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Lotus Petal Flap

The lotus petal flap (LPF) is a fasciocutaneous flap based on perforators of the internal pudendal artery (IPA), harvested from the gluteal fold / perineal crease, and named for the cumulative bilateral flap designs that resemble the petals of a lotus flower.[1][2] First described by Yii and Niranjan in 1996, it has become a workhorse for vulvoperineal reconstruction — reliable vascularity, hidden donor scar, thin pliable tissue, preserved sensation, and primary donor-site closure — with applications spanning vulvar cancer, ELAPE pelvic-floor reconstruction, scrotal reconstruction, and neovagina creation.[3][4]

This page is the foundations-level deep dive on the gluteal-fold IPA-perforator lotus petal. The closely related but distinct medial-thigh / posterior-labial-artery flap is covered separately on the Singapore (Pudendal Thigh) Flap page; lotus-petal use as a propeller variant is covered in the Propeller Flap page.

Nomenclature and Identity​

The flap has been described under multiple names that can cause confusion. All refer to the same gluteal-fold IPA-perforator flap:[1][2]

  • Lotus petal flap (Yii and Niranjan, 1996) — named for the bilateral petal-like design
  • Gluteal fold flap / gluteal sulcus flap — named for the donor site
  • Internal pudendal artery perforator (IPAP) flap — named for the vascular pedicle
  • "Singapore flap" is sometimes applied to either the lotus petal or the medial-thigh pudendal-thigh flap (Wee and Joseph 1989); WARWIKI keeps these separate pages because the donor sites and primary indications differ. The Wee-Joseph medial-thigh flap is the Singapore (Pudendal Thigh) Flap.

The flap can be configured as a transposition, propeller, or V-Y advancement, making it one of the most versatile local-flap concepts in the perineal region.[5]

Vascular Anatomy​

The lotus petal flap is based on perforators from the internal pudendal artery that emerge in the anogenital triangle:[1][6]

  • Hashimoto 2001 / 2014 — described 3–5 perforators in the perineal anogenital triangle, with the ischial tuberosity serving as the key landmark for the safe medial boundary of dissection.[5]
  • Giroux 2021 — color Doppler in 15 subjects identified 24 perforators > 0.5 mm. Mean distance ischial tuberosity → IPA perforator 27.3 mm. The authors concluded routine ultrasound mapping is not always required — perforators are sufficiently constant to allow safe harvest from anatomic landmarks alone.[1]
  • Jin 2009 cadaveric microdissection (22 sides) — 4 relatively constant perforating arteries with overlapping anastomoses forming upper / middle / lower vascular networks in the deep fascia. Four cutaneous nerves identified, enabling sensate harvest.[6]

The dense, overlapping perforator network explains the flap's exceptional reliability — multiple perforators can be captured within a single skin paddle, providing redundant supply.[1][6]

Design and Surgical Technique​

Classic design (Yii and Niranjan)​

Elliptical skin island centered over the gluteal fold, long axis parallel to the fold, base medial (toward the perineum); transposed into the vulvar or perineal defect.[3][7]

Modified (thinned) design — Warrier 2004​

A supra-fascial, thinned cutaneous flap harvested without formal identification of the blood supply, relying on the dense perforator territory:[3]

  • Easier transposition due to reduced bulk
  • Better aesthetic match to vulvar / perineal tissue
  • Maintained reliability — no partial or complete failures in the initial 8-patient / 12-flap series

Supra-fascial variant — Bodin 2015​

Raised above the fascia (rather than including it), further reducing bulk while maintaining perfusion through the dense subcutaneous perforator network. Particularly suited for posterior perineal cavity filling and skin resurfacing.[8]

Tunneled variant​

The flap is passed through a subcutaneous tunnel to reach the defect, avoiding an external skin bridge. Confalonieri 2017 found this variant superior in functional and cosmetic results vs. both the standard LPF and V-Y advancement for primary vulvar malignancies.[9]

Key design parameters​

  • Flap dimensions typically 3 × 4 cm to 13 × 12 cm depending on defect size[5]
  • Harvested unilaterally or bilaterally — bilateral flaps for total vulvectomy or neovagina[2][10]
  • Donor site closes primarily in virtually all cases, with the scar hidden in the natural gluteal fold[7][8]

