33 Pyoderma Gangrenosum Mimicking Post-Mastectomy Flap Failure: Management Lessons from a Contemporary Case and Literature Review

Background

Post-surgical pyoderma gangrenosum (PSPG) is a rare inflammatory dermatosis that can closely mimic infection or flap necrosis after breast surgery. Failure to recognize this entity often leads to inappropriate antibiotics and surgical debridement, which worsen disease through pathergy and result in prolonged morbidity and reconstructive failure. For breast surgeons, early recognition and correct management are critical to optimizing outcomes.

Materials and Methods

A review of the peer-reviewed literature was performed using PubMed/MEDLINE and reference-list screening to identify publications describing diagnostic features and management strategies for PSPG following breast surgery. Extracted data included diagnostic criteria, sentinel surgery details, and management strategies. Our institutional case was reviewed and integrated to illustrate points of diagnostic complexity and management decision-making.

Results

The literature consistently emphasizes that management of PSPG differs fundamentally from routine postoperative wound complications. First-line treatment consists of early initiation of high-dose systemic corticosteroids, often combined with other immunosuppressive agents such as cyclosporine. In refractory cases, targeted biologic therapies including tumor necrosis factor–α inhibitors, interleukin pathway inhibitors, and Janus kinase inhibitors have demonstrated efficacy. Conservative wound care, avoidance of further debridement, and multidisciplinary collaboration with dermatology and rheumatology are central to successful management. Negative-pressure wound therapy can be safely used as an adjunct once immunosuppression is established, and delayed surgical reconstruction may be performed under appropriate immunosuppressive coverage when needed.
Our patient, a 49-year-old woman who underwent left mastectomy with sentinel lymph node biopsy and prophylactic right mastectomy with immediate implant-based reconstruction for ductal carcinoma in situ, developed unexpected bilateral wound dehiscence, incision widening, and prolonged nonhealing. Despite extensive wound care and exclusion of rheumatologic disease, healing remained poor until the clinical diagnosis of PSPG was made. Further aggressive surgical intervention was avoided. Management was modified to focus on disease-specific wound care principles, and adjunctive tissue milling was performed to facilitate granulation and epithelialization, resulting in gradual improvement and eventual successful wound healing.

Conclusion

PSPG of post-mastectomy flaps is an uncommon but serious postoperative complication in breast surgery. This case highlights the importance of early recognition and implementation of immunosuppressive management strategies while avoiding further surgical trauma. For breast surgeons, awareness of PSPG and adherence to disease-specific management principles are essential to minimizing patient morbidity and preserving reconstructive outcomes.