面部除皱术局部氨甲环酸系统评价

2026年9月4日28 min read

Plastic and Reconstructive Surgery Global Open

本文目录

一分钟要点

背景：除皱术（rhytidectomy）是常见的面部年轻化手术，术后血肿是最常见且后果严重的并发症。氨甲环酸（TXA）是强效抗纤溶药，已广泛用于减少外科出血；但对其在除皱术中局部应用的临床证据尚缺高级别综合。
方法：系统检索 PubMed / Embase / MEDLINE / CENTRAL 自建库至 2025-12，纳入局部 TXA 与对照比较的成人除皱术研究；随机效应模型合并效应，ROBINS-I 评偏倚，GRADE 评证据确定性。
纳入：7 项研究、1122 例患者（596 例局部 TXA / 526 例对照）。
主要结果：局部 TXA 显著降低术后血肿风险（OR 0.35，95%CI 0.15–0.81，P=0.014，I²=0%）；估计出血量 EBL（SMD −4.53 mL，P=0.01）与 24h 引流量（SMD −1.10 mL，P<0.01）亦显著降低；其他术后并发症 OR 0.58（P=0.020）。
异质性：EBL 异质性高（I²=98.9%），主要源于术中出血测量方法差异；血肿与并发症异质性低。
结论与局限：局部 TXA 是除皱术安全有效的辅助止血策略，可降低出血 / 引流 / 血肿相关并发症；但需更多高质量、标准化方案与经济性评估研究确认合适剂量与给药方式。

Abstract 原文摘要

Background:Rhytidectomy is one of the most performed facial rejuvenation procedures, yet postoperative hematoma remains its most frequent and consequential complication, driving patient morbidity and compromising aesthetic outcomes. Tranexamic acid (TXA), a potent antifibrinolytic agent, has been widely adopted to mitigate surgical bleeding; however, a definitive high-level synthesis of evidence for its local application in rhytidectomy remains limited. We conducted a comprehensive systematic review and meta-analysis to highlight the efficacy and safety profile of local administration of TXA compared with control interventions in patients undergoing rhytidectomy.

Methods:A systematic search of PubMed, Embase, MEDLINE (EBSCO), and Cochrane Central Register of Controlled Trials (CENTRAL) was conducted from database inception through December 2025. Studies comparing the effects of local administration of TXA with a control in adults undergoing rhytidectomy were included. Pooled effect estimates were calculated using a random-effects model; risk of bias was assessed with risk of bias in non-randomized studies-of interventions (ROBINS-I); and the certainty of evidence was appraised using the grading of recommendations assessment, development, and evaluation (GRADE) framework.

Results:Seven studies met the inclusion criteria, comprising 1122 patients (596 local TXA and 526 controls). Meta-analysis revealed that local TXA was associated with a significant reduction in estimated blood loss (in milliliters) (standardized mean difference, −4.53; 95% confidence interval [CI], −8.09 to −0.97; P = 0.01), 24-hour postoperative drain output (in milliliters) (standardized mean difference, −1.10; 95% CI, −1.40 to −0.79; P < 0.01), and hematoma rates (odds ratio, 0.35; 95% CI, 0.15–0.81; P = 0.014).

Conclusions:In patients undergoing rhytidectomy, the application of local TXA significantly enhances surgical efficiency and patient safety by reducing blood loss, drain output, and postoperative hematologic complications.

INTRODUCTION

Rhytidectomy, or face lift, is the archetypal procedure in the pursuit of facial rejuvenation, a field propelled by robust and resilient global demand for aesthetic enhancement. 1 The procedure has evolved from its inception as a simple cutaneous excision to a sophisticated, anatomically complex procedure. Modern rhytidectomy is predicated on the manipulation of the superficial musculoaponeurotic system (SMAS), a fibrous network that invests the facial mimetic muscles and is continuous with the platysma. 2 Techniques have evolved from simple SMAS plication to more extensive deep-plane and composite dissections, which reposition ptotic facial soft tissues as a single unit to produce more natural and durable results. 3 This technical refinement has fueled a marked increase in the procedure’s popularity, with data from the Aesthetic Society 2023 national database indicating that rhytidectomy was the sixth most common surgical procedure, with 96,061 procedures performed in 2023 alone, representing a 37.3% increase from 2022 and an 81.5% increase since 2019. 4

Despite its technical sophistication and high rates of patient satisfaction, the extensive subcutaneous dissection inherent to rhytidectomy creates a vast raw tissue surface, rendering the procedure prone to hemorrhagic complications. 5 , 6 Postoperative hematoma remains the most frequent and feared adverse event, with a reported incidence ranging from 0.6% to 14.2% and representing the unequivocal leading cause of unplanned returns to the operating room. 6 – 12 The clinical sequelae are far from benign; an expanding hematoma can compromise the viability of the overlying skin flap, leading to ischemia and necrosis, while also increasing the risk of infection and necessitating a prolonged, painful recovery that can irrevocably compromise the final aesthetic outcome. 13 , 14

