Martius Flap
The modified Martius flap transfers vascularized labial fibrofatty tissue to a nearby urethral or vaginal repair. It can separate suture lines and supplement compromised tissue. Its value depends on the defect and the quality of the primary reconstruction; it does not replace a tension-free, watertight closure.[13][14]
This is the foundations-level harvest and selection page. The VVF, RVF and urethral-diverticulum pages cover the underlying condition and complete repair pathway.
Martius labial fat-pad flapOriginal schematic · v2026-09-11 · Clinical review pendingA labial fibrofatty flap is mobilized on a preserved vascular pedicle and tunneled to cover a nearby urethral or vaginal repair.View: Female perineum, anterior up. Scale: Conceptual schematic; not to scale. Units: No measured geometry; any dimensions are illustrative.Limits: Pedicle choice and dissection depend on anatomy; avoid inferring that every illustrated vessel or flap size is universal. Interposition is selective.Source check: 2026-09-11. This is an editorial check with the access limits below. No named clinician has signed off.EAU Non-neurogenic Female LUTS: disease management — 2026 web guideline. Access: official full text. Continence operations and fistula-repair principles; does not validate exact suture trajectories.WARWIKI original vector schematic; individual illustrator not recorded. No separate figure reuse license recorded; linked sources are concept references, not artwork licenses.Open original SVG with embedded source record ↗
A labial fibrofatty flap is mobilized on a preserved vascular pedicle and tunneled over a nearby repair. This schematic illustrates an inferiorly based flap; it does not prescribe a universal pedicle, side or flap size.
Tissue and vascular anatomy
The historical Martius operation included bulbocavernosus muscle. The modern labial fat-pad modification usually preserves the muscle. Older publications sometimes use “bulbocavernosus,” “graft” and “Martius” loosely; establish what tissue was actually transferred before comparing techniques.[1][13]
| Vascular contribution | Operative implication |
|---|---|
| Superior/anterior contribution from the external pudendal system | May support a superiorly based design |
| Inferior/posterior contribution from the internal pudendal system | Commonly preserved for an inferiorly based flap, including urethral and vaginal interposition |
The repair's anterior or posterior location alone does not determine which pedicle to preserve. Assess reach, scarring, prior operations and the actual vascular base. Preserve a broad pedicle and avoid a compressed or twisted tunnel.[13]
A ten-cadaver mapping study found differences in vascular and nerve density, including greater right-sided vascular density. This anatomical observation does not establish better clinical outcomes with routine right-sided harvest.[3]
Harvest and inset
The following describes the fat-pad modification; adapt exposure and dissection to the patient's anatomy and the planned repair.[13]
- Select the donor side and intended pedicle after assessing the recipient defect and required reach.
- Open the labium majus and identify the fibrofatty pad while preserving the overlying skin and deeper structures.
- Mobilize the pad with its vascular base intact. Protect the bulbospongiosus and vestibular tissues rather than automatically including muscle.
- Create an atraumatic tunnel wide enough for the flap and its pedicle; pass it without torsion or constriction.
- Secure the flap over the completed repair without tension, then close the recipient and donor wounds with careful hemostasis.
