title: Compromised breast flap treated with leech therapy, hyperbaric oxygen, pentoxifylline and topical nitroglycerin: A case report.
abstract: BACKGROUND
  Hyperbaric oxygen (HBO2) is often indicated in compromised surgical flaps. Although limited to animal models and human case reports, the utilization of leech therapy (Hirudo medicinalis) with HBO2 provides better outcomes than each modality alone. Topical nitroglycerin and pentoxifylline are also frequently used adjunctively for compromised flaps. We present a case of successful breast flap salvage utilizing a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline.
  
  
  METHODS
  A 34-year-old female, one day post-status cosmetic breast reduction mammoplasty developed a dusky discoloration of the left nipple areolar complex, indicating imminent flap failure. The patient was immediately treated with topical nitroglycerin, oral pentoxifylline, and referred for HBO2. After her first HBO2 treatment, there was clinical improvement to the superior portion of the areolar flap, with little improvement inferiorly where the discoloration had remained essentially unchanged. To address this, we added leech therapy and discontinued the topical nitroglycerin. Ceftriaxone for Aeromonas prophylaxis was started, and leeches were attached two at a time and removed from the area once feeding had ceased. These were applied three times per day for three days while receiving HBO2 twice per day for six days. The patient's flap improved and completely healed by Week 8 without need for further surgery.
  
  
  CONCLUSIONS
  This is the first case to our knowledge of successful breast flap salvage using a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Moffat
authors.forename: Lindell K
authors.initials: LK
authors.lastname: Weaver
authors.forename: William H
authors.initials: WH
authors.lastname: Tettelbach
mesh_terms: D000328:Adult; D000818:Animals; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002443:Ceftriaxone / Q000627:therapeutic use; D003131:Combined Modality Therapy / Q000379:methods; D005260:Female; D006085:Graft Survival; D006801:Humans; D006931:Hyperbaric Oxygenation / Q000379:methods*; D024763:Leeching / Q000379:methods*; D016462:Mammaplasty / Q000009:adverse effects*; D009558:Nipples / Q000601:surgery; D005996:Nitroglycerin / Q000627:therapeutic use*; D010431:Pentoxifylline / Q000627:therapeutic use*; D010859:Pigmentation Disorders / Q000628:therapy; D016879:Salvage Therapy / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply; D014665:Vasodilator Agents / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D014665:Vasodilator Agents; D002443:Ceftriaxone; D005996:Nitroglycerin; D010431:Pentoxifylline