Reconstructive microsurgical approach for treatment of pyoderma gangrenosum

Publication date: Available online 16 August 2017
Source:Journal of Plastic, Reconstructive & Aesthetic Surgery
Author(s): Karl Schwaiger, Elisabeth Russe, Hassan Kholosy, Michaela Hladik, Klemens Heinrich, Laurenz Weitgasser, Thomas Schöller, Gottfried Wechselberger
IntroductionPyoderma gangrenosum (PG) is a rare type of autoimmune disease that results in progressive ulcers with or without previous trauma. PG is not well understood to date, and its treatment therefore remains a challenge. Because of the disease's systemic characteristic and the unpredictability of the clinical course, no gold standard treatment is available, especially concerning surgical procedures to treat pyodermic lesions. Often, PG is not recognized during routine clinical practice, and standard ulcer treatment (conservative wound care, debridement, skin grafting, and local flap coverage) is started; this induces an autoinflammatory response, resulting in disastrous ulcers, thereby making free flap coverage necessary. The purpose of this study was to assess the outcome of microvascular free tissue transfer as a treatment option for extended soft-tissue defects resulting from PG.Materials and MethodsRetrospective evaluation of eight cases in five patients suffering from PG of the lower extremity receiving defect closure with a microvascular free-tissue transfer under immunosuppressive and corticosteroid therapy.ResultsThe average patient age was 60 years. Three patients were male, and two were female. Seven defects were covered with a free gracilis muscle flap. One patient received an anterolateral thigh flap. The average defect size was 93 cm². No flap loss was observed during follow-up. All patients received broad-spectrum antibiotic treatment and corticosteroids. Two patients also received infliximab.Discussion and ConclusionPG once diagnosed is not a contraindication for microvascular free tissue transfer. Multidisciplinary evaluation of each case is fundamental. All surgical treatments may be performed only with sufficient protective immunosuppression therapy. If the defect requires free flap coverage, it should be considered as a surgical option despite the potential risk of a pathergic response in PG and was a safe treatment option in all our cases. In conclusion, we share our experience regarding preoperative, intraoperative, and postoperative care of patients with PG receiving free flap surgery.Level of evidence: IV.



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