Dr. Sam Jejurikar: Good morning, everyone and welcome to another episode of 3 Plastic Surgeons and a Microphone. As always, I’m Dr. Sam Jejurikar, a plastic surgeon in Dallas and I’m joined by Doctor Sam Rhee, excellent aesthetic surgeon in New Jersey. He’s at, you can find him on Instagram @Bergencosmetic and by Doctor Salvatore Pacella, @SanDiegoPlasticSurgeon. One of the preeminent plastic surgeons in La Jolla. Good morning gentlemen. How are you guys today?
Dr. Sam Rhee: Wonderful.
Dr. Sal Pacella: Very good. Thank you.
Dr. Sam Jejurikar: Great. Well, today, we’re talking about kind of an interesting topic. Probably one that patients may not even know to search for. But it’s a very interesting hot topic in in surgery, not just plastic surgery about an agent called Tranexamic Acid and Doctor Rhee is going to lead us in a discussion of all that. But before we get to that, we’re going to let Doctor Pacella say a few words of medical necessity or legal necessity.
Dr. Sal Pacella: Is this thing odd? Is this odd? Alright, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon circumstances, situation, and medical judgement after appropriate discussion. Always seek the advice of your surgeon or other qualified health care provider with any questions you may have regarding medical care. Never describe professional medical advice or delay seeking advice because of something in this show.
Dr. Sam Jejurikar: So, Doctor Rhee, what is Tranexamic Acid or TXA and why should we care about it?
What is TXA?
Dr. Sam Rhee: TXA is a magic drug it is a magic drug that’s how I feel about it. If you never heard about TXA or Tranexamic Acid, it’s a medication that is used to reduce blood loss and we’ve had it around in the medical community for years. But I would say only in the past couple years or year or two it seems as hot on like wildfire. It’s used in everything in cosmetic surgery at this point, and it reminds me of that old Chris Rock routine where he would say how his dad used Robitussin for everything and he’d be like, “Daddy, I broke my leg”. And he’d be like, “Here, put some Tussin on it”. That’s right. Let that Tussin get right down to the bone, like there you go. That’s how I feel about TXA. I use it for everything.
It’s probably the one thing that I have put into nearly all of my cosmetic procedures. When we had our plastic surgery symposium at University of Michigan a couple weeks ago and someone asked, how many people now use TXA. Like 90% of People raise their hands and I think two years ago no one would have. So, let’s talk about TXA.
Dr. Sam Jejurikar: Someone’s calling to talk about it right now.
Dr. Sam Rhee: I need some of that Tussin. So, let’s talk about TXA, what it does and why it’s so popular. So, first off, what do you guys think about TXA and what do you use it for?
Dr. Sam Jejurikar: I’ll start. So, TXA is it’s a lysine analog which stabilizes clot. So, what the hell does that mean? Excuse my language. So, for patients out there, whenever someone is having any kind of surgical procedure, the body’s instinct is to immediately start to bleed when we make an incision or we traumatize an area. And when the bleeding happens, the cascade of factors occurs and along one of those steps TXA will actually intervene, cause the clots to stabilize and basically stop blood loss. The big fear when TXA first came around was that because it promoted clots and I know you’re going to talk about this, was that it could potentially create a situation that made people more likely to get blood clots during surgery which can obviously be potentially fatal.
I think be excited hear about what sort of data you’re presenting, but I think that the consensus is that maybe that’s more theoretical than we actually tend to see in practice. so, getting back to your question, what do I use TXA for? I use TXA for virtually every surgical procedure that I do at this point. I use it, it’s administered by the anesthesiologist in an intravenous form and if I’m doing a body contouring surgery where I am doing liposuction or even doing excision of large amount tissue. Often times infiltrate that tissue with a solution that contains TXA to help cut down blood loss.
