Abstract
We report a 63-year-old female with Factor V Leiden deficiency who underwent a left delayed DIEP flap reconstruction with contralateral symmetrising breast reduction following mastectomy. Hypercoagulable disorders are theorised to increase flap failure risk. Current evidence and operative guidance are limited. A focused review of the literature is provided.
Keywords: Factor V Leiden, DIEP breast flap, Autologous breast reconstruction, Hypercoagulable state, Microsurgery
Case presentation
A 63-year-old woman was referred to the plastics surgery in October 2024. In October 2023 this patient underwent a left mastectomy and targeted axillary dissection for infiltrating ductal carcinoma; TNM T2b N1 M0, ER positive and HER2 negative with lymphovascular invasion. There were no post-operative complications, and she was discharged with deep vein thrombosis (DVT) prophylaxis for 4 week with 5000 units of low molecular weight heparin (pLMWH) per day, as per hospital trust guidelines. Drain output was monitored and removed when output was <30 ml in twenty-four hours. She completed radiotherapy in February 2024 and subsequently commenced Letrozole. Her past medical history included Factor V Leiden (FVL) deficiency (heterozygous), for which she took Aspirin before long haul flights, and tonsillectomy. The patient was diagnosed with FVL genotype after he father tested positive for FVL. The patient underwent full thrombophilia screen at the time and was only positive for FVL. . Regarding the management of FVL, the patient was advised by her GP to take low dose aspirin before long flights, daily stockings, hydration and mobilisation. There is no conclusive evidence regarding prophylactic aspirin prior to flights in patients with FVL as per the literature.1 In March 2024, the patient was diagnosed with superficial thrombophlebitis of greater than 3 cm of the sapheno-femoral junction, this was managed under haematology with 42 days of prophylactic rivaroxaban 10 mg once a day. She was a non-smoker and on examination her body mass index was 30.5 kg/m2 (height 153 cm, weight 72 kg) and she wore a 38D cup size.
The patient was counselled regarding breast reconstruction options, with consideration given to the increased risk of complications associated with FVL deficiency. These potential complications included the risk of pulmonary embolism (PE) or DVT in the postoperative period, increased mortality risk and increased risk of free flap failure. Due to the patient's history of radiotherapy, her risk of capsular contracture was deemed very high. The gold standard in these cases is to proceed with autologous reconstruction. Pre-operative abdominoplasty views and standard breast views (AP, Lateral and Oblique) can be seen in Fig. 1.
Fig. 1.
Pre-operative standard breast views (anteroposterior and oblique).
In October 2025 the patient underwent a left delayed Deep inferior epigastric perforator (DIEP) reconstruction and right symmetrising breast reconstruction. The flap was raised based on a single medial row perforator using the Nahebedian muscle-sparing technique. During surgery, it was noted that the distal portion of the rectus muscle was atrophied. This was consistent with the pre-operative CT angiogram findings, as seen in Fig. 2.
Fig. 2.
CT Angiogram from October 2024. Demonstrating distal atrophy of the rectus abdominus muscle.
The internal mammary vessels were dissected, and the third rib was resected to facilitate exposure. In our unit the standard approach is to use a rib-sparing approach. However, given the potential for increased microvascular complications the pre-operative was to proceed with a rib-sacrificing technique. Microsurgical anastomosis was performed, with a total ischemia time of 34 min. The total flap weight was 966 g, with a partially reduced inset weight of 834 g. The total abdominal tissue resected weighed 1501 g. On the right, a wise pattern breast reduction was performed based on the superior pedicle, with 187 g of tissue excised. The abdomen was closed in layers, and a PICO negative pressure dressing (80 mmHg) was applied. The total operative time was 7 h with no immediate post-operative complications.
Flap observations were carried as per protocol. The patient had flowtrons and thrombo-embolus deterrent (TED) stockings, until fully mobile. Prophylactic enoxaparin 40 mg (as per trust guidelines according to weight) was administered at 22:00 h on the day of surgery and thereafter for a total of 4 weeks (enoxaparin 40 mg once a day). Post-operative prophylactic enoxaparin extended from 2 weeks, as per hospital protocol post-DIEP reconstruction, to 4 weeks. This decision was make as per the caprini score which assessed the incidence of VTE in patients following DIEP breast reconstruction; the patient scored a 7 indicating the need for extended prophylaxis of up to 4 weeks.2 Non-steroidal anti-inflammatory drugs (NSAIDs) were withheld during the post-operative period to mitigate against further bleeding risk which may result in flap compromise. This was based upon the theoretical risk of increase bleeding from the literature of the use of NSAIDs perioperatively due to the antiplatelet effect, which may lead to flap compromise due to complications such as haematoma formation.3
The patient was discharged after 72 h and followed up at weeks 1 and 2 and 6 months post-operatively. Post-operative photos were taken at 6 months, as seen in Fig. 3.
Fig. 3.
Post-operative standard breast views (anteroposterior and oblique).
