The current state of tranexamic acid in mastectomy and breast reconstruction: A systematic review and meta-analysis

Authors: Fung E, Godek Mm, Roth JM, Montalmant KE, Yu BZ, Hnderson PW

Affiliations: Icahn School of Medicine Mount Sinai

Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery, 2025.

PMID: 40156946

Key takeaways 

• TXA reduces postoperative hematoma formation after mastectomy ± reconstruction (2.4% vs 5.5%; OR 0.40; P = 0.001). 

• TXA shortens drain duration by ~1.2 days and reduces 24-hour drain output by ~42 mL. 

• No significant effect on seroma or surgical-site infection (SSI). 

• Safety: no increase in thromboembolism across 947 patients; one pulmonary embolism occurred in controls. 

• TXA mechanism of action: lysine analogue; indirectly inhibits fibrinolysis (i.e. stabilizes clot) by blocking plasminogen → plasmin activation 

• Dosing/administration: 1g IV (82%), 1g in 1L irrigation solution (18%) 

• Contraindications/adverse events: avoid in hypercoagulable patients; may lower seizure threshold and cause visual disturbances 

Background 

Use of tranexamic acid (TXA) in surgery is increasing; however, existing literature lacks high quality analysis. Outcomes specific to mastectomy and reconstruction require critical analysis to inform standardized protocols. 

Objective 

Quantify TXA’s effect on hematoma, seroma, SSI, drain output, and drain duration in mastectomy with and without reconstruction. 

Methods 

• Design: PRISMA-guided systematic review and meta-analysis. 

• Studies: 13 included in final review: RCTs (4), prospective comparative studies (5) and retrospective comparative studies (4) focusing on TXA in setting of mastectomy w/wo breast reconstruction 

  • 2,115 patients (44% received TXA) 

• Setting/procedures: mastectomy ± reconstruction (mastectomy alone (8 studies), autologous (2) or implant-based (3)). 

• Interventions: TXA via IV (82%) or topical (18%), typically intraoperative (83%); some continued postoperatively; dose varied (0.5-3g; most commonly 1 g). 

• Endpoints: primary—hematoma and seroma; secondary—SSI, drain output, drain duration, thromboembolic events, explantation. 

• Statistical approach: Mantel–Haenszel for odds ratios; inverse-variance for mean differences; subgroup analyses by study type, reconstruction type, and route. 

Results 

• Hematoma: 2.4% TXA vs 5.5% control; OR 0.40 (95% CI 0.23–0.70), P = 0.001. 

• Seroma: 23% TXA vs 21% control; pooled OR 0.82 (95% CI 0.61–1.10), P = 0.19. 

  • 29% of seromas in TXA required aspiration vs 43% of seromas in control 

• Subgroup analysis by study type, reconstruction type or route of TXA did not find significant differences between the study and control groups  

• Drain duration: average drain duration 6.6 ± 5.9 days in the TXA cohort vs 7.6 ± 5.3 days in control (mean difference −1.2, P = 0.03). 

• 24-hour drain output: significantly lower with TXA (pooled reduction ~41.8 mL). 

• SSI: no significant change with TXA. 

• Thromboembolism: none reported in TXA groups across four studies (n = 947); one pulmonary embolism in controls. 

• Implant explantation (subset): 8 TXA vs 18 control. 

Conclusion 

Across mastectomy ± reconstruction, TXA reduces hematoma, shortens drain duration, and lowers early drain output without increasing seroma, SSI, or thromboembolic events. 

Strengths & limitations 

• Largest, most current synthesis focused on mastectomy ± reconstruction. 

• Consistent hematoma benefit with improved drain-related outcomes. 

• Heterogeneity in timing, route, and dose; several studies underpowered for secondary endpoints. 

• Limited adverse-event reporting; need for standardized dosing and safety reporting. 

Future directions 

Standardize TXA dosing, route, and timing; include flap-specific safety endpoints and cost-effectiveness analyses in future RCTs. 

Clinical relevance 

For mastectomy ± reconstruction, consider a simple intraoperative TXA regimen (commonly 1 g IV) to reduce hematoma risk and potentially enable earlier drain removal. Counsel that seroma and SSI rates appear unchanged, and screen patients for thrombotic risk before use.