INTRODUCTION: Postoperative hematoma requiring intervention occurs more frequently in chest masculinization surgeries than in other types of breast surgeries, with incidences ranging from 0.7% to 13.2% per patient. Although there is increasing evidence that topically applied tranexamic acid (TXA) effectively reduces postoperative bleeding in breast surgeries, its impact on masculinization surgeries is understudied. AIMS: Examining the significance of topical TXA in reducing postoperative hematoma in chest masculinization surgeries. METHODS: This retrospective cohort comprises female-to-male transgender and non-binary patients who underwent chest masculinization at Helsinki or Tampere University hospitals between 2018 and 2024. Topical TXA (20 mg/ml, 25 ml per breast) was incorporated into routine use in October 2022, replacing the previous practices; Helsinki mainly operated without TXA, whereas Tampere routinely used intravenous (i.v.) TXA. RESULTS: A total of 198 patients undergoing chest masculinization surgery were included. Among them, 9 (4.5%) major hematomas occurred. The need for reoperation due to postoperative hematoma was lower in the topical TXA (3.2%, 2 out of 63 patients) and i.v. TXA (3.4%, 2 out of 58 patients) groups compared to the non-TXA group (6.5%, 5 out of 77 patients). Subpectoral incisions (71.2%, 141 patients) resulted in a 5.0% hematoma rate, whereas periareolar incisions (28.8%, 57 cases) had a 3.5% hematoma rate. CONCLUSIONS: Our study suggests that topical and i.v. TXA effectively reduce postoperative bleeding in chest masculinization surgeries, with similar outcomes between the 2 methods. Albeit our results lack statistical significance and they support the potential benefit of prophylactic TXA use in hematoma reduction.