IDEAS AND INNOVATIONS

Use of Tranexamic Acid to Reduce Blood Loss

in Liposuction
Alvaro Luiz Cansancao, M.D.
Background: The use of tranexamic acid for blood loss prevention has gained
Alexandra Condé-Green,
popularity in many specialties, including plastic surgery. However, its use in
M.D.
liposuction has not been studied. The authors present a prospective, double-
Joshua A. David, B.S. blind, nonrandomized study evaluating the efficacy of tranexamic acid in re-
Bethania Cansancao, M.D. ducing perioperative blood loss during liposuction.
Rafael A. Vidigal, M.D. Methods: Twenty women undergoing liposuction were divided into two co-
Rio de Janeiro, Brazil; Newark, N.J.; horts. Group 1 (n = 10) received a standard dose of 10 mg/kg of tranexamic
and New York, N.Y. acid intravenously in the preoperative and postoperative periods, whereas
group 2 (n = 10) received a placebo. Patient hematocrit levels were evaluated
preoperatively and postoperatively. Blood volume in the infranatant of the
lipoaspirate was also measured; t tests were used for statistical analysis.
Results: Age, body mass index, and volume of lipoaspirate were comparable
between the two cohorts. The volume of blood loss for every liter of lipoaspi-
rate was 56.2 percent less in the tranexamic group compared with the control
group (p < 0.001). Hematocrit levels at day 7 postoperatively were 48 percent
less in group 1 compared with group 2 (p = 0.001). Furthermore, a 1 percent
drop in the hematocrit level was found after liposuction of 812 ± 432 ml in
group 1 and 379 ± 204 ml in group 2. Thus, the use of tranexamic acid could
allow for aspiration of 114 percent more fat, with comparable variation in
hematocrit levels.
Conclusions: Tranexamic acid has been shown to be effective for minimizing peri-
operative blood loss in liposuction. Further large randomized controlled studies
are required to corroborate this effect.  (Plast. Reconstr. Surg. 141: 1132, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

L
iposuction remains one of the most com- inhibits the conversion of plasminogen to plas-
monly performed aesthetic surgical pro- min, thereby preventing the binding and degra-
cedures, and its popularity increases every dation of fibrin, and preserving the framework
year.1 However, since its inception, justified con- of its matrix structure.3 Studies in various medi-
cerns regarding patient safety have generated cal specialties, such as orthopedic surgery,4 car-
limits on the volume of fat that can be aspirated. diology,5 and gynecology,6 have shown that it
These limitations are largely influenced by the can reduce blood loss and transfusion require-
hemodynamic fluctuations and blood loss that ments. In recent years, the surgical application
can occur during liposuction.2 Tranexamic acid of tranexamic acid for minimization of blood
is an antifibrinolytic agent that competitively loss has undergone a revival, and its use has
been coopted by plastic surgeons for reduction
From the Department of Plastic Surgery, Universidade
of intraoperative bleeding. This has proven par-
­Iguaçu, Hospital da Plástica; the Division of Plastic Sur- ticularly effective in burns7 and in craniomaxil-
gery, Department of General Surgery, Rutgers New Jersey lofacial8 and aesthetic procedures. Although its
Medical School; and the Hansjörg Wyss Department of Plas- use in liposuction has been cited by some publi-
tic and Reconstructive Surgery, New York University Lan- cations,9,10 its efficacy in reducing perioperative
gone Medical Center. blood loss during liposuction has not yet been
Received for publication July 10, 2017; accepted November studied.
15, 2017.
Presented at Plastic Surgery The Meeting 2015, American
Society of Plastic Surgeons Annual Meeting, in Boston, Disclosure: The authors declare no conflicts of
Massachusetts, October 16 through 20, 2015. ­interests with respect to the authorship and/or publi-
Copyright © 2018 by the American Society of Plastic Surgeons cation of this article.
DOI: 10.1097/PRS.0000000000004282

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 Volume 141, Number 5 • Tranexamic Acid for Reducing Blood Loss

Fig. 1. Klein equation to calculate the volume of whole blood aspirated by liposuction.

