Tranexamic Acid Found to Reduce Bruising in Blepharoplasty

Laird Harrison

November 13, 2021

Tranexamic acid can reduce bleeding and bruising caused by upper eyelid blepharoplasty while facilitating surgery, researchers say.

Administered in a local anesthesia injection, the drug caused no complications in a randomized, controlled trial, said Anna Artymowicz, MD, an ophthalmology resident at SUNY Downstate Health Sciences University in Brooklyn, New York City.

"Those are all very successful results: a little quicker, easier surgery, a little less heat applied to the eye, less potential scarring, less bleeding afterward, and quicker recovery time for the patients," she told Medscape Medical News.

She presented the trial here at the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) 2021 Fall Scientific Symposium.

A common treatment for dermatochalasis, blepharoplasty can sometimes involve intraoperative bleeding that lengthens surgical time and increases the use of cautery, resulting in scars, Artymowicz said.

Postoperative bleeding can delay healing, cause discomfort, and even impair vision through post-septal dissection, she said.

"One of the things we think about is how can we make people happier about their surgeries," Artymowicz said. "And of course, for the surgeon, what minimizes risks and makes everything go even smoother?"

A synthetic lysine analog, tranexamic acid inhibits the activation of plasminogen to plasmin and thereby prevents plasmin from dissolving fibrin clots. Previous research has shown that it can reduce bleeding in periocular surgery, facelifts, and rhinoplasty, among other procedures.

Artymowicz and colleagues were able to find one previous trial of tranexamic acid in upper blepharoplasty. That trial, with 34 patients, did not find a statistically significant effect. So they recruited 110 patients for a new trial in the hope that the greater sample size would produce more definitive results.

They randomly assigned one upper eyelid in each patient to receive tranexamic acid while the contralateral upper eyelid received a placebo. And they suspended anticoagulant use in the patients for 7 days before surgery.

They excluded patients with a history of blood clots, an elevated risk for blood clots, relevant allergies, previous upper eyelid surgery or planned concurrent eyelid surgery, or inadequate follow up. The mean age of patients was 65.6 years and 62% were female.

A surgeon performed skin-only blepharoplasty, making the first skin incision 15 minutes after a local injection. The surgeon used high-temperature cautery for skin excision and hemostasis and running 6-0 plain gut sutures for closure.

In eyelids assigned to receive tranexamic acid, the researchers administered local injections containing 0.15 mL tranexamic acid, 0.67 mL lidocaine with epinephrine, and 0.67 mL bupivacaine with epinephrine.

In eyelids assigned to receive the placebo, they administered the same anesthetic blend but with 0.15 mL of normal saline in place of the tranexamic acid.

Nursing staff recorded operative and cautery time. The researchers took photos at postoperative day 7, and patients recorded the postoperative day the ecchymosis resolved. Two oculoplastic surgeons, who didn't know whether patients had received tranexamic acid or placebo, scored the ecchymosis using the 4-point Winker-Black Bruising Scale, with ranges from 0 = no bruising to 3 = severe bruising.

The surgery took less time, required less cautery, and resulted in less extensive and shorter-lasting ecchymosis (Table 1).

Table 1. Tranexamic Acid Versus Placebo

Outcomes Tranexamic acid Placebo value
Duration of surgery, min 12.1 13.9 .032
Duration of cautery, s 24 73 .001
Ecchymosis, 0-3 scale, on postop day 7 0.9 1.6 .014
Duration of ecchymosis, days 12.3 15.6 .026

Concerns have been raised that tranexamic acid could cause dangerous clotting, but the investigators saw no complications in this trial.

"I think it's a fantastic start, and it's enough for people to feel comfortable," Artymowicz said.

While the study's results did achieve statistical significance, future studies are needed to investigate the optimum dose of tranexamic acid, the best route of administration, and the effects in patients who remain on anticoagulants, Artymowicz said.

"This study shows it is definitely advantageous" to use tranexamic acid, said John Martin, MD, a facial plastic surgeon in Coral Gables, Florida, who has already incorporated the drug into his blepharoplasties. He agreed that knowing more about optimal dosing and administration would be helpful.

"I would say that, especially since I do facelifts, this has changed my life surgically," he told Medscape Medical News. "It has really made such a difference in the bigger surgeries, in terms of decreasing bruising, that I love it."

Martin and Artymowicz have reported no relevant financial relationships.

ASOPRS 2021 Fall Scientific Symposium. Presented November 11, 2021.

Laird Harrison writes about science, health, and culture. His work has appeared in national magazines, in newspapers, on public radio, and on websites. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at or follow him on Twitter:@LairdH.

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