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. 1. Introduction Medicinal leeches have been used in the past 50 years for the salvage of tissue with venous congestion. In 1960, Deganc and Zdravic [1] conducted the first treatment of congested flaps using leeches. Today, especially in the field of reconstructive microsurgery, medicinal leech therapy is enjoying a renaissance (for review see also [2, 3]). Leeches are generally used during the critical postoperative period when venous outflow cannot match the arterial inflow, which can lead to venous congestion, clinically identified by the dusky purple appearance of the skin. If this complication is not corrected, cell death may result and the flap or finger may be lost. Therefore, medicinal leeches are used to salvage compromised microvascular free-tissue transfers, replanted digits, ears, lips, and nasal tips until angiogenesis gradually improves the physiological venous drainage [4]. Frodel et al. [5] used medicinal leeches to salvage soft tissue avulsion in key facial structures of 4 patients involving avulsions of the ear, nose, lip, and scalp. In addition to using leech therapy in head and neck reconstruction, there are numerous studies showing the use of leech therapy for hematomas, penile and total scalp replantation, and pedicled skin flaps, as well as for the salvage of the entire lower limp [6–19]. Leech therapy is usually initiated after failure of more conventional treatment modalities such as warming, aspirin, rheomacrodex (i.v.), immobilization and elevation of the injured area, and use of local heparin and vasodilators to improve venous status. Venous obstruction causes microcirculatory thrombosis, platelet trapping, and stasis. Thus, even after successful reanastomosis, secondary changes in the microcirculation can persist and prevent adequate outflow from being reestablished. Free flaps, pedicled flaps, and replanted tissues can survive arterial insufficiency for up to 13 hours, but venous congestion can cause necrosis within three hours. Medicinal leeches may be helpful in treating tissues with venous insufficiency by establishing temporary venous outflow, until graft neovascularization takes place [20]. In July 2004, the FDA approved leeches as a medical device in the field of plastic and reconstructive surgery. A survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland showed that the majority of these units uses leeches postoperatively [21]. The aim of these recommendations is to review the practical use of medicinal leeches in reconstructive plastic surgery by reporting our experience with leeches in cases of reimplanted digits and free-tissue transfers. 2. Conditions for Treatment with Leeches Once venous congestion has been identified and the patient has agreed to undergo leech therapy, it is important that the patient is informed about the benefits and potential risks of the treatment. A written informed consent should be obtained from the patients, their parents, and/or the legal guardian before hirudotherapy is initiated. There is a general consensus that antibiotic prophylaxis for the Aeromonas bacteria, which are symbionts of leeches and which could lead to complications, should be initiated before leech therapy [22,