PATIENTS AND METHODS the control group had a mean age of 36.2 years
Here, we present a prospective, double-blind, (range, 28 to 51 years). The mean body mass index
nonrandomized study evaluating the effects of was 28.3 kg/m2 (range, 24 to 31 kg/m2) in group 1
tranexamic acid on blood loss of patients undergo- and 25.4 kg/m2 (range, 19 to 32 kg/m2) in group
ing liposuction. The institutional review board at 2. The average supernatant (fat) volumes were
our institution approved the study. Twenty women 4280 ml and 3715 ml, respectively, correspond-
undergoing liposuction were divided into two ing to 5.8 percent and 5.4 percent, respectively,
cohorts. The experimental group (group 1, n = 10) of patient body weight. The duration of all proce-
received a standard intravenous dose of 10 mg/ dures was approximately 3 hours (range, 2.5 to 3.0
kg of tranexamic acid, 30 minutes preoperatively hours). All patients were discharged to home on
and postoperatively (the recommended dos- postoperative day 1. None of the patients exhib-
age), whereas the control group (group 2, n = 10) ited side effects from the use of tranexamic acid.
received normal saline intravenously. Exclusion cri- Our results show that despite aspiration of similar
teria included patients younger than 18 and older absolute and relative volumes from both patient
than 65 years; body mass index greater than 35 kg/ cohorts, the total volume of blood in the total
m2; current smoking; a diagnosis of diabetes or lipoaspirate according to the Klein equation11 was
renal failure; an American Society of Anesthesiolo- 37.7 ml in group 1 and 59.9 ml in group 2, repre-
gists score greater than or equal to 3; and current senting 37 percent less perioperative blood loss in
anticoagulation or corticoid therapy. All operations patients who received tranexamic acid (p < 0.05).12
were performed under locoregional anesthesia, The volume of blood loss for every liter of super-
and a solution of normal saline and epinephrine at natant was 8.8 ml and 20.1 ml in groups 1 and 2,
1:500,000 was infiltrated subcutaneously according respectively, representing 56.2 percent less blood
to the superwet technique. Power-assisted liposuc- loss per liter of supernatant in group 1 (p = 0.001)
tion was performed 10 minutes after infiltration. (Table 1). There was a 1.3 percent drop in the
Intraoperative hydration was performed as follows: hematocrit level per liter of supernatant in group
lactated Ringer solution was administered at a rate 1 patients, and 2.7 percent in group 2, represent-
of 1:1 per volume of expected supernatant (fat). ing a drop in hematocrit that was 48 percent less
Fifty percent was injected during hour 1 of the pro- in the hematocrit level of patients who received
cedure, 25 percent during hour 2, and 25 percent tranexamic acid (p < 0.03). Therefore, a 1 per-
during hour 3. Postoperatively, lactated Ringer cent drop in the hematocrit level was found after
solution was again administered at a rate of 500 ml/ liposuction of 812 ± 432 ml in group 1 and 379
hour during the first 6 hours, and 250 ml/hour in ± 204 ml in group 2 (Table 2). Thus, the use of
the subsequent 6 hours. Patient hematocrit levels tranexamic acid could allow for aspiration of 114
were evaluated preoperatively and on day 7 post- percent more fat despite comparable variations in
operatively. The blood volume of the total lipoaspi- hematocrit levels (p < 0.009).
rate (supernatant and infranatant) was measured
according to the Klein equation11 (Fig. 1). The DISCUSSION
G*Power 3.1 statistical package was used for post
First introduced as a treatment for menorrha-
hoc power analysis, and nonparametric Wilcoxon-
Mann-Whitney tests were used to compare means gia and hereditary bleeding disorders in the 1960s,
between the groups. tranexamic acid has been rapidly adopted for use
in a wide variety of conditions and procedures.
Administration of tranexamic acid—locally, orally
RESULTS or intravenously—has been shown to minimize
Patient characteristics were compara- hematoma-related complications in rhinoplasty,13
ble between the two cohorts. Patients in the rhytidectomy,14 and reduction mammaplasty.15 In
tranexamic acid group had a mean age of addition to its proven hemostatic effects, it is gen-
40.7 years (range, 24 to 54 years) and patients in erally well tolerated; mild diarrhea and nausea

1133
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 Plastic and Reconstructive Surgery • May 2018

Table 1.  Comparative Results of Blood Volume in the Lipoaspirate of Groups 1 and 2
Group 1 Group 2 p
No. of patients 10 10
Aspirated volume, liters 4.280 ± 1.434 3.715 ± 1.693 0.3615
Percentage of body weight aspirated 5.8 ± 1.8 5.4 ± 1.7 0.6443
Blood volume in aspirate, ml 37.7 ± 15.5 59.9 ± 25.1 0.0410
Volume of blood per liter of aspirate, ml/liter 8.8 ± 2.0 20.1 ± 7.6 0.0010

Table 2.  Preoperative and Postoperative Hematocrit Levels of Groups 1 and 2

Group 1 Group 2 p
Initial Hct, g/dl 38.7 ± 4.4 39.3 ± 2.3 0.5407
Postoperative Hct, g/dl 32.9 ± 1.2 31.0 ± 2.8 0.0850
Hct reduction, g/dl 6.4 ± 2.6 7.9 ± 2.2 0.1807
Hct reduction per aspirated liter, g/dl/liter 1.3 ± 0.7 2.7 ± 1.1 0.0219
Aspirated volume to reduce Hct by 1%, ml 812 ± 432 379.2 ± 203.8 0.0089
Hct, hematocrit.

are the most common side effects.16 Because of cloudfront.net/News/Statistics/2016/plastic-surgery-statis-

the theoretical risks associated with fibrinolytic tics-full-report-2016.pdf. Accessed July 7, 2017.
2. Cansanção AL, Cansanção AJ, Cansanção BP, Vidigal RA.
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case reports of cerebral19 and arterial20 throm- intravenous bolus of tranexamic acid on blood loss in total
bosis, controlled randomized studies in cardiac21 hip replacement. J Bone Joint Surg Br. 2009;91:776–783.
and orthopedic surgery,22 and large retrospective 4. Amer KM, Rehman S, Amer K, Haydel C. Efficacy and safety
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Alvaro Luiz Cansancao, M.D.
Plast Reconstr Surg. 2015;136(Suppl):80.
Avenida das Americas 3200, Sala 212
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 Volume 141, Number 5 • Tranexamic Acid for Reducing Blood Loss

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