Tranexamic acid (TXA), a synthetic lysine analog, has emerged as a leading candidate in this search. Its potent antifibrinolytic effect is exerted by competitively and reversibly blocking lysine-binding sites on plasminogen. 15 This molecular action prevents the conversion of plasminogen to its active form, plasmin, the primary enzyme responsible for fibrin clot degradation. 15 The clinical utility of intravenous TXA was first established in high-hemorrhage surgical settings, where landmark trials such as clinical randomization of an antifibrinolytic in significant haemorrhage 2 (CRASH-2) and others demonstrated its capacity to significantly reduce blood loss and allogeneic transfusion requirements. 16 – 18 This clinical momentum extended to aesthetic surgery, where the American Society of Plastic Surgeons practice pattern data indicate that TXA has been adopted in 83.6% of rhytidectomies, 77.1% of neck lifts, 54.8% of forehead and brow lifts, and 55.0% of rhinoplasty procedures. 19

This success spurred a growing trend toward the use of local TXA in aesthetic surgery, where the goal is not to prevent exsanguination but to mitigate bleeding-related morbidity. 20 – 22 The rationale for this shift is compelling: local application via topical irrigation or subcutaneous infiltration achieves high therapeutic concentrations directly at the target tissue while minimizing systemic absorption. 23 This widespread adoption has vastly outpaced the publication of high-level synthesized evidence. This study was therefore conducted to address this critical evidence gap, aiming to quantify the efficacy and safety of local TXA administration in rhytidectomy and to provide an evidence-based foundation for formalizing its role in modern facial rejuvenation surgery.

METHODS

Protocol Registration

This systematic review with meta-analysis was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. 24 , 25 ( See figure, Supplemental Digital Content 1 , which displays the PRISMA-compliant checklist, https://links.lww.com/PRSGO/F220.) The study protocol was prospectively registered with an international registry (PROSPERO; protocol no. CRD420251247589) to ensure transparency and methodological rigor.

Eligibility Criteria

Eligible studies were required to (1) be randomized or nonrandomized studies of interventions (NRSIs); (2) involve adult patients undergoing rhytidectomy; (3) directly compare an intervention group receiving local TXA with a control group receiving either placebo or regular local anesthesia; and (4) report quantitative data for at least one of the predefined outcomes, listed as follows: estimated blood loss (EBL) (in milliliters), drain output within the first postoperative day (in milliliters), postoperative hematoma rates, and composite complication rates (including seroma, surgical-site infections, wound-healing complications, and facial nerve neuropraxia). Studies were excluded if they did not include a comparator arm; reported the use of local versus systemic TXA; did not report any of the predefined outcomes; or were review articles, case reports, series, editorials, conference abstracts, or preprints.

Search Strategy and Data Collection

A comprehensive systematic search of PubMed (National Library of Medicine, Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), MEDLINE via EBSCO host (EBSCO Information Services, Ipswich, MA), and the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library, London, United Kingdom) was conducted from their inception through December 2025. The search strategy was developed in consultation with a medical librarian and combined controlled vocabulary (eg, MeSH, Emtree) with free text keywords encompassing 2 main concepts: (1) rhytidectomy and (2) locally administered TXA, with the full search strategy given in Supplemental Digital Content 2. ( See figure, Supplemental Digital Content 2 , which displays the full search strategy for each of the databases included in this study, https://links.lww.com/PRSGO/F221.)

Two reviewers (J.M. and M.H.) independently performed title and abstract screening, followed by a full-text eligibility assessment, using Covidence (Veritas Health Innovation, Melbourne, Australia). 26 A standardized data extraction form was developed and piloted on Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). The same 2 authors independently extracted relevant data, including study design, patient demographics, intervention details (TXA dose, concentration, volume, and route of administration), control type, and outcome data. All data were extracted from the published articles; any missing data were retrieved by contacting the corresponding author and, if needed, converted to numerical values by using validated methods. 27

Endpoints and Sub-analyses

Primary Outcomes

The primary outcomes in this meta-analysis were selected to reflect the direct hemostatic and efficiency benefits of TXA, representing objective, quantifiable measures of intraoperative and immediate postoperative bleeding. The first outcome of interest was the incidence of hematoma, defined as a clinically significant blood collection requiring either surgical evacuation in the operating room or bedside drainage. The second primary outcome was EBL, defined as the volume of blood lost during the surgical procedure (calculated by the surgical or anesthesia team based on the volume of blood collected in suction canisters and the weight of blood-soaked surgical sponges). The final primary outcome was the 24-hour postoperative drain output, defined as the total volume of fluid (in milliliters) collected in closed-suction surgical drains.

