Highlights from the Literature Two
Tranexamic Acid Prevention of Hemorrhagic Complications Following Interpolated Flap Repair: A Single Center Retrospective Cohort Study
By Arif Aslam, MBChB, FRACP, FACD
Novel direct oral anticoagulants and antiplatelet agents are now more commonly prescribed worldwide, and it's estimated that 40% of patients undergoing Mohs surgery are taking either an antiplatelet or anticoagulant agent. These agents are associated with a higher risk of postoperative bleeding in addition to more complex repairs. Tranexamic acid (TXA) is a low-cost antifibrinolytic agent that stabilizes fibrin matrices by preventing the conversion of plasminogen to plastic, therefore preventing fibrin degradation. Its local use has been reported as a method of controlling bleeding in several surgical subspecialties.
The aim of this retrospective study was to assess bleeding events after interpolated flap repair in patients receiving TXA as a local injection into a pedicle compared to those who did not. A bleeding event was divided into major and minor. A major event was defined as all unplanned medical visits to address postoperative bleeding and a minor event included unplanned patient phone calls or messages specific for bleeding through the electronic medical record. Over a five-year period, of the 115 patients who underwent interpolated flap repairs, 21 (18.3%) received subcutaneous TXA injection at the time of flap placement. 18 of these underwent repair with a forehead flap and three a cheek-nose flap. Of note, 85.7% of the TXA group were forehead flaps and 71.3% of the non-TXA group were cheek-nose. The results show the number of bleeding events was low with the injection of TXA and was significantly higher in the non-TXA patients undergoing a forehead flap repair.
Whilst this study was a single-institution non-randomized retrospective review, it did show that subcutaneous TXA, which is relatively inexpensive, given directly into a pedicle flap can significantly lower rates of bleeding.
This paper also highlights the importance of meticulous surgical technique for hemostasis with either cautery of every single bleeding point or the use vessel ties during interpolated flap repairs.