Pyoderma gangrenosum with pathergy: A potentially significant complication following breast reconstruction

The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy should alert the clinician to other diagnoses. Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that is typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a condition known as pathergy. We present a case series of PG arising after immediate reconstruction for breast oncological surgery from 1st January 2006 to 1st September 2014. 395 immediate breast reconstructions were performed in 335 patients. Three cases of post-surgical PG were identified (0.9%), all in the setting of mastectomy for breast cancer. Two cases underwent immediate reconstruction with pedicled transverse rectus abdominus myocutaneous flaps, and one underwent submuscular expander insertion. A mean delay of 6.3 days was observed from first presentation of symptoms to diagnosis of PG. Immunosuppressants commonly used included methylprednisolone, prednisone, and ciclosporin, with good success at halting disease progress. Significant scarring affected all three women. Once the disease was deemed quiescent, intravenous immunoglobulin used in the perioperative period for further surgical procedures provided favorable results. A diagnostic algorithm is suggested to guide surgeons in investigations and management when post-surgical PG is suspected.