This article presents a protocol for the perioperative care of patients undergoing digital replantation, which is the most common microsurgical procedure performed today. Venous congestion, a common complication of digital replantation, often has been treated through surgical exploration and creation of arteriovenous anastomosis. Leech therapy, however, is experiencing a resurgence among surgeons as an alternative method for treating venous congestion. This article discusses the anatomical, physiological, and clinical indications and methods of leech therapy in digital replantation.