Martius Labial Fat-Pad Flap for Vesicovaginal Fistula
The Martius flap (Martius labial fat-pad flap) is the most commonly used interposition flap for transvaginal VVF repair.[1] It is a vascularized fibroadipose tissue graft harvested from the labium majus and interposed between the bladder and vaginal-wall closures, providing additional tissue bulk, blood supply, and a physical barrier between the suture lines. Routine use is controversial for simple fistulae but valuable for complex, recurrent, radiation-induced, and urethral-involving fistulae, with reported success 80–97% in those scenarios.[2][3][4]
For the general flap anatomy and harvest details across all reconstructive uses, see the Martius Flap foundations page. For the transvaginal repair techniques the Martius can be added to, see Latzko Repair and Sims-Simon Multilayered Closure.
Historical Background
Heinrich Martius (1885–1965), a German gynecologist, first described use of labial tissue for urogenital reconstruction in 1928 — originally as a bulbocavernosus muscle flap. Cadaveric studies by Elkins, DeLancey, and McGuire (1990) established that the tissue actually harvested in the modern Martius flap is fibroadipose tissue of the labium majus, not bulbocavernosus muscle. The graft has a prominent superficial fibrous tunic (analogous to the dartos in males) and considerable internal fibrous septa, making it a stronger graft than adipose tissue from other anatomic sites.[5][6]
Anatomy and Blood Supply
| Pedicle | Source artery | Use |
|---|---|---|
| Anterior | External pudendal artery (femoral) | Proximal / apical fistulae where the posterior pedicle would not reach.[5] |
| Posterior | Internal pudendal artery (internal iliac) | Mid-vaginal and distal fistulae — the most commonly used pedicle.[5][6] |
The two systems form a rich vascular plexus within the fibroadipose tissue, supporting reliable vascularity and neovascularization at the recipient site.[5][6]
A 2025 cadaveric neurovascular mapping study (Rothenberger n = 10) provided practical harvest guidance:[7]
- Highest vascular density in the lateral aspects of the labial fat pad.
- Highest nerve density in the anterior and medial aspects.
- The right labium had significantly greater vascular density (+8%) and nerve density (+9%) than the left.
- Implications: the right labium may yield a safer flap, and a lateral approach preserves the richest vascular pedicle while minimizing nerve injury.
Indications — Stratified by Strength of Evidence
Based on the Kapriniotis 2024 contemporary review:[2]
Strong indications (Martius most beneficial)
- Radiation-induced VVF — poorly vascularized tissue benefits most from the additional blood supply. Used in 41% of radiation-induced VVF repairs in the Pushkar 210-patient series.[8]
- Recurrent / failed prior repair — 91.7% (11/12) success with Martius vs 42.9% (3/7) with anatomic repair alone for recurrent fistulae.[3]
- Significant tissue loss or large fistulae (>4 cm) — when local tissue is insufficient for tension-free layered closure.[5]
- Urethral involvement / urethrovaginal fistula — flap provides bulk to reconstruct periurethral tissue.[3]
- Multiple fistulae — 87.5% (7/8) success with Martius vs 33.3% (3/9) with anatomic repair alone.[3]
Relative / debatable indications
- Simple, non-irradiated iatrogenic VVF — graftless repair achieves 86–100% closure; added morbidity of harvest may not be justified.[2]
- Obstetric fistulae — tissue interposition has been almost completely abandoned in contemporary practice, with large series reporting closure >90% with graftless repair even for complex obstetric fistulae.[2]
Surgical Technique
The Martius is adjunctive — placed between the bladder and vaginal-epithelial closures of either a Latzko or Sims-Simon repair.[9][5][6]
1. Labial incision
- Longitudinal incision over the labium majus on the side ipsilateral to (or closest to) the fistula.
- From the level of the clitoral hood superiorly to the labiocrural fold inferiorly — approximately 8–10 cm.
- Skin and subcutaneous tissue incised to expose the underlying fibroadipose tissue.
2. Flap mobilization
- Sharply dissect the fibroadipose tissue from overlying labial skin and the underlying bulbospongiosus / vestibular bulb.
- Mobilize circumferentially, preserving the chosen vascular pedicle.
- Typical flap dimensions: 3–5 cm wide × 6–10 cm long.
