Optimizing liposuction with tranexamic acid in tumescence: a double-blind, contralateral, randomized clinical trial

Authors: Hoyos AE, Perez Pachon M, Borras Osorio M, Castiblanco MP, Leon-Machicado M

Affiliation: Private practice, Bogotá, Colombia

Journal: Plastic and Reconstructive Surgery, February 2026

PMID: 40674620

Key takeaways

• Adding TXA to tumescent solution (for arm liposuction) reduced postoperative day 1 pain and bruising versus placebo in a split-body randomized trial. There was no difference in edema (arm circumference)

• No TXA-related adverse events were reported, but the study was not powered to establish thromboembolic safety.

Background

Arm contouring with liposuction is increasing in popularity. TXA has attracted interest as an adjunct to reduce bleeding, bruising, and possibly inflammation.

Prior liposuction studies suggested that TXA can reduce blood loss and ecchymosis, but route, dose, and procedure-specific benefit remain inconsistent. This trial asked: does adding TXA to tumescence fluid improve early postoperative recovery in patients undergoing arm liposuction?

Objective

To determine whether adding TXA to tumescent solution for arm liposuction reduces postoperative pain, ecchymosis, and edema compared with placebo.

Methods

• Design: Single-center, double-blind, contralateral randomized clinical trial.

• Setting: Specialized plastic surgery institution in Bogotá, Colombia, May 2022 to February 2024.

• Population: 78 adults undergoing arm liposuction, either isolated or combined with other aesthetic procedures.

• Demographics: 78.2% female; mean age 37.6 years; mean BMI 24.7 kg/m².

• Inclusion criteria: Age 18 to 60 years, no major comorbidities, planned arm liposuction.

• Exclusion criteria: Follow-up of 1 month or less, incomplete data, or contraindication to TXA.

• Intervention: One arm randomized to TXA tumescent solution and the contralateral arm to placebo.

• TXA formulation: 250 mg TXA per 1 L of standard tumescent solution.

• Control formulation: Standard tumescent solution only.

• Technique: High-definition liposculpture with infiltration, ultrasound-assisted emulsification, and suction-assisted extraction. Most cases used VASER and MicroAire. Many patients also underwent additional liposculpture and contouring procedures.

• Primary measured outcomes: Day 1 pain by visual analog scale (VAS), arm circumference over time, and ecchymosis area from standardized photographs using ImageJ.

• Follow-up for study endpoints: Pain on postoperative day 1; circumference on days 1, 7, 15, and 30; ecchymosis on days 1 and 8.

• Statistics: Fisher exact test for categorical pain scores; Kruskal-Wallis for nonparametric continuous outcomes; significance threshold 0.05. Post hoc power analysis was performed for day 1 pain.

Results

• Sample analyzed: 78 patients overall, but endpoint completeness varied.

  • Pain analysis: 62 patients.

  • Ecchymosis analysis: 47 patients.

  • Circumference analysis: 40 to 47 patients depending on time point.

• Operative profile: Mean operative time 271 minutes; mean infiltration volume 5573 mL; mean suction volume 4121 mL; mean lipoaspirate 2803 mL.

• Concomitant procedures were common: abdomen liposculpture in all patients, back in nearly all, thighs in most, with frequent intramuscular fat grafting and other adjunctive procedures.

Primary and notable secondary outcomes

• Pain, postoperative day 1: significantly lower in the TXA arm.

  • Mean VAS: 3.37 ± 0.84 with TXA versus 5.58 ± 1.14 with placebo.

  • Distribution favored TXA: most TXA arms were in the mild pain range, whereas most control arms were in the moderate pain range.

  • P < 0.001.

• Ecchymosis, postoperative day 1: significantly lower in the TXA arm.

  • Median ecchymosis area: 2.26% versus 5.21%.

  • P = 0.021.

• Ecchymosis, postoperative day 8: numerically lower with TXA but not statistically significant.

  • Median ecchymosis area: 0.97% versus 2.54%.

