Currently, there are no guidelines to determine the minimal time required to leech a congested prefabricated flap. We present a case of a prefabricated free flap successfully leeched for 54 hours and comment on the physiological basis for the duration of therapy.
An 8-year-old girl presented with a severe neck burn contracture 2 years after sustaining an 80 percent total body burn. The only unburned skin was on the lateral aspect of her left thigh. Doppler examination detected a perforator within this area on unburned skin, presumably coming from the descending branch of the lateral circumflex artery. During surgery to harvest the anterolateral thigh free flap, the perforator was found to traverse more medially to the unburned skin. Therefore, a prefabricated flap was designed using the descending branch of the lateral circumflex artery and vein in conjunction with a tissue expander under this pedicle and the unburned skin. Eight weeks later, the flap was raised and transplanted as a free flap via anastomoses to the superior thyroid artery and external jugular vein. A second vein was not available for anastomosis. The flap became acutely venous congested (Fig. 1), and leech therapy was begun intraoperatively. Leeching was stopped 54 hours later (i.e., after morning rounds), with no return of venous congestion. After débridement of some distal skin and fat necrosis on postoperative day 17, 90 percent of the flap survived (Fig. 2).
The minimal duration of leeching for prefabricated free flaps is unknown. Most prefabricated flaps will develop congestion.1 Factors that may affect venous congestion in a prefabricated flap are the extent to which the pedicle extends into the flap, as well as the time from pedicle transfer to flap harvest. Comparing the physiology and outcomes of leeching in congested, nonprefabricated flaps provides a reference point for deciding when to initially stop leeching. The initial venous anastomosis in a free flap serves to provide venous outflow until the flap forms new venous connections to the recipient site. The time required to develop sufficient new venous channels to drain the flap varies by species, tissue type, and flap size. In rats and pigs, flaps can survive total vein ligation after 3 and 5 days.2 In humans, retrospective series of free flaps indicate that 6 to 10 days of leeching are necessary when leeching provides the only outflow.3 Pedicled and cutaneous flaps with acute congestion have required between 2 to 6 days of leeching.4,5 Histological studies demonstrate that the newly formed capillaries and venuoles serving to drain the flap after its transfer increase sequentially over time. This suggests that leeching must be continued until the venous drainage of the nonoccluded venous anastamosis and newly formed venuoles combined is sufficient for the given tissue amount and type.
For a prefabricated flap with venous congestion, we advocate first removing the leeches after 48 hours. Leeches can be reapplied if congestion returns. Leeches can be removed earlier in cases with mild venous congestion, but repeated episodes of venous congestion may lead to additional areas of tissue necrosis requiring débridement.
Parents or guardians provided written consent for use of the patient’s images.
The authors have no financial interest to declare in relation to the content of this article.
Alexander J. Rajic, B.A.
University of Colorado School of Medicine
Frederic W.-B. Deleyiannis, M.D., M.Phil., M.P.H.
University of Colorado School of Medicine and
Children’s Hospital Colorado
1. Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head and neck: A 10-year experience. Plast Reconstr Surg. 1999;103:808–820
2. Nakajima T. How soon do venous drainage channels develop at the periphery of a free flap? A study in rats. Br J Plast Surg. 1978;31:300–308
3. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN. Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg. 2002;128:960–965
4. Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014;2014:205929
5. Whitaker IS, Josty IC, Hawkins S, et al. Medicinal leeches and the microsurgeon: A four-year study, clinical series and risk benefit review. Microsurgery. 2011;31:281–287
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