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Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction

Case Series and Management Guidelines

Li, Wai-Yee MD, PhD*; Andersen, James C. MD; Jung, Jae MD; Andersen, James S. MD, FACS*

doi: 10.1097/SAP.0000000000001782

Introduction Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery.

Methods This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included.

Results Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days.

Conclusions Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

From the *Department of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte; and

Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA; and

Department of Dermatological Oncology, Norton Cancer Institute, Louisville, KY.

Received April 28, 2018, and accepted for publication, after revision November 4, 2018.

This work was presented at the fourth Congress of the World Association of Plastic Surgeons of Chinese Descent, Hong Kong, November 2014.

The authors declare no conflict of interest.

Reprints: James S. Andersen, MD, FACS, Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91011. E-mail:

Online date: May 13, 2019

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