Tranexamic acid is the latest adjunct in cosmetic surgery for the reduction of bleeding, bruising, and postoperative swelling. Popular in the oral form (Lysteda) as a treatment for heavy menses since the 1980s, and the intravenous form (Cyklokapron) in cardiovascular and orthopedic surgery for the control of surgical hemorrhage for decades, it has also been used effectively by direct application to the surgical field by irrigation, soaked pledgets and tissue injection in hair transplantation and various aesthetic procedures of the face, breasts, and abdomen including liposuction. We have been using topical tranexamic acid in blephoroplasty, breast augmentation, abdominoplasty, liposuction, and abdominoplasty, and vaginoplasty for the past year with similar positive findings to those of recent authors. There is no precedent in vaginoplasty to the best of our knowledge.
How we use tranexamic acid in cosmetic gynecology
A wide range of effective dosages for topical tranexamic acid is reported in the literature. Our most common application is in liposuction and the dosage we have been using for this procedure is 500mg tranexamic acid per liter of tumescent local anesthesia (TLA). We have used the same dose for all other applications including vaginoplasty. The method of topical application has been direct tissue injection at the time of local anesthesia infiltration and TLA-soaked surgical sponges.
In the vaginoplasty example above, the right sided puborectalis muscle (medial border inked) is about to be injected with Tranexamic-TLA in preparation for levatorplasty. A midline pleated rectocele repair has been completed and the suture line is obvious centrally. Notice the excellent hemostasis of the entire field despite the extent of the dissection.
Same operation after completion of a three-layer continuous levatorplasty. There is no bleeding from the puborectalis suture line. This means less postoperative swelling, inflammation and discomfort.
Same operation at final stage (perineal reconstruction) showing hemostasis of the deep transverse perineal muscles (inked), superfical perineal muscles, and bulbocavernosus. The surgical sponge in the vaginal canal is serving as a temporary scaffolding for contour adjustment purposes, not for hemostasis.
What precautions need to be taken when using tranexamic acid?
Tranexamic acid is excreted through the kidneys. Patients must have normal renal function. Also, the concomitant use of oral contraceptives or a history of thromboembolic disease are contraindications to the use of tranexamic acid. The use of tranexamic acid has not been found to increase the surgical risk of thrombembolic disease.
How does tranexamic acid work?
This post was written as a practice pearl, recipe-style. You can delve into the mechanisms of action of tranexamic acid here. In brief, tranexamic acid keeps newly-formed blood clots from being broken down (fibrinolysis) by inhibiting plasmin.
Marco A. Pelosi, III, MD, is a cosmetic gynecologist, surgeon, lecturer & cofounder of the ISCG. You may contact him directly at firstname.lastname@example.org