New Methods to Reduce Bleeding and Bruising During Rhinoplasty and Cosmetic Surgery
Like all surgical procedures, there is always a small amount of bleeding when we perform Rhinoplasty surgery.
As surgeons, we try to minimize bleeding and bruising for several reasons:
Bleeding can cause more bruising and swelling after surgery
Bleeding makes it more difficult to see the surgical field and, therefore, creates a more challenging surgery
Bleeding can lead to complications such as a hematoma. A hematoma is a collection of blood that forms a small bubble under the skin. In some situations, a patient can develop a hematoma that produces pressure on the skin, resulting in severe scarring.
Bleeding after surgery can also cause complications and affect the rhinoplasty outcome. Severe bleeding is uncommon in Rhinoplasty surgery; however, it is also a risk. A nosebleed after rhinoplasty surgery can cause considerable problems. If it is severe enough, a patient can lose a lot of blood. Fortunately, this is very rare. Treating a nosebleed can also result in changes to the cosmetics of the nose.
What is Bruising?
The medical term for bruising is “Ecchymosis” (pronounced “eh-chuh-mow-sis”). Bruising occurs when there is bleeding under the skin. It doesn’t mean anything went wrong with the surgery, as all patients who have surgery have some element of bleeding under the skin.
The most interesting aspect of bruising is all the changing colors that it produces. There is a scientific explanation for all this. The cells begin to break down as the blood collects under your skin. The first thing that happens is the hemoglobin (the iron-containing protein) breaks down and reacts with oxygen. This causes the deep purple, usually the first sign you see. Once this occurs, the hemoglobin begins to break down into smaller proteins and chemicals, biliverdin (a green color) to bilirubin (yellow) to hemosiderin (golden brown). This doesn’t always happen in order; thus, various colors occur simultaneously.
In addition to bruising, there are other, some more serious, types of bleeding that can occur after surgery:
A hematoma is a blood collection under the skin or anywhere in the body. A small hematoma is usually not a concern, but any large, painful, or growing hematoma can be a medical emergency. In surgery, we always try to prevent hematomas.
Petechiae: These are small little pinpoint areas (less than 2 millimeters) of dots on your skin.
Purpura: These are smaller than a bruise and due to small little blood vessels leaking under you skin
Arnica
Arnica is an herb or flower taken as a supplement to reduce bleeding and bruising. It is a common medication that patients take, and there is very little risk involved with it. There is some evidence in research studies indicating that Arnica supplements, taken before and after surgery, reduce bleeding. The challenge is that many of these studies are of poor quality. Nevertheless, there is some evidence that it works, and given the low risk, many patients use this supplement.
Transexamic Acid (TXA)
Due to the potential severity of bleeding during and after surgery, surgeons try to reduce the risk of bleeding during and after rhinoplasty surgery.
Recently, surgeons have started using a medication that reduces the risk of bleeding: Tranexamic Acid (TXA). TXA improves blood clots' stability and platelet function, improving the body's ability to stop bleeding.
When you have a cut or are bleeding, your body forms clots made of platelets and a protein called Fibrin. Your body also produces an enzyme called Plasminogen that gets converted to Plasmin. Plasmin then can break down the blood clot. TXA works by preventing Plasminogen from changing to Plasmin and, thus, temporarily reducing these blood clots' breakdown.
There are two ways by which Rhinoplasty surgeons can administer TXA to patients: as a pill or through an IV.
What Does TXA Do When Given Before Rhinoplasty Surgery?
Research into TXA has demonstrated some crucial findings in rhinoplasty surgery. Specifically, giving TXA to surgery patients:
Reduced Total Blood Loss during surgery
Reduced risk of hematoma formation
Reduced Bruising
Reduced blood loss during surgery and, therefore, improvement in the surgical field, which allows the surgeon to see the tissue better
Are there any Risks to TXA?
Like all medications, there are potential risks, but with TXA, it is very uncommon. Typically, patients don’t even notice they received the medication. The most common side effect is a mild headache.
Infrequent but more serious risks include blood clots forming, mainly if someone is at a high risk of having one of these blood clots. If you have a history of blood clots, you should not use TXA.
TXA and Hormonal Birth Control
A controversial topic is using hormonal birth control pills and TXA. Birth control is known to slightly increase the risk of having blood clots, and thus, some people think that you shouldn’t use TXA. Most studies looking into this demonstrate a very low risk of developing a blood clot and, therefore, use TXA with birth control. Also, when we use TXA in the OR, we only give one or two doses; thus, the risk is very low. This is a decision you can make with your surgeon.
When you meet Dr Bonaparte for your Pre-Op visit before your Rhinoplasty Surgery, he will discuss whether TXA is right for you. Most patients chose to use TXA as the benefits far outweigh the risks.
Other Surgery and TXA
TXA can also help with other cosmetic surgeries, including facelifts, neck lifts, and lidops. Talk to your doctor to determine if TXA is right for you.