1
|
Hom DB, Ostrander BT. Reducing Risks for Local Skin Flap Failure. Facial Plast Surg Clin North Am 2023; 31:275-287. [PMID: 37001930 PMCID: PMC10990621 DOI: 10.1016/j.fsc.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Local tissue flaps are a fundamental technique in cutaneous reconstruction. Reducing the risk of flap failure is of critical importance. The intrinsic vascularity of a flap is the most important determinant of success. Good surgical techniques, including flap design, delicate tissue handling, and tension-less closure, help reduce the risk of flap compromise. Determining the etiology of compromise, including arterial, venous, hematologic, or infectious, is the first step in salvaging a failing flap. Common causes include pedicle kinking, hematoma, pressure/tension, systemic patient factors, and poor surgical technique. Swift action to restore perfusion or venous outflow through numerous strategies is required.
Collapse
Affiliation(s)
- David B Hom
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, 9300 Campus Point Drive, MC 7895, La Jolla, CA 92037-7895, USA.
| | - Benjamin T Ostrander
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, 9300 Campus Point Drive, MC 7895, La Jolla, CA 92037-7895, USA
| |
Collapse
|
2
|
Utilization of Leech Therapy after Rhinoplasty. Plast Reconstr Surg 2022; 149:1090e-1095e. [PMID: 35383721 DOI: 10.1097/prs.0000000000009096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of medicinal leeches in modern reconstructive surgery is well-described. Leech therapy after rhinoplasty has not been previously well-characterized. METHODS The medical records of all patients who underwent open rhinoplasty by a single surgeon over a 4-year period were reviewed. Patient demographics, including age, sex, medical comorbidities, number of previous rhinoplasty surgeries, time to utilization of leech therapy, adjunct therapies used, resolution of skin changes, and smoking status, were recorded. Operative reports were reviewed for pertinent information, including number of tip grafts used, graft materials used, and placement of septal extension grafts or "unicorn" grafts. RESULTS Between April of 2016 and March of 2020, 545 patients underwent rhinoplasty performed by the senior author (P.S.N.). Of these patients, 39 (7.2 percent) underwent leech therapy postoperatively. The mean age of included patients was 47.4 years. Of the patients who required leech therapy, 34 (87.2 percent) had undergone revision rhinoplasty. The mean number of previous rhinoplasties was 3.4. The mean number of tip grafts used was 2.6. Thirty-three patients (84.6 percent) had either a traditional septal extension graft or unicorn graft placed. Nine patients (23.1 percent) were former smokers. Complete resolution of skin color changes was seen in 38 patients (97.4 percent). There were no major complications after leech therapy. CONCLUSIONS Leech therapy is a useful tool for the rhinoplasty surgeon, particularly in the setting of complex revision rhinoplasty, in patients who have undergone multiple previous nasal surgical procedures, or in patients who require significant cartilage grafting to reconstruct the nasal tip or lengthen the nose. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
3
|
Mousavian A, Sabzevari S, Parsazad S, Moosavian H. Leech Therapy Protects Free Flaps against Venous Congestion, Thrombus Formation, and Ischemia/Reperfusion Injury: Benefits, Complications, and Contradictions. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:252-260. [PMID: 35514759 DOI: 10.22038/abjs.2022.55013.2736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
The use of free cutaneous or myocutaneous flaps in some surgeries, especially in reconstructive surgeries, is routine and imperative; nevertheless, it is controversial because of fear of flap loss due to tissue congestion and partial or complete necrosis. Different mechanisms are discussed in this process, and based on the involved mechanisms, various agents and approaches are suggested for flap salvage. Among these agents and strategies, leech therapy (hirudotherapy) can be a valuable complementary treatment; however, in this way, full attention should be given to all beneficial and harmful aspects to reach the best results. This study included a literature review of the essential complications following free tissue transfer and explained the effects of leech therapy for the respective complications. Based on the review of the literature, the essential complications following free tissue transfer were (I) venous obstruction and congestion, (II) delay in blood flow reestablishment, (III) ischemia/reperfusion injuries, and (IV) thrombus formation. Leech therapy can protect free flaps against the mentioned complications as a complementary treatment. Leech therapy is an appropriate complement, however, not a definite approach for flap salvage. Therefore, in some patients, other alternative methods or even flap removal may be a better option.
