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

Novel Treatment of Pyoderma Gangrenosum With Porcine-Derived Extracellular Matrix Following Bilateral Latissimus Dorsi Breast Reconstruction: A Case Report

Pyoderma gangrenosum (PG) is a rare disease characterized by ulcerative cutaneous lesions that can occur postoperatively and is often associated with autoimmune disorders. PG is diagnosed by excluding other conditions that can cause ulcerations, such as infections, which may also result in immunosuppressive treatment delays and suboptimal wound care. Operative debridement of wounds has traditionally been avoided in the acute setting secondary to pathergy. This article presents a case of extensive breast PG that was successfully treated with surgical debridement, porcine-derived extracellular matrix, and negative pressure wound therapy while on systemic immunosuppressive therapy.

Postoperative pyoderma gangrenosum after gunshot wound: A case report

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of unclear etiology that exhibits pathergy and can develop post-operatively in surgical incisions. To the best of our knowledge, this is the first case report of PG developing after a gunshot wound (GSW) injury or in a contaminated surgical wound. We further propose umbilical sparing as a key clinical finding differentiating the diagnosis of PG from more common infectious etiologies.

Pyoderma gangrenosum after deep inferior epigastric perforator flap: how prompt diagnosis and treatment can avoid surgical debridement and further morbidity

Pyoderma gangrenosum (PG) is a skin disorder characterized by painful, enlarging necrotic ulcers with bluish borders surrounded by advancing zones of erythema. The key histologic feature is neutrophilic infiltration of the superficial and deep layers of the dermis and the absence of microorganisms. Although rare and associated with autoimmune diseases such as rheumatoid arthritis, ulcerative colitis and Crohn's disease, the diagnosis is commonly missed at presentation and patients are often treated for infection with antibiotics and surgical debridement. We present a case of PG in a 51 year-old woman after a deep inferior epigastric perforator (DIEP) flap for breast reconstruction who was promptly diagnosed and treated with steroids with appropriate response. Our case highlights the importance of rapid diagnosis and treatment of this disease to avoid incorrect management including surgical debridement, which can exacerbate the disease and increase its morbidity.

Post-breast Reduction Pyoderma Gangrenosum Managed With Gender-Affirming Top Surgery

Pyoderma gangrenosum (PG) is a rare skin condition characterized by ulcerative lesions and most often associated with inflammatory bowel diseases (IBDs), ulcerative colitis, or Chron’s disease. Postsurgical pyoderma gangrenosum (PSPG) of the breast is exceptionally rare and can occur in the absence of IBD. We report on a patient with pyoderma gangrenosum following elective breast reduction and subsequent reconstruction with gender-affirming top surgery. Through discussion of this IRB-reviewed case, we encourage reconstructive surgeons to incorporate understanding of a patient’s gender identity, expression, or goals during treatment to optimize their patient-centered care.

Dermatologic Complications Following Cosmetic and Reconstructive Plastic Surgery: A Systematic Review of the Literature

PURPOSE

Plastic surgery procedures, including minimally invasive cosmetic procedures, continue to grow in popularity. Although dermatologic complications following plastic surgery procedures are rare, the authors have encountered several of these complications in their practice, including herpes simplex virus (HSV-1) and varicella zoster virus (VZV) infections, pyoderma gangrenosum (PG), contact dermatitis, and suture hypersensitivity. These cases prompted a systematic literature review of dermatologic complications following plastic surgery procedures.

METHODS

The authors conducted a systematic review of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library to identify relevant articles published from 1975 to 2021. Articles were independently reviewed by the authors to determine whether studies met inclusion criteria.

RESULTS

The majority of articles that met inclusion criteria represented level V evidence. The most robust evidence in the literature was for PG, for which there were 63 total studies. Pyoderma gangrenosum was most frequently reported following breast surgery (85.1%), while HSV-1 infections were frequently seen following minimally invasive procedures (84.6%). VZV reactivation was reported after a range of interventions, including pedicled flap surgeries and laser treatments. Other complications, such as suture hypersensitivity, were less frequently reported in the literature, usually as isolated case reports.