Dr. Sal Pacella: I have to laugh here every time the word TXA comes up in the operating room. One of my good friends and anesthesiologist Doctor Mark Sinzer calls it TX&A from like the old Borax, US a day because a TXA a day. So, it’s just funny, but I think it’s an absolute wonder drug has really changed the game in surgeons concern about bleeding and I can say that from really two forms of it, right. so, there’s the injectable form and then there’s the IV form, right. So, it’s actually the same thing but just the method of how it’s delivered. So, I get a lot of this information from orthopedic surgery colleagues. So, when they’re doing joint replacement or some sort of bloody orthopedic procedure, they’re actually doing not only a bolus injection but they’re doing a drip of TXA. I just simply give the bolus injection. There’s some data on that.
Where I’ve seen it just to medically improved cosmetic surgery is in the injectable camp. So, I usually create a dilution of a volume of injection much like you do Sam for your intravenous solution. That’s a fresh epinephrine, fresh lidocaine, fresh Marcene and TXA in a certain percentage. This has dramatically change my issues with face lifts. Face lift is a procedure that once you start working on the other side, the original side starts bleeding. So, this is really completely changed the game. I mean, I use it for everything from rinsing the patient and irrigating solution to injectables and it has a dramatic effect on blood loss. I mean, it’s fantastic.
Dr. Sam Jejurikar: And there’s actually a third form. There’s an oral form of it as well which was originally, I think how it was first prescribed. I believe the first indication was for menorah women that had really heavy menses and it’s available in oral form. I know many plastic surgeons use it for their injectable fillet patients or even for the night before facial aesthetic surgery.
Dr. Sal Pacella: Oh wow.
Wht makes TXA FDA approved?
Dr. Sam Rhee: Yeah, you’re absolutely right. So, let’s talk a little bit about what it’s actually approved for in the FDA. So, both of you’re absolutely right. It comes in an tumescent solution form and a pill form. There’re literally only 2 FDA approved indications for TXA. Short-term use in hemophiliacs to reduce or prevent hemorrhage during and following tooth extraction and then as the Sam’s cyclic heavy menstrual bleeding. That’s all it’s actually used, supposed to be used for but obviously surgeons and physicians have been using TXA off label from cardiac surgery, to orthopedic surgery, to dental procedures everything. As Sam got into a little bit maybe it bears a little bit of getting into the basic science. So, not a ton but let’s just talk very briefly.
So, as Sam said it’s an anti-fibroline, sorry fibrinolytics. So, what does that mean? It basically means, it stops the conversion of plasminogen to plasmin which is the enzyme that breaks down fibrin clots. So, what happens is a blood vessel gets damaged, either it’s cut, its bruised, what have you. Platelets, which are the small cell fragments in the bloodstream collect around that broken area. They form a little plug called the platelet plug, and those plugs cause thrombin to attach and then that causes fibrin to become a hard plug which results in a clot. Those are the clots that protect us when we bleed so that we don’t die from bleeding. And if you have a disorder in this whole cascade which we learned about in medical ad nauseum, you can get hemophilia which is a genetic disorder, which prevents this clotting from occurring and if you have another disorder where this system goes too far out of whack, then, you’re prone to developing tons of blood clots.
For example, like Leg clots or lung clots which can be devastating. And getting that balance is really important in our human bodies and we actually have drugs that do the opposite that break up these clots and we use them in other types of surgery like TPA, which is Tissue Plasminogen Activator, which breaks up these clots as opposed to TXA which helps the clots to form. So, there was a weaker version of this back in the day which you might have used as residence. I know I did in cardiac surgery called Amicar or Aminocaproic acid. It’s about 8X weaker than TXA. So, I think they still use it but there’s no reason to because it’s so much weaker, and then there was another similar drug called Aprotinin, which they took off the market because it was bovine based and it cause a lot of other problems with it. But this is one of the few drugs now that we have that reduces bleeding, which does not seem to have very many major issues. But let’s talk about those issues. Like what potential issues, if you may ask your surgeon, you may not even know if your surgeons been using TXA.
