temperature as the original. Approximately 8 leeches should be kept in 1 liter of water. Leeches should be handled gently by wearing nitrile or latex gloves, which would also prevent leeches from biting the health provider during maintenance of or treatment with leeches. 4. Application of Leeches to the Skin Before application, leeches are thoroughly rinsed with deionized water. The area to be exposed to leeches should be cleaned with sterile distilled water and ointments such as Doppler gel are removed. A plastic adhesive membrane or a thick layer of gauze can be applied around the leech(es) to prevent detached leeches from attaching themselves in other parts of the skin or even under the flap, to fall inside the dressing around the wound or other parts of the patient’s body or on the bed, which could upset the patient and be unpleasant for other patients nearby. In general leeches should be applied on the darker spots of the reattached body parts or flaps. In the case of reimplanted fingers, leeches could be also placed on the region of the removed nail. The leeches are usually placed on a given spot of the skin using a 5 mL syringe. For this purpose, the nozzle of the syringe is removed using a scissor or scalpel. The leech is placed in the barrel of the syringe and the open end of the syringe is placed on the area to be treated. When the leech starts feeding, the syringe is removed gently (Figure 1) Application of a leech to the area to be treated using a syringe. Leeches normally start feeding immediately, although in some cases the skin has to be punctured with a sterile needle so that oozing blood will stimulate the leeches to feed. Pricking the site to be treated could also demonstrate whether there is sufficient blood-flow in the area. When the leech refuses to feed in a given place, the syringe is moved to the neighboring area, until an appropriate place is found as close as possible to the congested area. Depending on the intensity of blood-flow in the area, feeding can last for 30–90 min. During feeding drops of clear liquid can be seen oozing from the leech (Figure 2); this is the superfluous water in blood, which the leeches remove to concentrate the red blood cells in their digestive tract. Feeding leech: transparent liquid can be seen oozing from the body of the leech. During hirudotherapy the patient should be under permanent surveillance by a healthcare provider; leeches may seek other places to suck blood or after feeding may drop into the surrounding area. After autodetachment, the leeches are killed in 70% ethyl alcohol and are disposed in bags for biological waste. In cases of intraoral leeching, the path to the oropharynx should be blocked with gauze to prevent leech migration into the more distal aerodigestive tract, and the perioperative tracheotomy is left in position to protect the airway [29]. Specially shaped glass containers can be used for this purpose [33]. Attention should be paid to leeches, which attach but do not change in size and have no visible gut peristalsis within 30 min after their attachment. It could be assumed that they are only attached but not feeding and should be replaced with other leeches or they should be transferred to other parts of the treated area. The use of active (swimming) and larger leeches could be of help. 5. Treatment Procedure Depending on the severity and the size of the congestion, 1–10 leeches are used for each treatment, although some authors recommend higher numbers of leeches. The degree of