Collapse
Affiliation(s)
- Alireza Mousavian
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Sabzevari
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shafagh Parsazad
- Anatomical and Clinical Pathology, University of Pittsburgh Medical Center, USA
| | - Hamidreza Moosavian
- Department of Clinical Pathology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| |
Collapse
|
4
|
Wang Z, Upchurch DA. Anaemia following medical leech therapy for caudal superficial epigastric skin flap salvage in a Shorthaired Chihuahua. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Zhe Wang
- Veterinary Health Centre at Kansas State University Manhattan Kansas USA
| | - David A. Upchurch
- Veterinary Health Centre at Kansas State University Manhattan Kansas USA
| |
Collapse
|
5
|
Amoozadeh E, Malek M, Katouzian A, Sarafrazi A. Estimating population density of the medicinal leech Hirudo orientalis Utevsky and Trontelj, 2005 (Clitellata: Hirudinida) using Visible Implant Elastomer tags. J NAT HIST 2021. [DOI: 10.1080/00222933.2021.1874559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Elham Amoozadeh
- School of Biology and Center of Excellence in Phylogeny of Living Organisms, College of Science, University of Tehran, Tehran, Iran
| | - Masoumeh Malek
- School of Biology and Center of Excellence in Phylogeny of Living Organisms, College of Science, University of Tehran, Tehran, Iran
| | - Ahmadreza Katouzian
- School of Biology and Center of Excellence in Phylogeny of Living Organisms, College of Science, University of Tehran, Tehran, Iran
| | - Alimorad Sarafrazi
- Department of Insect Taxonomy Research, Institute of Plant Protection
- IRIPP · Insect Taxonomy Research Department, Tehran, Iran
| |
Collapse
|
6
|
Iwama RE, Tessler M, Siddall ME, Kvist S. The Origin and Evolution of Antistasin-like Proteins in Leeches (Hirudinida, Clitellata). Genome Biol Evol 2021; 13:evaa242. [PMID: 33527140 PMCID: PMC7851590 DOI: 10.1093/gbe/evaa242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 02/07/2023] Open
Abstract
Bloodfeeding is employed by many parasitic animals and requires specific innovations for efficient feeding. Some of these innovations are molecular features that are related to the inhibition of hemostasis. For example, bloodfeeding insects, bats, and leeches release proteins with anticoagulatory activity through their salivary secretions. The antistasin-like protein family, composed of serine protease inhibitors with one or more antistasin-like domains, is tightly linked to inhibition of hemostasis in leeches. However, this protein family has been recorded also in non-bloodfeeding invertebrates, such as cnidarians, mollusks, polychaetes, and oligochaetes. The present study aims to 1) root the antistasin-like gene tree and delimit the major orthologous groups, 2) identify potential independent origins of salivary proteins secreted by leeches, and 3) identify major changes in domain and/or motif structure within each orthologous group. Five clades containing leech antistasin-like proteins are distinguishable through rigorous phylogenetic analyses based on nine new transcriptomes and a diverse set of comparative data: the trypsin + leukocyte elastase inhibitors clade, the antistasin clade, the therostasin clade, and two additional, unnamed clades. The antistasin-like gene tree supports multiple origins of leech antistasin-like proteins due to the presence of both leech and non-leech sequences in one of the unnamed clades, but a single origin of factor Xa and trypsin + leukocyte elastase inhibitors. This is further supported by three sequence motifs that are exclusive to antistasins, the trypsin + leukocyte elastase inhibitor clade, and the therostasin clade, respectively. We discuss the implications of our findings for the evolution of this diverse family of leech anticoagulants.
Collapse
Affiliation(s)
- Rafael Eiji Iwama
- Department of Natural History, Royal Ontario Museum, Toronto, Ontario, Canada
- Department of Ecology and Evolutionary Biology, University of Toronto, Ontario, Canada
| | - Michael Tessler
- Department of Biology, St. Francis College, Brooklyn, New York, USA
- Division of Invertebrate Zoology, American Museum of Natural History, New York, New York, USA
- Sackler Institute for Comparative Genomics, American Museum of Natural History, New York, New York, USA
| | | | - Sebastian Kvist
- Department of Natural History, Royal Ontario Museum, Toronto, Ontario, Canada
- Department of Ecology and Evolutionary Biology, University of Toronto, Ontario, Canada
| |
Collapse
|
7
|
Irvine LE, Azizzadeh B, Kerulos JL, Nassif PS. Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty. Facial Plast Surg Aesthet Med 2020; 23:118-125. [PMID: 33054380 DOI: 10.1089/fpsam.2020.0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Importance: This is the first study to review the incidence of nasal skin compromise after open rhinoplasty surgery and outcomes of treatment. Objectives: To determine whether risk of skin compromise after open rhinoplasty surgery can be predicted and whether our treatment protocol led to acceptable outcomes. Design, Setting, and Participants: This is a retrospective chart review of the senior author's private patients. In total, 384 rhinoplasty cases were reviewed and all cases with signs of vascular compromise requiring treatment were analyzed. Main Outcomes and Measures: Descriptive statistics were used to evaluate characteristics of patients who developed intra- and postoperative skin compromise, and unpaired two-tailed t-test was used to compare the characteristics of patients with and without compromised nasal skin when possible. Overall satisfaction results and complications in the skin compromise group were reported. Results: A total of 384 open rhinoplasties were performed by the senior author between October 1, 2015, and December 31, 2018. Of them, 109 were primary rhinoplasties and 275 were revision rhinoplasties. Of the 384 rhinoplasties, 27 (7%) had skin compromise leading to unplanned postoperative treatment. Two of the patients in the skin compromise group underwent primary surgeries (7.4%) and 25 underwent revision procedures (92.6%). Advanced age (p < 0.0001), prior or current history of smoking (p = 0.027), and greater number of prior rhinoplasty surgeries (p = 0.0002) were significantly correlated with risk of skin compromise. The average time to last follow-up in the skin compromise group was 392 days (range 15-1057 days). At their last follow-up, 12 patients had complete resolution of all signs of nasal skin compromise with no further treatment required (44.4%). The revision rate for patients experiencing skin compromise was 22.2%. One patient underwent revision surgery directly related to a complication of skin compromise and one is considering revision directly related to skin breakdown. Conclusions and Relevance: The rate of skin compromise after open rhinoplasty is low. Older patients and patients with more prior rhinoplasty surgeries may be at increased risk. Prompt treatment of compromised nasal blood supply after rhinoplasty surgery can salvage skin in most patients.
Collapse
Affiliation(s)
| | - Babak Azizzadeh
- Division of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA.,Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA
| | - Julia L Kerulos
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago-College of Medicine, Chicago, Illinois, USA
| | - Paul S Nassif
- Nassif MD, Inc., and Associates, Beverly Hills, California, USA.,Department of Head and Neck Surgery, Keck School of Medicine at the University of Southern California, Los angeles, California, USA
| |
Collapse
|
8
|
Leeching as Salvage Venous Drainage in Ear Reconstruction: Clinical Case and Review of Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 6:e1820. [PMID: 30881774 PMCID: PMC6414113 DOI: 10.1097/gox.0000000000001820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/16/2018] [Indexed: 11/26/2022]
Abstract
Background Ear avulsion is a rare complication of different traumas, such as car accidents, human or animal bites and stab wounds, and can result in dramatic cosmetic consequences for the patient. Ear replantation, revascularization, and reattachment are the options offering best aesthetic results. But venous outflow insufficiency is responsible for a high rate of failures. Leeching is one the most efficient methods to relieve venous congestion. It has been used as an alternative venous outflow in case of severe impairment of the physiologic one. Methods We present a case of successful rescue of a congested reattached ear by leeching after subtotal avulsion, along with a review of the literature on cases of avulsed auricle reconstruction salvaged by hirudotherapy. Data were collected and analyzed to identify a best regimen to deal with venous congestion. Results More than 130 cases of avulsed auricle savage are described in the literature, in a fourth of which leech therapy was used in the management of venous congestion. Discussion In case of both venous outflow deficit or absence, leeches are a potentially successful option to correct the congestion while new veins reestablish normal physiology. The need for anticoagulant/antiaggregant therapy, antibiotics, and often blood transfusion are the main pitfalls of leeching. Conclusion Leeches can be considered a salvage method for ear replantation and reattachment in those cases that lack venous outflow in the presence of valid arterial inflow.