Possible side affects of TXA
It’s just part of many drugs that plastic surgeons use to treat their patients. But if you were to ask them, like what kind of problems could you have with it? There aren’t that many. The first contraindication to using TXA would be and Steve mentioned this during the symposium, combination hormonal contraception. It’s a relative contraindication. It’s not an absolute. We know that birth control pills can increase the risk of clotting and so they worry that taking TXA at the same time might increase that risk to a higher level. If you have any other issue with clots in the past, we’ve all had patients that have had history of clots. Either DVTs like Deep Vein Thrombosis in the legs or strokes or other problems and obviously TXA is not indicated for those patients.
Then finally, there are very very rare cases of allergic reactions to TXA, extremely rare. I think in the literature I saw, there was a single case reported in a large study of in shock and maybe a single severe allergic reaction of throat tightening and facial flushing.
Dr. Sam Jejurikar: Can I ask a couple of questions about that Sam so?
Dr. Sam Rhee: Yes, absolutely.
Dr. Sam Jejurikar: Those are relative contraindications. Has anything actually been shown that in the case of patients who are on oral contraception that TXA will actually push them even further over into having a risk of a blood clot afterwards or is that just speculation?
Dr. Sam Rhee: It’s speculation. I did not see any good evidence that being on oral contraceptives and taking TXA resulted in an actual incident of, increase in incidents of DBTs or PEs or symptomatic issues with that.
Dr. Sam Jejurikar: And your guys’ elective practice, what is your standard practice, where oral contraceptives are concerned with surgery? Like do you typically have your patients stop taking oral contraceptives before they have cosmetic surgery?
Dr. Sam Rhee: I mean, for me, I do. I make sure that none of my patients are on oral contraceptives at least for a month before surgery.
Dr. Sam Jejurikar: Yeah, Sam.
Dr. Sal Pacella: I do too. Yeah.
Dr. Sam Jejurikar: So then, in that situation, that might potentially in in our world in the plastic surgery world potentially eliminate that as a relative contraindication seeing how we have them stop it anyways. I guess the other question is for patients with a history of blood clots. I know my protocol typically is to have them see a hematologist if they have a history prior to having their elective surgery and more often than not, they seem to be put on a post-operative blood-thinning regimen of some kind. So, I’m wondering in that scenario knowing that a patient might be on a post-operative blood thinner. Would that make you more or less likely to use TXA intra-operatively given their previous risk? I’m just curious because I don’t know how to handle that myself. Either one of you guys can chime in.
Dr. Sal Pacella: It’s a very good question and I will tell you, I have in my skin cancer reconstructive practice, I have as you know what, significant amount of older patients who are taking blood thinners and usually Eliquis or whatever. And the cardiologist tells them get off of it two days ahead of time. I found that to be very minimal, like it’s still causing a tremendous amount of bleeding. But the benefit for me is that if it’s a tiny little small skin cancer repair that takes 20 minutes I can deal with a little bit of bleeding till the incisions close, but it’s big kind of massive open procedure big nasal reconstruction or eyelid reconstruction. It’s a challenge and I use TFA in IV, in injectable, but I haven’t thought to use the preoperative oral world yet.
Dr. Sam Rhee: I mean it really depends on the situation. I hate anyone on blood thinners. I’ve done fillers on blood thinners and they will bleed, like they’ll bruise like nobody’s business sometimes. And for aesthetic procedures if they’ve had History of clots, there had better be a whole lot of yeah, I don’t know, if I’ve ever actually operated on someone who had those major issues. I’ve had a couple patients who had had leg clots secondary to COVID and I haven’t really figured out what to do with them. Like for cosmetic surgeries. I mean certainly if it was something big like an abdominoplasty or something. I’m not sure I would actually do the case. I might actually, I mean I’d never actually been in a situation like that but I’m dealing with it right now with a couple patients and I’m not sure what to do myself.
Dr. Sam Jejurikar: Yeah, I don’t think there’s a clear-cut protocol in terms of what to do for that situation. In my situation, I think I’m pretty comfortable using postoperative Lovenox or an injectable blood thinner for those bigger body contouring cases. But in that situation, I’m probably going to be more likely to use TXA intra-operatively to try to minimize intraoperative blood loss and to try to stabilize the clot like TX it does so that’s that patient can safely be on the blood thinners afterwards. So, yeah, go for it.
