Assessing current applications of tranexamic acid in reconstructive microsurgery and future direction: An 11-year meta-analysis

BACKGROUND: The use of tranexamic acid (TXA) in plastic surgery is increasing due to its anti-inflammatory properties, particularly in reducing postoperative seromas. However, its role in reconstructive microsurgery remains limited due to concerns about microvascular thrombosis and flap compromise. This study reviewed the literature on TXA use in microsurgery with a meta-analysis of clinical outcomes. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines searched PubMed, Cochrane, Embase, and Google Scholar for clinical studies published from 2013 to 2023 utilizing TXA in microsurgical procedures. Two independent reviewers assessed the studies using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool. Outcomes of interest included the TXA administration protocol and postoperative complications. Meta-analysis was conducted using Cochrane Review Manager, evaluating for weighted relative risk (wRR) and heterogeneity (I2) of pooled data. RESULTS: Five studies investigated TXA in microsurgery, with four using intravenous (IV) TXA and included in the meta-analysis. A total of 718 patients and 854 flaps were analyzed, with 403 flaps receiving TXA. IV TXA was used in 308 patients, and topical TXA in 36. In the IV TXA cohort, there were no differences in the incidence of complications or in the risk of flap loss (wRR, 0.63; 95% CI, 0.17-2.32; p=0.49; I2=9%), thrombosis/venous congestion of the anastomosis (wRR, 0.39; p=0.06; I2=0%), hematoma (wRR, 0.76; 95% CI, 0.21-2.75; p=0.68; I2=54%), or overall systemic venous thromboembolism (wRR, 0.17; p=0.10; I2=0%). Topical TXA to the donor site wound bed demonstrated a significant decrease in the risk of various complications (relative risk [RR], 0.52; 95% CI, 0.29-0.94; p=0.03) and a significant decrease in the duration of postoperative drains by nearly 7.5 days (p=0.022). CONCLUSION: TXA is associated with decreased donor site complications without increasing the risk of flap complications or systemic thromboembolic events in microsurgery. Additionally, TXA may demonstrate anti-inflammatory properties that promote healing. TXA is a safe and effective adjunct in reconstructive microsurgery, and a randomized controlled trial may help devise a standardized treatment protocol.

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Systematic review and meta-analysis of five studies (718 patients, 854 flaps) of tranexamic acid in microsurgery: intravenous TXA did not raise flap loss, anastomotic thrombosis/venous congestion, hematoma or venous thromboembolism risk, while topical TXA reduced donor-site complications and drain duration.

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