Episode 55: Thursday October 20

Should you be asking for TXA (Tranexamic acid) in your cosmetic surgery procedure?

If you asked plastic surgeons 5 years ago if they used TXA- nearly all of them would have said no.

Originally approved for heavy menstrual bleeding and tooth extraction in hemophiliacs, TXA has been used off-label in cardiac, orthopedic and many other types of surgery.

Recently TXA has made its way to plastic surgery, where surgeons are reportedly using it for nearly every aesthetic plastic surgical procedure - facelifts, liposuction, tummy tucks, breast lifts, and more.

Does it really reduce bleeding, swelling and increase speed of recovery? Dr. Sam Rhee @bergencosmetic, Dr. Salvatore Pacella @sandiegoplasticsurgeon and Dr. Sam Jejurikar @samjejurikar discuss TXA, how and why they use it, and whether it really is a "WONDER DRUG" for cosmetic plastic surgery.

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#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S03E55 THE WONDER DRUG TXA TRANEXAMIC ACID

[00:00:00] Dr. Sam Jejurikar: Good morning everyone, and, and welcome to another episode of Three Plastic Surgeons and a microphone. As always, I'm Sam Jejurikar, a plastic surgeon in Dallas, and I'm joined by Dr. Sam Re, excellent aesthetic surgeon in New Jersey. He's at, You can find him on Instagram at at Bergen Cosmetic and by Dr.

Salvato Pacella. At San Diego Plastic Surgeon, one of the preeminent plastic surgeons in La Jo. Good morning gentlemen. How are you guys today? Wonderful. Very good. Thank you. Great. Well, you know, 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 Tran acemic acid.

And Dr. Rhee is gonna lead us in a discussion of all that. But before we we get to that, we're gonna let Dr. Pacella say a few words of medical necessity or legal necessity.

[00:00:58] Dr. Salvatore Pacella: Is this thing on? Is this on

All right. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show for informational purposes only. Treatment and results may vary based upon circumstances, situation, and medical judgment. After appropriate discussion, always seek advice of your surgeon or.

Qualified healthcare provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something in this show.

[00:01:29] Dr. Sam Jejurikar: So, Dr. Re, what is training the scenic acid or txa and why should we care about it?

[00:01:35] 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 trax acid, it's a medication that is used to. 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. Hot on like wildfire. It's, it's used in everything in cosmetic surgery at this point.

And it reminds me of that old Chris Rock routine where, you know, he would say how his dad used Rob robot tussin 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. Look that tuss again. Right down to the bone. Like, there you go, . And that's how I feel about txa.

I. For everything. It's, it's probably the one thing that I have put into nearly all of my cosmetic procedures. And 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 raised their hands, and I think two years ago, no one would have.

So let's talk about txa.

[00:02:45] Dr. Sam Jejurikar: Someone's calling to talk about it right now.

[00:02:49] Dr. Sam Rhee: I need some of that tossing. 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?

[00:02:59] Dr. Sam Jejurikar: I'll start. So txa is a it's a lyce analog, which stabilizes clot.

So what the hell does that mean? Excuse my language. So for patients out there, whenever 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, the cascade of of factors occur and along one of those steps, txa will actually intervene, cause the, 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 gonna 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. And I'll be excited to hear about, you know, what sort of data you're, you're presenting, but I think that the, 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 amounts of tissue, I'll oftentimes infiltrate that tissue with a solution that contains TXA to help cut down blood loss.

[00:04:28] Dr. Salvatore Pacella: I, I I have to laugh here. Every time the word txa comes up in the operating room, one of. Good friends and anesthesiologist, Dr. Mark Zinser calls it tx n a from like the old Boad movie, us n a, so he calls it tx n a. And so it's, it's just funny but I, I think it's an absolute wonder drug has really changed the game and.

In surgeon's concern about bleeding, You know, I, and I can say that, you know, from really two forms of it, right? So there's the injectable form and then there's the the I IV form, right? So, it's, it's actually the same thing, but just the, the method of how it's the delivered and. You know, I get a lot of this information from our orthopedic surgery colleagues.

So when they're doing a, a joint replacement or, or some sort of bloody orthopedic procedure, they're actually doing not only a, a bolus injection, but they're doing a drip of txa. And, and I I just simply give the bolus injection. There's some data on that. Where I've seen it just dramatically improve.

Cosmetic surgery is in the inject. Form. So I, I usually create a dilution of a volume of injection, much like you do Sam, for your ES solution. That's fresh epinephrine, fresh lidocaine, fresh mar cane, and txa in a certain percentage. And this has dramatically changed my, my issues with facelifts.

You know, facelift is a procedure. You know, once you start working on the other side, the original side starts bleeding. And so, this has really completely changed the game. I mean, I use it for everything from rinsing the patient and irrigating solution to, to injectables, and it's just, it, it has a dramatic effect on blood loss.

I mean, it's fantastic.

[00:06:17] Dr. Sam Jejurikar: And there's actually a third form. There's an oral form of it as well, which which can be, which was originally, I think, how it was first prescribed. I believe the first indication was, was for menage or women that had really heavy, heavy menses. And it's, it's available in oral form and I know many plastic surgeons will use it for their injectable filler patients.

