venous congestion is estimated from the percentage of violaceous color of flap skin pedicle, testing capillary refill, and color of the blood oozing from the bite site or after having been pierced with a needle. At the beginning of the treatment, the patient might need two or more treatments per day. Chepeha et al. [29] used a protocol according to which leech placement was continuous (3 leeches per hour) and tapered slowly according to clinical assessment of inosculation. In the Iowa Head and Neck Protocol [30], leeches are applied every 2 hours. The number of treatments per day depends also on the bleeding of previous bite sites. In cases where the bleeding stops shortly after the leeches detach, or when leeches do not become fully engorged, a more aggressive treatment should be followed by using a larger number of leeches and 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. In fact, the decision regarding the duration of the leech treatment is empiric, based on subjective appreciation of the color of the skin, capillary refill, and the color of bleeding after pinprick [12, 29, 34–36]. Flap monitoring consists of listening to the Doppler signal and examining the flap every 1-2 hrs until the flap is stabilized and thereafter every 2–4 hrs [29]. Antithrombotic therapy could be administered with aspirin, heparin sodium, and/or dextran 40 in parallel with hirudotherapy, although it should be noted that the leech saliva also demonstrates antithrombotic activity. The patients may lose 5–15 mL of blood per leech, per session. However, the wound may continue to ooze up to 24 hours after the leech is removed. Accordingly, hematologic evaluations should be performed every 4 hrs and consist of complete blood cell count, partial thromboplastin time, and serum chemistry studies. However, the number of hematocrit checks depends on the number of leeches used, frequency of sessions, and total duration of therapy. In many cases, the patients have to receive blood transfusions when the hemoglobin level is lower than 8 g/dL [29]. After detachment of the leech, the bite areas could be cleaned hourly with gauze soaked in isotonic sodium chloride solution or heparin solution (5,000 U/mL) to stimulate hemorrhage from leech bite sites [22, 33]. Successful salvage of decongested tissues with leeching has been reported in 70–80% of cases [10, 21, 37, 38]. In Israel, Mumcuoglu et al. [22] used hirudotherapy in 23 patients, 8–79 years old, presenting with venous congestion of revascularized or replanted fingers and free or local flaps. Of the 15 fingers, 10 fingers were saved (66.7%) (4 out of 9 replanted fingers and 6 out of 6 revascularized fingers), while 17 out of 18 flaps (94.4%) were salvaged (3 out of 4 free flaps and all 14 island and random flaps) (Figure 3). Similar results were reported from countries such as the USA [15, 22], UK [17], Germany [39], and S. Africa [31]. Treatment of a skin flap of the face, after removal of the skin with scars and coverage of the area with the enlarged, adjacent skin. The degree of venous congestion can be estimated by describing the percentage of ruborous and violaceous color of the flap skin pedicle, testing capillary refill, and observing color and amount of blood oozing from leech bite sites. Serial photographs can help assess the intensity of venous congestion on a daily basis. The progress of treatment should be also documented. It