration in rhinoplasty procedures to reduce blood loss. Further high-level studies are needed to determine TXA's effects on hematoma rates in face-lift surgery and breast-related procedures. There is moderate-certainty evidence to support the use of TXA in burn care. Further studies are required to provide quantitative conclusions on the effects of TXA administration in microsurgery.

CONCLUSIONS

This is the largest study to date on the use of TXA in plastic surgery and the first to provide clinical recommendations. The literature highlights TXA's promising role in the fields of craniofacial surgery, cosmetic surgery, and burn care. Standardized, objective measurements are required to provide quantitative conclusions regarding TXA's effects on ecchymoses and edema in cosmetic surgery procedures.

Efficacy of topical tranexamic acid soaked absorbable gelfoam in relieving post-extraction pain in warfarin patients: a randomized, triple-blinded, split-mouth, active-controlled clinical trial

BACKGROUND

Warfarin patients who need dental extraction face the problem of bleeding and no sufficient hemostasis results in dry socket and postoperative pain. This study aimed to evaluate and compare the efficacy of the topical application of tranexamic acid-soaked absorbable Gelfoam (TXA-Gel) and saline-soaked absorbable Gelfoam (saline-Gel) in relieving postoperative pain following bilateral simple extraction of permanent mandibular molars in warfarin patients.

METHODS

This was a randomized, triple-blinded, split-mouth, active-controlled clinical trial. It was performed at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Damascus University, between November 2021 and October 2023. 60 bilateral permanent mandibular molars, which were indicated for simple extraction in 30 warfarin patients randomly assigned into two groups according to the topical hemostatic agents after extraction used: Group 1: control group, saline-Gel (n = 30). Group 2: TXA-Gel (n = 30). A simple randomization method was performed by flipping a coin. The primary outcome measure was the visual analogue scale (VAS). The intensity of pain was evaluated at the baseline (t0), and on the 1st (t1), 2nd (t2), 3rd (t3), 4th (t4), 5th (t5), 6th (t6), and 7th (t7) days following extraction. The Kolmogorov-Smirnov test and the Mann-Whitney U test were performed. The level of significance was set at 0.05 (p < 0.05).

RESULTS

The mean vas scores was 4.17 ± 1.76 at t1 and decreased to 0.73 ± 0.78 at t7 in the TXA-Gel group. However, in the Gelfoam group, the mean vas scores was 4.83 ± 2.18 at t1 and decreased to 1.80 ± 1.00 at t7. The results of the Mann-Whitney U test showed that there was no statistically significant difference between the two groups at t1 (p = 0.236) and t2 (p = 0.155). However, there was a statistically significance difference at the rest time points (p < 0.05).

CONCLUSIONS

TXA-Gel played a prominent role in alleviating post-extraction pain in warfarin patients.

TRIAL REGISTRATION

The trail was retrospectively registered at the ISRCTN registry (ISRCTN71901901).

The effect of different hemostatic agents following dental extraction in patients under oral antithrombotic therapy: a network meta-analysis

This network meta-analysis was done to thoroughly evaluate the available literature on the use of different hemostatic agents for dental extraction in patients under oral antithrombotic therapy, aiming to identify the agent with the best/worst performance in bleeding control. Considering that such patients have a higher risk of bleeding, choosing the right hemostatic is essential. Twenty-three randomized clinical trials articles were included after completing the literature search. Cyanoacrylate tissue adhesive showed a reduction in the odds of postoperative bleeding events compared with conventional methods (i.e., gauze/cotton pressure, sutures), with a tendency toward a statistical significance (OR 0.03, P = 0.051). Tranexamic acid was the only agent that demonstrated a significantly lower risk of developing postoperative bleeding events (OR 0.27, P = 0.007). Interestingly, chitosan dental dressing and collagen plug had the shortest time to reach hemostasis. However, they ranked last among all hemostatic agents, regarding bleeding events, revealing higher odds than conventional measures. Therefore, it is concluded that the use of cyanoacrylate tissue adhesive and tranexamic acid gives favorable results in reducing postoperative bleeding events following dental extractions. Although chitosan dental dressing and collagen exhibited a faster time to reach hemostasis, they led to a higher occurrence of bleeding events.