3. Pedicle selection
| Pedicle | Divide | Best for |
|---|---|---|
| Posterior pedicle (internal pudendal) | Anterior end | Mid-vaginal and distal fistulae (most common).[5][6] |
| Anterior pedicle (external pudendal) | Posterior end | Proximal / apical fistulae where posterior pedicle would not reach.[5] |
4. Tunnel creation
- Create a subepithelial tunnel from the labial incision to the vaginal repair site, passing beneath vaginal epithelium and the lateral vaginal wall.
- Tunnel must be wide enough to accommodate the flap without compression or kinking of the pedicle.
5. Flap transposition and fixation
- Pass the flap through the tunnel; position between the bladder closure and the vaginal epithelial closure.
- Secure to underlying pubovesical fascia or bladder muscularis with interrupted 3-0 delayed absorbable sutures.
- The flap should lie flat and tension-free, covering the entire bladder suture line.
- Offset the bladder and vaginal-epithelial suture lines from each other, with the Martius flap interposed.
6. Labial wound closure
- Layered closure with absorbable sutures.
- A small drain may be placed in the labial wound to prevent seroma / hematoma.
- Skin closed with interrupted or subcuticular absorbable sutures.
7. Vaginal closure
- Close vaginal epithelium over the flap with interrupted or running absorbable sutures.
Modifications
| Modification | Use |
|---|---|
| Full-thickness cutaneous Martius flap | When vaginal epithelium is insufficient — full-thickness flap including labial skin provides interposition + epithelial coverage.[10] |
| Modified Martius + PRP | Adjuvant platelet-rich-plasma injection has been combined with Martius placement for radiation-induced recurrent VVF — successful closure reported after two failed Latzko procedures.[11] |
| Bilateral Martius flaps | Very large defects; increases donor-site morbidity. |
Outcomes
| Series | n | Fistula type | Success | Key finding |
|---|---|---|---|---|
| Eilber 2003[4] | 34 (Martius) | Complex / recurrent iatrogenic | 97% | Comparable to peritoneal flap (96%); Martius preferred for distal fistulae |
| Rangnekar 2000[3] | 21 (Martius) | Obstetric VVF + urethrovaginal | 100% VVF, 87.5% urethrovaginal | 0% recurrence with Martius vs 19% without; 0% vs 33% dyspareunia |
| Elkins 1990[5] | 37 fistulae | Complex (large, recurrent, radiation) | 86.5% | Anatomic studies confirmed fibroadipose composition |
| Pushkar 2009[8] | 86 (Martius) | Radiation-induced | 48.1% primary, 80.4% cumulative | Used in 41% of 210 radiation-induced VVF repairs |
| Kapriniotis 2024 (review)[2] | — | All types | 80–97% for complex fistulae | Unnecessary for most obstetric fistulae; valuable for radiation / recurrent |
The Flap-vs-No-Flap Controversy
Whether the Martius (or any interposition flap) improves outcomes over graftless repair is one of the most debated questions in VVF surgery.[1][2]
Arguments for routine Martius use
- Adds a tissue layer between bladder and vaginal suture lines, reducing risk of overlapping suture-line breakdown.
- Brings new blood supply to ischemic or irradiated tissue.
- May reduce dyspareunia by cushioning the repair from the vaginal lumen — 0% dyspareunia with Martius vs 33% without in one series.[3]
- May reduce recurrence in complex, recurrent, and multiple fistulae.[3][1]
Arguments against routine use
- No high-quality RCT comparing Martius vs no flap for VVF repair. Cochrane identified this as a key comparison with limited data.[1]
- Contemporary large series achieve >90% closure without any tissue interposition for both obstetric and simple iatrogenic fistulae.[2]
- Adds donor-site morbidity — seroma, hematoma, numbness, pain, labial distortion.[1][12][13]
- Increases operative time and complexity.