Collapse
|
9
|
Sugiyama M, Saijo H, Kazuto H, Takato T. Rescue of lip switch flap at risk of necrosis due to venous congestion for cleft lip deformity. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2016; 3:41-3. [PMID: 27583269 PMCID: PMC4996059 DOI: 10.1080/23320885.2016.1181522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/18/2016] [Indexed: 11/25/2022]
Abstract
In a 21-year-old male with bilateral cleft lip who developed marked venous congestion of a lip switch flap, we returned the grafted flap to the donor site to improve blood circulation of the flap and then re-transplanted it, which prevented flap necrosis. Here, we report the procedure and case.
Collapse
Affiliation(s)
- Madoka Sugiyama
- Department of Oral-Maxillofacial Surgery, The University of Tokyo Hospital , Tokyo , Japan
| | - Hideto Saijo
- Department of Oral-Maxillofacial Surgery, The University of Tokyo Hospital , Tokyo , Japan
| | - Hoshi Kazuto
- Department of Oral-Maxillofacial Surgery, The University of Tokyo Hospital , Tokyo , Japan
| | - Tsuyoshi Takato
- Department of Oral-Maxillofacial Surgery, The University of Tokyo Hospital , Tokyo , Japan
| |
Collapse
|
10
|
Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: Systematic review and practical recommendations. ANN CHIR PLAST ESTH 2016; 62:e1-e13. [PMID: 27427444 DOI: 10.1016/j.anplas.2016.06.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/12/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams. MATERIALS AND METHODS We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications. RESULTS For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy. CONCLUSION Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.
Collapse
Affiliation(s)
- C Herlin
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France.
| | - N Bertheuil
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rennes, 35000 Rennes, France
| | - F Bekara
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France
| | - F Boissiere
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France
| | - R Sinna
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Picardie, 80080 Amiens, France
| | - B Chaput
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rangueil, 31400 Toulouse, France
| |
Collapse
|
11
|
Welshhans JL, Hom DB. Are leeches effective in local/regional skin flap salvage? Laryngoscope 2016; 126:1271-2. [PMID: 26844537 DOI: 10.1002/lary.25855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Jamie L Welshhans
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - David B Hom
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| |
Collapse
|
12
|
Characterization of the digestive tract microbiota of Hirudo orientalis (medicinal leech) and antibiotic resistance profile. Plast Reconstr Surg 2014; 133:408e-418e. [PMID: 24572887 DOI: 10.1097/01.prs.0000438461.06217.bb] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There are at least three distinct European leech species used medicinally: Hirudo medicinalis, H. orientalis, and H. verbana. Infection caused by leech microbiota is the most widely reported complication. Few studies have reported the culturable and unculturable bacteria and examined the antibiotic resistances in H. orientalis. METHODS Following stratified random sampling from a major worldwide leech supplier, Hirudo orientalis leeches were identified by visual comparison and amplification and sequencing the cox1 locus. Combined culture and culture-independent approaches were used to characterize the microbiota of the midgut, and bacterial gyrB sequences from distinct colonies were used to identify the Aeromonas isolates. Nonculturable studies involved clone libraries of 16S rRNA genes, and Etests were used to investigate antibiotic sensitivities. RESULTS Analysis of 16S rRNA gene clone libraries revealed the presence of several species in the intraluminal fluid of the crop, including a new finding of Morganella morganii, with Rikenella-like (35 percent) and Aeromonas veronii (38 percent) dominant members. The intestinum contained bacteria not previously isolated from the leech: Magnetospirillium species and Roseospira marina. Etests showed all A. veronii isolates were sensitive to ciprofloxacin, with either a complete or intermediate resistance to Augmentin. CONCLUSIONS The authors show diverse microbiota in the leech digestive tract. The pathogenic potential of the additional gut symbionts isolated in this study is yet to be elucidated; however, M. morganii, which is a known human pathogen, is a new finding. In addition to adding to the knowledge base regarding antibiotic sensitivities, this article serves as an update to the reconstructive surgeon regarding leech therapy.
Collapse
|
13
|
Agha RA, Gundogan B, Fowler AJ, Bragg TWH, Orgill DP. The efficacy of the Cook-Swartz implantable Doppler in the detection of free-flap compromise: a systematic review protocol. BMJ Open 2014; 4:e004253. [PMID: 24622948 PMCID: PMC3963127 DOI: 10.1136/bmjopen-2013-004253] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The Cook-Swartz implantable Doppler monitors venous or arterial blood flow from free flaps and can detect free-flap compromise. Previous studies have shown that the use of this Doppler can improve detection and salvage rates as it provides an earlier warning than the current method of clinical assessment. Such studies assert that the implantable Doppler is of great value in monitoring free flaps in current microsurgical units. This systematic review aims to compare the efficacy of the Cook-Swartz implantable Doppler in monitoring free-flap compromise against conventional clinical free-flap monitoring techniques. METHODS AND ANALYSIS Various electronic databases will be systematically searched for studies that compare the use of Cook-Swartz implantable Doppler with clinical assessment. The selected studies will then have their titles and abstracts screened by two authors. Articles selected after title and abstract screen will have full text downloaded and the complete article will be assessed for suitability. Once the articles have been selected for inclusion, data extraction will take place. For data analysis, the outcomes of the studies will be tabulated, with descriptive statistics performed as appropriate and the detection rate of the Doppler and clinical assessment will be compared and synthesised where possible. ETHICS AND DISSEMINATION The authors hope to disseminate the findings as widely as possible. This systematic review will be published in a peer-reviewed journal and include a number of recommendations as its conclusion based on the evidence contained within. Given the wide range of specialties now utilising flaps, it will be presented at a wide range of national and international conferences. PROTOCOL REGISTRATION IN PROSPERO CRD42013005818 The literature search and data extraction went on until 28 January 2014. These steps were revised in line with peer review comments.
