Medicinal Leech Fixation in Precarious Locations

Successful use of the medicinal leech Hirudo medicinalis in the salvage of microvascular free flaps has been widely described.[1] The potent anticoagulant hirudin injected by the leech reduces venous engorgement nonsurgically[2] [3] by improving blood drainage from the flap. Potential risks include local infection (mainly by Aeromonas hydrophila), sepsis,[4] blood loss, and leech migration.[1] [5] A method described by Granzow et al employs limiting the movement of medicinal leeches from the surgical site by affixing one end of a surgical suture to the leech and tying the free end to a firm object or dressing.[6] The following case description reports a modification of this technique by suturing a leech to the skin close to an engorged composite graft at the nasal columella.

An otherwise healthy 61-year-old woman presented with a large lesion involving the right nostril floor and columella. Tissue biopsy revealed a Morpheus-type basal cell carcinoma. A Mohs procedure was performed excising the nasal columella, the right vestibular mucosa on the septum, the lining mucosa of the right nostril, and the right septal mucosa.

Several composite grafting procedures were needed to achieve acceptable structural results. After the last of these operations, the graft appeared to be congested (Fig. [1]), and the patient was readmitted to undergo medicinal leech treatment. The proximity of the graft to the nasal orifice posed a therapeutic challenge, as the risk of leech translocation into the nostril and to the mouth was high. This obstacle was overcome by placing a suture piercing through the middle of the leech and fastening it to the underlying tissue using a connective buttonhole, thus preventing migration into the nasal cavity (Fig. [2]).

Figure 1 Congested columella flap site 1 week after fourth operation.

Figure 2 Leech sutured to target site.

The medicinal leech Hirudo medicinalis has been successfully used in the salvage of congested microsurgical flaps by creating an alternative outflow for engorged blood in a flap compromised by poor venous drainage.[7] [8] [9] Attachment is achieved by manipulation of the leech toward the designated area, both physically and chemically by creating a feeding substrate such as a sucrose solution or fresh blood by needle pricking the target tissue. Once sated, the leech will spontaneously detach, at which point arises the risk of translocation.

Traditional methods of gauze application surrounding the treatment site may not be applicable in areas anatomically proximal to apertures such as the nose, ears, mouth, and genital orifices. Transmigration into virtually every bodily cavity has been described,[1] posing an impending risk of internal bleeding. The emotional apprehension associated with leech therapy at any site is further heightened when applied near these challenging sites. These factors warrant the conception of creative solutions enabling safe use of the leech by the microvascular surgeon. The simple approach described negated the need to revise a problematic surgical site or the use of alternative methods of decreasing congested grafts while providing successful salvage of the free-tissue flap.

REFERENCES

• 1 de Chalain T M. Exploring the use of the medicinal leech: a clinical risk-benefit analysis.  J Reconstr Microsurg. 1996;  12 165-172
• 2 Dabb R W, Malone J M, Leverett L C. The use of medicinal leeches in the salvage of flaps with venous congestion.  Ann Plast Surg. 1992;  29 250-256
• 3 Soucacos P N, Beris A E, Malizos K N, Kabani C T, Pakos S. The use of medicinal leeches, Hirudo medicinalis, to restore venous circulation in trauma and reconstructive microsurgery.  Int Angiol. 1994;  13 251-258
• 4 Lineaweaver W C, Hill M K, Buncke G M et al.. Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery.  Ann Plast Surg. 1992;  29 238-244
• 5 Whitaker I S, Izadi D, Oliver D W, Monteath G, Butler P E. Hirudo medicinalis and the plastic surgeon.  Br J Plast Surg. 2004;  57 348-353
• 6 Granzow J W, Armstrong M B, Panthaki Z J. A simple method for the control of medicinal leeches.  J Reconstr Microsurg. 2004;  20 461-462
• 7 Mortenson B W, Dawson K H, Murakami C. Medicinal leeches used to salvage a traumatic nasal flap.  Br J Oral Maxillofac Surg. 1998;  36 462-464
• 8 Weinfeld A B, Yuksel E, Boutros S, Gura D H, Akyurek M, Friedman J D. Clinical and scientific considerations in leech therapy for the management of acute venous congestion: an updated review.  Ann Plast Surg. 2000;  45 207-212
• 9 Smoot E C, Ruiz-Inchaustegui J A, Roth A C. Mechanical leech therapy to relieve venous congestion.  J Reconstr Microsurg. 1995;  11 51-55