Risk of bleeding in anticoagulated patients undergoing dental extraction treated with topical tranexamic acid compared to collagen-gelatin sponge: Randomized clinical trial

This two-arm, parallel-group, double-blind, randomized clinical trial design evaluated the risk of postoperative bleeding in anticoagulated patients undergoing dental extraction treated with topical TXA in comparison to collagen-gelatin sponge. Forty patients were randomly included in one of the study groups: (1) topical use of 4.8% TXA solution; and (2) resorbable hydrolyzed collagen-gelatin sponge applied to the surgical alveolus. Primary outcomes were postoperative bleeding episodes and secondary outcomes were thromboembolic events and postoperative INR values. The relative risk (RR), the absolute risk reduction (RAR) and the number needed to treat (NNT) were used as effect estimates and calculated from the counting of bleeding episodes observed during the first postoperative week. The bleeding rate under the TXA treatment was 22.2%, while in the collagen-gelatin sponge group it was 45.7%, resulting in a RR of 0.49 (95% CI 0.24-099; p = 0.046), RAR 23.5% and NNT 4.3. TXA was more effective in reducing bleeding in surgical sites located in the mandible (RR = 0.10; 95% CI 0.01-0.71; p = 0.021) and the posterior region (RR = 0.39; 95% CI 0.18-0.84; p = 0.016). Within the limitations of the study it seems that topical TXA is more effective in controlling bleeding after tooth extractions in anticoagulated patients than collagen-gelatin sponge. CLINICAL TRIAL REGISTRATION: RBR-83qw93.

The role of hemostatic agents after tooth extractions: A systematic review and meta-analysis

BACKGROUND

Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy.

TYPES OF STUDIES REVIEWED

The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events.

RESULTS

Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, -1.02; 95% CI, -1.70 to -0.35; P = .003 and standardized mean difference, -2.30; 95% CI, -3.20 to -1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup.

CONCLUSIONS

The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures.

PRACTICAL IMPLICATIONS

Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.

Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis

BACKGROUND

The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol.

METHODS

The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered.

RESULTS

A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment.

CONCLUSIONS

The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.

Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study

INTRODUCTION

Local applications of tranexamic acid (TXA) have been effective in treating various hemorrhagic conditions. In patients with gross hematuria, the main treatment in the emergency department (ED) is continuous bladder irrigation (CBI). However, CBI has no pharmacological effects except blood clot removal from dilution. The aim of this study was to evaluate the impact of the intravesical TXA injection before CBI.

METHODS

This study was a before-and-after, retrospective, and single-center study. The target population was hematuria patients who received CBI via a 3-way Foley catheter. As the intervention procedure, 1000 mg of TXA was injected through the Foley catheter and after 15 min, the Foley catheter was declamped and CBI started. Since the intervention started in March 2022, the patients from March 2022 to August 2022 were assigned to the after group and the patients from March 2021 to August 2021 were assigned to the before group. The primary outcomes were the length of stay in the ED and duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for CBI within 48 h after discharge.

RESULTS

The numbers of patients in the before group and after group were 73 and 86, respectively. The median length of stay in the ED was shorter in the intervention group than in the group not treated with TXA (274 min vs. 411 mins, P < 0.001). The median duration of Foley catheter placement was also shorter in the intervention group than not treated with TXA (145 min vs. 308 mins, P < 0.001). The revisits after ED discharge were lower in the after group than in the before group (2.3% vs. 12.3%, P = 0.031). There was a trend for lower admissions in the TXA treatment group than before group (29.1% vs. 45.2%, P = 0.052).

CONCLUSION

After the TXA intervention, reduction in the length of stay in the ED, the duration of Foley catheter placement, and the revisits after ED discharge was observed.

Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis

Dental procedures have posed challenges in managing anticoagulated patients due to early reports of oral hemorrhage. This study aims to evaluate the risks of postoperative bleeding with the local application of tranexamic acid. A systematic search was conducted until 31 March 2022, with keywords including tranexamic acid, oral hemorrhage, dental, and/or coagulation. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane Library. Statistical analysis was conducted using Review Manager 5.4. In total, 430 patients were pooled in with the local application of tranexamic acid using mouthwash, irrigation, and compression with a gauze/gauze pad. The mean age was 61.8 years in the intervention group and 58.7 in the control group. Only 4 patients in the intervened group out of the 210 discontinued the trial due to non-drug-related adverse events. The risk difference was computed as -0.07 (p = 0.05), meaning that patients administered with local antifibrinolytic therapy for postoperative bleeding reduction for dental procedures were at a 7% less risk of oral bleeding. Current evidence on managing anticoagulated patients undergoing dental or oral procedures remains unclear. The present study presents favorable outcomes of postoperative bleeding with local tranexamic acid used in the postoperative period.