Urogynecologic Applications​

Vulvar reconstruction after oncologic resection — primary indication​

The most extensively studied application:

  • Hellinga 2018 — largest complications series: 93 patients, 137 lotus petal flaps:[11]
    • 30.1% no complications; 51.7% Clavien-Dindo I–II; 18.3% reoperation under GA (Clavien-Dindo IIIb), usually for debridement (64.7%)
    • Donor-site morbidity 14.0%
    • Complication rates did not differ between vulvar, perineal, and vulvoperineal reconstruction
    • Patients < 60 years had a significantly lower complication risk (p = 0.015; OR 0.235)
  • Argenta 2013 — 59 consecutive patients, 80 lotus petal flaps for vulvar carcinoma / melanoma (66.1%), vulvar dysplasia (20.3%), colorectal disease (8.5%), hidradenitis suppurativa (5.1%). Mean defect 29 cm². Complications 36% (superficial wound separation 15% most common). No complete flap loss; partial loss 8.8%.[4]
  • Confalonieri 2017 — largest comparative study (V-Y 234 vs. LPF 128). Overall complications V-Y 21% vs. LPF 13% (p = 0.588). LPF — particularly the tunneled variant — was superior in functional and cosmetic results for primary vulvar malignancies.[9]
  • Sawada 2004 — 5 patients with mean vulvoperineal defects of 157.9 cm² covered with bilateral LPF. All flaps survived without fatal necrosis. No pain, abnormal sensation, or impact on excretion or hip mobility; donor scars hidden in the gluteal fold.[7]

Vulvar reconstruction algorithm — Negosanti 2015​

A defect-based classification from 22 consecutive patients:[10]

TypeResection extentFirst-line reconstruction
IAHalf-vulvar resection, vagina preservedUnilateral LPF
IBTotal vulvar resection, vagina preservedBilateral LPF
IIVulvar + vaginal resection, large pelvic dead spacePedicled DIEP (LPF insufficient for bulk)

The algorithm positions the LPF as first-line for vulvar-only defects (Types IA / IB); distant flaps are reserved when substantial pelvic dead space requires greater bulk.

Pelvic-floor reconstruction after extralevator abdominoperineal excision (ELAPE)​

  • Hellinga 2016 — 28 patients with LPF reconstruction after ELAPE; 89.3% had preoperative RT, 28.6% biological mesh augmentation. No total flap loss; 21.4% no complications; 46.4% minor (Clavien-Dindo I–II); 32.1% reoperation (Clavien-Dindo IIIb), 3 needing a second LPF. Median time to wound healing 14 weeks. The flap also enabled neovagina creation when needed.[12]
  • Hellinga 2020 QoL follow-up — no significant differences in QoL between LPF patients and primary-perineal-closure controls despite presumably larger resections in the LPF group; 33% of LPF patients sexually active postoperatively (vs. 87% preoperatively); no perineal herniation in any LPF patient; hip-joint ROM bilaterally reduced vs. normal values.[13]

Posterior perineal reconstruction​

Bodin 2015 — 10 supra-fascial LPF procedures (6 patients; unilateral in 2, bilateral in 4) for posterior perineal cavity filling and skin resurfacing. 4 patients had prior RT. No wound complications or flap necrosis over 20.5-month follow-up. Mean LOS 11.3 days; healing time 35.2 days.[8]

Complex pelvic-perineal reconstruction (combined flaps)​

For extensive defects requiring more tissue than a single LPF can provide:

  • Contedini 2015 — pedicled ALT flap combined with bilateral lotus petal flaps for a complex pelvic-perineal defect after pelvic exenteration. The ALT provided bulk for pelvic dead-space obliteration; bilateral LPFs resurfaced the perineum. Good result with no major complications.[14]
  • Bini & Stavrianos 2025 — 34 patients with pelvic / perineal reconstruction after advanced tumor resection using VRAM, gracilis, IGAP, IPAP, and LPFs. SSI and wound dehiscence more common with thigh flaps than abdominal flaps; 15/34 achieved 5-yr disease-free survival, reflecting tumor biology rather than flap performance.[15]