Secondary Outcomes

The principal secondary outcome was the incidence of other postoperative complications—a composite dichotomous outcome, defined as the occurrence of 1 or more of the following adverse events within the study follow-up period: (1) seroma defined as a collection of serous fluid requiring aspiration or drainage; (2) surgical-site infection evaluated as an infection at the surgical site requiring antibiotic treatment or surgical intervention; (3) marginal mandibular neuropraxia defined as a temporary conduction block of the marginal mandibular branch of the facial nerve (cranial nerve VII) without axonal disruption; and (4) wound-healing complications defined as prolonged epithelialization or wound closure, including persistent wound dehiscence, wound breakdown, or the need for ongoing local wound care beyond the expected postoperative period. The number of patients experiencing at least one of these events was extracted for both groups to calculate a pooled odds ratio (OR).

Subgroup Analyses

A prespecified subgroup analysis was performed to evaluate whether the effect of local application of TXA on postoperative hematoma differed by surgical technique. Studies were categorized into SMAS-based rhytidectomy and non–SMAS-based rhytidectomy (including deep-plane and multiplane approaches) based on the operative descriptions provided in each study.

Sensitivity Analyses

To assess the stability and reliability of the pooled estimates, sensitivity analyses were performed. Studies that contributed disproportionately to heterogeneity were systematically evaluated, and a leave-one-out sensitivity analysis was conducted, in which each study was sequentially omitted to assess its influence on the overall effect size. Consistent with methodological standards, substantial heterogeneity was defined as an I 2 value of more than 40%.

Quality Assessment

The methodological quality of all included studies was independently evaluated by 2 reviewers (J.M. and L.K.-R.) using validated, study design–appropriate tools and was rated as low, moderate, or serious risk of bias. NRSIs were evaluated using the ROBINS-I instrument, which assesses 7 domains of potential bias. Complementing these assessments, the certainty of evidence for each outcome was independently graded by 2 authors (J.M. and M.H.) using the GRADE methodology, incorporating considerations of risk of bias, inconsistency, indirectness, imprecision, and publication bias. Final determinations were reached through consensus, supported by GRADEpro GDT, 28 ensuring a transparent, reproducible, and methodologically appropriate evaluation.

Statistical Analysis

All analyses were performed using a random-effects model with the DerSimonian–Laird estimator to account for expected clinical and methodological heterogeneity across the included studies. Continuous outcomes were synthesized using standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs). Dichotomous outcomes were assessed using ORs with corresponding 95% CIs. Statistical significance was defined as a 2-sided P value of less than 0.05. Heterogeneity was quantified using the I 2 statistic and Cochran Q test, with heterogeneity considered significant at a P value of less than 0.10 or an I 2 value of more than 40%. All analyses were carried out with R (version 4.4.1, 29 R Foundation for Statistical Computing, Vienna, Austria) using the meta and metafor packages.

RESULTS

Study Selection and Characteristics

The literature search yielded 545 unique records (Fig. 1 ). Following the exclusion of duplicated studies and irrelevant titles or abstracts, 13 articles warranted full-text evaluation. Subsequent eligibility assessment identified 7 studies 30 – 36 that met all predefined inclusion criteria, comprising 1122 patients (596 local TXA and 526 controls), with an average female proportion of 93.3% and an average age of 62.9 years. The included studies comprised 5 retrospective single-surgeon cohort studies, 31 , 32 , 34 – 36 1 retrospective case–control single-surgeon study, 30 and 1 prospective single-surgeon cohort study, 33 published between 2020 and 2025, primarily from the United States. The surgical technique varied across studies, including SMAS plication, deep-plane dissection, and multiplane dissection. The method of local TXA administration also varied, with subcutaneous infiltration, topical irrigation, and soaked gauze application being the most common approaches (Table 1 ).

