Beware of Pyoderma Gangrenosum Complicating Mastopexy: The Importance of Early Detection and Treatment

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.

Fig. 1 Preoperative view and surgical plan.

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.

Fig. 2 Deep ulceration with undermined borders. Involvement of deep dermis and subcutaneous tissue. Note that the nipple is spared.

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.

Fig. 3 Patient at 2 months follow-up. Pyoderma gangrenosum is still present in the left nipple-areolar complex.

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]).

Fig. 4 Complete remission of the disease at 6 months follow-up.

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]].

Fig. 5 Biopsy from the same patient. Wide ulceration with dermal and subdermal abscess. Infiltration of polymorphonuclear leukocytes (H&E, ×100).

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

• References

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