In an adult undergoing a forehead flap for nasal reconstruction without hypercoagulable risk, does tranexamic acid increase the risk of venous congestion?

Does TXA Increase the Risk of Venous Congestion in a Forehead Flap?

No, tranexamic acid does not increase the risk of venous congestion in forehead flaps for nasal reconstruction, and should be considered as a safe hemostatic adjunct in this population without hypercoagulable risk factors.

Evidence from Plastic Surgery Populations

The most recent and directly relevant evidence comes from a 2026 large-scale retrospective cohort study specifically examining plastic and reconstructive surgery of the head and neck. This study of 1,011 patients receiving IV TXA versus 157,959 controls found no increased risk of venous thromboembolism (VTE) within 90 days postoperatively (OR 0.62,95% CI: 0.13-3.04, p = 0.55), supporting TXA's continued use as a safe hemostatic adjunct in this exact patient population 1.

This finding is particularly relevant because:

• Forehead flaps are a subset of head and neck plastic surgery procedures where venous congestion would manifest as a VTE or microvascular thrombotic complication 1
• The study population included the specific anatomic region and surgical specialty relevant to your question 1
• The 90-day follow-up window captures both immediate perioperative and delayed thrombotic complications 1

Broader Surgical Safety Data

Multiple lines of evidence across surgical specialties reinforce this safety profile:

• A 2021 meta-analysis of 57 randomized controlled trials (n=5,698 patients) across all surgical disciplines found that a single preoperative dose of IV TXA reduced perioperative blood loss by 153 mL without increasing venous thromboembolic events 2
• The most commonly used safe and effective dose is 15 mg/kg as a single preoperative bolus 2
• A 2024 systematic review of cranial neurosurgery demonstrated TXA successfully reduces blood loss without predisposing patients to VTE (P < 0.01) 3

Mechanism: Why TXA Does Not Cause Venous Congestion

The theoretical concern about venous congestion stems from misunderstanding TXA's mechanism:

• TXA is an antifibrinolytic that prevents clot breakdown, not a procoagulant that initiates clot formation 4
• Venous congestion in flaps results from mechanical venous outflow obstruction or surgical technique issues, not from systemic antifibrinolytic therapy 5
• Large-scale evidence including over 8,000 patients receiving lysine analogues like TXA demonstrated no increased risk of arterial or venous thrombotic events 4

FDA Safety Profile

The FDA drug label for TXA acknowledges thromboembolic risk but contextualizes it appropriately:

• TXA is contraindicated only in patients with active intravascular clotting 6
• The label warns against concomitant use with pro-thrombotic agents (Factor IX concentrates, hormonal contraceptives) but does not contraindicate use in reconstructive surgery 6
• Most documented thrombotic events occurred with doses 10-fold higher than recommended (primarily in cardiac surgery) or with inadvertent intrathecal administration 6

Clinical Implementation for Forehead Flaps

For an adult undergoing forehead flap reconstruction without hypercoagulable risk:

1. Administer 15 mg/kg IV TXA as a single preoperative bolus over 10 minutes prior to incision 5, 2
2. Screen for absolute contraindications: active intravascular clotting, severe hypersensitivity to TXA, or concomitant use of pro-thrombotic agents 6
3. Assess renal function preoperatively, as TXA is 90% renally excreted and accumulates in renal failure 7, 8
4. For procedures expected to exceed 2-3 hours, consider maintenance infusion of 1g over 8 hours 5

Important Caveats

Situations requiring caution (but not absolute contraindication):

• Patients on oral contraceptives have increased baseline thrombotic risk and require careful risk-benefit assessment 6
• Recent stroke or arterial thrombosis within 3 months warrants caution 7
• Renal impairment (CrCl <50 mL/min) requires dose adjustment to prevent neurotoxicity 7, 8

Common pitfall to avoid:

• Do not confuse systemic antifibrinolytic therapy with local flap venous congestion—these are separate pathophysiologic processes 5. Venous congestion in forehead flaps results from surgical technique (pedicle kinking, excessive tension, inadequate venous drainage design) rather than systemic hemostatic agents 5.

Quality of Life and Morbidity Considerations

From a morbidity and quality of life perspective, TXA offers clear benefits:

• Reduced perioperative blood loss decreases transfusion requirements and associated complications 2
• Lower transfusion rates reduce hospital length of stay and transfusion-related morbidity 2
• No evidence suggests TXA compromises flap survival or increases revision surgery rates in head and neck reconstruction 1