Neovagina creation​

Bilateral lotus petal flaps can be used for neovagina formation. Höckel and Dornhöfer noted that bilateral local axial-pattern flaps (including LPF) are needed for full neovagina formation, although tubularization of a single musculocutaneous flap may suffice in some cases.[2] The Hellinga ELAPE series confirmed LPF-enabled neovagina creation as part of pelvic-floor reconstruction.[12]

Urologic Applications​

Scrotal reconstruction after Fournier's gangrene​

Payne 2009 described the first reported use of lotus petal flaps for scrotal reconstruction in a male patient following necrotizing fasciitis after circumcision:[16]

  • Bilateral lotus petal flaps were transposed to create a neoscrotum with adequate volume for testicular cover
  • Combined with Integra dermal regeneration template for penile-shaft resurfacing
  • The LPF "integrated well with the remaining scrotal sac to produce a good volume neoscrotum"
  • Erectile capability preserved with the Integra-covered penile shaft

The LPF — originally designed for vulvovaginal defects — adapts well to male scrotal reconstruction, providing tissue of appropriate thickness and pliability to recreate a functional scrotal pouch.

In the broader Fournier's literature, a 2026 SR of 619 patients / 625 flaps reported flap loss in only 1.6% of cases, with medial-thigh, pudendal-thigh, ALT, and gracilis flaps most commonly utilized — the lotus petal / pudendal-thigh family is well represented among these options.[17]

Perineal reconstruction in males — IPAT and IPAP variants​

The internal pudendal artery turnover (IPAT) flap — a simplified IPAP / lotus petal variant — was described by Nassar 2021 in 38 consecutive patients for perineal reconstruction:[18]

  • Requires no visualization or dissection of perforating vessels
  • At 3 months 37/38 flaps fully healed; no flap failures or partial losses
  • Complications in 10/38 (9 minor, 1 reoperation)
  • Effective for deep three-dimensional defects following perineal excisions

This variant simplifies the lotus-petal concept further, making it accessible without microsurgical training while maintaining the same vascular territory and reliability.

Loreti 2023 reported 11 IPAP-based flaps (8 rotation, 2 advancement island, 1 propeller) after abdominoperineal resection. All 11 flaps survived without major complications, even in irradiated patients (73%).[19]

Presacral defect reconstruction​

Van der Meer 2014 described a partially de-epithelialized lotus petal perforator flap for an extended chronic presacral defect after radiotherapy and rectal cancer resection — wound healing achieved at 12 days. The authors concluded the LPF is "a relatively simple and successful choice" for this indication.[20]

Complications​

Pooled across the largest series:[4][11][12]

CategoryRate
No complications30.1%
Minor (Clavien-Dindo I–II)51.7%
Major (Clavien-Dindo IIIb)18.3%
Donor-site morbidity14.0%
Complete flap loss0% across all major series
Partial flap loss7–8.8% (managed conservatively or with minor revision)

Risk factors: age > 60 years (OR 0.235 for < 60).[11]

Comparison with other perineal options. In the Witte 2021 SR of 1,988 patients after pelvic exenteration, VRAM flaps had dehiscence rates of 15–32% and infection rates of 8–16%, with partial necrosis 2–4% and total flap loss 0–2%. The LPF compares favorably, with 0% total flap loss across major series and lower donor-site morbidity than musculocutaneous alternatives.[21]

Comparison with Other Perineal / Vulvar Reconstruction Options​

FeatureLotus petalV-Y advancementPropeller (IPAP)VRAMGracilis
Vascular basisIPA perforators (multiple)Subcutaneous / perforatorSingle skeletonized perforatorDeep inferior epigastricMedial circumflex femoral
Tissue typeFasciocutaneous (thin)FasciocutaneousFasciocutaneous (thin)Musculocutaneous (bulky)Musculocutaneous
Perforator dissectionNo (landmark-based)NoYes (skeletonization)No (named vessel)No (named vessel)
SensateYes (perineal nerves)VariableVariableNoNo
Donor scarHidden in gluteal foldVisible (perineal / thigh)Hidden in gluteal foldAbdominal (significant)Medial thigh
Donor-site morbidityLow (~14%)LowLowSignificant (hernia risk)Moderate (thigh weakness)
Bulk for dead spaceLimitedLimitedLimited–moderateExcellentModerate
Neovagina creationYes (bilateral)LimitedYesYes (tubularized)Yes (tubularized)
Best indicationMedium vulvar / perineal defectsModerate vulvar defectsExtensive penoscrotal / vulvarLarge pelvic-floor defectsModerate defects, vaginal reconstruction
Total flap loss0%Rare0–5.6%0–2%1.6%

