The use of medicinal leeches (Hirudo medicinalis) for the salvage of tissues with venous congestion has been intermittent over the last two centuries. During the last decade, interest in leech therapy has undergone a resurgence. Hirudo's tricuspid bite injects a highly potent anticoagulant. The site usually bleeds for 1 to 2 hours and under special circumstances may bleed for up to 24 hours. This collective series presents four patients in whom immediate postoperative venous congestion threatened the survival of three tissue replants and one latissimus dorsi flap. Two of the replants were completely salvaged; the other two failed due to infection. Hirudo medicinalis is an important adjunct in preventing flap or replant failure secondary to venous congestion, but its use is associated with significant risks.
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