Procedure-Specific Efficacy of Tranexamic Acid in Breast Surgery: A Propensity-Score Adjusted Analysis of 5,202 Procedures.

BACKGROUND

Hematoma remains a major complication following breast surgery. While tranexamic acid (TXA) efficacy is established in reduction mammaplasty, its utility across other breast procedures remains unclear.

METHODS

This retrospective cohort study included 5,202 consecutive procedures (2019-2025) performed by multiple surgeons at a single private hospital: primary augmentation (n=3,738), reduction mammaplasty (n=943), explantation with mastopexy (n=358), and explantation alone (n=163). TXA administration was at surgeon discretion. Inverse Probability of Treatment Weighting controlled for temporal adoption bias and confounders. Primary outcome was hematoma requiring surgical intervention within 30 days; isolated ecchymosis without palpable collection was not classified as hematoma.

RESULTS

TXA adoption increased from 7.0% (2019) to 93.0% (2025). After achieving covariate balance (all SMD <0.2), procedure-specific effects emerged. In reduction mammaplasty, TXA significantly reduced hematoma (2.2% vs 7.2%; adjusted OR 0.28, 95% CI 0.14-0.58, p<0.001; NNT=20). Explantation with mastopexy showed similar benefit (1.6% vs 6.0%; OR 0.42, 95% CI 0.20-0.88, p<0.001). Primary augmentation demonstrated no statistically detectable difference (1.2% vs 1.2%; OR 0.94, 95% CI 0.36-2.42, p=0.905), regardless of implant plane. No thromboembolic events occurred. Surgical site infection showed a nominally significant difference (OR 0.47, p=0.02) but should be considered exploratory given small event counts and absence of a plausible biological mechanism. Seroma and wound dehiscence showed no significant differences.

CONCLUSIONS

TXA efficacy is procedure-dependent. It provides significant protection in reduction mammaplasty and mastopexy involving extensive parenchymal dissection, but shows no statistically detectable benefit in primary augmentation. These findings support procedure-specific practice guidance rather than universal prophylaxis.