Going Medieval on Your Breast

The leech is beautiful, more graceful than I expected, hanging blackly with a long and slender taper from Diane's tweezers. As we lay it down for its meal, it glistens and curls its sightless head against gravity like a swan's neck before latching its proboscis on the special du jour: Mrs. E's reconstructed breast.

* * *

"Ilene, please tell me you're joking."

My boyfriend does not want to believe me when I tell him that I leeched a patient today. "It's 2005, not 505. I think you were sleep deprived."

I don't blame him. I had been incredulous, too.

Mrs. E's mastectomy had gone well, and the plastic surgery team was beginning its work on her abdomen, making a fishmouthed tummy tuck incision. Reconstructive surgery is a "steal from Peter to pay Paul" proposition, and Dr. K had to obtain a flap of skin and fat to tranplant to Mrs. E's chest. But the game of anatomical muscial chairs is more complicated than just grabbing a hunk of flesh from the belly and slapping it onto her breast. Our challenge was to dissect out the tiny system of veins and arteries that supply Mrs. E's abominal tissue and hook them up with the blood vessels running down her breastbone. The vessels average two millimeters in size and are sewn together by microscope with sutures less than one twentieth of a milimeter thick - about half the diameter of a hair.

Even before we had completed the dissection in Mrs. E's abdomen, though, we knew something subtle was wrong. Her skin wasn't right. After the flap had been disconnected from her belly and reconnected to her her torso, it was a pinkish purple, as if her breast were blushing in embarassment. When we ran our fingers over it, nothing happened. Normal skin will "blanch" when pressed. It's like stepping on a garden hose: the skin will turn white as blood vessels are cut off, then change to pink when you take the pressure off the garden hose.

"Looks a bit congested," Dr. K said. She took a needle and pricked the skin, which bled dark, almost brown blood - unoxygenated, venous circulation and that the blood flow out of the graft was blocked.

"I think we're going to have to get the leeches," Dr. K said firmly. I sidled up to my resident and whispered.

"Umm, what does she mean by leeches? She doesn't mean... I mean, is it a kind of dressing?"

"No, like a worm. The animal. They've been shown to excrete hirudin, an anticoagulant. By sucking the blood trapped in the veins, they relieve the congestion until the body creates alternate vessels."

"Where do they get them? Do they just keep leeches in the pharmacy?"

"I guess so."

They brought five of them in a specimen container. "We've got to take the extra ones back to the pharmacist," the tech told us. The nurses groaned.

"You mean every time we need a leech we have to go to the pharmacy?"

Dr. K leaned over and drew out a leech, sleek and thin. The first time she laid it on Mrs. E's skin it curled up and fell off. She made another pinprick in the skin, placed it on the pooling blood, and it stuck, one end spooning out like a suction cup as it began to nurse.

Our patient, groggy, looked down on her side.

Dr. K took her eyes off the leech. "Roberta, so we're just using these leeches to reduce the amount of blood in the flap. It won't hurt. They have an anesthetizing agent in their bite." She turned to the nurses. "So, one leech every two hours. They'll just fall off when they're done, and you can dispose of them in that alcohol over there." The staff had created a little marked off area with tweezers and specimen cups, and "Leeches" written in permanent marker on a waterproof cover.

When I came back an hour later for a post operative check, the leech was still latched on to the curve of Mrs. E's chest, defying gravity. It was twice its size, looking more like a chubby thumb than a pinky. Already her skin was less pink, and when I touched it lightly with my gloved finger it turned briefly white, then filled up again.

"Looks great," I told her. "Kind of crazy, huh?"

"Yeah, it kind of feels like the Middle Ages," Mrs. E said sleepily. "But whatever works."