Background Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis which is characterised by the development of painful ulcers with a violaceous boarder and purulent base in the absence of infection. Whilst a quarter of cases are idiopathic, PG is associated with systemic disease in up to 70% of patients and can occur post operatively. Numerous cases of postsurgical PG (PSPG) after breast reduction exist in the literature, however very few cases after free autologous breast reconstruction are reported. Methodology Following an extensive literature review (PubMed and Ovid from inception to December 2023) we were able to identify 13 women who underwent 19 free tissue flaps who were diagnosed with PG in 16 flaps; median age was 52.38 years. 8 women developed PG in the abdominal donor site, 3 had a related systemic disease and 2 had received previous radiotherapy. All underwent surgical debridement prior to diagnosis, all were eventually treated with steroids, and all wounds healed. Case report We present the only reported case of a 43F who underwent a unilateral reverse sequence mastectomy and immediate DIEP free flap reconstruction with contralateral symmetrising mastopexy who developed PSPG bilaterally. She was successfully treated with IV and topical steroids and eventually underwent split thickness skin grafting to good effect. Conclusion PG after autologous breast reconstruction is a rare, however, morbid pathology, often made worse by misdiagnosis given the complexity in post operative flap monitoring. Despite its elusiveness, surgeons should consider PG as a differential diagnosis when confronted with post operative breast ulcerative skin changes and early dermatology opinion should be sought if concerned.