Pyoderma Gangraenosum as a Major Complication in Breast Reconstruction with Free Double-DIEP-Flap

Background: Pyoderma gangraenosum (PG) as an idiopathic, ulcerative inflammatory skin disease with varying clinical pictures has an estimated incidence of 0.3/100000 and is due to the non-specific histology primarily a clinical exclusion diagnosis. The rapid progression, as well as the often fatal course of the pathergy phenomenon after surgical intervention is a therapeutic challenge. With the example of the complicated course of a 47-year-old patient with free DIEP flap for bilateral breast reconstruction due to PG, we want to direct attention to this often underrated disease. Patients: For bilateral breast reconstruction, a 47-year-old patient received a double free DIEP flap, which had to be resected on the right due to multiple arterial thromboses. The clinical presumptive diagnosis of a PG arose and an IV steroid therapy was started immediately. After 13 days a further debridement and mesh graft transplantation were performed. Now, the histological examination was for the first time compatible with PG. Under the initiated steroid treatment the wounds could be stabilised and the remaining defects could be covered. After 6-week stay, the patient was finally discharged with healed wound conditions, but an unsatisfactory aesthetic result. Conclusions: If unclear, rapidly progressive ulcers occur in surgical interventions one should always think of pyoderma gangraenosum. In particular, since a surgical intervention can result in an uncontrolled exacerbation due to the pathergy phenomenon. Laboratory parameters and histology are not specific. Under a systemic immunomodulatory therapy, a sequential surgical wound management may accelerate wound healing.