Collapse
Affiliation(s)
- Riaz A Agha
- Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, UK
| | | | | | - Thomas W H Bragg
- Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, UK
| | - Dennis P Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
14
|
Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2014; 2014:205929. [PMID: 24653746 PMCID: PMC3933224 DOI: 10.1155/2014/205929] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/05/2013] [Accepted: 12/27/2013] [Indexed: 12/19/2022]
Abstract
A written informed consent should be obtained from the patient before hirudotherapy is initiated. The patients should be treated each day of leech therapy with anti-Aeromonas antibiotics. Leeches should be applied on the darker spots of the reattached body parts or flaps. Usually 1-10 leeches are used for each treatment, while at the beginning, the patient might need two or more treatments per day. Leech therapy is used until venous capillary return is established across the wound border by angiogenesis. Usually the treatment with leeches lasts for 2-6 days. Hematologic evaluations should be performed every 4 hrs and the patient has to receive blood transfusions when the hemoglobin level is lower than 8 g/dL. Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and subfebrile temperature can occur. Contraindications related to hirudotherapy include arterial insufficiency, hemophilia, hemorrhagic diathesis, hematological malignancies, anemia, hypotension, and sepsis. Leech therapy is not recommended in pregnancy and lactation and in patients with an unstable medical status, history of allergy to leeches or severe allergic diathesis, and disposition to keloid scar formation, as well as in those using anticoagulants and immunosuppressants.
Collapse
Affiliation(s)
- Kosta Y. Mumcuoglu
- Parasitology Unit, Department of Microbiology and Molecular Genetics, The Kuvin Center for the Study of Infectious and Tropical Diseases, The Hebrew University, Hadassah Medical School, P.O. Box 12272, Jerusalem 91120, Israel
| |
Collapse
|
15
|
Management of flap venous congestion: The role of heparin local subcutaneous injection. J Plast Reconstr Aesthet Surg 2014; 67:48-55. [DOI: 10.1016/j.bjps.2013.09.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 08/27/2013] [Accepted: 09/01/2013] [Indexed: 11/20/2022]
|
16
|
Nikolis A, Christopoulos A, Saint-Cyr M, Cordoba C, Guertin L, Harris PG. Recurrent venous thrombosis following free flap surgery: The role of heparin-induced thrombocytopenia. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2013; 11:37-40. [PMID: 24115848 DOI: 10.1177/229255030301100107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Complications following free tissue transfer have been well established in the literature. Common and rare causes of free flap failure must be addressed by the treating surgeon when microvascular patency is threatened. With the evolution and prevalence of microsurgery, 'rare' causes of free flap failure will become increasingly frequent. A high index of suspicion must be established in patients with multiple failed operative interventions. A case of recurrent free flap failure secondary to heparin-induced thrombocytopenia is presented in a patient with a history of squamous cell carcinoma of the floor of the mouth, and a long-standing history of alcohol and tobacco consumption.
Collapse
Affiliation(s)
- Andreas Nikolis
- Division of Plastic and Reconstructive Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec
| | | | | | | | | | | |
Collapse
|
17
|
Elyassi AR, Terres J, Rowshan HH. Medicinal leech therapy on head and neck patients: a review of literature and proposed protocol. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116:e167-72. [DOI: 10.1016/j.oooo.2011.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 11/13/2011] [Accepted: 12/20/2011] [Indexed: 10/28/2022]
|
18
|
Maloney K. Partial avulsion of the right ear treated with a pocket technique: a case report and review of the literature. J Maxillofac Oral Surg 2013; 14:288-92. [PMID: 25838712 DOI: 10.1007/s12663-013-0498-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 03/13/2013] [Indexed: 10/27/2022] Open
Abstract
Avulsive injuries to the ear are not common and are variable in presentation. This article describes a case of subtotal auricular avulsion treated utilizing a pocket. Other techniques used for these types of injuries are reviewed.
Collapse
Affiliation(s)
- Karl Maloney
- Division of Oral and Maxillofacial Surgery, Montefiore Medical Center, Bronx, New York, NY USA ; Division of Oral and Maxillofacial Surgery, St. Luke's Hospital, Bethlehem, PA USA
| |
Collapse
|
19
|
|
20
|
Jewett BS. Reconstruction of the Nose. Dermatol Surg 2012. [DOI: 10.1002/9781118412633.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
21
|
Outcomes of flap salvage with medicinal leech therapy. Microsurgery 2012; 32:351-7. [DOI: 10.1002/micr.21960] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 11/07/2022]
|
22
|
Whitaker IS, Oboumarzouk O, Rozen WM, Naderi N, Balasubramanian SP, Azzopardi EA, Kon M. The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases. Microsurgery 2012; 32:240-50. [PMID: 22407551 DOI: 10.1002/micr.20971] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 09/21/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although there are numerous case reports and small case series describing the experiences of leech therapy in various circumstances, there are relatively few large studies evaluating the effectiveness of leeching to relieve venous congestion. The therapeutic value of leeching is illustrated by these reports but the current literature lacks a cohesive summary of previous experiences. METHODS An electronic search of PubMed, the Cochrane library and the Centre for Reviews and Dissemination between 1966 and 2009 was used to retrieve human studies published in the English language evaluating outcomes following leech therapy. The "success" and "failure" of leech therapy were the primary outcome measures and secondary outcomes included complications, number of leeches used, pharmacological adjuncts and blood transfusion requirements. RESULTS In total, out of 461 articles, 394 articles met the exclusion criteria. The 67 included papers reported on 277 cases of leech use with an age range of 2-81 years and a male to female ratio of almost 2:1. The overall reported "success" rate following leech therapy was 77.98% (216/277). In terms of secondary outcome measures, 49.75% of cases (N = 101) required blood transfusions, 79.05% received antibiotics (N = 166) and 54.29% received concomitant anticoagulant therapy. The overall complication rate was 21.8%. CONCLUSION In the absence of robust randomized controlled trials on which the evidence may be based, this synthesis of current best evidence guides clinicians during the process of consenting patients and using leeches in their practice.
