Pyoderma Gangrenosum after Deep Inferior Epigastric Perforator Breast Reconstruction: Systematic Review and Case Report

Abstract

Background:Pyoderma gangrenosum (PG) is a rare skin disorder of the neutrophilic dermatoses spectrum that can mimic wound infections in surgical patients. PG after breast surgery has been reported but in limited amounts in autologous breast reconstruction patients. We present the first case of PG after a delayed bilateral deep inferior epigastric perforator flap breast reconstruction in the setting of systemic disease along with a systematic review.Methods:PubMed, Ovid, and Web of Science were systematically searched to obtain cases of PG after autologous breast reconstruction. Sixty articles were identified but only 16 were relevant to this study.Results:Systemic disease was present in 2 patients (13%). Wound onset occurred typically 5 days after surgery. Fever and/or leukocytosis was observed in 10 patients (63%). Wound cultures were positive in 2 patients (13%). Donor-site wounds were present in 9 patients (56%). Bilateral breast wounds were present in 67% of bilateral cases. Debridement was performed in 10 cases (63%). Skin graft or substitute was performed in 6 cases (38%). Resection of autologous flap was performed in 3 cases (19%). All patients were treated with systemic steroids (81%) and/or immunosuppressive medications (50%). Complete wound healing occurred by 4 months on average.Conclusion:If early ulcerative wounds develop at multiple sites after autologous breast reconstruction with worsening after debridement and antibiotic therapy, then PG should be considered. It is imperative that an early diagnosis and subsequent treatment with steroids and/or immunosuppressive medications be initiated so further surgical procedures, flap loss, and scarring can be minimized.

Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator (DIEP) Breast Reconstruction: A Case Report

“…In 2 recent systematic reviews, 18 (86%) of 21 cases of PSPG following breast reconstruction, including DIEP and TRAM flaps, developed donor-site PG. 6,8 Abdominal donor-site involvement was present in our case and aided in recognition and diagnosis of PSPG.…”

“…Other research groups have suggested forgoing tissue biopsy and focusing instead on a clinical diagnosis of PG. 8 The consultant dermatologist involved in our patient’s inpatient care was confident in the PG diagnosis despite the equivocal pathology results. Indeed, previous PG diagnostic criteria proposed by Su et al 9 featured major criteria that did not require histopathologic confirmation.…”

“…Pyoderma gangrenosum is a diagnosis of exclusion and may masquerade clinically as vasculitis, malignancy, drug reaction, exogenous tissue injury, or infection, as in our case report. 1,8 In a recent review of 2273 patients with PG, 77.4% of cases were initially misdiagnosed, with the most common misdiagnosis being cellulitis in 9.4% of cases. 2 In the study population, the mean age was 56 years, 66.4% of participants were female, and 71.1% were Caucasian.…”

Pyoderma gangrenosum confined to the irradiated chest wall of the reconstructed breast

“…Pyoderma gangrenosum after breast reconstruction is a rare complication sparking systematic reviews to illuminate risk factors. [7][8][9] In this report, both patients received adjuvant PMRT, had no prior history of any PG associated conditions, and developed PG involving only the irradiated mastectomy chest wall tissue bed; the donor sites and autologous flaps were spared. Furthermore, Case 2 had bilateral reconstruction and developed PG only on the previously irradiated side; the contralateral reconstructed breast was unaffected.…”

“…Regarding the role of PMRT in the pathogenesis of PG, current reports and systematic reviews have failed to link the two 5,6 . While many patient factors have been associated with PG, prior radiation therapy is not currently described as a risk factor 2,7‐9,12 . This is despite evidence that radiation exposure fundamentally alters interleukin homeostasis in human tissues, including IL‐8 8,13‐15 .…”