Volume 146, Number 4 • Viewpoints

Tranexamic Acid in Microvascular Free Flap
Reconstruction
Sir:
T ranexamic acid (trans-4-aminomethylcyclohexane-
1-carboxylic acid) is an antifibrinolytic medication
considered by the World Health Organization as one
of the most effective and safe medications needed
in a health system.1 Its ability to limit intraoperative
blood loss and reduce transfusion requirements with-
out increasing the risk of deep venous thrombosis
makes its use appealing for surgical patients.1 Its effi-
cacy and safety have been explored in plastic surgery.2
Its indications and use are expanding rapidly, and it
is increasingly likely that patients undergoing micro-
vascular reconstruction will receive tranexamic acid
during their hospital course. However, the effects
of tranexamic acid on microvascular reconstruction
remain unclear. To better elucidate these concerns, we
reviewed the literature and identified three studies that
evaluated the use of tranexamic acid in patients having
flap-based reconstructive surgery (Table 1).3–5

Table 1.  Studies Performed Using Tranexamic Acid with Flap-Based Reconstruction Surgery
Reference Design Flaps Methods Results Conclusions
Rogers Retrospective, Flaps for head TXA group, 4 TXA administered to 4 patients having TXA 1 g should
et al., case series and neck patients; control free flaps with a preoperative to be given
20193 cancer; 65 group, 95 patients intraoperative reduction of 30 g/ intraoperatively
(50%) liter; 98% of patients were anemic during tissue
soft-tissue intraoperatively; 10 of 13 patients were resection; flap
free flaps, given at least one RBC cell transfusion, complications
34 (26%) compared with 16 of 86 of those were not
composite free without complications reported, nor
flaps, and (p < 0.001); 5 hematomas, 4 flap were subgroup
32 (24%) neck failures, 1 flap salvage, 1 bleeding/ analyses
dissections tracheostomy, 1 blowout and of patients
only evacuation of a hematoma; 4 receiving TXA
transfusions were administered before
operation, 12 on the day of operation,
13 the next day, 6 after 2 days, 4 after
3–8 days, and 2 after 19 and 31 days
Lardi Retrospective, Free flaps for TXA group: Second TXA group: no thrombosis of TXA
et al., single immediate 12 mo TXA microanastomosis (0%), 5 hematomas administration
20184 surgeon, breast administered for (10%), 0 DVT, mean blood loss resulted in a
cohort reconstruction 50 patients and 63 158.4 ml, 1 transfusion, 2 flap losses 41% reduction
free flaps; titrated (SGAP, DIEP) in blood loss;
intraoperatively Flaps: blood loss was
and postoperatively   DIEP: 31 (49.2%) significantly
according to EBL   PAP: 7 (11.1%) lower
(100 ml = 1 g TXA,   TMG: 12 (19%) after TXA
200 ml = 2 g TXA,   SGAP: 13 (20.6%) administration
300 ml = 3 g TXA) Ischemia time: mean ± SD, 65.2 ± 26.4 min (p < 0.001);
Control group: First Control group: 1 thrombosis of flap vein TXA did not
12 mo, no TXA for (3%), 6 hematomas (18.2%), 0 DVT, significantly
33 patients and mean blood loss 231.5 ml, reduce the
35 free flaps 0 transfusion, 0 flap losses need for blood
Flaps transfusions
  DIEP: 17 (48.6%) when
  PAP: 3 (8.6%) compared to
  TMG: 13 (37.1%) controls
  SGAP: 2 (5.7%)
Ischemia time: mean ± SD, 57.9 ± 16.2 min
Valerio Retrospective, 173 extremity TXA group: 16 TXA group: VTE rate was 0%, 26% No significant
et al., cohort flap procedures patients; control complications [infection 0 (0%), differences
20155 were group, 133 patients hematoma 3 (16%), venous congestion in total flap
performed 0 (0%), partial necrosis 1 (5%), total complications
in battle for necrosis 1 (5%), 1 flap failure (5%)] (p = 0.571) or
limb coverage Control group: VTE rate was 26.6%, flap failures
of extremities 21% complications [infection 7 (5%), (p = 0.564)
(100 pedicle, 73 hematoma 12 (8%), venous congestion for patients
free flaps) 89 2 (1%), partial necrosis 5 (3%), total who received
necrosis 2 (1%), 6 flap failures (4%)] TXA and those
TXA, tranexamic acid; RBC, red blood cell; EBL, estimated blood loss; DVT, deep vein thrombosis; DIEP, deep inferior epigastric artery
perforator; PAP, profunda artery perforator; TMG, transverse musculocutaneous gracilis; SGAP, superior gluteal artery perforator; VTE, venous
thromboembolism.