Collapse
Affiliation(s)
- Iain S Whitaker
- Department of Burns and Plastic Surgery, Morriston Hospital, Swansea, Wales, UK.
| | | | | | | | | | | | | |
Collapse
|
23
|
Comments and Notes. J Dtsch Dermatol Ges 2011. [DOI: 10.1111/j.1610-0387.2011.07703.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
24
|
Leech therapy in reconstructive maxillofacial surgery. J Oral Maxillofac Surg 2011; 70:221-7. [PMID: 21550156 DOI: 10.1016/j.joms.2011.02.083] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/15/2011] [Accepted: 02/12/2011] [Indexed: 11/22/2022]
Abstract
PURPOSE Corrective plastic surgery is indicated after accidents, burns, cancer surgery, or postoperative wound healing disorders with large tissue defects. The range of reconstructive techniques includes local skin flaps, pedicle grafts, and microvascular anastomosed flaps in the case of large defects. Main complications such as arterial and venous insufficiency caused by a vessel collapse or a vascular spasm are reported regularly in the area of anastomosed vessels and are the concern of any surgeon. Today, leeches are used if wound healing is at risk because of hemodynamic imbalance or a venous insufficiency. PATIENTS AND METHODS A retrospective evaluation of 148 patients who underwent medical leech therapy in the case of local or pedicaled flaps and some patients who had undergone reconstruction with microvascular flaps from 2005 and 2010 was conducted. Our sample had the typical symptoms of venous congestions of their flaps, despite suture removal, relief of pressure on the flap, and the elimination of a hematoma beyond the flap after surgery. Medical leech therapy was used in these cases. RESULTS Our series has confirmed the excellent and predictable healing after medical leech therapy for local and microsurgical anastomosed flaps in the case of venous congestion. CONCLUSION Leech therapy should be considered as a reliable additional procedure and an advantage in maxillofacial and plastic reconstructive surgery to remedy complications resulting from a hemodynamic imbalance or venous insufficiency in the immediate postoperative period.
Collapse
|
25
|
Riede F, Koenen W, Goerdt S, Ehmke H, Faulhaber J. Medicinal leeches for the treatment of venous congestion and hematoma after plastic reconstructive surgery. J Dtsch Dermatol Ges 2011; 8:881-8. [PMID: 21182735 DOI: 10.1111/j.1610-0387.2010.07473.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Leeches were used for medical purposes as long as 2 000 years ago in ancient Egypt. In recent years the use of medicinal leeches became rather popular again, e. g. to improve blood circulation in ischemic tissue after reconstructive plastic surgery. PATIENTS AND METHODS In a single center, retrospective study 23 consecutive cases were analyzed in which medicinal leeches had been used therapeutically after plastic reconstructive surgery. All cases were categorized regarding the indication for leech therapy, the onset, the duration, the number of leeches and the number of sessions. RESULTS Among the group of patients there were 7 female and 16 male patients with a mean age of 73 ± 14 years (48-94 years) altogether. The main indications were venous congestion (12/23; 52 %) and hematoma (9/23; 39 %). Two cases were diagnosed with a necrosis of the tip of the flap and therefore received leech therapy (2/23; 9 %). The average number of leeches was 2.6 leeches/session, the number of sessions was 1.7 ± 0.8. 20/23 patients (87 %) showed a restitutio ad integrum after leech therapy, in 3/23 patients (13 %) a necrosis of the tip of the flap could not be prevented. A clinical improvement was noticed after an average of 1.1 ± 0.3 days. CONCLUSIONS The early application of medicinal leeches can improve local hemodynamic conditions. Leech therapy is a simple and effective method; the cost efficiency of the treatment is high.
