Pyoderma Gangrenosum Presentation After Abdominoplasty and Augmentation Mastopexy

INTRODUCTION/OBJECTIVE: Pyoderma gangrenosum is a rare ulcerative skin disease of uncertain etiology, which can be misdiagnosed as an infectious process. In even more unique cases, this can occur in the post-operative period, in which case it is termed post-surgical pyoderma gangrenosum. This is a case of a 55-year-old female who presented with multiple wounds following mastopexy and abdominoplasty. With a prompt diagnosis and multidisciplinary approach, we were able to accurately care for the patient and minimize poor aesthetic sequelae. METHODS: A 55-year-old female presented in June 2022 for consultation with bilateral breast ptosis and abdominal lipodystrophy. In August 2022, the patient underwent bilateral augmentation mastopexy, abdominoplasty, and liposuction of her anterior and posterior waist without any intraoperative complications. On post operative day five, she presented to the ED with periumbilical ecchymosis and pain. After a full workup and evaluation by the Plastic Surgery team, she was discharged home on oral antibiotics and instructions to apply silvadene to her umbilical wound twice daily. On post operative day nine, she presented to the clinic with dehiscence of abdominal, umbilical, and bilateral breast incisions. Her nipple areolar complexes appeared to be mostly spared, except for a small area of the superior left nipple areolar complex. She was admitted to the hospital with infectious disease consultation. Her white blood cell count was 22.9 and she was started on empiric IV antibiotic therapy. The following day she underwent wound debridement, removal of the right breast implant, and application of negative pressure wound therapy. Multiple tissue samples and fluid were taken and sent for culture and pathology. RESULTS: All intraoperative cultures returned with no bacterial growth and dermatology was consulted with presumptive diagnosis of pyoderma gangrenosum. Thorough inflammatory and immunologic workup was performed. She was started on daily prednisone and instructed to apply clobetasol ointment and metronidazole gel to her wounds. Tissue biopsy resulted with epidermal ulceration with underlying dense neutrophil rich inflammation, confirming diagnosis of pyoderma gangrenosum. Dermatology recommended against further debridement. Her negative pressure therapy was continued with weekly changes. She was started on cyclosporine 100 mg BID. Her wounds healed after nine weeks of negative pressure therapy and local wound care. In December 2022, she underwent repeat right breast augmentation. She continued immunosuppressants during the preoperative and perioperative period without complications. CONCLUSION: Post-surgical pyoderma gangrenosum is a rare disease that often has no association with autoimmune disorders. Often these patients are initially misdiagnosed, so a high index of suspicion is required to avoid unnecessary debridements and to promptly initiate appropriate treatment. This disease can have devastating consequences of skin and soft tissue loss if not recognized and treated in a timely fashion. CORRESPONDING AUTHOR: Daniel Sherbert, MD, Plastic and Reconstructive Surgeon, West Maple Plastic Surgery, 5807 W Maple Rd, Ste. 177, West Bloomfield, MI 48322