Key Advantages​

  1. Simplicity — can be harvested from anatomic landmarks alone without preoperative imaging or intraoperative perforator dissection (Giroux); accessible to surgeons without microsurgical training.[1][18]
  2. Reliability — 0% total flap loss across > 300 reported flaps, owing to the dense overlapping IPA perforator network.[4][5][11]
  3. Hidden donor scar in the natural gluteal fold.[7][8]
  4. Sensate reconstruction — perineal sensory nerves can be preserved within the flap, maintaining vulvoperineal sensation critical for sexual function.[2][6][7]
  5. Tissue match — gluteal-fold skin closely matches vulvar / perineal skin in thickness, texture, color, and pliability.[3][7]
  6. Versatility — transposition, propeller, V-Y, or tunneled configurations; uni- or bilateral; combinable with distant flaps for complex defects.[5][10][14]

Key Limitations​

  1. Limited bulk — not suitable for large pelvic dead-space obliteration (Type II defects) where VRAM or gracilis is preferred.[10][21]
  2. Minor wound complications are common (~50% Clavien-Dindo I–II), reflecting the inherently challenging perineal wound-healing environment.[11][12]
  3. Caution in heavily irradiated gluteal-fold tissue — while the flap can survive in irradiated fields, complication rates rise; for heavily irradiated perineal tissue, distant flaps (ALT, VRAM) raised outside the radiation field may be preferred.[15][21]

Technical Pearls​

  • Map the ischial tuberosity as the medial boundary of safe dissection — Hashimoto's anatomic anchor.[5]
  • Skip the routine Doppler in straightforward primary cases — Giroux data support landmark-based harvest; reserve Doppler for irradiated or reoperative fields.[1]
  • Choose the variant by defect — Warrier-thinned for surface vulvar coverage, Bodin supra-fascial for posterior cavity filling, tunneled (Confalonieri) for primary vulvar malignancies, IPAT (Nassar) when avoiding perforator dissection altogether.
  • Plan bilaterally for total vulvectomy, neovagina, or large midline defects — closure tension is shared and the bilateral petal design produces a midline result that single-flap repair cannot match.
  • Combine with distant flaps when bulk is required — bilateral LPF + ALT (Contedini) or LPF as the surface-cover layer over a deep VRAM / gracilis.[14]

See Also​

References​

1. Giroux PA, Dast S, Assaf N, Lari A, Sinna R. "Internal Pudendal Perforator Artery Flap Harvesting Without Pre-Operative Imaging: Reliability and Approach." J Plast Reconstr Aesthet Surg. 2021;74(6):1355–1401. doi:10.1016/j.bjps.2020.12.017

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. Warrier SK, Kimble FW, Blomfield P. "Refinements in the Lotus Petal Flap Repair of the Vulvo-Perineum." ANZ J Surg. 2004;74(8):684–688. doi:10.1111/j.1445-1433.2004.03119.x

4. Argenta PA, Lindsay R, Aldridge RB, et al. "Vulvar Reconstruction Using the 'Lotus Petal' Fascio-Cutaneous Flap." Gynecol Oncol. 2013;131(3):726–729. doi:10.1016/j.ygyno.2013.08.030

5. Hashimoto I, Abe Y, Nakanishi H. "The Internal Pudendal Artery Perforator Flap: Free-Style Pedicle Perforator Flaps for Vulva, Vagina, and Buttock Reconstruction." Plast Reconstr Surg. 2014;133(4):924–933. doi:10.1097/PRS.0000000000000008

6. Jin B, Hasi W, Yang C, Song J. "A Microdissection Study of Perforating Vessels in the Perineum: Implication in Designing Perforator Flaps." Ann Plast Surg. 2009;63(6):665–669. doi:10.1097/SAP.0b013e3181999de3

