What is the role of plastic surgery in the management of pyoderma gangrenosum?

Plastic Surgery in Pyoderma Gangrenosum Management

Avoid surgical debridement during active pyoderma gangrenosum disease, as pathergy will worsen the lesions; plastic surgery reconstruction should only be performed after medical immunosuppression has controlled disease progression. 1, 2

Critical Principle: Pathergy and Surgical Trauma

• Surgical intervention during active disease causes pathergy—the phenomenon where trauma triggers new or expanding lesions—making debridement catastrophic rather than therapeutic. 1, 3
• If a postoperative wound with pustules, bullae, or ulcerations fails to improve after debridement and instead shows centrifugal extension with negative cultures, immediately suspect pyoderma gangrenosum and stop further surgical intervention. 4
• The average time from surgery to pyoderma gangrenosum presentation is 5.5 days, with diagnosis often delayed to 17 days due to misdiagnosis as surgical site infection. 5

When Plastic Surgery is Contraindicated

• Do not perform debridement before dermatologic consultation if pyoderma gangrenosum is suspected. 3
• Active disease requires medical management first—systemic corticosteroids as first-line treatment, with infliximab if rapid response to steroids is not achieved (>90% response rate when disease duration <12 weeks, <50% when >3 months). 6, 1
• Aggressive surgical debridement strategies appropriate for necrotizing infections will cause devastating wound enlargement in pyoderma gangrenosum. 3, 7

When Plastic Surgery is Appropriate

Reconstructive surgery becomes safe only after immunosuppressive therapy has stopped disease progression and controlled inflammation. 2

Reconstruction Options (in order of preference):

1. Small defects (<5 cm): Allow healing by secondary intention to minimize pathergy risk. 7

2. Medium defects: Split-thickness or full-thickness skin grafts after disease control (used in 82.1% of reconstructed cases). 5, 2

3. Large defects: Local, pedicled, or free flaps for extensive tissue loss (used in 42.9% of cases, with 21.4% requiring both grafts and flaps). 5, 2

4. Negative pressure wound therapy can be used as a bridge to definitive reconstruction after inflammation is controlled. 2

High-Risk Surgical Populations Requiring Prophylaxis

Patients with history of pyoderma gangrenosum (16.8% of post-surgical cases), inflammatory bowel disease (5.9%), rheumatoid arthritis (3.6%), or hematologic malignancies (8.6%) undergoing breast (25%), cardiothoracic (14%), or abdominal surgery (14%) should receive perioperative corticosteroids. 3

• Perioperative prednisone in at-risk patients undergoing skin grafting or subsequent surgeries showed favorable outcomes in 8.6% of cases who received prophylaxis. 3
• For breast surgery specifically (bilateral reduction mammoplasty 45%, reconstruction 25%), prophylactic steroids prevent the destructive wound enlargement that characterizes post-surgical pyoderma gangrenosum. 3

Special Situation: Peristomal Pyoderma Gangrenosum

Closure of the stoma itself may lead to resolution of peristomal pyoderma gangrenosum lesions, making stoma reversal a definitive surgical treatment option. 6, 1

Common Pitfalls to Avoid

• Misdiagnosis occurs in a substantial percentage of cases—the key distinguishing feature is sterile purulent material on culture (unless secondary infection has occurred) combined with treatment failure despite antibiotics. 8, 4
• Repeated debridement attempts before recognizing pyoderma gangrenosum cause progressive tissue destruction through pathergy. 4, 7
• Recurrence rate exceeds 25%, often at the same anatomic location, so long-term surveillance is mandatory even after successful reconstruction. 1, 9