- In obstetric fistulae, tissue interposition has been almost completely abandoned in modern practice.[2]
Current consensus
Repair should be individualized (Kapriniotis 2024). Martius interposition is probably unnecessary for the majority of obstetric fistulae within otherwise healthy tissues but may still have a place in select higher iatrogenic fistulae and most radiation-induced cases.[2]
Donor-Site Morbidity
| Series | n | Outcome |
|---|---|---|
| Petrou 2002[12] | 8 | 25% identical to preop appearance; 25% minimal change; 12% marked difference; 62% permanently decreased sensation / numbness; 13% dyspareunia; 38% intermittent discomfort at 1 yr. |
| Lee 2013[13] | 97 (mean 7-yr follow-up; largest long-term series) | 81% normal sensation; 14% numbness; 5% pain; 7% labial distortion; no perioperative complications. Concluded minimal early and delayed morbidity. |
The Cochrane review notes Martius harvest is associated with seroma, hematoma, numbness, pain, and labial distortion.[1]
Martius vs Alternative Interposition Flaps
| Flap | Best for | Success | Advantages | Disadvantages |
|---|---|---|---|---|
| Martius (labial fat pad) | Distal / mid-vaginal fistulae | 80–97% | Single surgical field; robust blood supply; no abdominal incision | Labial numbness; limited reach for very high fistulae |
| Peritoneal flap | Proximal / apical fistulae | 96% | Minimal morbidity; transvaginally accessible | Limited to fistulae with peritoneal access |
| Omental flap | Transabdominal repairs | 95–100% | Large, well vascularized; excellent reach | Requires laparotomy; ileus / abdominal-pain risk |
| Gracilis muscle flap | Very large defects; radiation | Variable | Large bulk | Significant donor-site morbidity; thigh weakness |
| Full-thickness labial flap | Insufficient vaginal epithelium | 33% | Provides epithelial coverage | Poor success rate; significant donor morbidity |
The Raz group's 10-year experience (n = 207) showed the peritoneal flap matches the Martius (96% vs 97%) with less morbidity — they preferred peritoneal for proximal fistulae and Martius for distal.[4]
Special Scenarios
- Radiation-induced VVF. Even with Martius, primary success was only 48.1% in the Pushkar series; cumulative success reached 80.4% with repeat operations. Multistep closure with progressive defect reduction is often required.[8]
- Recurrent fistulae. Martius shows the most dramatic benefit — 8.3% failure (1/12) vs 57.1% failure (4/7) without Martius (Rangnekar).[3]
- Urethrovaginal fistula. Martius provides periurethral bulk and support — 87.5% success.[3]
See Also
- Martius Flap (foundations / general anatomy)
- Transvaginal Latzko Repair
- Transvaginal Sims-Simon Multilayered Closure
- Endoscopic VVF Management
- Conservative VVF Management
- Vesicovaginal Fistula (clinical)
- Female Fistula Repair (atlas)
- Fistula Repair Principles
References
1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413
2. 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
3. Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary-vaginal fistulas. J Am Coll Surg. 2000;191(3):259–263. doi:10.1016/s1072-7515(00)00351-3
4. 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
5. 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.
6. Leach DA, Gebhart JB. Martius labial fat pad graft (use in rectovaginal fistula repair). Int Urogynecol J. 2020;31(11):2427–2429. doi:10.1007/s00192-020-04315-3
7. Rothenberger RW, Feroz R, Hogarth N, et al. Neurovascular mapping of the labial fat pad: implications for optimal Martius flap harvest. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06383-9
8. 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
9. Marina T, Lago V, Padilla P, Matute L, Domingo S. Vesicovaginal fistula repair by modified Martius flap: a step-by-step surgical technique video. Ann Surg Oncol. 2021;28(2):1002–1006. doi:10.1245/s10434-020-09020-5
10. Carr LK, Webster GD. Full-thickness cutaneous Martius flaps: a useful technique in female reconstructive urology. Urology. 1996;48(3):461–463. doi:10.1016/S0090-4295(96)00193-8
11. Kołodyńska A, Streit-Ciećkiewicz D, Kot A, Kuliniec I, Futyma K. Radiation-induced recurrent vesicovaginal fistula — treatment with adjuvant platelet-rich plasma injection and Martius flap placement: case report and review of literature. Int J Environ Res Public Health. 2021;18(9):4867. doi:10.3390/ijerph18094867
12. Petrou SP, Jones J, Parra RO. Martius flap harvest site: patient self-perception. J Urol. 2002;167(5):2098–2099.
13. Lee D, Dillon BE, Zimmern PE. Long-term morbidity of Martius labial fat pad graft in vaginal reconstruction surgery. Urology. 2013;82(6):1261–1266. doi:10.1016/j.urology.2013.08.032