Drain use depends on the dissection and dead space. Published techniques include a temporary labial drain; “no drain required” is not a universal rule.[13][14]
Vesicovaginal fistula: use interposition selectively
For a simple VVF with healthy tissue and a sound closure, routine Martius interposition has not demonstrated an additional closure benefit. The 2024 systematic review found no clear benefit from vaginal interposition overall; its studies mixed flap types, fistula characteristics and study designs. The result should not be generalized to extensive radiation injury or every recurrent defect.[15]
| Evidence | Finding and application |
|---|---|
| Singh 2019 randomized comparison | Among 57 vaginal repairs of selected simple fistulas, closure occurred in 27/29 with Martius vs 27/28 without. Nine of 29 flap recipients reported labial numbness or pain. The study did not establish equivalence and excluded recurrent, radiation-associated and other complex/complicated fistulas. |
| Eilber 2003 observational series | Of 207 vaginal repairs, 34 used Martius, 83 peritoneum and three a skin interposition. Reported 97% Martius closure concerns the 34-patient subgroup; differences in defect location and selection preclude a head-to-head efficacy comparison. |
| Pushkar 2009 radiation series | Of 216 patients, 210 underwent a vaginal approach, including 86 Martius repairs. First-attempt success was 48% and cumulative success after further attempts 80.4% across the vaginal cohort, not a Martius-specific success rate. |
Sources: Singh, Eilber and Pushkar.[14][5][6]
Consider vascularized interposition when tissue loss, fibrosis, prior failure or radiation injury compromises reconstruction. Choose tissue with adequate health, bulk and reach; severe radiation damage may require a different reconstruction or diversion. No flap makes an otherwise inadequate closure reliable.[4][13]
Urethral diverticulectomy and urethral reconstruction
Martius interposition can support selected complex or recurrent diverticulectomy, urethroplasty and urethrovaginal-fistula repairs. It is an adjunct to urethral reconstruction, not a continence sling.[13]
In Malde's 70-patient diverticulectomy series, all patients received a Martius flap and one had recurrence. Of 41 women without preoperative stress incontinence, ten developed it initially and five still reported symptoms at 12 months (overall mean follow-up 19 months): the reported persistent de novo rate is approximately 12% of those at risk, not 12% of all 70. Without a no-flap comparator, this series cannot establish the incremental benefit of the flap.[7]
For bladder-neck closure, interposition is part of selected salvage reconstruction of a devastated outlet, with a separate long-term bladder-drainage plan. It is not routine treatment for stress incontinence.[13]
Rectovaginal fistula
ASCRS 2022 recommends gracilis or Martius interposition for recurrent or otherwise complex RVF (strong recommendation, low-quality evidence; 1C). Assess the fistula's cause, sphincter function, tissue quality, infection and previous repairs before selecting the operation.[8]
The 2024 Martius meta-analysis included 137 flaps in 12 nonrandomized studies: 44 primary and 93 recurrent RVFs. Pooled success was 91.4% for primary and 77.5% for recurrent fistulas. The pooled complication estimate was 29%, with substantial heterogeneity and a wide 95% CI of 9.0–54.7%. These are selected series with differing outcomes and follow-up, not individual success predictions or proof of superiority over another flap.[9]
Pastier's retrospective multicenter cohort included 62 patients who underwent 55 Martius and 24 gracilis procedures. Success required absence of both fistula and stoma. Immediate success was 35% and 31%; both groups reached a reported 69% after further treatment at median 23-month follow-up. Repeated procedures and nonrandom selection prevent an equivalence conclusion or a universal “Martius first, gracilis second” rule.[10]
Diversion is individualized. ASCRS generally supports an adjunctive stoma for these complex flap repairs while acknowledging limited evidence. Selected repairs without diversion have been reported; they do not prove omission is safe for every patient. Control infection and address active inflammatory disease before definitive reconstruction.[8][10]
Mesh exposure versus erosion into the urinary tract
These require different decisions. ACOG/AUGS Committee Opinion 694 (2017) describes Martius coverage of a functioning but persistently vaginally exposed sling as an option supported by case reports when preservation remains the patient's preference. It is not a recommendation to cover mesh eroding into the urethra or bladder.[11]
Urinary-tract erosion or a mesh-associated fistula requires assessment of the involved mesh and the necessary excision and reconstruction. Martius tissue may reinforce the repair after appropriate mesh management; it does not remove the source of injury. In Blaivas's small series, the 78% overall closure rate included several fistula types and reconstructions and was not a Martius-only outcome.[11][12]
Donor morbidity and counseling
Discuss hematoma, infection, wound problems, labial asymmetry, altered sensation, persistent pain and sexual symptoms. Complication estimates depend on how actively these outcomes are sought.[2][14]
Malde's mixed-indication series of 159 patients reported two hematomas, one infection and one cosmetic dissatisfaction report; 79% rated the appearance good or excellent. The 31% sensory-symptom finding in Singh's small randomized vaginal subgroup demonstrates why one series' low event count cannot be converted into a universal “less than 5% complications” guarantee.[2][14]
Document anatomical closure separately from continence, pain, sexual function and need for further procedures. Choose an alternative flap when the labial tissue or pedicle cannot safely reach the defect.[13][15]
Related reconstruction options
- Gracilis — additional vascularized tissue for selected complex perineal defects.
