PURPOSE:  
Microvascular tissue transfer has become a commonly performed procedure for breast reconstruction. Venous congestion in the postoperative period can be a problem with microsurgical procedures. Management of venous compromise includes both surgical and nonsurgical interventions.  Medicinal leech therapy has been used successfully in the management of venous congestion in microsurgery.   
                                
METHOD:
Our patient is a 51 year old female with history of stage II right breast cancer who underwent neoadjuvant chemotherapy, bilateral mastectomies followed by radiation therapy.  Thirteen months after her radiation was completed she underwent delayed breast reconstruction with bilateral free muscle sparing TRAM flaps.  Her initial postoperative course was uneventful, however on postoperative day ten she noted coolness and bluish discoloration to the reconstructed left breast mound.  On examination there was venous congestion noted to the dependent areas of the left TRAM skin island despite arterial Doppler signals throughout the flap and brisk capillary refill.

RESULTS:
Starting postoperative day eleven, medicinal leech therapy was utilized to alleviate the venous congestion to the left TRAM flap.  Leeches were applied every 1-2 hrs to different locations on the flap skin paddle.  Over the next several days there was improvement in the overall appearance of the flap with near complete resolution of the venous congestion by day six of the leech therapy.  The patient was discharged to home on therapeutic low molecular weight Heparin for an additional two weeks.  A subsequent hematologic workup to rule out an underlying thrombophilic disorder demonstrated an elevated Factor VIII level.  At her one year follow up, the patient was noted to have volume loss to the left TRAM flap without associated fat necrosis or flap loss.   She eventually underwent placement of subpectoral silicone gel implants bilaterally to improve the volume symmetry of her reconstruction.

CONCLUSION:
Reported rates of successful late free flap salvage range from 0-33%. Nonsurgical salvage of late venous congestion with medicinal leech therapy may be possible because of the neovascularization that occurs to some extent between the flap and the recipient bed. We report a case such a case of  late salvage of a free TRAM flap with medicinal leech therapy.