CONCLUSIONS

Dermatologic complications represent a rare but serious concern following plastic surgery procedures. While most dermatologic complications resolve with appropriate treatment, sequelae of these conditions can be devastating to the patient's overall outcome. Plastic surgeons performing procedures at a high risk of these complications should recognize the diagnostic criteria to facilitate appropriate treatment.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: A systematic review and personal experience

Pyoderma gangrenosum (PG) is a rare painful ulcerative neutrophilic inflammatory skin disease, necessitating a high level of diagnostic suspicion associated with appropriate treatment to avoid progression. Negative pressure wound therapy (NPWT) has been efficiently used in the treatment of different types of wounds. However, the role of NPWT in the management of PG is still controversial, due to the risk of the pathergy phenomenon. In this article, we conducted a systematic review (according to the PRISMA guidelines) on the use of NPWT in the treatment of PG, and we report our personal experience with two patients treated with this device. The result of the review showed that articles on the topic are, in their entirety, of low levels of evidence, such as case series, case reports, and reviews. Improvement in wound healing with the use of NPWT was observed in 85.1% of the patients studied. Besides, a significant association between improvement in wound healing with NPWT and immunosuppressive therapy was observed. Regarding the cases reported here, both showed good outcomes with the use of NPWT and skin graft during the treatment of PG injuries. Due to the rarity of PG, there is a scarcity of studies with robust evidence for standardization and comparison between treatments, which consequently makes it difficult to select therapeutic options. However, based on this systematic review and reported cases, we consider NPWT a safe option for adjuvant treatment of wounds caused by PG if combined with systemic immunosuppression, which plays a key role in greater chances of successful treatment. This approach should be recommended, whenever possible, associated with skin grafting to accelerate wound closure. The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: a systematic review and personal experience.

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

Pyoderma gangrenosum (PG) is a diagnosis of exclusion worsened by surgical debridement. This report presents two atypical manifestations of PG in the reconstructed breast, whereby the disease is only confined to the irradiated chest wall tissue bed, sparing the abdominal donor sites and the contralateral reconstructed breast.

Postsurgical Pyoderma Gangrenosum After Breast Surgery: A Plea for Early Suspicion, Diagnosis, and Treatment

BACKGROUND

Pyoderma gangrenosum (PG) is a rare inflammatory cutaneous disorder. Although PG is a diagnosis of exclusion, prompt recognition is essential to attain the desired outcomes. From an aesthetic standpoint, this is especially critical with breast involvement and other body segments. We present a consecutive case series of four patients who developed PG following breast surgery and responded to early intervention.

METHODS

A chart review identified four patients who were identified as having developed PG after either aesthetic or reconstructive breast surgery. Their histories, associated risk factors, diagnosis, course of treatment, and results were documented. The PubMed database was then searched to find the literature for comparison.

RESULTS

The average time from surgery to the onset of symptoms was 11 days, and the average time from the onset of symptoms to the correct diagnosis of PG was 41 days. The average length of steroid therapy was 25 days. The average time from the initiation of steroids to complete wound closure was 51 days. The average time from the onset of symptoms to complete wound closure bilaterally was 87 days. All wounds healed with conservative management.

CONCLUSION

Postsurgical PG is a rare but recognized cause of postoperative wound breakdown in patients who have undergone plastic surgery procedures to the breast. Early recognition and treatment can facilitate prompt reversal of the inflammatory process leading to complete wound healing and limitation of the morbidity that can be associated with the disease.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines

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.

Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases

Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.

Pyoderma Gangrenosum Masquerading as Necrotizing Infection after Autologous Breast Reconstruction

Pyoderma gangrenosum (PG) is a diagnostic dilemma when it presents with a superimposed infection and previous surgery without subsequent inflammatory infection. In this setting, PG is not at the forefront of the surgeon’s mind. Furthermore, the treatment for PG, systemic steroids, may cause serious morbidity if the necrotizing infection is the actual culprit. We present an autologous breast reconstruction patient with previous uncomplicated surgery and no personal history of inflammatory disease. Important clinic clues to aid the surgeon in diagnosis include irregular violaceous undermined border, purulence limited to the skin, bilateral involvement, the involvement of the abdominal wound, sparing of the mastectomy site, and relative sparing of the nipples and umbilicus.

Post-surgical pyoderma gangrenosum of the breast: needs for early diagnosis and right therapy

Post-surgical pyoderma gangrenosum (PSPG) of the breast is a rare dermatosis that worsens surgical manipulation, with a chronical relapsing course. Diagnosis is mostly clinical and made by exclusion after the failure of antibiotic therapies and surgical debridement, while the mainstay of therapy is corticosteroid-based. Here we report a case of PSPG of the breast in a young woman with breast cancer, to emphasize the needs of an early and accurate diagnosis, to guarantee the most efficacious treatment and to avoid life-threatening complications.