- Peritoneal flap — an option for suitably accessible vaginal repairs.
- Omental flap — abdominal interposition when viable omentum can reach.
- Blandy flap — vaginal-flap urethroplasty.
- Flaps in GU reconstruction — general flap selection and handling.
References
1. Elkins TE, DeLancey JO, McGuire EJ. "The Use of Modified Martius Graft as an Adjunctive Technique in Vesicovaginal and Rectovaginal Fistula Repair." Obstet Gynecol. 1990;75(4):727–733.
2. Malde S, Spilotros M, Wilson A, et al. "The Uses and Outcomes of the Martius Fat Pad in Female Urology." World J Urol. 2017;35(3):473–478. doi:10.1007/s00345-016-1887-2
3. Rothenberger RW, Feroz R, Hogarth N, et al. "Neurovascular Mapping of the Labial Fat Pad: Implications for Optimal Martius Flap Harvest." Int Urogynecol J. 2026;37(7):1997–2003 (published online 2025). doi:10.1007/s00192-025-06383-9
4. Kapriniotis K, Loufopoulos I, Gresty HCM, Greenwell TJ, Ockrim JL. "The Utility of Martius Fat Pad in the Repair of Urogenital Fistulae: Review of Current Evidence." BJU Int. 2024;134(3):365–374. doi:10.1111/bju.16350
5. Eilber KS, Kavaler E, Rodríguez LV, Rosenblum N, Raz S. "Ten-Year Experience With Transvaginal Vesicovaginal Fistula Repair Using Tissue Interposition." J Urol. 2003;169(3):1033–1036. doi:10.1097/01.ju.0000049723.57485.e7
6. Pushkar DY, Dyakov VV, Kasyan GR. "Management of Radiation-Induced Vesicovaginal Fistula." Eur Urol. 2009;55(1):131–137. doi:10.1016/j.eururo.2008.04.044
7. Malde S, Sihra N, Naaseri S, et al. "Urethral Diverticulectomy With Martius Labial Fat Pad Interposition Improves Symptom Resolution and Reduces Recurrence." BJU Int. 2017;119(1):158–163. doi:10.1111/bju.13579
8. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473
9. Swindon D, Izwan S, Ng J, et al. "Martius Flaps for Low Rectovaginal Fistulae: A Systematic Review and Proportional Meta-Analysis." ANZ J Surg. 2024;94(9):1471–1479. doi:10.1111/ans.18922
10. Pastier C, Loriau J, Denost Q, et al. "Rectovaginal Fistula: What Is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy?" Dis Colon Rectum. 2024;67(8):1056–1064. doi:10.1097/DCR.0000000000003148
11. American College of Obstetricians and Gynecologists; American Urogynecologic Society. Management of mesh and graft complications in gynecologic surgery. Committee Opinion No. 694. Obstet Gynecol. 2017;129:e102–e108. ACOG guidance.
12. Blaivas JG, Mekel G. "Management of Urinary Fistulas Due to Midurethral Sling Surgery." J Urol. 2014;192(4):1137–1142. doi:10.1016/j.juro.2014.04.009
13. Wilson A, Pillay S, Greenwell T. How and why to take a Martius labial interposition flap in female urology. Transl Androl Urol. 2017;6(Suppl 2):S81–S87. doi:10.21037/tau.2017.04.38.
14. Singh V, Mehrotra S, Bansal A, Akhtar A, Sinha RJ. Prospective randomized comparison of repairing vesicovaginal fistula with or without the interposition flap: result from a tertiary care Institute in Northern India. Turk J Urol. 2019;45(5):377–383. doi:10.5152/tud.2019.85233.
15. Thompson JC, Halder GE, Jeppson PC, et al. Repair of vesicovaginal fistulae: a systematic review. Obstet Gynecol. 2024;143(2):229–241. doi:10.1097/AOG.0000000000005468.