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.

Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery

OBJECTIVES

A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures.

MATERIALS AND METHODS

A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction.

RESULTS

33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants.

CONCLUSIONS

No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks.

CLINICAL RELEVANCE

direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.

Facelift Part II: Surgical Techniques and Complications

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

LEVEL OF EVIDENCE: 4

Does Platelet-Rich Fibrin Prevent Hemorrhagic Complications After Dental Extractions in Patients Using Oral Anticoagulant Therapy?

PURPOSE

The number of anticoagulated patients requiring dental extractions and other minor dentoalveolar surgical procedures has increased significantly. The purpose of this study was to determine whether the use of platelet-rich fibrin (PRF) prevents hemorrhagic complications after dental extractions in patients being treated with oral anticoagulants.

METHODS

A 2-phase PROSPERO-registered systematic review of published within-subject controlled trials (CRD42020186678) was conducted in accordance with the PRISMA statement. Searches were conducted through Medline via PubMed, Web of Science, LILACS, Central Cochrane, Scopus, DOSS, and Google Scholar, until May 2020. The predictor variable was the study group (PRF vs use/non-use of other hemostatic agents). The main outcome of interest was the risk of bleeding after tooth extraction and the covariates were postoperative complications. Data analysis included synthesis of results, risk of bias (RoB) evaluation, meta-analysis (random effects; I²-based heterogeneity; 95% confidence), and certainty of evidence assessment.

RESULTS

From a total of 216 articles, 3 articles (low-moderate RoB) were included for evaluation in this systematic review and meta-analysis. A total of 130 patients were involved. The outcomes of the meta-analysis showed that the use of PRF in extraction wounds did not reduce the risk of bleeding after extraction in anticoagulated patients (P= .330; I² = 99%). Furthermore, the use of PRF did not improve pain scores (P = .470; I² = 96%) or the risk of postoperative alveolitis (P = .4300; I² = 38%) in anticoagulated patients. The certainty of the evidence ranged from moderate to low.

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that PRF does not prevent hemorrhagic complications after tooth extraction in patients using oral anticoagulant therapy.

Effectiveness of local hemostatic to prevent bleeding in dental patients on anticoagulation: A systematic review and network meta-analysis

This study aimed to determine the effectiveness of hemostatic protocols to prevent bleeding in dental procedures among individuals undergoing oral anticoagulation therapy. A systematic review and network meta-analysis were accomplished. Searches of literature and grey literature were performed in different electronic databases. Clinical trials were considered as part of the inclusion criteria. Data extraction and assessment of the risk of bias of the included articles were performed. Assessment of the certainty of evidence was also performed. As results we find that the N-butyl-2-cyanoacrylate [RR -35.00 (95% CI - 107.12, -5.78)], calcium sulfate (CaSO₄) [RR -5.62 (95% CI -11.41, -1.03)], and tranexamic acid (TXA) [RR -3.46 (95% CI -7.63, -0.77)] showed beneficial effects compared to placebo. However, only TXA presented beneficial effects with moderate certainty evidence. N-butyl-2-cyanoacrylate and CaSO₄ presented very low certainty evidence. In the comparisons between the hemostatic agents, no differences were observed. For the mean bleeding time, no significant difference in the comparisons was observed as well. Concluding, bleeding events in individuals on oral anticoagulation decreased with the use of TXA compared to placebo. N-butyl-2-cyanoacrylate and CaSO₄ were also superior to placebo, but the certainty of evidence was low. For the mean bleeding time, no significant difference in hemostatic agents was observed.

Local Tranexamic Acid for Local Hemostasis in an Animal Liver Injury Model

Background:

Hyperfibrinolysis is a state of increased clot resolution often seen in trauma patients with ongoing hemorrhage. Tranexamic acid (TXA) inhibits fibrinolysis preventing clot resolution affecting hemorrhage continuation and is used by intravenous administration.

