Custom facial implants are like all other facial procedures in terms of inducing postoperative swelling and bruising. This is typically a relatively short-lived aesthetic issue that has largely abated by one month after surgery. Bruising or ecchymoses always resolve before all swelling has subsided. As a result there usually is not much concern about early bruising since it always goes away.
The one exception to postoperative bruising concerns is in the periorbital area, particularly the lower eyelids. The drainage from the anterior scalp, forehead, temples, and eyelids end up in the lower eyelid area and gets ‘stuck’ at the lower lid/cheek junction. At this anatomic upper midface area it can take a long time for bruising to resolve and, in some cases with certain skin pigments may result in hemosiderin staining. Such lower eyelid staining could take months to resolve and may even be permanent and require laser therapy for removal.
The custom infraorbital-malar (IOM)implant is the one facial implant in particular that notoriously can create some persistent lower eyelid bruising. As a result every effort in surgery is made to try and decrease the potential for such bruising. One of the most recent techniques in that regard is pharmacologic, the use of tranexamic acid. (TXA) TXA has gained considerable popularity amongst surgeons, plastic surgeons in particular, to decrease the risk of intra- and postoperative bleeding/hematomas as well as protracted bruising. Aesthetic facial procedures such as facelifts and blepharoplasties are prime candidates for the use of this drug and some surgeons absolutely swear by its effectiveness. But does it really work? Clinical studies have reported mixed results.
In the August 2024 issue of the Plastic and Reconstructive Surgery Global Open an article was published one this topic entitled ‘The Effect of Intravenous Tranexamic Acid on Postoperative Ecchymosis after Upper Blepharoplasty’. In this clinical study the authors evaluated blepharoplasty patients for their response to IV tranexamic acid (TXA) given just prior to surgical incisions as either a treated group or as a control (no TXA) in 325 patients prospectively. (138 experimental, 187 controls) Their amount of residual bruising was photographically assessed eight (8) days after the procedure. Their ecchymosis ratings averaged 5.8 for the controls and 4.1 for the experimental. They concluded the trend was for less bruising in the TCX group but it was not statistically significant.
This clinical study falls in line with many others…suggesting possible reduced bruising benefits but not convincingly so. Despite this weak evidence I still use it for all custom infraorbital-malar implants as it has no real adverse side effects and is a low cost drug. But I use in a more comprehensive fashion combining an IV does with topical application. Prior to the surgical incision 1 gm of TXA is given IV. Once each infraorbital-malar implantation site is dissected out through a lower eyelid a cottonoid soaked in TXA is placed into the pocket. This is allowed to stay in place until the other pocket is dissected out.
Thereafter the TXA sponges are removed and the implants placed with screw fixation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon