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Original Investigation
September 2018

Preoperative Tranexamic Acid for Treatment of Bleeding, Edema, and Ecchymosis in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Investigative Pathology Laboratory, Federal University of Sergipe, Brazil
  • 2Brazilian Society of Plastic Surgery, São Paulo, Brazil
JAMA Otolaryngol Head Neck Surg. 2018;144(9):816-823. doi:10.1001/jamaoto.2018.1381
Key Points

Question  Is tranexamic acid effective and safe in reducing intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty?

Findings  In this systematic review and meta-analysis of 5 randomized clinical trials (276 patients), tranexamic acid was shown to reduce bleeding during rhinoplasty and decrease eyelid edema and periorbital ecchymosis within the first postoperative week. There were no reports of thromboembolic events.

Meaning  Preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding, postoperative eyelid edema, and ecchymosis in patients who undergo rhinoplasty.


Importance  Evidence has emerged on the efficacy of tranexamic acid to control blood loss and postoperative complications after rhinoplasty.

Objective  To investigate the results of tranexamic acid use to reduce intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty.

Data Sources and Study Selection  For this systematic review of randomized clinical trials, searches were performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, Science Direct, Google Scholar, OpenThesis, and ClinicalTrials.gov from inception to December 23, 2017. Key words included tranexamic acid, rhinoplasty, and nasal surgical procedures. The following elements were used to define eligibility criteria: (1) population: patients undergoing rhinoplasty surgery; (2) intervention and controls: tranexamic acid vs placebo solution or no-treatment control group; (3) outcomes: intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis, and thromboembolic events; and (4) study type: randomized clinical trials.

Data Extraction and Synthesis  Two reviewers extracted data and assessed study quality according to the Cochrane guidelines for randomized clinical trials. Treatment effects were defined as weighted mean difference (WMD) and 95% CIs. The strength of evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation rating system.

Main Outcomes and Measures  Intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis. To calculate the effect sizes, means and SDs were obtained for each study group and outcome of interest.

Results  Five studies comprising 276 patients were included in the systematic review: 177 patients (64.1%) were women, and mean age was 26.8 (range, 16-42) years. Four studies comprising 246 patients estimated the amount in intraoperative bleeding as a primary outcome and were included in the meta-analysis. Eyelid edema and ecchymosis were evaluated as outcomes in 2 studies. Tranexamic acid was associated with reduced bleeding during rhinoplasty was found (WMD, −42.28 mL; 95% CI, −70.36 to −14.21 mL), with differences (P = .01) between oral (WMD, −61.70 mL; 95% CI, −83.02 to −40.39 mL; I2 = 0%) and intravenous (WMD, −23.88 mL; 95% CI, −45.19 to −2.58 mL; I2 = 56%) administration. Eyelid edema and ecchymosis scores in patients receiving tranexamic acid were significantly lower compared with the control group within the first postoperative week: lower eyelid edema, WMD, −0.76; 95% CI, −1.04 to −0.49 and lower eyelid ecchymosis, WMD, −0.94; 95% CI, −1.80 to −0.08. No cases of thromboembolic events were reported.

Conclusions and Relevance  Current available evidence suggests that preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding as well as postoperative eyelid edema and ecchymosis in patients undergoing rhinoplasty.