Deep Inferior Epigastric Perforator Flap Reconstruction of Breast Necrobiosis Lipoidica

Necrobiosis lipoidica (NL) is a granulomatous disease presenting as plaques with potential for progression to chronic ulcerating lesions. Breast involvement of the disease is rare. There are currently no FDA-approved medical therapies, and surgical treatment is controversial due to concerns for disease recurrence. Limited historical cases of surgical management demonstrate success when excision is taken to deep fascia. No prior reconstruction of NL manifesting on the breast has been documented in the literature. In this report, we present a patient with isolated ulcerated NL of the right breast refractory to medical management who was treated with resection to deep fascia and free flap reconstruction utilizing a deep inferior epigastric perforator flap. The patient initially presented with right breast implant rupture and underwent implant removal. After a 7-month monitoring period without disease progression, the patient elected for resection of her right breast NL with reconstruction by deep inferior epigastric perforator flap. The diseased tissue of the right breast was resected down to pectoralis fascia and immediately reconstructed with a deep inferior epigastric perforator flap. Although her postoperative course was complicated by infection, she subsequently recovered well with no NL recurrence and viable flap reconstruction at 10 months postoperatively. The patient was satisfied with her aesthetic outcome. To our knowledge, this is the first report describing reconstruction of NL of the breast and demonstrates the feasibility of resection to deep fascia and coverage without disease recurrence in refractory cases of NL.