Postsurgical Pyoderma Gangrenosum in Breast Surgery: An Updated Systematic Review, Takeaways, and the 6 Commandments

Postsurgical pyoderma gangrenosum (PSPG) is a rare and under-recognized inflammatory dermatosis that can develop after surgery. When it occurs following breast procedures, its clinical presentation often mimics surgical-site infection or necrosis, leading to delayed diagnosis and inappropriate treatment, with potentially severe aesthetic and functional consequences. In this study, the authors aim to update the literature on PSPG following reconstructive and aesthetic breast surgery and provide clinicians with practical tools for early recognition and management, including clinical red flags, a diagnostic framework, and therapeutic guidelines. A systematic review was conducted in March 2025 according to PRISMA guidelines, updating the work of Ehrl et al by including studies published from 2017 onward. Data from 65 new cases were extracted and analyzed descriptively. The authors also report 3 institutional cases and 1 case of recurrence to provide additional clinical insight. A total of 65 new PSPG cases were identified across 45 studies, for a cumulative total of 152. Reduction mammoplasty was the most frequent surgical trigger. The condition involved multiple sites in 71.4% of combined breast-abdominal procedures. Pain was the most common symptom (86.2%), and the nipple-areola complex (NAC) was spared in 80.7% of cases. C-reactive protein (CRP) was often elevated (>200 mg/L), and microbiological cultures were negative in 76.9% of cases. Systemic corticosteroids were the most effective treatment. Mean healing time was 4.5 months; surgical reconstruction was needed in 29% of the cases. PSPG remains a diagnostic challenge with significant consequences if unrecognized. Key clues include exaggerated postoperative pain, NAC sparing, elevated CRP, and poor response to antibiotics. In this study, the authors propose a practical flowchart and summarize 6 core management principles. Preoperative counseling and informed consent, particularly in reduction mammoplasty, should include this rare but serious complication. Level of Evidence: 3 (Therapeutic)