BACKGROUND: Factor XIII deficiency is a rare inherited bleeding disorder that is often difficult to diagnose. As there are no standard screening tests established patients with Factor XIII deficiency are not correctly identified. Especially postoperative bleeding and haemorrhage after difficult plastic reconstructive operations such as free flap transfer may lead the plastic surgeon to the wrong diagnosis. This again leads to the wrong indication such as revision with the aim to find a surgical origin of bleeding. Instead a haematological deficiency such as Factor XIII is the reason for acute postoperative bleeding and haemorrhage.

CASE REPORT: We report the case of a 69-year old Caucasian male who received a free latissimus dorsi flap to the right knee after osteomyelitis and infection of a knee total endoprothesis. The patient had severe postoperative bleeding and haemorrhage from all 8 drains including the donor side of the split thickness skin graft area. Shortly before the indication of performing a revision and trying to find the surgical origin of bleeding a factor XIII test was performed. The results showed a high deficiency of factor XIII which was immediately replaced by 2500 Units (i.E.) Fibrogammin. Within 12 hours the bleeding rapidly reduced and no revision was necessary.

CONCLUSIONS: Postoperative acute but diffuse bleeding after free flap operations in plastic surgery may not be all due to insufficient operative techniques.