Background <p>Tranexamic acid (TXA) is widely used to reduce perioperative bleeding across surgical disciplines, yet its role in plastic breast surgery remains incompletely defined. This study aimed to evaluate the effect of TXA on postoperative outcomes in implant-based and autologous breast procedures.</p> Methods <p>A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Embase, Scopus, MEDLINE, PubMed, and Cochrane were searched from inception through March 2026. Studies evaluating TXA in plastic breast reconstruction or augmentation were included. Primary outcomes were hematoma, seroma, and length of hospital stay. Random-effects meta-analyses were performed. Risk of bias was assessed using RoB 2 and ROBINS-I.</p> Results <p>Eleven studies (<i>n</i> = 2,922 patients; 6,681 breasts) were included. TXA use was associated with a significant reduction in seroma formation (RR 0.73, 95% CI 0.55–0.97) and shorter hospital stay (mean difference − 0.80 days, 95% CI − 0.94 to − 0.65). A reduction in hematoma incidence was observed but did not reach statistical significance (RR 0.53, 95% CI 0.26–1.07). Exploratory subgroup analyses by route of administration showed no statistically significant differences, although point estimates favored TXA in both systemic and topical groups. Most studies also reported reduced drainage volume and earlier drain removal with TXA use. No increase in thromboembolic events or flap-related complications was observed.</p> Conclusions <p>Tranexamic acid appears to be a safe and effective adjunct in plastic breast surgery, associated with reduced seroma formation, improved drain-related outcomes, and shorter hospitalization, with a trend toward decreased hematoma. Further prospective, procedure-specific studies are required to determine optimal dosing, route of administration, and patient selection. Level of Evidence: not gradable</p>