Three decades of hematoma prevention in outpatient plastic surgery: 44,133 consecutive cases and suggested protocol

Hematoma prevention in outpatient plastic surgery is crucial for patient safety and procedural success. This study evaluates hematoma rates over three decades of outpatient cosmetic procedures and outlines a structured multimodal prevention protocol. We conducted a single-center, retrospective review of 44,133 consecutive cosmetic procedures performed by board-certified plastic surgeons between 1995 and 2024 at an accredited outpatient surgical facility with postoperative nursing observation capabilities. A structured 5-Step Hematoma Prevention Protocol, incorporating tranexamic acid (TXA), was implemented. Hematoma was defined as a postoperative blood collection requiring reoperation within 30 days. Overall, 203 hematomas occurred, yielding a rate of 0.46%. Following adoption of the protocol, the hematoma rate declined to 0.2% during 2017-2024. In facial procedures, TXA use was associated with a 91% reduction in hematoma rates (0.74% vs. 0.06%; p<0.0001). To our knowledge, this represents the largest single-center analysis of outpatient hematoma prevention, spanning three decades and over 44,000 cases. This analysis supports the role of a structured multimodal protocol-with TXA as a key component-in minimizing hematoma risk. Broader adoption of standardized strategies may enhance patient safety and optimize outcomes in aesthetic surgery.