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Reply: The Role of Tranexamic Acid in Plastic Surgery: Review and Technical Considerations

Cho, Min-Jeong M.D.; Rohrich, Rod J. M.D.

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 424e
doi: 10.1097/PRS.0000000000004670

Department of Plastic Surgery, University of Texas Southwestern Medical Center

Dallas Plastic Surgery Institute, Dallas, Texas

Correspondence to Dr. Rohrich, Dallas Plastic Surgery Institute, 9101 North Central Expressway, Suite 600, Dallas, Texas 75231, Twitter: @DrRodRohrich, Instagram: @Rod.Rohrich

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We thank Drs. Nayak and Linkov for their interest in and comments on our article, “The Role of Tranexamic Acid in Plastic Surgery: Review and Technical Considerations.1” In their letter, the authors also reported their use of tranexamic acid in a tumescent solution at 0.075% concentration and a local infiltration at 1% concentration.

Although there are many articles in the literature on the use of tranexamic acid delivered by topical or intravenous means, including meta-analyses in the orthopedic literature, there are no studies regarding the use of tranexamic acid as a local infiltration at this time.2,3 In our experience, we have found it more convenient to use a saline solution with 3% tranexamic acid topically because there is substantial literature, primarily from orthopedics, supporting this concentration for topical application.4 In addition, tranexamic acid delivered topically has been shown in numerous comparative trials and meta-analyses to have efficacy comparable or superior to intravenously delivered4 tranexamic acid.4,5

Moreover, the authors report that their concentration of tranexamic acid in a tumescent solution is 0.075%, whereas it is 1% in a local infiltration for rhinoplasty local anesthesia. Currently, the typical topical tranexamic acid solution used is 3%. Wong et al. found that a concentration less than 3% led to decreased efficacy, and there is some indication from the literature that concentrations of 1% or less for topical application are not as efficacious.4,6

Although the concentration of lidocaine used in the tumescent solution described by Drs. Nayak and Linkov is not mentioned in their letter, our own experience in mixing tranexamic acid with lidocaine was less successful. Currently, tranexamic acid can be mixed with other aqueous solutions, including electrolyte, amino acid, dextran, and carbohydrate solutions, but it should not be mixed with blood or fat for injection.7

Although the benefit and outcomes of using tranexamic acid in a tumescent solution and local infiltration are not available in literature with a high level of evidence, the observations of Drs. Nayak and Linkov in their practice are promising. As the role of tranexamic acid in plastic surgery is just beginning, we anticipate an increased number of studies on its outcomes, benefits, and satisfaction in plastic surgery patients in the near future.

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Rod J. Rohrich, M.D., receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing; is a Clinical and Research Expert for Allergan, Inc., and MTF Biologics, and the Owner of Medical Seminars of Texas, LLC. No funding was received for this com munication. Min-Jeong Cho, M.D., has no financial interest to declare in relation to the content of this communication.

Min-Jeong Cho, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center

Rod J. Rohrich, M.D.
Dallas Plastic Surgery Institute
Dallas, Texas

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1. Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic surgery: Review and technical considerations. Plast Reconstr Surg. 2018;141:507515.
2. Fu Y, Shi Z, Han B, et al. Comparing efficacy and safety of 2 methods of tranexamic acid administration in reducing blood loss following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016;95:e5583.
3. Xie J, Hu Q, Huang Q, Ma J, Lei Y, Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis. Thromb Res. 2017;153:2836.
4. Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: A randomized, controlled trial. J Bone Joint Surg Am. 2010;92:25032513.
5. Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev. 2013;7:CD010562.
6. Sa-Ngasoongsong P, Wongsak S, Chanplakorn P, et al. Efficacy of low-dose intra-articular tranexamic acid in total knee replacement: A prospective triple-blinded randomized controlled trial. BMC Musculoskelet Disord. 2013;14:340.
7. Pfizer. CYKLOKAPRON (tranexamic acid). Available at: Accessed March 18, 2018.
Copyright © 2018 by the American Society of Plastic Surgeons