Or even for, you know, the night before, before before facial aesthetic surgery. Oh.

[00:06:40] 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 you're both of, you're absolutely right. It comes in an intravenous solution form and a pill form. And there's literally only two FDA approved indications for txa short term use in hemophilia Xs to reduce or prevent hemorrhage during and following tooth extraction.

And then as Sam said, cyclic heavy, menstrual integral 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. And 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 antifibrotic, Sorry, Fibrinolytic. So what does that mean? It basically means it stops the conversion of plasma egen to plasma, which is the enzyme that breaks down. Fibrin clots. So what happens is, is a blood vessel gets damaged.

Either it's cut, it's bruised, what have you, platelets, which are the small cell fragments in the bloodstream collect around that broken area. They, they form a little plug called a platelet plug. And those plugs cause Thrombin to attach. And then that causes fibrin to become a hard plug, which results in a clot.

And 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 school At nausea 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 outta 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. 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 plasma activator, which, 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 I, you might have used as residents. I know I did in cardiac surgery called AMA Car or Amina Caproic acid. It's about eight times weaker than than txa. And so, you know, 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. a proin, which they took off the market cuz it was bovine based and it caused 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 know, you may ask your sur you know, you may not even know if your surgeon's been using txa.

You know, it's just part of many drugs that plastic surgeons use to treat their, their. 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 you know, we've all had patients that have had history of clots, either d vts, like deep vein thrombosis in the legs or, or strokes or other problems.

And obviously, TXA is not indicated for those patients. And then finally, there are very, very rare cases. Allergic reactions to txa? Extremely rare. I think in, in the literature I saw there was a single case reported in a large study of, of a anaphylactic shock and, and maybe a single severe allergic reaction of, you know, throat tightening and facial flushing.

Can I

[00:10:54] PREMIERED WAV: ask

[00:10:54] Dr. Sam Jejurikar: a couple questions about that, Sam? So yes, absolutely. So, so you said those are relative contraindications. Has anything actually been shown that in the case of patients who are on oral contraception that that TXA will actually push them even further over into having a risk of a blood clot afterwards?

Or is that just speculation?

[00:11:13] Dr. Sam Rhee: It's speculation. I did not see any good evidence. You know, being on oral contraceptives and taking TXA resulted in an actual incidence of increase in incidents of DTS or PEs or symptomatic issues. With that

[00:11:29] 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?

[00:11:41] Dr. Sam Rhee: I mean, for me, I do, I, I make sure that none of my patients are on oral contraceptives at you know, at least for a month before surgery.

[00:11:49] Dr. Sam Jejurikar: Yeah, I same I do too. Yeah. 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 clot, , 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 intraoperatively given their previous? I'm just curious cuz I don't know how to handle that myself.

Either one of you guys can chime in. .

[00:12:41] Dr. Salvatore Pacella: Yeah, that's, I mean, that's a, that's a very good question and,

[00:12:44] Dr. Sam Jejurikar: and

[00:12:46] Dr. Salvatore Pacella: you know, I will tell you, I have, you know, in my skin cancer reconstructive practice I have. You know, a significant amount of older patients who are taking blood thinners and usually Eliquis or, or whatever, and the cardiologist tells them, you know, get off of it two days ahead of time.

And I, I found that to be very minimal. like, it, it's still, still causes a tremendous amount of bleeding. But, you know, 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 you know, if it's big, kind of massive open procedure, big nasal reconstruction or eyelid reconstruction, it's, it's a challenge.

And I, I just haven't, I haven't I use txa op in, you know, IV and I injectable, but I haven't thought to use the, the preoperative oral, you know,

[00:13:37] 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 mm-hmm and for aesthetic procedures, if they've had a 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, who, who had those major issues. I, 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 abdominalplasty or something, I'm not sure I would actually do the case.

I might actually, I mean, I've 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.

[00:14:27] 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, in my situation, I think I, I'm pretty comfortable using postoperative ox or an injectable blood thinner for those bigger body contouring cases.

But in that situation, I'm probably gonna be more likely to use txa intraoperatively to try to minimize intraoperative. Blood loss and to try to stabilize the clot like TXA does, so that, so that patient can safely be on their blood thinners afterwards. So, so the reason I ask, Oh yeah, well, don't go for it.

When you, when you

[00:14:59] Dr. Salvatore Pacella: guys are giving lovanox for your body contouring cases do you give a preoperative dose or just start a post-operative dose on post-operative

[00:15:07] Dr. Sam Jejurikar: day number? So 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 postoperative day zero, typically six to eight hours postoperatively. I have in the past done preoperative Lovenox as well. But my current regimen is, Starting in about six hours post-op on the patients.

After I can, I'll typically use drains and I'll be able to check their drain up, but to make sure they're not bleeding. Mm-hmm. . Mm-hmm. before I start it, but I don't, I think that's sort of, Different topic than, than the TXA topic, so sorry.