Collapse
Affiliation(s)
- Friederike Riede
- Department of Dermatology, Venereology and Allergy, University of Heidelberg, University Medicine Mannheim, Germany
| | | | | | | | | |
Collapse
|
26
|
Jang HK, Heo DS. The literature review of Leech therapy. J Pharmacopuncture 2010. [DOI: 10.3831/kpi.2010.13.1.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
27
|
Whitaker IS, Kamya C, Azzopardi EA, Graf J, Kon M, Lineaweaver WC. Preventing infective complications following leech therapy: Is practice keeping pace with current research? Microsurgery 2009; 29:619-25. [DOI: 10.1002/micr.20666] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
28
|
Kwak BM, Hong KE. Case of buerger's disease Improve by Gi-Chim Treatment (Leech Therapy). J Pharmacopuncture 2009. [DOI: 10.3831/kpi.2009.12.2.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
29
|
Schlaudraff KU, Bezzola T, Montandon D, Pepper MS, Pittet B. Mixed Arterio-Venous Insufficiency in Random Skin Flaps in the Rat: Is the Application of Medicinal Leeches Beneficial? J Surg Res 2008; 150:85-91. [DOI: 10.1016/j.jss.2008.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 12/10/2007] [Accepted: 01/10/2008] [Indexed: 11/30/2022]
|
30
|
Tremblay DM, Harris PG, Gagnon AR, Cordoba C, Brutus JP, Nikolis A. Heparin-induced thrombocytopenia syndrome as a cause of flap failure: A report of two cases. J Plast Reconstr Aesthet Surg 2008; 61:78-83. [DOI: 10.1016/j.bjps.2006.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Accepted: 12/11/2006] [Indexed: 11/30/2022]
|
31
|
Hullett JS, Spinnato GG, Ziccardi V. Treatment of an Ear Laceration With Adjunctive Leech Therapy: A Case Report. J Oral Maxillofac Surg 2007; 65:2112-4. [PMID: 17884550 DOI: 10.1016/j.joms.2006.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Revised: 09/21/2006] [Accepted: 09/28/2006] [Indexed: 10/22/2022]
Affiliation(s)
- Jason S Hullett
- Department of Oral and Maxillofacial Surgery, University of Medicine & Dentistry of New Jersey, Newark, NJ 07103, USA
| | | | | |
Collapse
|
32
|
Kleintjes WG. Forehead anatomy: arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg 2007; 60:593-606. [PMID: 17485046 DOI: 10.1016/j.bjps.2006.12.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 09/14/2006] [Accepted: 12/09/2006] [Indexed: 11/16/2022]
Abstract
The largest prospective cadaver study done over a 3-year period to investigate the arterial variations of the forehead is presented. The primary goal was to find anatomical support for various forehead flaps previously designed. Thirty cadaver foreheads (60 hemi-foreheads) were dissected from deep to superficial to identify arterial variations. The arteries were filled with a latex solution prior to dissection. The results show that the supratrochlear and dorsal nasal arteries have a relatively constant origin. Vertical (VB), oblique (OB), medial (MB) and lateral branches (LB) of the supraorbital artery were identified. The frontal branch of the superficial temporal artery (FBSTA) was found to continue in the direction of the scalp at the lateral orbital rim vertical line and gave off a transverse branch, the transverse frontal artery (TFA), to supply the forehead. The oblique branch of the supraorbital artery (OBSOA) most often anastomosed with either the transverse frontal artery or the frontal branch of the superficial temporal artery at the lateral orbital rim vertical line. A central artery (CA) was consistently found originating from the dorsal nasal artery usually 5mm from its origin. The central artery had a constant anastomosis with the opposite central artery in the inferior transverse third of the forehead. The central artery was not easily identifiable in the superior third of the forehead. The angular artery (AA) was found to have a variable termination. The angular artery could communicate with the supratrochlear artery (STrA) at the supraorbital rim (SOR) or it could continue up into the forehead medial to the STrA. This artery was called the paracentral artery (PCA). The central artery, paracentral artery and supratrochlear artery have an important relationship with the most prominent central vein that is relevant to flap construction. The significance of the central artery and vein favours the median forehead flap as anatomically superior and the prominent central vein is a constant landmark on which to select the side of the pedicle. Clear landmarks for defining the pedicle base for the median forehead flap are provided.
Collapse
Affiliation(s)
- Wayne George Kleintjes
- University of Stellenbosch, Department of Plastic and Reconstructive Surgery, University of Stellenbosch Medical School, South Africa.
| |
Collapse
|
33
|
Abstract
INTRODUCTION Meningococcal septicemia remains one of the most common infectious causes of admission to a pediatric intensive care unit. Numerous treatment strategies aimed at the thromboembolic complications inducing purpura fulminans and limb/digital ischemia have been attempted, with variable results. The successful use of medicinal leeches for pneumococcal purpura fulminans has been described, and we present a similar case of meningococcal purpura fulminans. PATIENT AND INTERVENTION A 5-wk-old female infant with meningococcal meningitis and septicemia and progressive purpura fulminans of the left hand was treated with medicinal leeches. Medicinal leeches were applied to the left dorsal hand on a daily basis for 4 consecutive days. RESULT The swelling and limited functionality visibly improved after 48 hrs, and by 120 hrs, perfusion in the distal phalanges of the thumb and middle finger was evident. Reperfusion of the distal phalanges was not fully sustained, and at 6 wks the plastic surgery department debrided the distal phalanges of her left hand, excluding the thumb. She fully recovered from the meningococcal septicemic shock; the functionality of her left thumb was preserved, and she has limited functionality of her left hand. CONCLUSION The unique combination of salivary products in leech therapy has theoretical benefits and requires future study.
Collapse
Affiliation(s)
- Ricky Dippenaar
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Children's Hospital, Tygerberg, South Africa
| | | | | | | |
Collapse
|
34
|
Hart K, Baur D, Hodam J, Lesoon-Wood L, Parham M, Keith K, Vazquez R, Ager E, Pizarro J. Short- and Long-Term Effects of Sildenafil on Skin Flap Survival in Rats. Laryngoscope 2006; 116:522-8. [PMID: 16585853 DOI: 10.1097/01.mlg.0000200792.67802.3b] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Distal ischemic necrosis of the flap remains an unsolved, challenging problem. Phosphodiesterase (PDE) inhibitors, which include the drug sildenafil, are a relatively new class of U.S. Food and Drug Administration-approved medications whose effect on tissue viability has not been widely explored. The vasodilatory effects of these drugs have the potential to enhance blood flow to flaps and increase their survivability. The purpose of this study was to examine the short- and long-term effects of sildenafil, administered intraperitoneally at a dose of 9 mg/kg per day, on the survival of surgical skin flaps in rats. METHODS A McFarlane-type random pattern skin (3 x 10-cm) flap model was used to evaluate the effect of sildenafil on necrosis at multiple time points. Rats were assigned to sildenafil-treated (9 mg/kg per day intraperitoneally; n = 34), vehicle control (n = 35), or sham (no injection; n = 40) groups. In each group, caudally based, dorsal, rectangular (3 x 10-cm) flaps were created. Flap necrosis was determined using orthogonal polarization spectral imaging and digital photography analysis on days 1, 3, 5, and 7 postsurgery. RESULTS Orthogonal polarization spectral imaging results showed a significant decrease in necrosis and stasis in rats treated with sildenafil on days 1 and 3. Although reductions observed at days 5 and 7 were not as dramatic as days 1 and 3, digital photography analysis confirmed a decrease in the area of necrosis at all time points evaluated. CONCLUSIONS These results suggest that PDE 5 inhibitors may play a more important role in early postoperative skin flap viability rather than at later time points and may be beneficial for skin flap viability as shown in the rat model. PDE 5 inhibitors may reduce the extent of necrosis after reconstructive surgeries.