Dr. Sal Pacella: When you guys are giving Lovenox for your body contouring cases, do you give a preoperative dose or just start a post operative dose on post operative day number one?
Dr. Sam Jejurikar: That is one of the problems in plastic surgery now. There is not a well-defined protocol for what is considered to be the right thing to do. What I believe most people are doing these days in body contouring surgery is starting a dose. I started on post operative base zero typically 6-to-8 hours post operatively. I have in the past done preoperative Lovenox as well, but my current regimen is starting in about 6 hours post op on the patients, after I’ll typically use and I’ll be able to check the drain up but to make sure they’re not bleeding before I started. But I think that’s sort of a different topic than the TXA topic. So sorry.
Dr. Sam Rhee: In terms of other concerns, people would ask what happens in pregnant women. It’s not been studied in pregnant women specifically but studies in animals have showed no problems with harm to the fetus with TXA. It does cross the placenta. So, it is present in fetal blood concentrations. So, it’s one of category B drugs where it doesn’t seem to cause harm in animals, but no human studies have been done. Then the only other issue is in patients who have other health issues. It’s a process in the kidneys. 95% of it is excreted in the urine unchanged and it takes about 24 hours for 90% of TXA to be eliminated out of the bloodstream. So, if you have someone who has some kidney issues, you would have to adjust the TXA but otherwise there’s no contraindication to using it in patients who have any kind of kidney problems. You just have to adjust the dose to whatever their kidney function is. That’s it.
They report what happens when you overdose someone on TXA, and most of the symptoms are generally pretty mild. You might have some nausea, vomiting, diarrhea, low blood pressure, like orthostatic hypertension. Maybe some visual changes, which may or may not be related to retinal circulation and we could talk about that if we need to. Rash, but they haven’t reported severe impairment or death related to overdose on TXA. They’ve gone pretty high on some of these animal doses as well.
So, the other, the one issue that I would like to talk about a little bit which is of concern to some patient, or to some doctors and patients or is seizures. So, that is probably the one side effect or negative issue has been seen in some of these better studies. Especially in the IV form given during cardiovascular surgery. They typically were giving fairly high doses about 10 times the highest recommended human dose, and they did report some increase in seizures in those patients. There was a large retrospective study of 11,000 patients who underwent cardiac surgery and they showed that TXA was an independent predictor of post operative seizures.
For these patients who received it as an infusion and I think you mentioned about how it’s given or the dose or amount which might make an issue in that regard. It’s been used in plastic surgery with as you mentioned rhinoplasty, face lift, breast surgery, body contouring, liposuction, tummy tucks, you name it. intravenous It’s really the dosing in those cases have has ranged all over the place. I haven’t found any good studies to show whether or not there’s an ideal dose for face lifts, rhinoplasty, bluffs. They’ve used it every which way which we use it too we use it topically like Sal mentioned irrigating the tissue or using pledge. It’s used as an injectable and I’ve used it in a tumescent solution as Sal has and pre-op pill dosing as well as IV solutions. So, why do you use it and what makes the biggest difference why you use it in terms of what you see in patients?
Why use it?
Dr. Sam Jejurikar: I mean, I use it with two-fold reasons. One, to lessen intra-operative blood loss. I have found that when I infiltrate tissue with it and it’s administered intravenously, there’s less intra-operative blood loss. I know that to be true subjectively. I know that to be true when I look at the aspiration of the fat that comes out when I’m doing liposuction. There’re also some reports out there and I definitely believe this to be true in my own patient population of there being less operative bruising. When I am doing a facial aesthetic procedure versus a big body contouring operation. In both scenarios, I tend to see less bruising and I think it’s a byproduct a little less swelling as well. So, it helps me inter-operatively and I think it helps the patient post-operatively.
Sam Jejurikar3: Agree, I mean I think for me the biggest issue is bruising and intra-operative blood loss during facial procedures. And if that not that this is blood loss that’s cause some sort of hemodynamic instability, it’s really an annoyance blood loss on a large tissue plane. It’s little pinpoint bleeding vessels that can accumulate to cause a hematoma during or after the surgery. It’s keep the tissue planes very clear and it just makes it a much more efficient way for patients to spend time in the operating room. So, we don’t have to kind of get all these little pinpoint tissues
Dr. Sam Rhee: Yeah, I feel like.
