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

Background: 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. Methods: 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. Results: 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. Conclusions: 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.