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Labia Majora Fasciocutaneous Flap

The labia majora fasciocutaneous flap transfers a full-thickness pedicled skin island, subcutaneous tissue and fascia for vaginal-wall replacement. It overlaps with the previously described full-thickness cutaneous Martius flap. The conventional modified Martius flap transfers a labial fat pad for interposition without an epithelial surface.[1][13]

It is an option for selected complex urogynecologic fistulas with concomitant vaginal-wall deficit, in which fistula closure alone may leave an inadequate, rigid or absent vagina.[1]

Vascular Basis​

The labia majora receives dual blood supply:

  • Anterior labial arteries (from the external pudendal system) contribute to anterior labial perfusion.
  • Posterior labial arteries (from the internal pudendal system) contribute to posterior labial perfusion.

Pedicle choice and orientation depend on defect position, reach, prior incisions and the vascular territory preserved in the individual flap.

The epifascial and subfascial arterial networks of the perineal region permit peninsula or island designs in selected defects.[2][3] Sensory preservation depends on the individual flap design and nerve dissection.[2][3]

Rothenberger and colleagues mapped the Martius labial fat pad, not the full-thickness fasciocutaneous flap, in 10 cadavers. Vascular density was 8% greater in the right labium than the left (p < 0.001), with the highest density in the right lateral labium, and the medial-versus-lateral difference was not significant (p = 0.55). Nerve density was highest in the anterior and medial fat pad.[4]

For the conventional Martius fat-pad flap, the same labial vascular system supports an interposition pad without the overlying skin and fascia.

Indications​

The defining indication is a complex urogynecologic fistula with vaginal deficit, where the vagina itself is inadequate and the defect requires tissue replacement and not just interposition.[1]

  • Complex VVF with a rigid, non-capacious, radiated vagina. A fistula after radiotherapy for primary cancer treatment may indicate tumor recurrence; assess for this before reconstruction.[16] Labia majora tissue augments both the fistula repair and the vaginal wall.[1]
  • Urethrovaginal fistula with anterior vaginal wall loss and stenosis. The flap restores vaginal caliber while closing the fistula.
  • Vesicolabial fistula. The fistula tract communicates with the labia; flap repair is natural.
  • Recurrent VVF after failed Martius interposition, where full-thickness tissue replacement may be considered
  • Post-obstetric or post-radiation vaginal-wall loss where vaginal reconstruction is needed concurrent with fistula closure

Harvest and Technique​

Design​

  • Flap outlined on the labia majora on one side (or bilaterally for larger defects), selecting hairless medial skin for vaginal lining when anatomically possible.[13][14]
  • Full-thickness flap including skin, subcutaneous fat, underlying fibrofatty tissue, and investing fascia
  • Pedicle preserved posteriorly (posterior labial a.) or anteriorly (anterior labial a.) depending on required reach
  • Flap dimensions tailored to the defect and a tension-free, perfused inset; published dimensions should be checked in the specific operative report before being used as a template

Dissection​

  1. Assess field readiness and expose the defect. Once any oedema, inflammation, tissue necrosis or infection has resolved, use perineotomy or vaginal dissection to expose the fistula and deficient vaginal wall. The EAU rates individualized repair timing as a weak recommendation.[16]
  2. Close the fistula (cystorrhaphy, urethrorrhaphy) with a standard technique. For VVF, Tatar et al. describe cystoscopic tract mapping, ureteral catheterization when an orifice is close, and a diluted-methylene-blue leak test before completing vaginal closure.[17]
  3. Elevate the labia majora flap from distal to proximal, sparing the pedicle
  4. Identify and preserve the labial artery and its venae comitantes on the undersurface of the flap
  5. Tunnel the flap beneath the perineal skin to the vaginal defect through a passage wide enough to avoid pedicle compression.[14]
  6. Inset as vaginal wall replacement. The flap skin becomes neovaginal epithelium.
  7. Donor site closed primarily in most cases; may require local rotation advancement if large
  8. Postoperative bladder drainage. Maintain continuous drainage until fistula healing is confirmed. The EAU rates this a weak recommendation; its suggested 14–21 days for complex or post-radiation repair is expert opinion and should be tailored to the repair.[16]

The sequence above is a general outline. Gupta's series describes several technical modifications made for individual fistulas.[1]

Principle​

The labia majora fasciocutaneous flap (1) covers the fistula repair with a vascularized interposition layer, like a Martius flap, and (2) provides vaginal wall tissue, with skin and fascia replacing the missing vaginal surface. The second contribution distinguishes it from the conventional Martius fat-pad flap, which provides only interposition.