Aims:

The purpose of this study was to evaluate the local tranexamic acid application for hemostatic control in an experimental animal liver injury model.

Settings and Design:

This study was an experimental prospective treatment study to check the local TXA effects on liver injury. This study was approved by the Ethics Committee.

Materials and Methods:

Twenty adult male Sprague-Dawley white rats were equally randomized to two groups after a standardized liver injury was conducted under anesthesia. One group were “liver-packed” with gauze (TXA [−]) and the other group with gauze soaked in TXA (TXA [+]). Bleeding from the injured middle liver lobe was measured at 2 and 15 min, and at 48h second-look surgery, with euthanasia conducted at 14 days. The liver was sent for histopathological and stereological analysis.

Statistical Analysis and Results:

There was no difference in bleeding at 2 or 15 min after packing; however, larger amount of free blood at 48 h in the TXA (−) group was noticed. Five animals in the TXA (−) were alive at 14 days compared to eight animals in the TXA (+) group. Significantly larger volume density of fibrosis, granulation tissue, and amorphous tissue were seen in the TXA (+) group compared to the TXA (−) group at the stereological analysis.

Conclusion:

Local TXA application on the injured liver surface might offer better hemostatic control than packing alone. Further studies are mandated before the clinical application of our findings.

Dental extraction in a patient with undiagnosed Von Willebrand's Disease: a case report

Dental extractions are a common part of general dental practice. While dentists routinely screen for medical contraindications during the preoperative assessment, undiagnosed coagulopathies have the potential to severely complicate a seemingly routine extraction. We report a case of surgical removal of a mandibular third molar in a patient with undiagnosed Von Willebrand Disease.

International normalized ratio (INR) values in patients receiving oral vitamin K antagonists and undergoing oral surgery: A clinical audit

INTRODUCTION

Dental extractions can be safely carried out on patients under vitamin K antagonists (VKAs) therapy, without stopping or changing the dosage, but the international normalized ratio (INR) needs to be monitored on the day of the intervention, showing adequate rates before proceeding.

OBJECTIVES

This study aims at evaluating INR values, measured before oral surgery procedures, to assess the rate of patients, under VKAs therapy, outside the therapeutic range.

MATERIALS AND METHODS

A clinical audit was carried out involving patients under VKAs, who needed minor oral surgery procedures, over a period of 18 months. The patient was instructed to not modify or suspend VKAs prior to the intervention. Before surgery, each patient fulfilled a questionnaire on dietary and oral hygiene habits, and a blood sample was collected for INR assessment (cut-off value for surgical procedure ≤3.5).

RESULTS

One hundred twenty-two patients were enrolled: 69 (56.6%) had an INR value within the established therapeutic range, 53 (43.4%) were out of range. No intra- or postsurgical major bleeding was recorded.

CONCLUSIONS

INR, measured on the same day of oral surgery, has the potential to prevent bleeding complications by the identification of those patients out of range, who may require adjusting the drug therapeutic dosage.

Local Infiltration of Tranexamic Acid With Local Anesthetic Reduces Intraoperative Facelift Bleeding: A Preliminary Report

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 documented. 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 solution. 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.

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.

Nanostructured fibrin agarose hydrogel as a novel haemostatic agent

Blood loss remains a major concern during surgery and can increase the morbidity of the intervention. The use of topical haemostatic agents to overcome this issue therefore becomes necessary. Fibrin sealants are promising haemostatic agents due to their capacity to promote coagulation, but their effectiveness and applicability need to be improved. We have compared the haemostatic efficacy of a novel nanostructured fibrin‐agarose hydrogel patch, with (c‐NFAH) or without cells (a‐NFAH), against two commercially available haemostatic agents in a rat model of hepatic resection. Hepatic resections were performed by making short or long incisions (mild or severe model, respectively), and haemostatic agents were applied to evaluate time to haemostasis, presence of haematoma, post‐operative adhesions to adjacent tissues, and inflammation factors. We found a significantly higher haemostatic success rate (time to haemostasis) with a‐NFAH than with other commercial haemostatic agents. Furthermore, other relevant outcomes investigated were also improved in the a‐NFAH group, including no presence of haematoma, lower adhesions, and lower grades of haemorrhage, inflammation, and necrosis in histological analysis. Overall, these findings identify a‐NFAH as a promising haemostatic agent in liver resection and likely in a range of surgical procedures.