Collapse
Affiliation(s)
- Kristopher Hart
- Department of Oral and Maxillofacial Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia 30905, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Whitaker IS, Cheung CK, Chahal CAA, Karoo ROS, Gulati A, Foo ITH. By what mechanism do leeches help to salvage ischaemic tissues? A review. Br J Oral Maxillofac Surg 2005; 43:155-60. [PMID: 15749217 DOI: 10.1016/j.bjoms.2004.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2004] [Indexed: 11/19/2022]
Abstract
The therapeutic use of leeches in medicine dates back to 50 b.c. and was cited by ancient authors. The medicinal leech, Hirudo medicinalis, has been used with increasing frequency during the past few years by reconstructive surgeons to help salvage ischaemic tissues. We aim to summarise the anatomy, physiology, and pharmacological mechanisms of action of leeches to provide reconstructive surgeons with a theoretical basis for their use.
Collapse
Affiliation(s)
- I S Whitaker
- Department of Otolaryngology and Head and Neck Surgery, Leeds General Infirmary, Leeds, UK.
| | | | | | | | | | | |
Collapse
|
36
|
Frodel JL, Barth P, Wagner J. Salvage of partial facial soft tissue avulsions with medicinal leeches. Otolaryngol Head Neck Surg 2005; 131:934-9. [PMID: 15577793 DOI: 10.1016/j.otohns.2004.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Medicinal leeches have been demonstrated to be extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps. OBJECTIVE To demonstrate the utility of medicinal leeches in the salvage of venous outflow-compromised traumatic soft tissue avulsions in key facial structures. METHODS A retrospective review of 4 cases involving the external ear, nose, lip, and scalp in which apparent venous outflow compromise was present. Medicinal leeches were applied acutely in each of these 4 cases, salvaging each of the partially avulsed soft tissue segments. RESULTS Complete or near complete salvage of each soft tissue segment after using medicinal leeches. CONCLUSIONS Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. This is particularly important in vital structures such as the ear, nose, lip, and eyelid in which acute or secondary reconstruction is complex. EBM RATING C.
Collapse
Affiliation(s)
- John L Frodel
- Department of Otolaryngology--Head and Neck Surgery, Geisinger Medical Center, Danville, Pennsylvania 17822, USA.
| | | | | |
Collapse
|
37
|
Aydin A, Nazik H, Kuvat SV, Gurler N, Ongen B, Tuncer S, Hocaoglu E, Kesim SN. External decontamination of wild leeches with hypochloric acid. BMC Infect Dis 2004; 4:28. [PMID: 15329153 PMCID: PMC516442 DOI: 10.1186/1471-2334-4-28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2004] [Accepted: 08/25/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive surgery, to relieve venous congestion and to improve the microrevascularization of flaps. In many countries, wild leeches are still provided from local markets and utilised with antibiotic prophylaxies. In this research, results of identification of bacteria in the transport fluid is reported, oral and intestinal floras and the antibiograms of the identified microorganisms are investigated. Also, to avoid possible infections, the ability of hypochloric acid, a disinfectant, to suppress the relevant microorganisms without changing the life style and behavior of leeches in terms of sucking function, is investigated. METHODS Bacterial identifications and antibiograms of oral and intestinal flora and transport medium were performed for 10 leeches. The optimum concentration of hypochloric acid which eliminated microorganisms without affecting the viability and sucking function of the leeches were determined by dilution of hypochloric acid to 100, 50, 25, 12.5, 6.25 ppm concentrations in different groups of 25 leeches. Finally, 20 leeches were applied atraumatically to the bleeding areas of rats, the duration of suction was determined and compared statistically between the leeches treated and not treated with hypochloric acid solution. RESULTS Aeromonas hydrophilia was the most commonly identified microorganism and found to be resistant to first generation cephalosporins, frequently used in prophylaxis at surgical wards. In the next stages of the study, the leeches were subjected to a series of diluted hypochloric acid solutions. Although disinfection of the transport material and suppression of the oral flora of hirudo medicinalis were successful in 100, 50, 25, 12.5, 6.25 ppm concentrations; 12.5 ppm solution was the greatest concentration in which hirudo medicinalis could survive and sucking function was not affected significantly. CONCLUSIONS External decontamination of wild leeches with 12.5 ppm hypochloric acid enables bacterial suppression without causing negative effects on leech sucking function and life.
Collapse
Affiliation(s)
- Atakan Aydin
- Department of Plastic and Reconstructive Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Hasan Nazik
- Department of Clinical Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Samet Vasfi Kuvat
- Department of Plastic and Reconstructive Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Nezahat Gurler
- Department of Clinical Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Betigul Ongen
- Department of Clinical Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Serdar Tuncer
- Department of Plastic and Reconstructive Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Emre Hocaoglu
- Department of Plastic and Reconstructive Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sinan Nur Kesim
- Department of Plastic and Reconstructive Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| |
Collapse
|
38
|
Whitaker IS, Izadi D, Oliver DW, Monteath G, Butler PE. Hirudo Medicinalis and the plastic surgeon. ACTA ACUST UNITED AC 2004; 57:348-53. [PMID: 15145739 DOI: 10.1016/j.bjps.2003.12.016] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2003] [Accepted: 12/16/2003] [Indexed: 11/30/2022]
Abstract
Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.