517e
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • October 2020
Rogers et al. retrospectively reviewed a series of 99
patients who underwent soft-tissue or composite free
flap surgery for head and neck cancer. Tranexamic
acid was administered intraoperatively to four of the
99 patients undergoing free flap surgery in accordance
with National Institute for Health and Care Excellence
guidelines.3 Unfortunately, flap-specific outcomes were
not reported; however, this study further illustrates that
the use of tranexamic acid is becoming more common,
and microsurgeons should remain vigilant and care-
fully consider the risks and benefits.
Lardi et al. retrospectively reviewed two series of
cohorts who underwent free flap surgery for imme-
diate breast reconstruction. During the first year, 33
control patients were not administered tranexamic
acid, whereas during the following year, 50 patients
were administered tranexamic acid for free flap sur-
gery. Comparative groups were relatively similar over
1-year periods. The authors established a tranexamic
acid dosing algorithm for intravenous administration
according to both intraoperative and postoperative
estimated blood loss. There was no difference in flap
failure between groups. Less blood loss was observed
with tranexamic acid administration, and there were no
differences in the number of transfusions or other per-
tinent clinical outcomes when compared to controls.4
The study by Valerio et al. assessed the use of
tranexamic acid in a cohort of military trauma casu-
alties who underwent microvascular reconstruction
with free or pedicled flaps. Both the tranexamic acid
and no–tranexamic acid groups averaged 24 years
of age, which is notably younger than many patients
undergoing microvascular reconstruction.5 There was
no significant difference in flap failure or overall flap
complications in patients who had received tranexamic
acid during their prior hospital course. Importantly,
this population is at an already increased risk of throm-
boembolism because of multiple prior life-saving
operations, frequent extended immobilization from
multisystem injuries, thrombocytosis, and endothelial
injury from the battlefield and surgical procedures,
limiting the findings’ generalizability.5
Tranexamic acid use is rapidly becoming more
widespread. The benefits (i.e., decreased blood loss
and transfusions) are great; however, there is a paucity
of data evaluating the effects on microvascular recon-
structions. Although limited, preliminary evidence
suggests that tranexamic acid administration does not
significantly increase the risk of flap complications.
DOI: 10.1097/PRS.0000000000007190
Kevin M. Klifto, Pharm.D.
Division of Plastic Surgery
University of Pennsylvania School of Medicine
Philadelphia, Pa.
Philip J. Hanwright, M.D.
Department of Plastic and Reconstructive Surgery
The Johns Hopkins University School of Medicine
Baltimore, Md.
518e
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Justin M. Sacks, M.D., M.B.A.
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Mo.
Correspondence to Dr. Sacks
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
660 South Euclid Avenue
St. Louis, Mo. 63110
jmsacks@wustl.edu
@jmsbigpoppa, @JMSacks
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this article.
REFERENCES
1. World Health Organization. WHO model list of essential
medicines, 20th list. Available at: https://apps.who.int/iris/
handle/10665/273826. Accessed August 18, 2019.
2. Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic
surgery: Review and technical considerations. Plast Reconstr
Surg. 2018;141:507–515.
3. Rogers SN, Horisk K, Groom P, Lowe D. Management of
anaemia and blood in patients having neck dissections or
free flaps for head and neck cancer. Br J Oral Maxillofac Surg.
2019;57:543–549.
4. Lardi AM, Dreier K, Junge K, Farhadi J. The use of tranexamic
acid in microsurgery: Is it safe? Gland Surg. 2018;7(Suppl
1):S59–S63.
5. Valerio IL, Campbell P, Sabino J, et al. TXA in combat casu-
alty care: Does it adversely affect extremity reconstruction
and flap thrombosis rates? Mil Med. 2015;180(Suppl):24–28.
Bimaxillary Surgery with Occlusal Plane
Alterations: A New Frontier for Gender
Confirmation?
Sir:
O
cclusal plane alterations in orthognathic surgery
remain among the most useful techniques for altera-
tion of facial skeletal morphology.1,2 Synchronous rotation
of the maxilla and mandible, in either the clockwise or
counterclockwise direction, results in predictable altera-
tion of the anterior and posterior face heights, chin posi-
tion, and nasolabial morphology.3 Although classically
performed for management of primary dentofacial skel-
etal differences, recent advances have demonstrated the
utility of occlusal plane alterations for primarily aesthetic
purposes (i.e., patients without malocclusion), without
the concomitant use of orthodontic appliances.4 Similarly,
other studies have demonstrated that orthodontic treat-
ment with clear aligners (e.g., Invisalign; Align Technol-
ogy, San Jose, Calif.) can allow for predictable correction
of skeletal differences in patients with malocclusions, with-
out the burden of conventional fixed appliance therapy.5
Facial skeletal and soft-tissue proportions are criti-
cal elements of gender identity.6 As such, alterations of
facial form have a prominent role in gender-confirma-
tion surgery. Current techniques for facial surgery in