Occult Hemophilia B and Plastic Surgery: Preventing Bleeding Events

Summary: Hemophilia, particularly Hemophilia B, is a rare bleeding disorder resulting from factor IX deficiency. Evolution in long-acting factor IX concentrates have enhanced surgical suitability. Due to inherent bleeding concerns and limited literature on hemophilia and other coagulopathies like von Willebrand disease, plastic surgery can be particularly challenging for these patients. We describe the case of a transgender woman with undiagnosed hemophilia B, who developed delayed postoperative bleeding following facial feminization surgery. This unexpected bleeding event served as a reminder of the inadequacy of screening coagulation tests that frequently miss mild factor deficiencies or subclinical disease which requires careful preoperative assessment. The uneventful perioperative period of subsequent surgery underlines the importance of a multidisciplinary strategy, particularly a detailed preoperative evaluation that includes factor specific activity assays and analysis for inhibitors. Maintaining factor levels and using antifibrinolytic agents are important strategies. This case highlights the importance for plastic surgeons to maintain vigilance for occult bleeding disorders and following strict screening protocols to ensure safe outcomes in aesthetic and reconstructive surgery. The purpose of this article is to provide a review of the existing hemophilia-related literature in plastic surgery and to emphasize the importance of preoperative recognition and individualized management protocols.