Collapse
Affiliation(s)
- I S Whitaker
- Department of Anatomy, University of Cambridge, Downing Street, Cambridge CB2 3DY, UK.
| | | | | | | | | |
Collapse
|
39
|
Shaw A, Ko C, Tomlinson J. A 2-year-old boy, born with polysplenia syndrome, esophageal atresia, and tracheoesophageal fistula (TEF). J Pediatr Surg 2004; 39:1002. [PMID: 15224683 DOI: 10.1016/j.jpedsurg.2004.02.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
40
|
Whitaker IS, Rao J, Izadi D, Butler PE. Historical Article: Hirudo medicinalis : ancient origins of, and trends in the use of medicinal leeches throughout history. Br J Oral Maxillofac Surg 2004; 42:133-7. [PMID: 15013545 DOI: 10.1016/s0266-4356(03)00242-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2003] [Indexed: 11/17/2022]
Abstract
Blood letting and the therapeutic use of Hirudo medicinalis date back to ancient Egypt and the beginning of civilisation. Their popularity has varied over the years, reaching such a peak in Europe between 1825 and 1850 that supplies were exhausted. Towards the end of the century they fell out of favour and, during this period, the leech, once used by the physicians of emperors and influential academic surgeons, became associated with lay therapists and quackery. Leeches have enjoyed a renaissance in reconstructive microsurgery during the last 15 years, having been used by maxillofacial [Br. J. Oral Maxillofac. Surg 41 (2003) 44] and other reconstructive surgeons to aid salvage of compromised microvascular free tissue transfers [Laryngoscope 108 (1998) 1129; Br. J. Plast. Surg. 34 (1984) 358], replanted digits [Int. J. Microsurg. 3 (1981) 265], ears [Ann. Plast. Surg. 43 (1999) 427], lips [Plast. Reconstr. Surg. 102 (1998) 358; J. Reconstr. Microsurg. 9 (1993) 327] and nasal tips [Br. J. Oral Maxillofac. Surg. 36 (1998) 462]. Peer-reviewed evidence suggests that the survival of compromised, venous-congested tissues is improved by early application of a leech [J. Reconstr. Microsurg. 12 (1996) 165; Arch. Otolaryngol. Head Neck Surg. 114 (1988) 1395; Br. J. Plast. Surg. 45 (1992) 235]. Leeches have also recently been used to treat a wide range of conditions, including periorbital haematomas [Br. J. Ophthalmol. 75 (1991) 755], severe macroglossia [Otolaryngol. Head Neck Surg. 125 (2001) 649; J. Laryngol. Otol. 109 (1995) 442] and purpura fulminans [Ann. Plast. Surg. 35 (1995) 300]. The first medicinal leech farm, Biopharm, was set up in Swansea in 1981 by Dr Roy Sawyer, and now supplies leeches to hospitals all over the world. In this paper, we summarise the history of treatment with Hirudo medicinalis from its origin to the present day, and take a brief look at the possible future of the annelid.
Collapse
Affiliation(s)
- I S Whitaker
- Department of Anatomy, University of Cambridge, Cambridge, UK.
| | | | | | | |
Collapse
|
41
|
|
42
|
Rao J, Whitaker IS. Use of Hirudo medicinalis by maxillofacial surgical units in the United Kingdom: current views and practice. Br J Oral Maxillofac Surg 2003; 41:54-5. [PMID: 12576043 DOI: 10.1016/s0266-4356(02)00284-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J Rao
- South Manchester University Hospitals NHS Trust, Manchester, UK
| | | |
Collapse
|
43
|
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the indications for the use of free-tissue transfer in lower extremity reconstruction. 2. Understand modalities to enhance the healing and care of soft tissue and bone before free-tissue transfer. 3. Understand the lower extremity reconstructive ladder and the place of free-tissue transfer on the ladder. 4. Understand the specific principles of leg, foot, and ankle reconstruction. 5. Understand the factors that influence the decision to perform an immediate versus a delayed reconstruction. Free-tissue transfer using microsurgical techniques is now routine for the salvage of traumatized lower extremities. Indications for microvascular tissue transplantation for lower extremity reconstruction include high-energy injuries, most middle and distal-third tibial wounds, radiation wounds, osteomyelitis, nonunions, and tumor reconstruction. The authors discuss the techniques and indications for lower extremity reconstruction.
Collapse
Affiliation(s)
- L Heller
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | | |
Collapse
|
44
|
Vural E, Key JM. Complications, salvage, and enhancement of local flaps in facial reconstruction. Otolaryngol Clin North Am 2001; 34:739-51, vi. [PMID: 11511473 DOI: 10.1016/s0030-6665(05)70016-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Complications are part of every surgical procedure and their occurrences are inevitable if the surgeon performs enough operations during his/her lifetime. Learning how to prevent complications and how to manage them when they occur are as important as learning how to perform any given surgical procedure. This is especially true in facial reconstruction with local flaps, as complications threaten not only the functional restoration of the integrity, but also the cosmetic appearance of the patient. This article describes common complications and their underlying mechanisms seen in facial reconstruction with local flaps as well as their treatment or prevention, when possible.
Collapse
Affiliation(s)
- E Vural
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
| | | |
Collapse
|
45
|
Smolle J, Cerroni L, Kerl H. Multiple pseudolymphomas caused by Hirudo medicinalis therapy. J Am Acad Dermatol 2000; 43:867-9. [PMID: 11050598 DOI: 10.1067/mjd.2000.110043] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Therapy with medicinal leeches (Hirudo medicinalis) is now frequently applied in plastic surgery and in the management of chronic venous insufficiency. We observed a patient in whom firm, brown-red, pea-sized papules developed at each site where leeches had been applied on the lower legs. Histology, immunohistology, and molecular analysis of T-cell receptor and immunoglobulin heavy chain gene rearrangement proved these lesions to be follicular pseudolymphomas.
Collapse
Affiliation(s)
- J Smolle
- Department of Dermatology, University of Graz, Austria
| | | | | |
Collapse
|