Outcomes — Complex Urogynecologic Fistula​

Gupta 2022 series (7 patients, complex urogynecologic fistulas):[1]

  • All patients with radiation-induced VVF had no postoperative leak, except one who became dry only after later colpocleisis. The series does not report a cohort-wide success rate.
  • The patient with urethrovaginal fistula and vaginal stenosis was continent with a capacious vagina and regular menstrual periods. The patient with vesicolabial fistula was dry at six months.

Vulvar Reconstruction After Oncologic Resection​

Various skin flaps, including axial pattern, fasciocutaneous and musculocutaneous flaps, can restore vulvovaginal form and function with acceptable donor-site and recipient-site morbidity, and function is harder to restore in irradiated tissue.[2] A 2024 review of 49 studies (1,840 patients) found no significant difference in short-term complication rates between perforator and non-perforator vulvoperineal flaps; it did not compare labia majora flap variants specifically.[15] Examples of flap choice by defect from published series. For vulvar cancer reconstruction, ESGO 2023 recommends selecting the reconstruction type by patient and tumor characteristics and surgical-team experience ([IV, B]); its panel endorsed no preferred technique.[20]

  • Small-to-medium vulvar defects. Salgarello's algorithm uses island V-Y flaps, island gluteal fold flaps or pedicled pudendal-thigh flaps. Among these, Salgarello preferred the island V-Y flap for its versatility, reliability and technical simplicity with a very low complication rate (31 flaps in 20 reconstructions).[6]
  • Anterior and posterior commissure defects. Anteriorly or posteriorly based labial flaps are used as appropriate.[2]
  • Hemivulvectomy defects. Unilateral labial or pudendal-thigh flaps are used.[2]
  • Symmetric anterior defects. Moschella and Cordova used a V-Y amplified sliding flap from the pubis, vascularized by the deep arterial network of the pubis and sensate through ilioinguinal nerve branches.[3]
  • Posterior defects after hemivulvectomy or radical vulvectomy. Moschella and Cordova raised a fasciocutaneous island flap from one or both gluteal folds, vascularized by pudendal artery perforators and innervated by perineal branches of the pudendal nerve.[3]
  • Large or very large defects. In Salgarello's algorithm V-Y flaps close large defects, and a distally based vertical rectus abdominis flap is recommended for very large defects extending anteriorly and posteriorly.[6]

Kwong studied mixed locoregional vulvar flaps, not a cohort specific to the labia majora fasciocutaneous flap (136 flaps in 69 women):[5]

  • 92.6% (126/136) of flaps had none-to-mild complications at 7 days.[5]
  • 83.1% (113/136) had none-to-mild complications during days 8–30.[5] Five necrotic flaps in two women required debridement.
  • Patient-reported genital, urinary, sexual and body-image measures improved in assessed subsets at 12 months.

Al-Benna and Tzakas reported that 12 of 13 local fasciocutaneous flaps with superficial-fascial-system repair healed primarily after vulvar ablation. Complications were two superficial wound infections and one minor dehiscence.[7]

Vaginoplasty and Neovagina Creation​

  • Flack 1993. A related but distinct labia minora flap with Lucite dilators for vaginal agenesis, reported in three teenage girls without postoperative complications at 1 year.[8]
  • Belloli 1997. A separately described tissue-expanded labial-skin-flap vaginoplasty in two adolescents. Its reported freedom from postoperative dilation does not apply to nonexpanded labia majora flaps.[9]
  • Partial vaginal defects. Labial flaps are well suited to functionally important small-volume vaginal defects, such as those resulting from fistula excision.[2]

Tubularized Labial Urethroplasty for Complex Female Stricture​

Xu and colleagues treated 8 women with urethral strictures and urethrovaginal fistulas after pelvic fracture using transpubic access and a pedicled labial skin flap urethroplasty. The flap (about 3 × 3.5 × 3 cm from the labia minora or majora) was tubularized over an 18–22 Fr stent in five women, and two smaller flaps were pieced together in three:[10]

  • No postoperative complications were reported. Transient dysuria and stress incontinence resolved spontaneously.
  • One patient needed urethral dilation for difficulty voiding at 3 months, and the other seven had normal micturition after catheter removal (mean follow-up 48 months, range 10–118).[10]
  • The authors describe the technique for extensive urethral damage in this setting.