Discussion
DIEP flap breast reconstruction is widely regarded as the gold standard for autologous breast reconstruction following mastectomy, owing to its reliability and low donor-site morbidity. However, its use in patients with inherited thrombophilia, particularly FVL, has traditionally raised concern due to the increased risk of postoperative venous thromboembolism (VTE), pulmonary embolism (PE), microvascular complications and flap failure. Typical flap failure rates for unilateral DIEP procedures is approximately 1%4 but the literature reporting DIEP outcomes in this cohort remains sparse. FVL is the most commonly inherited thrombophilia in the UK, accounting for 5% of the population, so it is important to outline a protocol for surgical planning in these patients to decrease the risk of complications.
Existing literature provides mixed outcomes in this cohort, as demonstrated in Table 1. Yeap et al. estimated a flap failure rate on 20% in free flap reconstruction patients with heterozygous FVL.5 Conversely, Veeramani et al. compared heterozygous FVL carriers undergoing DIEP flap reconstruction with matched non-FVL controls and found no significant increase in microvascular thrombosis, flap loss, or postoperative VTE with standard thromboprophylaxis.6 Zarb et al. reported comparable outcomes with hypercoagulable disorders,7 observing no postoperative VTE or mortality. Importantly, most patients in this cohort were discharged on extended pLMWH, appearing to be safe and protective. Furthermore, Fadell et al. reported a 4% flap failure rate in patients with hypercoagulable disorders who underwent autologous reconstruction, with 83% of procedures being DIEPs; outcomes were favourable when anticoagulation was individualised in collaboration with haematology.8 Our case suggests that the risk of flap failure in patients with FVL is not any more common when compared to a standard case when pre-operative, operative and post-operative measures are implemented.
Table 1.
Summary of published studies reporting outcomes of autologous breast reconstruction in patients with Factor V Leiden or hypercoagulable disorders. Flap failure is reported per flap, whereas venous thromboembolism (VTE) events are reported per patient.
| Study | Study design | Patients (n) | Flaps (n) | FVL status | Reconstruction type | Anticoagulation protocol | Flap failure (n/per flap) | VTE events (n/patients) |
|---|---|---|---|---|---|---|---|---|
| Yeap et al. [5] | Literature review | Not reported | 24 | FVL (heterozygous subgroup reported) | Free flap reconstruction | Variable protocols across included reports | 9/24 | Not recorded |
| Veeramani et al. [6] | Retrospective cohort with matched controls | 50 | 81 | heterozygous FVL | DIEP flap | Standard peri‑operative thromboprophylaxis | 0/81 | 0/50 |
| Zarb et al. [7] | Case series | 15 | 27 | Hypercoagulable disorders (12 heterozygous FVL) | Microsurgical breast reconstruction | Extended prophylactic LMWH in most patients | 0/27 | 0/15 |
| Fadell et al. [8] | Retrospective cohort | 13 | 23 | Primary hypercoagulable disorders | Autologous breast reconstruction (83% DIEP) | individualised anticoagulation with haematology input | 1/23 | 0/13 |
FVL confers a hypercoagulable state that theoretically increases the risk of micro-anastomotic thrombosis and flap failure. However, as demonstrated in our case and the wider literature, successful DIEP reconstruction can be achieved safely in this patient group when anticoagulation and perioperative management is appropriately tailored. Preoperative assessment included early identification of thrombophilia status and an individualised anticoagulation plan. In our case, the thrombophilia status was identified, and the patient was adequately counselled on the risks, including the increased risk of flap failure and clot formation. Pre-operative planning allowed for risk stratification including considering additional factors such as body mass index, malignancy, and immobility.
Operative efficiency is critical, as prolonged anaesthetic time may lead to increased thrombotic risk. In this case, a low-dose intravenous heparin bolus was not administered routinely at the time of microvascular anastomosis but was reserved for intraoperative use if initial anastomosis was unsuccessful. Intraoperatively the anastomosis was monitored by clinical assessment of the vessels under the microscope, there was no concerns intraoperatively with the anastomosis. Assessed intraoperatively the anastomosis was assessed to be patent with visible arterial pulsation. Post-operatively the flap was monitored through clinical assessment (capillary refill time, turgor, colour, drain output) and through doppler ultrasound assessment of the arterial and venous flow.
Considering the increased risk of thrombosis, postoperative management involved an extended course of pLMWH, continued beyond the routine inpatient period. In addition, flowtrons and TED stockings were used until the patient was fully mobile. Vigilant postoperative monitoring of flap perfusion was undertaken as per protocol. NSAIDs were also avoided during the pre-operative and post-operative period to mitigate against the risk of bleeding. As per standard protocol for DIEP breast reconstruction, it remains essential to encourage early post-operative mobilisation.
Conclusion
This case contributes to the literature on hypercoagulable disorders, such as FVL, emphasising the importance of early identification, multidisciplinary coordination, and extended thromboprophylaxis in optimising outcomes following DIEP reconstruction. Our case suggests that DIEP reconstruction can be conducted safely without an increased risk of flap failure in patients with FVL, highlighting the need for standardised management protocols.
Informed consent
Written informed consent was received by the patient for clinical data and images.
Role of the funding source
This study did not receive any specific grants from funding agencies in the public, commercial, or non-profit sectors.
Statement of ethical approval
Not required.
Declaration of competing interest
The authors have no conflicts of interest to declare.
References
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