Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.5999/aps.2015.42.3.368
Beware of Pyoderma Gangrenosum Complicating Mastopexy: The Importance of Early Detection and Treatment
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/lookinside/thumbnails/10_5999_aps_2015_42_3_368_368-1.jpg)
Cosmetic breast procedures are widely performed by plastic surgeons all over the world with high satisfaction rate for patients. The most common complications described for reduction mammaplasty and mastopexy are wound dehiscence, breast asymmetry, partial or total loss of the nipple-areolar complex (NAC). Pyoderma gangrenosum (PG) is a rare ulcerative dermatitis of unclear origins first described in 1930. In most of the cases, it is associated with autoimmune systemic conditions such as Inflammatory Bowel Diseases and several rheumatologic diseases. PG has been reported to occur predominately in lower limbs but any other area of the body can be affected [[1],[2]].
A 50-year-old patient presented to my outpatient clinic seeking mastopexy. She was healthy, non-smoker and reported no history of systemic diseases. After routine consultation, she was scheduled for surgery two weeks later. Surgical plan included autoaugmentation mastopexy using Ribeiro's pedicle and a superomedial pedicle for the NAC ([Fig. 1]). No breast tissue was discarded during the procedure. Immediate postoperative course was uneventful and patient was discharged the day after the operation.
At 10 day follow-up small ulcerations mimicking a suture reaction were observed along the vertical scar of the right breast and at the level of the left nipple. Conservative treatment was adopted, with general antibiotic ointment and frequent dressing changes. No improvements were noted in the following days: ulcers became larger and painful, increasing patient's discomfort.
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/thumbnails/10_5999_aps_2015_42_3_368_368-g001.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Sporadic cases of PG complicating breast procedures have been reported. PG often arises following any trauma, leading to a pathergic phenomenon with catastrophic non-healing wound complications which can cause distress for both the patient and the surgeon [[3]].
On postoperative day 20, expanding ulcers with purulent-like appearance involving both breasts, resembling wound dehiscence on the right side were noted. PG was suspected and patient scheduled for surgical revision ([Fig. 2]). Moreover, to exclude any systemic illness associated with PG, patient underwent colonoscopy and serology testing for antinuclear antibodies, lupus anticoagulant, anticardiolipins, cryoglobulin, and anti-neutrophil cytoplasmic antibodies with negative results.
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/thumbnails/10_5999_aps_2015_42_3_368_368-g002.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Under local anesthesia, the right vertical breast scar was debrided and accurately closed in two layers using few deep 3-0 Monocryl sutures and separated 4-0 Ethilon sutures for the skin. In the left areolar region, conservative debridement was performed followed by application of antibiotic ointment. Some tissue samples were taken and send for histopathology examination. Eventually, prednisone (2 mg/kg/day) was prescribed for 15 days.
At the end of corticosteroid treatment, scar of the right side remained closed and small improvements of the ulcerative condition were observed ([Fig. 3]). Oral cyclosporine A (3 mg/kg/day) was then prescribed for 3 months at the end of which patient was disease-free.
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/thumbnails/10_5999_aps_2015_42_3_368_368-g003.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
At 6 months follow-up, complete remission of PG was observed. Scar healing wasgood and small volume deficit was present in the right breast, due to aggressive surgical debridement performed during revision surgery ([Fig. 4]).
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/thumbnails/10_5999_aps_2015_42_3_368_368-g004.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
PG is defined as a chronic noninfectious neutrophilic dermatosis. The disease typically starts with one or more pustules and nodules which rapidly evolve in pinkish painful ulcers with usually well-defined and undermined borders; granulation tissue is often present. Nodules and ulcers extend in the skin and in the subcutaneous tissue. In the rare cases occurring after breast surgery, nipples are typically spared. Three others rare variants, the bullous, vegetative and peristomal types, have been also described.
Diagnosis is based on the exclusion of local complications such has wound infection or other types of cellulitis, and of any underlying systemic autoimmune conditions.
Histological findings ([Fig. 5]) are not specific, showing epidermal and dermal tissue necrosis with intense suppurative neutrophilic infiltration, often associated with a perivascular lymphocityc component and fibrinoid necrosis [[4]].
![](https://www.thieme-connect.de/media/10.1055-s-00051611/201503/thumbnails/10_5999_aps_2015_42_3_368_368-g005.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Management of PG often requires a multidisciplinary approach. Corticosteroids are usually effective in the acute phase but treatment with more effective drugs should be prolonged for 3-6 months to avoid the risk of recurrence. Cyclosporine A, azathioprine, mycophenolate mofetil and other immunosoppressive agents represent the gold standard. Adjunctive therapy with topical tracolimus also proved to be effective [[5]]. Surgical management by means of surgical revision alone should be avoided for the risk of wound enlargement with subsequent worsening of the lesions.
Presentation of PG affecting the breast can be subtle and its diagnosis challenging. This dermatosis should be suspected in any breast surgery case when apparently inexplicable ulcerative wound healing impairment occurs. Although rare after surgery, early recognition of pathognomonic signs is essential for effective treatment with immunosuppressive therapy and local wound care.
Publication History
Received: 19 January 2015
Accepted: 10 February 2015
Article published online:
05 May 2022
© 2015. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonCommercial License, permitting unrestricted noncommercial use, distribution, and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes. (https://creativecommons.org/licenses/by-nc/4.0/)
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Gonzalez-Moreno J, Ruiz-Ruigomez M, Callejas Rubio JL. et al. Pyoderma gangrenosum and systemic lupus erythematosus: a report of five cases and review of the literature. Lupus 2015; 24: 130-137
- 2 Schoemann MB, Zenn MR. Pyoderma gangrenosum following free transverse rectus abdominis myocutaneous breast reconstruction: a case report. Ann Plast Surg 2010; 64: 151-154
- 3 Tuffaha SH, Sarhane KA, Mundinger GS. et al. Pyoderma gangrenosum after breast surgery: diagnostic pearls and treatment recommendations based on a systematic literature review. Ann Plast Surg. 04.07.2014. [Epub] https://dx.doi.org/10.1097/SAP.0000000000000248
- 4 Ouazzani A, Berthe JV, de Fontaine S. Post-surgical pyoderma gangrenosum: a clinical entity. Acta Chir Belg 2007; 107: 424-428
- 5 Doren EL, Aya-ay ML. Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids. Aesthet Surg J 2014; 34: 394-399