Recurrent Urethrovaginal Fistula​

Candiani 1993 described a distinct island bulbocavernosus musculocutaneous flap raised from the labium majus to reconstruct the anterior vaginal wall after urethral suture in one woman with a recurrent postpartum urethrovaginal fistula.[11]

Perineal Reconstruction​

Windhofer 2011 described a distinct fasciocutaneous infragluteal flap for perineal reconstruction after rectal and anal disease. Complete healing occurred in 13 of 14 patients in that series.[12]

Design Variations​

Flap designVascular basisBest indicationKey feature
Anteriorly based labial flapExternal pudendal arteriesPosterior commissure, RVFRotates posteriorly[2]
Posteriorly based labial flapPosterior labial artery (internal pudendal)Anterior defects, urethral pathology, VVFRotates anteriorly[2]
V-Y amplified sliding flap from the pubis (Moschella–Cordova)Deep pubic arterial networkSymmetric anterior vulvar defectsSensate through ilioinguinal branches[3]
Island fasciocutaneous flap (gluteal fold)Pudendal artery perforatorsHemivulvectomy, posterior defectsScars in natural folds; sensate through perineal branches of the pudendal nerve[3]
Composite fasciocutaneous + fat padDual pudendal supplyComplex fistula with vaginal deficitProvides both epithelial surface and interposition[1]
Tubularized labial flapLabial vascular pedicleSelected post-pelvic-fracture strictures with urethrovaginal fistulaCreates neourethra[10]
Tissue-expanded labial-skin flapLabial vascular pedicleMüllerian agenesis vaginoplastyGenerates large non-hair-bearing neovaginal lining[9]

Advantages​

  • Tissue replacement and interposition. The flap addresses vaginal deficit and fistula in one operation.
  • Full-thickness vascularized tissue. It may help selected scarred or previously irradiated fields when an adequate pedicle and recipient bed are available.
  • Donor site in the operative field. No distant harvest is needed.
  • Bilateral harvest. It is possible for very large vaginal deficits.

Limitations​

  • Female patients only. The technique is anatomy-specific.
  • Labial disfigurement or asymmetry. Donor-site change is a significant counseling point.
  • Potential hair transfer. The selected skin island may be hair-bearing; Belloli's expanded labial-skin flaps used non-hair-bearing skin.[9] For internal vaginal lining, select hairless medial labial skin when feasible.[13][14] Hair-bearing urethral grafts have caused impaired flow, recurrent infection and calculi; favor hairless skin for urethral lining.[18] If hair-bearing tissue is unavoidable, plan hair reduction and discuss persistent internal hair growth; evidence on preoperative hair removal comes largely from other genital reconstructions.[19]
  • Bilateral harvest doubles donor morbidity and is reserved for the largest defects.
  • Limited tissue volume compared with thigh-based flaps for very large defects

Comparison with Martius Flap​

FeatureConventional Martius fat-pad flapLabia majora fasciocutaneous flap
Tissue harvestedLabial fat pad onlySkin + fat + fascia (full-thickness)
Primary roleInterposition layer between repaired planesVaginal wall tissue replacement
Donor morbidityModest; labial contour changeVisible labial asymmetry
Best forComplex VVF without vaginal-wall deficitComplex VVF with vaginal-wall deficit
BilateralPossible for larger interpositionPossible for large vaginal reconstruction

The two flaps have complementary tissue roles: an interposition fat pad when the vaginal surface is adequate, versus an epithelialized flap when vaginal-wall replacement is required. Choice also depends on anatomy, perfusion, defect size and reconstructive alternatives.

Comparison with Other Local Vulvovaginal / Urogenital Flaps​

FlapTissue typeSkin islandSensateBest forLimitations
Labia majora fasciocutaneousFasciocutaneous ± fat padYesDesign-dependentFistula with vaginal deficit; vulvar defectsLimited volume; hair-bearing
Martius (labial fat pad)Fibroadipose onlyNoNoFistula interposition; sling erosionNo epithelial surface
Singapore / pudendal-thighFasciocutaneousYesYesPartial vaginal defects; vulvarBulky base; hair growth
Lotus petal (infragluteal)FasciocutaneousYesYesVulvar / perineal defectsLimited reach anteriorly
Gracilis musculocutaneousMusculocutaneousYesLimitedLarge / extended defects; neovaginaBulky; thigh donor morbidity
VRAMMusculocutaneousYesNoPelvic exenteration; large defectsAbdominal-wall morbidity; hernia risk

Technical Pearls​

  • Preoperative hair removal on the planned flap skin may reduce neovaginal hair growth
  • Identify the labial artery Doppler-wise before incision in re-operative or scarred fields
  • Donor-site closure benefits from a small lateral undermining to reduce tension
  • Postoperative stenting, packing or dilation, when used, should follow the specific reconstruction and surgeon's protocol; a universal five-to-seven-day schedule or prevention of contraction is not established here

