Successful Nose Replantation Using Leeches for Venous Draining

A 70-year-old woman was bitten in the face by her dog, avulsing a large piece of tissue. She had hypertension, type 2 diabetes, and an earlier history of smoking, and her body mass index was 38. The patient was transported by ambulance to the nearest hospital and was directly referred to the regional university hospital. The avulsed tissue was transported in a cooler ([Figs. 1] and [2]).

Fig. 1 Result of the dog bite and the extent of the injury. On the right hand side, there is a ligature placed on the nasolabial artery.

Fig. 2 Avulsed tissue.

The injury avulsed her nose, approximately 75% of the upper lip and parts of her cheeks. Part of her left upper lip was still attached to the face and the septal cartilage was intact. The nasolabial artery on the right side and the angular artery on the left side were both anastomosed with 9–0 sutures. Arterial circulation was restored within 7 hours of the injury. Further exploration of the injury yielded a small vein in the avulsed tissue which was anastomosed to a branch of the facial vein using an interposition vein graft. However, adequate venous drainage could not be established and therefore leech therapy was initiated in the operating room. The duration of the operation was 15 hours.

The patient was moved to the intensive care unit (ICU) with continued leech therapy. A regimen of low-molecular-weight heparin (LMWH; Klexane 40 mg) twice daily, ASA 75 mg daily, and dextran (Macrodex 500 mL daily) was initiated. Macrodex treatment was continued for 5 days and the LMWH therapy was reduced to half when leech treatment was discontinued after 14 days. Broad-spectrum antibiotics were given. To further increase venous drainage, mechanical traumatization of the congested tissue was initially performed with needle pricks and stab wounds. This was subsequently stopped in favor of leech therapy. Leeches were used regularly so that the color of the replanted tissue matched that of the intact tissue.

On day 1 after the replantation, the patient received a tracheostomy and a gastrostomy. On day 2, she was taken back to the operating room to reassess the vein anastomosis, but the vein was thrombotized ([Fig. 3]). Leech therapy was continued in the ICU and the patient substituted with blood and plasma. She was woken up on day 3 and mobilized. Fourteen days after the replantation, the patient had been treated with 358 leeches and had received 39 units of blood and 6 units of plasma. The patient was moved to the general ward on day 13 and discharged 24 days after the injury. A sloughing of necrosis in the replanted upper lip occurred resulting in a volume loss and scar retraction of the lip. The lip was reconstructed with an Abbé flap, together with minor scar revisions and a dermal graft to augment the upper lip, 179 days after the injury. The Abbé flap was divided after 28 days. No further corrective surgery has been performed.

Fig. 3 Two days postoperatively with the tissue congested and medicinal leeches in place.

On 3-year follow-up, the patient's nose and lip were aesthetically and functionally well ([Fig. 4]).

Fig. 4 Follow-up results 3 years after the injury.