Management of Postsurgical Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction

A Role for a Dermal Regeneration Template

Aishu Ramamurthi, BS; Karri A Adamson, MD; Kai J Yang, MD; James Sanger, MD; Justin P Ling-LeBlanc, MD; Barbara Wilson, MD; John A LoGiudice, MD

Disclosures

Wounds. 2021;33(11):E67-E74. 

In This Article

Abstract and Introduction

Abstract

Introduction: Pyoderma gangrenosum (PG) is a relatively uncommon necrotizing and ulcerative cutaneous disorder. It is often associated with a systemic inflammatory disease but may also present following trauma to the skin due to pathergy. Given its rare occurrence and nonspecific histology, PG is primarily a diagnosis of exclusion, which often results in delayed treatment. Very few cases of PG following autologous breast reconstruction have been reported in the literature, particularly in the absence of systemic disease.

Case Report: Presented is the case of a 62-year-old female with a history of ductal carcinoma in situ who underwent a left breast mastectomy with immediate deep inferior epigastric perforator flap breast reconstruction complicated by fever and leukocytosis as well as erythema, edema, and bullae involving the mastectomy flaps. Initially, necrotizing soft-tissue infection was suspected, and 2 debridements were performed. A diagnosis of PG was made on postoperative day 7, and the patient responded favorably to high-dose prednisone. Reconstruction was performed with a bilayer wound matrix and delayed skin grafting. Despite significant loss of mastectomy skin flap, the free flap was preserved.

Conclusions: Although PG is a rare complication, it should be considered in the differential diagnosis for patients with atypical presentation of infection following breast reconstruction, even in the absence of systemic inflammatory disease. Early diagnosis and multidisciplinary management may prevent unnecessary surgical intervention and enable flap preservation. Furthermore, bilayer wound matrix placement may be useful as an intermediate reconstruction to determine if it is safe to proceed with skin grafting to avoid further pathergy. The findings in this case suggest that final reconstruction may be safely performed sooner than noted in the literature.

Introduction

Pyoderma gangrenosum (PG) is a rare necrotizing and ulcerative cutaneous disorder. It most commonly occurs on the lower extremity, although other skin or mucous membranes may also be affected.[1–4] Although PG is often associated with a systemic inflammatory disease, 30% of cases occur following trauma to the skin due to pathergy.[5] Given its rare occurrence and nonspecific histology, PG is primarily a diagnosis of exclusion. Postsurgical PG, which occurs most often after breast surgery, is particularly challenging to diagnose as it presents similarly to infection.[6,7] Misdiagnosis leads to ineffective treatment with antibiotics and surgical debridement, which further exacerbates disease progression.[5,8,9]

The lesions generally respond well to systemic immunosuppressive therapy and a local wound care regimen.[1,10,11] However, reconstruction may be necessary to manage resulting wounds too large to heal by secondary intention or those in esthetically sensitive areas. Although there have been many reports of PG following reduction mammoplasty, very few cases of PG following autologous breast reconstruction have been reported in the literature. Furthermore, clear guidelines are lacking for the timing of and approach to reconstruction for PG-related defects following diagnosis and treatment initiation.

The authors of the current study reviewed the literature and analyzed 15 cases of PG following autologous breast reconstruction: 8 deep inferior epigastric perforator (DIEP) flaps,[5,8,9,12–16] 6 transverse rectus abdominis myocutaneous flaps,[17–22] and 1 latissimus dorsi flap.[23] This case report presents the clinical course and management at the authors' institution of a 62-year-old female with ductal carcinoma in situ who underwent a left breast mastectomy with immediate DIEP flap breast reconstruction complicated by PG. Medical management of PG and the role of surgical intervention are discussed.

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