LEECH THERAPY IN PLASTIC AND RECONSTRUCTIVE SURGERY: A REVIEW ARTICLE

Medicinal leech therapy (hirudotherapy) has re-emerged over the past five decades as an important adjunct in plastic and reconstructive surgery, chiefly for the salvage of flaps and replanted or revascularised tissue compromised by venous congestion. The medicinal leech (Hirudo medicinalis and related species) secretes a complex mixture of bioactive salivary compounds — including hirudin, calin, hyaluronidase, destabilase, apyrase, eglins and bdellins — that produce local anticoagulation, vasodilatation, controlled decongestive bleeding and anti-inflammatory effects, thereby providing temporary venous outflow until spontaneous neovascularisation (inosculation) restores physiological drainage. Leeches have been used in the salvage of free and pedicled flaps, digit replantation and revascularisation, and replantation of the ear, nose, lip, scalp and other composite tissues, and were approved by the United States Food and Drug Administration as a medical device for this indication in 2004. Pooled data from systematic reviews report tissue salvage rates ranging from approximately 61% to 88%, though outcomes vary considerably by tissue type, with pedicled flaps generally salvaged more successfully than free flaps or digital replants. The principal risks of leech therapy are blood loss requiring transfusion and infection with Aeromonas species harboured in the leech gut, which necessitates antibiotic prophylaxis, though rising antimicrobial resistance among Aeromonas isolates is an emerging concern. This review summarises the biology and mechanism of action of medicinal leeches, their indications and technique of application in plastic and reconstructive surgery, the evidence for efficacy, associated complications and their management, contraindications, alternative techniques, and the direction of future research.