Utilization of Intraoperative Intravenous TXA in Facial Feminization Surgery

Introduction: Tranexamic acid (TXA) reduces blood loss and transfusion needs in craniofacial and orthognathic surgeries, but its use in facial feminization surgery (FFS) is not well-studied. FFS patients often take estrogen-containing hormone replacement therapy (HRT), increasing the risk of venous and arterial thrombosis. Given TXA’s procoagulant properties, its use in FFS patients may affect the risk of bleeding complications. This study investigates the effects of intraoperative TXA in FFS. Methods: A retrospective chart review of FFS patients from 2020 to 2025 was conducted. Data analyzed included TXA use, estimated blood loss (EBL), hematoma and DVT/PE formation, and 30-day reoperation rates. SPSS was used for statistical analysis, employing Mann Whitney U and Fisher’s exact tests to evaluate differences in TXA and non-TXA groups. Results: Fifty-one patients underwent 55 FFS cases. TXA was administered in 22 cases (40%). In general, TXA use was not associated with significant differences in EBL (190.5 mL vs 208.2 mL; P = .518), operative time (278.1 minutes vs 219.0 minutes; P = .159), or length of stay (1.18 days vs 0.91 days; P = .172) when examining all cases together. When stratified by facial location, forehead-only cases saw decreased EBL with TXA (168.46 mL vs 219.62 mL; P = .036). No patients experienced hematoma, DVT/PE, or required reoperation within 30 days. One case of superficial thrombophlebitis occurred in a non-TXA patient ( P = 1.000). Two cases without TXA required postoperative drains ( P = .511). Discussion: TXA does not significantly impact EBL, length of surgery, length of stay, or postoperative complications in our full cohort. However, it may aid in decreasing blood loss in isolated surgeries on the forehead. These results indicate TXA may be safely used in patients with higher baseline risk for thrombosis, and may be selectively beneficial depending on surgical site, however, larger studies are needed to confirm these findings.