PURPOSE   Pyoderma gangrenosum is a rare idiopathic necrotizing cutaneous disease process which can be triggered spontaneously by surgical trauma.  Although lesions mimic an early wound infection, cultures are negative and antibiotic therapy fails to control the painful skin necrosis.  The treatment usually consists of high-dose immunosuppressive therapy.  Surgeons may hesitate to initiate such treatment in the early postoperative period as diagnosis of this condition is typically made by exclusion supported by non-specific findings on tissue biopsy.  When appropriate treatment is administered, the process resolves- leaving the patient and surgeon with the uncertainty of recrudescence at the time of future surgical procedures.  We sought to characterize the clinical presentations and surgical outcomes of patients undergoing reconstructive surgery whose post-operative course was complicated by pyoderma gangrenosum.     

METHOD A retrospective review was conducted of 4 patients presenting who developed this condition over a 4-year period at a cancer center.  Records were reviewed to determine timing and course of initial lesion, time interval to diagnosis and initiation of immunosuppressive therapy, and subsequent period to resolution.  Outcome assessment included partial and total flap loss, hospital re-admissions, secondary procedures, long-term scarring, and impact on the planned reconstruction and subsequent surgery. RESULTS   Four patients were identified with pyoderma gangrenosum who underwent a total of 6 free flap reconstructions (2 unilateral, 2 bilateral) for varying stages of breast cancer.  This comprised < 1% of all patients undergoing reconstruction during this period.  Clinical findings were first identified an average of 4.5 days after reconstruction (range 2-8).  Tissue biopsies suggestive of pyoderma gangrenosum were obtained at an average 8.5 days (range 7-11) after reconstruction.  Three patients had no microorganism identified from the wounds, and the fourth failed to respond to appropriate antibiotics.  All patients improved dramatically with immunosuppressive therapy initiated an average of 11.5 days (range 8-16) after the initial surgery and an average of 7 days (range 5-10) after the first lesions were noted.  Each patient sustained ulceration and tissue loss, and 2 free flaps were lost due to microvascular thrombosis.   All cases required multiple debridements and patients suffered from persistent scarring in the areas of tissue necrosis.  One patient developed permanent restrictive pulmonary disease resulting in long-term disability.  One patient underwent secondary surgery to revise a donor site and developed the condition again, despite steroid prophylaxis.

CONCLUSION   Pyoderma gangrenosum complicating reconstructive surgery is a rare clinical entity which results in severe morbidity including flap loss, protracted recovery, repeated debridement, and extensive scarring.  Long-term disability and the threat of recrudescence with further surgery were also seen.  This rare condition should be considered in previously normal patients who develop progressive ulcerative lesions and deteriorate without response to antibiotic therapy.  Dermatologic evaluation should be considered in wounds where standard therapy does not yield improvement. High-dose steroids are a mainstay of treatment, and early institution of immunosuppressive therapy may limit the extent of tissue loss.  Patients affected by this disease are at risk of recrudescence at the time of subsequent surgical procedures.