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Page 4 of 11 Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32

At our institution, the preferred method for evaluation of mastectomy skin flaps, in addition to clinical
judgment, for immediate flap reconstruction is ICG fluorescence angiography (ICGFA). We also utilize
ICGFA for flap evaluation and perforator selection. The majority of flaps at our institution are performed in
a delayed fashion, which eliminates this issue. In the case of immediate flap reconstruction, if there is a
concern for significant MSFN, then a delayed inset of 5-7 days can be performed. We have also used
nitroglycerin paste when there is a concern about the perfusion of the nipple-areolar complex following
nipple-sparing mastectomy with immediate DIEP flap reconstruction.

INFECTION
Postoperative infections can be classified as surgical site, deep surgical site, or organ space infection. A
retrospective American College of Surgeons (ACS) National Surgical Quality Improvement Project
(NSQIP) database analysis in 2021, which included 1924 free flap breast reconstructions, found adjusted
[30]
rates of 2.3%, 1.3%, and 0.3%, respectively, within 30 days of surgery . The effects of radiation on infection
rates have been mixed, with some studies showing increased infection rates versus non-radiated fields
[31]
(4% vs. 0.5%) , while other studies have demonstrated no difference in placing a flap in a previously
[32]
irradiated field . Active smoking and body mass index (BMI) have also been reported as risk factors for
postoperative infection . In 2010, Reiffel published the results of a survey of the American Society for
[33]
Reconstructive Microsurgery related to the use of peri-operative antibiotics. It was found that for
microsurgical breast reconstruction, the first choice was a first-general cephalosporin for patients with no
known allergies (93.5%), and clindamycin (79.5%) or vancomycin (20.5%) as the choice for patients with a
penicillin allergy. Duration of antibiotic coverage varied greatly from a single dose (5.3%), < 24 h (26.7%), 1
[34]
to 3 days (33.3%), 4 to 5 days (12.0%), > five days (4.0%), and until drain removal (18.7%) . Liu et al.
compared a cohort of peri-operative antibiotics for 24 h versus greater than 24 h (median 10 days) in
microsurgical breast reconstruction and found no difference in surgical site infection (15.5% vs. 19.5%, P =
[35]
0.47) . Additional studies have yielded similar results with no significant difference in SSI for patients
receiving 24 h of antibiotics versus greater than 24 h in autologous breast reconstruction and DIEP flap
[36]
reconstruction specifically .
[37]
The current practice at our institution is continuing antibiotics until drain removal. This remains an
uncommon complication of autologous breast reconstruction in our practice, even with the use of mesh for
reconstruction of the abdominal donor site. We presently require three months of preoperative smoking
2
cessation, a BMI of less than 35 kg/m , and a hemoglobin A1C of < 7.0 with the goal of reducing the
incidence of postoperative surgical site infection.

PYODERMA GANGRENOSUM
Pyoderma gangrenosum (PG) is a rare complication in free autologous breast reconstruction. First
described by Brunsting in 1930, PG is a neutrophilic dermatosis characterized by ulcers, bullae, and/or
[38]
pustules . It can present very similar to a surgical site infection and even mimic a necrotizing soft tissue
infection, making diagnosis difficult. Traditionally, PG has been a diagnosis of exclusion. Several diagnostic
criteria have been proposed to aid in the diagnosis of PG. Su et al. proposed two major criteria and four
minor criteria, with diagnosis requiring both major and at least two minor criteria . A Delphi consensus in
[39]
2018 proposed one major and eight minor criteria, with a diagnosis made when the one major and four of
eight minor criteria were met . Table 1 summarizes the major and minor criteria for each.
[40]
A 2016 review of published cases of postoperative pyoderma gangrenosum (PPG) found a lower association
with systemic disease than other forms of PG. Additionally, it was noted PPG is often misdiagnosed, which
[41]
may lead to initiation of antibiotic drug therapy and debridement with possible subsequent morbidity .