7. Sawada M, Kimata Y, Kasamatsu T, et al. "Versatile Lotus Petal Flap for Vulvoperineal Reconstruction After Gynecological Ablative Surgery." Gynecol Oncol. 2004;95(2):330–335. doi:10.1016/j.ygyno.2004.07.038

8. Bodin F, Dissaux C, Seigle-Murandi F, et al. "Posterior Perineal Reconstructions With 'Supra-Fascial' Lotus Petal Flaps." J Plast Reconstr Aesthet Surg. 2015;68(1):e7–e12. doi:10.1016/j.bjps.2014.10.028

9. Confalonieri PL, Gilardi R, Rovati LC, et al. "Comparison of V-Y Advancement Flap Versus Lotus Petal Flap for Plastic Reconstruction After Surgery in Case of Vulvar Malignancies: A Retrospective Single Center Experience." Ann Plast Surg. 2017;79(2):186–191. doi:10.1097/SAP.0000000000001094

10. Negosanti L, Sgarzani R, Fabbri E, et al. "Vulvar Reconstruction by Perforator Flaps: Algorithm for Flap Choice Based on the Topography of the Defect." Int J Gynecol Cancer. 2015;25(7):1322–1327. doi:10.1097/IGC.0000000000000481

11. Hellinga J, Khoe PCKH, Stenekes MW, Eltahir Y. "Complications After Vulvar and Perineal Reconstruction With a Lotus Petal Flap." Ann Plast Surg. 2018;80(3):268–271. doi:10.1097/SAP.0000000000001271

12. Hellinga J, Khoe PC, van Etten B, et al. "Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction After Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina." Ann Surg Oncol. 2016;23(12):4073–4079. doi:10.1245/s10434-016-5332-y

13. Hellinga J, Stenekes MW, Werker PMN, et al. "Quality of Life, Sexual Functioning, and Physical Functioning Following Perineal Reconstruction With the Lotus Petal Flap." Ann Surg Oncol. 2020;27(13):5279–5285. doi:10.1245/s10434-020-08771-5

14. Contedini F, Negosanti L, Pinto V, et al. "Reconstruction of a Complex Pelvic Perineal Defect With Pedicled Anterolateral Thigh Flap Combined With Bilateral Lotus Petal Flap: A Case Report." Microsurgery. 2015;35(2):154–157. doi:10.1002/micr.22304

15. Bini A, Stavrianos S. "Pelvic and Perineal Reconstruction After Bowel, Gynecological or Sacral Tumor Resection: A Case Series." J Clin Med. 2025;14(9):3172. doi:10.3390/jcm14093172

16. Payne CE, Williams AM, Hart NB. "Lotus Petal Flaps for Scrotal Reconstruction Combined With Integra Resurfacing of the Penis and Anterior Abdominal Wall Following Necrotising Fasciitis." J Plast Reconstr Aesthet Surg. 2009;62(3):393–397. doi:10.1016/j.bjps.2007.09.015

17. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. "Flap Reconstruction Following Fournier's Gangrene: A Systematic Review of Techniques and Outcomes." Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

18. Nassar MK, Jordan DJ, Quaba O. "The Internal Pudendal Artery Turnover (IPAT) Flap: A New, Simple and Reliable Technique for Perineal Reconstruction." J Plast Reconstr Aesthet Surg. 2021;74(9):2104–2109. doi:10.1016/j.bjps.2020.12.074

19. Loreti A, Arelli F, Spallone D, Bruno E, Abate O. "The Use of the Internal Pudendal Artery Perforator Flap After Abdominoperineal Reconstruction: A Single Center Study." J Plast Reconstr Aesthet Surg. 2023;84:87–92. doi:10.1016/j.bjps.2023.05.015

20. van der Meer JG, Moerman E, van de Kar AL, Vermaas M, Gerhards MF. "Lotus Petal Perforator Flap for Reconstruction of an Extended Chronic Presacral Defect After Radiotherapy and Rectal Cancer Resection." Colorectal Dis. 2014;16(6):O220–O222. doi:10.1111/codi.12511

21. Witte DYS, van Ramshorst GH, Lapid O, Bouman MB, Tuynman JB. "Flap Reconstruction of Perineal Defects After Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods." Plast Reconstr Surg. 2021;147(6):1420–1435. doi:10.1097/PRS.0000000000007976