Table 1. Baseline Study Designs and Patient Characteristics

Study	Local TXA, n	Control, n	Study Design	Country of Study	Surgical Technique	Female, n	Age, y	Follow-up, d	Topical TXA Administration	Control Administration
Coombs et al 30	72	73	Retrospective single-surgeon case control	United States	Extended SMAS rhytidectomy	134	64.65 ± 8.65 *	616 †	1–2 mg/mL of TXA per 1 mL of 0.5% lidocaine with 1:200,000 epinephrine local infiltration	0.5% lidocaine with 1:200,000 epinephrine local infiltration
Darras et al 31	261	261	Retrospective single-surgeon cohort	United States	Deep-plane rhytidectomy ± platysmaplasty	488	64.46 †	232 (180–365) ‡	1–2 mg/mL of TXA per 1 mL of 0.5% lidocaine with 1:200,000 epinephrine local infiltration	0.5% lidocaine with 1:200,000 epinephrine local infiltration
Pou et al 32	120	55	Retrospective single-surgeon cohort	United States	Deep-plane rhytidectomy ± platysmaplasty	167	61.09 †	182 †	25 mg/mL of TXA soaked gauze or 0.5 mL of 100 mg/mL TXA with 9.5 mL of 0.5% lidocaine with 1:200,000 epinephrine local infiltration	40 mL of 0.5% lidocaine with 1:200,000 epinephrine local infiltration
Schroeder et al 36	44	32	Retrospective single-surgeon cohort	United States	Deep-plane rhytidectomy with platysmaplasty	76	62.3 †	60 †	Topical/infiltrative TXA (9.1 mg/mL) added to local 1:1 mixture of 2% lidocaine and 0.5% bupivacaine with 1:200,000 epinephrine + 0.3% xylocaine with 1:600,000 epinephrine	Local 1:1 mixture of 2% lidocaine and 0.5% bupivacaine with 1:200,000 epinephrine + 0.3% xylocaine with 1:600,000 epinephrine
Serrano Reyes et al 33	15	15	Prospective single-surgeon cohort	Brazil	Round rhytidectomy with SMAS plication	29	62 ± 7.64 *	90 †	Irrigation of 20 mL of TXA in 20 mL of sterile water	Irrigation of 20 mL of sterile water
Trimas et al 34	34	40	Retrospective single-surgeon cohort	United States	Standard SMAS plication rhytidectomy	64	62.8 (43–81) ‡	60 †	Local infiltration of 250 mg of TXA added to tumescent solution of 12.5 mL of 1% lidocaine, 12.5 mL of 0.25 Marcaine, 1 mL of 1:1000 epinephrine, and 250 mL of saline	Tumescent solution of 12.5 mL of 1% lidocaine, 12.5 mL of 0.25 Marcaine, 1 mL of 1:1000 epinephrine, and 250 mL of saline
Ziegler Rodríguez et al 35	50	50	Retrospective single-surgeon cohort	Peru	Multiplane facial rhytidectomy	88	59.5 (47.75–65) ‡	60 †	Local infiltration of 10 mL/1 g of TXA added to 800 mL of saline, 2 mL of 1:400,000 epinephrine, 20 mL of 2% lidocaine, and 800 mL of saline	Local infiltration of 2 mL of 1:400,000 epinephrine added to 20 mL of 2% lidocaine, and 800 mL of saline

Fig. 1.

Fig. 1. PRISMA flow diagram of study selection demonstrating the systematic identification, screening for title, abstract, full-text reviews, and inclusion of studies following PRISMA 2020 guidelines. IV, intravenous.PRISMA 2020 文献筛选流程图，展示系统检索→筛选→纳入的全过程。

Pooled Analysis of All Included Studies

EBL

Across 3 studies 32 , 34 , 35 involving 349 patients (204 local TXA and 145 controls), EBL was significantly lower in the local TXA cohort (SMD, −4.53 mL; 95% CI, −8.09 to −0.97]; P = 0.01; I 2 = 98.9%; Fig. 2 ). The considerable heterogeneity is likely attributable to differences in intraoperative blood-loss measurement.

Fig. 2.

Fig. 2. Forest plot demonstrating the pooled effect of local administration of TXA on EBL. Results are presented as SMDs with 95% CIs for EBL across relevant included studies.局部 TXA 对 EBL（估计出血量）的森林图（SMD 合并效应）。注意高异质性（I²≈98.9%）。

Drain Output in the First 24 Hours

Three comparative studies 32 , 33 , 36 totaling 281 patients (179 local TXA and 102 controls) reported data on drain output during the first 24 hours postoperatively. Pooled analysis revealed that the local TXA cohort had a significantly lower drain output within the first 24 hours (SMD, −1.10 mL; 95% CI, −1.40 to –0.79]; P < 0.01; I 2 = 16.1%; Fig. 3 ).

Fig. 3.

Fig. 3. Forest plot summarizing the pooled effect of local administration of TXA on postoperative drain output in the first 24 hours. Results are presented as SMDs with 95% CIs across relevant included studies.对 24h 术后引流量的森林图（SMD 合并效应）。

Hematoma

All included studies, 30 – 36 comprising 1122 patients (596 local TXA and 526 controls), reported postoperative hematoma rates. The pooled analysis demonstrated that local TXA was associated with a significantly lower risk of hematoma (OR, 0.35; 95% CI, 0.15–0.81; P = 0.014; I 2 = 0.0%; Fig. 4 ).

Fig. 4.

Fig. 4. Forest plot demonstrating the pooled effect of local administration of TXA on hematoma rates. Results are presented as ORs with 95% CIs across all included studies. MH, mantel haenszel.对血肿发生率的森林图（OR 合并效应，I²=0%）。