Perioperative tranexamic acid in abdominally based free-flap breast reconstruction: A single-surgeon retrospective series

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Background: Tranexamic acid reduces perioperative bleeding in many surgical settings, but its safety in microvascular breast reconstruction remains incompletely defined given theoretical concerns for anastomotic thrombosis. We evaluated outcomes after routine perioperative tranexamic acid in abdominally based free-flap breast reconstruction and contextualized findings with the evolving microsurgical literature. Materials/Patients and Methods: A retrospective review was performed of consecutive patients undergoing abdominally based deep inferior epigastric perforator free-flap breast reconstruction by a single surgeon after adoption of routine tranexamic acid (February-December 2025). All included patients received 1 g intravenous tranexamic acid at anesthesia induction and an additional 1 g at closing. Primary outcomes included hematoma, flap thrombosis, venous thromboembolism, and transfusion. Secondary outcomes included wound complications, inpatient complications, and length of stay. Results: Seventy-one reconstructions were performed in 46 patients (46 unilateral, 25 bilateral) with median follow-up of 6 months. Flap survival was 100% with no inpatient complications. No hematomas, flap thrombosis events, or transfusions occurred. Delayed complications occurred in 9 patients (19.6%), most commonly donor-site wound healing (8.7%) and skin-paddle healing (4.3%). Two patients (4.3%) required interventional radiology drainage for an abscess and seroma, and one patient experienced a segmental pulmonary embolism. Conclusions: In this single-surgeon series, perioperative tranexamic acid use during free flap breast reconstruction was safe and not associated with thrombotic or bleeding-related complications. Combined with the limited existing literature, these findings support tranexamic acid as a safe adjunct in microvascular breast reconstruction. Larger, multicenter prospective trials are needed to validate tranexamic acid's role in this population.

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