Dr. Sal Pacella: TXA, TX&A, it is nice.
Dr. Sam Rhee: I can see Sal’s OR is a fun OR. That’s the fun OR to be and I can film.
Dr. Sam Jejurikar: Yeah.
Dr. Sam Rhee: The bruising and swelling I see every time I use it. like there’s such a reduction in that, and you’re right. It’s not necessarily a clinically like hemodynamic or otherwise significant change because it’s not like in these cosmetic surgeries. You should be losing liters of blood to begin with as you might in other surgical procedures. But the after results in terms of the swelling and just a nice, cleaner field in terms of not having blood over the place just does make a huge difference. I have found I give it an oral dose an hour pre-op. Larry actually in his talk about face, was a faceless. He gives another dose an hour after the surgery oral. I don’t do that, but I do.
Dr. Sam Jejurikar: That’s Doctor Larry Tong in Toronto, Ontario.
Dr. Sam Rhee: Oh, that’s right. Shout out to Larry. This was one of the best facelifts talks I’ve heard in a really long time and his results were absolutely amazing. So, if you’re in Toronto and you’re looking for plastic surgery, he’s the guy to go for sure. And I will put it in my tumescent. I will put it in my local that I’m injecting for lidocaine and Epi and if I’m in the hospital I will have it in the IV. But it’s hard for me to know dose wise what works and what is safe. Have you ever seen any seizure activity in any of your patients and how do you figure out your dosing? Especially if you’re doing multiple forms of it, you’re putting it in your infuse it, you’re putting it in your local, you’re putting it in your IV. Like how do you calculator know how much to use?
Dr. Sam Jejurikar: So, I think that when plastic surgery we’re using far less than some of these other specialties like orthopedics and neurosurgery and spine surgery where they’re running continuous trips the entire time during the case. I typically give one gram IV pre-operatively or right before we start the surgery. If I’m doing liposuction or some sort of procedure where I’m injecting a large amount of fluid into the patient. I used to use a higher dosage of 1,000 milligrams per bag. I’ve cut it down once to 500 milligrams per bag without noticing any change. I’ve heard reports from Alfredo Hoyas and Columbia, who’s actually cutting it down to 250 milligrams per bag at this point. So, I think a little goes a long way but that’s probably going to be my next maneuver of actually cutting down on it. So, the overall dose I mean I think most people feel very comfortable doing 5 or 6 grams in one surgical setting. I’m doing tomorrow less than that.
Dr. Sal Pacella: Interesting.
Dr. Sam Jejurikar: Yeah.
Dr. Sam Rhee: And you Sal?
Dr. Sam Jejurikar: I’ve never seen a seizure by the way.
Dr. Sal Pacella: So, I don’t I don’t use it in my tumescent solution but I think after this podcast I may start.
Dr. Sam Rhee: Excellent. Well, I think that sort of covers TXA. If you’re a patient and you want your plastic surgeon to nerd out with you a little bit, you can always ask if they’re using it and how they’re using it. I think at this point, everyone that I know is using it in some form. It’s exceptionally safe. I don’t know if I mentioned it, but in the best study that the New England Journal of Medicine published in May, there was no difference in terms of symptomatic clot PE or DVT reported in TX patients versus placebo. This was almost 10,000 patients that underwent a randomized double winded study. Which I thought was the best evidence that we’ve had out there about the efficacy and safety of TXA out there.
So, I’m glad that you guys are using it. I’m glad I’m using it. I think we’ll probably hear a lot more about it too in terms of some guidelines in the future and I really appreciate being able to talk to you guys about it. I’m interested to hear more about what you guys end up using for it and how you guys figure out your dosing in the future as well.
Dr. Sam Jejurikar: Well, always eliminating Doctor Rhee. Thanks for all that, and have a great weekend guys.