See Also​

References​

1. Gupta P, Kalra S, Dorairajan LN, et al. "Labia Majora Fasciocutaneous Flap Reconstruction in Complex Urogynecological Fistulas With Vaginal Deficit — A Versatile Approach." Urology. 2022;167:241–246. doi:10.1016/j.urology.2022.05.017

2. Höckel M, Dornhöfer N. "Vulvovaginal Reconstruction for Neoplastic Disease." Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

3. Moschella F, Cordova A. "Innervated Island Flaps in Morphofunctional Vulvar Reconstruction." Plast Reconstr Surg. 2000;105(5):1649–1657. doi:10.1097/00006534-200004050-00008

4. 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;37:1997–2003 (online 2025). doi:10.1007/s00192-025-06383-9

5. Kwong FL, Pounds R, Farah Y, Yap JKW. "Vulval Flap Reconstruction in Women With Benign, Preneoplastic and Malignant Vulval Conditions: A Prospective Study." BJOG. 2025;132(8):1156–1165. doi:10.1111/1471-0528.18156

6. Salgarello M, Farallo E, Barone-Adesi L, et al. "Flap Algorithm in Vulvar Reconstruction After Radical, Extensive Vulvectomy." Ann Plast Surg. 2005;54(2):184–190. doi:10.1097/01.sap.0000141381.77762.07

7. Al-Benna S, Tzakas E. "Postablative Reconstruction of Vulvar Defects With Local Fasciocutaneous Flaps and Superficial Fascial System Repair." Arch Gynecol Obstet. 2012;286(2):443–448. doi:10.1007/s00404-012-2262-1

8. Flack CE, Barraza MA, Stevens PS. "Vaginoplasty: Combination Therapy Using Labia Minora Flaps and Lucite Dilators — Preliminary Report." J Urol. 1993;150(2 Pt 2):654–656. doi:10.1016/s0022-5347(17)35575-1

9. Belloli G, Campobasso P, Musi L. "Labial Skin-Flap Vaginoplasty Using Tissue Expanders." Pediatr Surg Int. 1997;12(2–3):168–171. doi:10.1007/bf01349991. PMID 9069225

10. Xu YM, Sa YL, Fu Q, et al. "Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated With Urethrovaginal Fistulas Secondary to Pelvic Fracture." Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046

11. Candiani P, Austoni E, Campiglio GL, et al. "Repair of a Recurrent Urethrovaginal Fistula With an Island Bulbocavernous Musculocutaneous Flap." Plast Reconstr Surg. 1993;92(7):1393–1396. PMID 8248420

12. Windhofer C, Michlits W, Heuberger A, Papp C. "Perineal Reconstruction After Rectal and Anal Disease Using the Local Fascio-Cutaneous-Infragluteal Flap: A New and Reliable Technique." Surgery. 2011;149(2):284–290. doi:10.1016/j.surg.2009.10.040

13. 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

14. 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

15. Wendelspiess S, Kouba L, Stoffel J, et al. "Perforator versus non-perforator flap-based vulvoperineal reconstruction: a systematic review and meta-analysis." Cancers (Basel). 2024;16(12):2213. doi:10.3390/cancers16122213

16. European Association of Urology. "EAU Guidelines on Non-neurogenic Female LUTS: Disease Management, section 4.8 (Urinary Fistula)." EAU Guidelines. Arnhem: EAU Guidelines Office; 2026. Guideline

17. Tatar B, Oksay T, Cebe FS, Soyupek S, Erdemoglu E. "Management of Vesicovaginal Fistulas After Gynecologic Surgery." Turk J Obstet Gynecol. 2017;14(1):45–51. doi:10.4274/tjod.46656

18. Finkelstein LH, Blatstein LM. "Epilation of Hair-Bearing Urethral Grafts Using the Neodymium:YAG Surgical Laser." J Urol. 1991;146(3):840–842. doi:10.1016/S0022-5347(17)37937-5

19. Zhang WR, Garrett GL, Arron ST, Garcia MM. "Laser Hair Removal for Genital Gender Affirming Surgery." Transl Androl Urol. 2016;5(3):381–387. doi:10.21037/tau.2016.03.27

20. Oonk MHM, Planchamp F, Baldwin P, et al. "European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023." Int J Gynecol Cancer. 2023;33(7):1023–1043. doi:10.1136/ijgc-2023-004486