[00:15:50] Dr. Sam Rhee: Right. 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 those category B drugs where it doesn't seem to cause harm in animals, but no human studies have been done.

And then the only other issue is in patients who have other health issues, it's processed in the kidneys. 95% of it is excreted in the urine, unchanged. And it takes about 24 hours for 90% of txa to. Eliminated outta the bloodstream. So, you know, if you have someone who has some kidney issues, you would have to dose 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 you. Severe impairment or death related to overdose on txa, and they've, 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 are, is seizures.

So that is probably the one side effect or negative issue that 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, uh, large retrospective study of 11,000 patients who underwent cardiac surgery, and they showed that TXA was an independent predictor of post-operative seizures. You know, for these patients who received it as an infusion and I think you mentioned about how you, how, 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, facelift, breast surgery, body contouring, liposuction, tummy tucks you name it. And it's. The dosing in those cases has, has ranged all over the place. And, and I haven't found any good studies to show whether or not there's an ideal dose for facelifts, 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 intumescent solution as Sal has. And you know, pre-op pill dosing as well as IV solutions. So what are the, why do you use it and, and what makes the biggest difference why you use it in terms of what you see in patients?

[00:19:16] Dr. Sam Jejurikar: I mean, I, I use. Uh, For twofold reasons, one, to lessen intraoperative blood loss. I have found that when I infiltrate tissue with it and it's administered intravenously there's less intraoperative blood loss. I, I know that to be true subjectively. I know that to be true when I look at the, the aspiration of the fat that comes out when I'm doing liposuction.

There's also some, some you know, some reports out there, and I definitely believe this to be true in my own patient population of there being. Postoperative 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 as a byproduct, a little less swelling as well.

And so it helps me intraoperatively and I think it helps the patient postoperatively.

[00:20:02] Dr. Salvatore Pacella: I agree. I mean, I think for me the biggest issue is bruising and intraoperative blood loss during facial procedures. And, you know, the, not that this is blood loss that's gonna cause some sort of hemodynamic instability. It's just. It's really an annoyance of blood loss on a large tissue plane. You know, it's little pinpoint bleeding vessels that can accumulate and cause a hematoma during or after the surgery.

It's, you know, keeps the tissue planes very clear and it just makes it a much much more efficient way, you know, for patients to, to spend time in the operating room so we don't have to kind of get all these little pinpoint tissue bleeders.

[00:20:45] Dr. Sam Rhee: Yeah, I feel

[00:20:46] Dr. Salvatore Pacella: like tx a, tx and a, it is nice.

[00:20:55] Dr. Sam Rhee: I, I can see Sal's or as a fun, or That's, that's the fun. Or to be in, I, I, I can tell yeah, the, the bruising and swelling I see every time I use it. Like there's such a reduction in, in that. And you're right. It, 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, in other surgical procedures.

But the after results in terms of the swelling and just the nice cleaner field in terms of not having blood all over the place just does make a huge difference. I have found I give it a, a, an oral dose, an hour pre-op. Larry actually, and his talk about face was a facelift. He, he gives another dose an hour after the surgery oral.

I don't do that, but I do. Perfect.

[00:21:44] Dr. Sam Jejurikar: That's, that's, that's such a Larry to in Toronto, Ontario.

[00:21:48] Dr. Sam Rhee: Oh, that's right. Shout out to Larry, which was one of the best facelift talks I've, 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 to for sure.

I will put it in my Tencent, I will put it in my local that I, I'm injecting for Lidocaine and epi. And if I'm in the hospital, I will have it in the iv, but it's, 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 know you're putting it in your infuse eight, you're putting it in your local, you're putting it in your iv. Like how do you calculate or know how much to use?

[00:22:32] Dr. Sam Jejurikar: So I, I think that when plastic surgery, we are 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 preoperatively. Or in, you know, right before we start the surgery if I'm doing liposuction or, you know, some sort of procedure where I'm injecting a large amount of fluid into the patient, I used to I used to use a higher dosage of, of of a thousand milligrams per bag.

I've cut it down once to 500 milligrams per bag without noticing any any change. And I've heard reports. From Alfred Hoyos 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. That's probably gonna be my next maneuver of actually cutting down on it.

So the overall dose, I mean, I think, I think most, you know, most people feel very comfortable giving five or six grams in one surgical setting. I'm doing far less than that.

Interesting. Yeah. And you sound I've never, and I've never seen a seizure by,

[00:23:33] Dr. Salvatore Pacella: So I, I don't use it in my Esent solution, but I think after this podcast I may start

[00:23:43] Dr. Sam Rhee: Excellent. Well, I think that that sort of covers txa. If, 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. 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 clo PE or D V T reported in TXA patients versus placebo.

And this was almost 10,000 patients that underwent a randomized double double blinded study, which, which I thought was, was the best. Evidence that we've had out there about the efficacy and safety of, 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.

And I'm interested to hear more about what you guys end up using it for and how you guys figure out your dosing in the future as.

[00:24:46] Dr. Sam Jejurikar: Well always, at least always illuminating. Dr. Reid, thanks for all that and have a great weekend guys.