  • P = 0.167.

• Arm circumference: no significant difference at baseline or postoperative days 1, 7, 15, or 30.

  • This argues against a measurable edema benefit using this metric.

Safety and satisfaction

• Overall complication rate: 8.9%.

• Reported complications: abdominal seroma, anemia, cellulitis, umbilical hematoma, and infection/immune response.

• Important nuance: none of the adverse events were attributed to the arm lipoplasty itself or to TXA in the tumescent solution.

• Patient-reported satisfaction: among 73 respondents, 91.8% rated results 8 to 10 out of 10 on a Global Aesthetic Improvement Scale-based survey.

• Late issues: with follow-up up to 6 months in most patients, no scar formation, fibrosis, or cording was reported.

Conclusion

In healthy patients undergoing arm liposuction, adding TXA to the tumescent solution improved early recovery by reducing postoperative day 1 pain and bruising without a detectable difference in arm circumference. The authors conclude that tumescent TXA is a safe and effective adjunct for body contouring recovery, although the strongest evidence here is for early pain and ecchymosis rather than edema.

Strengths

• Randomized, double-blind, split-body design is a major strength and controls for many patient-level confounders.

• Objective bruise quantification with standardized photography and ImageJ is better than subject ratings.

• Clinically relevant outcomes for aesthetic patients: pain, bruising, and recovery experience.

• The signal size for day 1 pain was large.

Limitations

• Single-center study in a healthy, selected population limits generalizability.

• Endpoint completion dropped substantially; not all 78 patients contributed to each outcome.

• Most patients had multiple simultaneous body contouring procedures, which can complicate interpretation of pain and recovery.

• Arm circumference is a crude edema surrogate and may be too insensitive to detect meaningful tissue swelling differences.

• The safety dataset is too small to define thromboembolic risk or rare TXA-related events.

• The paired, within-patient design is excellent, but the statistical approach was not as rigorous as a fully paired or mixed-effects analysis would have been.

Clinical relevance

Adding TXA appears to be a reasonable, low-friction strategy to decrease bruising and improve day 1 comfort in carefully selected patients.

Literature context

• Earlier liposuction studies already suggested that TXA reduces blood loss and bruising, but most were small, heterogeneous, or not truly arm-specific.

• A 2018 liposuction study showed substantially lower blood loss per liter of lipoaspirate with TXA, supporting a blood-sparing effect.

• A 2021 split-site flank liposuction study found less bruising on the TXA-treated side at days 1 and 7, which aligns closely with the current paper’s ecchymosis findings.

• A 2021 retrospective donor-site study in fat-grafting patients also showed less ecchymosis with local TXA infiltration.

• A 2022 randomized liposuction trial found reduced blood loss with TXA in tumescent solution and no TXA-related adverse events.

• A 2022 multicenter randomized trial from the same research group suggested that intravenous TXA outperformed local/subcutaneous TXA for hemoglobin preservation, which is important: local TXA may help bruising, but IV TXA may still be superior if the main endpoint is blood conservation.

• A 2023 randomized study again supported TXA, reporting less blood loss and less bruising, with the largest reduction seen in the local TXA group.

• More recent liposuction-specific and aesthetic-surgery meta-analyses support an overall blood-sparing effect of TXA, but they consistently emphasize heterogeneity in dose, route, outcome reporting, and study quality.

Editorial Notes

• Why did only 62 patients contribute pain data and only 47 contribute ecchymosis analysis? A fuller accounting of missingness by randomized side and by patient characteristics would strengthen confidence.

• The edema question remains largely unanswered because circumference is a blunt tool for detecting postoperative tissue swelling after liposuction. Ultrasound, 3-dimensional imaging, or tissue thickness measurements would have been more informative.

• Pain findings should be interpreted cautiously because most patients underwent concomitant procedures. 

• The dose was 250 mg/L, which is lower than some previously reported tumescent regimens. That raises an important practical question: is this near the minimum effective dose for bruising reduction, or could a higher dose produce more durable benefit?