Bleeding, Drains, and Reoperation in Transmasculine Chest Surgery: What 2,534 Patients Tell Us About Tranexamic Acid

Hematoma, seroma, and unplanned reoperation are the most frequent early complications after gender-affirming mastectomy with hematoma being the most common complication and the most common reason for reoperation. Tranexamic acid (TXA) is increasingly incorporated into enhanced-recovery protocols, yet its route-specific benefits remain unclear.

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases were searched for comparative studies of TXA versus no TXA in transmasculine chest surgery. Review Manager 5.4 was used for statistical analysis.

Seven retrospective cohorts (2534 patients) met the inclusion criteria. Overall, TXA significantly reduced hematoma risk by 41% (relative risk reduction [RRR] = 41%; risk ratio [RR] = 0.59, 95% confidence interval: 0.41-0.83; P = 0.003; I² = 3%). Subgroup analysis for route of administration demonstrated that the benefit was confined to intravenous (IV) TXA (RR 0.49, 0.25-0.95), not topical (RR 0.74, 0.43-1.26). Unplanned returns to the operating room fell by 62% with IV TXA (RRR = 62%; RR = 0.38, 0.23-0.64). The overall effect on seroma was nonsignificant (RR 0.89, 0.59-1.36), but subgroup analysis showed that IV TXA lowered seroma risk by 33% (RRR = 33%; RR 0.67, 0.51-0.88; P = 0.004); topical TXA showed no benefit. Pooled analysis for infection was not significant (RR 0.77, 0.34-1.73); IV TXA halved infections (RR 0.38, 0.15-0.95), whereas topical TXA did not. Nipple-areola necrosis and wound-healing complications were unaffected. TXA did not increase thromboembolism.

IV TXA safely reduces risks of hematoma, seroma, and reoperation after gender-affirming mastectomy, without increasing venous thromboembolism risk. Topical TXA confers no measurable advantage.