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Martius Flap

The Martius flap (also known as the Martius labial fat pad flap or bulbocavernosus flap) is the most commonly used interposition flap in female pelvic reconstructive surgery, first described by Heinrich Martius in 1928. It consists of a well-vascularized fibroadipose tissue pedicle harvested from the labium majus and is used to reinforce repairs of vesicovaginal fistulas, rectovaginal fistulas, urethral diverticula, urethral strictures, and mesh erosions, with an overall complication rate of < 5%.[1][2][3]

This page is the foundations-level deep dive. Site-specific technique pages — VVF / RVF / UVF repair, urethral diverticulum, urethroplasty — link back here.

Historical Context and Nomenclature​

Martius originally described the flap in 1928 as a bulbocavernosus muscle flap for urethral reconstruction. Anatomical studies have since shown that the tissue harvested in the modern "Martius flap" is composed primarily of fibroadipose tissue from the labium majus — not the bulbocavernosus muscle itself. The prominent fibrous component arises from a superficial tunic of fibrous tissue analogous to the male tunica dartos, along with considerable fibrous septa within the adipose tissue.[1] The terms "Martius flap," "Martius fat pad," "bulbocavernosus flap," and "labial fat pad graft" are used interchangeably in the literature.

Vascular Anatomy and Blood Supply​

The Martius flap has a dual blood supply, allowing it to be pedicled either anteriorly or posteriorly:[1][4][5]

PedicleSupplyReach
Anterior pedicleExternal pudendal artery (branch of the femoral)Anterior / urethral targets
Posterior pedicleInternal pudendal artery (branch of the internal iliac)Posterior / perineal targets (RVF)
Lateral contributionObturator artery (variable)[5]—

These vessels form a plexus within the graft, providing robust vascularity that promotes rapid neovascularization at the recipient site.[1][6]

Rothenberger 2025 — cadaveric neurovascular mapping in 10 cadavers:[4]

  • Highest vascular density at the lateral aspect of the right labial fat pad
  • Highest nerve density anterior and medial bilaterally
  • The right labium had significantly greater vascular density (8% increase, p < 0.05) — supporting right-sided harvest as the default when laterality is otherwise neutral

Harvest Technique​

Standard harvest sequence:[5][6][7]

  1. Incision — vertical incision over the labium majus from the level of the clitoral hood to the labiocrural fold (typically 4–6 cm).
  2. Flap mobilization — the fibrofatty tissue is mobilized lateral-to-medial. The skin is preserved over the labium.
  3. Pedicle selection — divide the flap at one pedicle and preserve the other:
  • Posterior pedicle preserved → for anterior / urethral targets (VVF, urethral diverticulum, female urethroplasty)
  • Anterior pedicle preserved → for posterior targets (RVF, perineal defects)
  1. Subcutaneous tunneling from the labium to the recipient site, wide enough to accommodate the flap without kinking.
  2. Interposition — flap passed through the tunnel and sutured to the underlying tissue (periurethral fascia, rectovaginal fascia, bladder wall) without tension.
  3. Closure — vaginal wall over the flap; labial incision closed in layers. No drain typically required.

Application 1 — Vesicovaginal Fistula Repair​

The Martius flap is the most commonly used interposition flap for transvaginal VVF repair.[8][9] It adds a well-vascularized tissue layer between the bladder and vaginal suture lines, reducing recurrence and dyspareunia.

  • Kapriniotis 2024 comprehensive review — most simple non-irradiated obstetric and iatrogenic fistulae can be closed without tissue interposition (> 90% success with graftless repair). Martius flap remains valuable in complex fistulae — difficulty achieving tension-free closure, significant tissue loss, urethral involvement, or poorly vascularized tissues after radiotherapy — with success rates of 80–97%.[9]
  • Eilber 2003 10-year series (207 VVFs) — Martius flap used for distal fistulas with 97% cure (vs. 96% with peritoneal flap for proximal fistulas).[10]
  • Pushkar 2009 (216 patients with radiation-induced VVF) — Martius flap used in 41%; cumulative success 80.4% after multiple procedures.[11]
  • Safan 2009 RCT (40 patients) — fibrin glue vs. Martius flap interposition for complicated obstetric VVF: no significant difference (68% vs. 58%).[12]
  • Rangnekar 2000 — recurrent / multiple fistulas: Martius 0% recurrence vs. anatomic repair 16.7% for primary fistulas, and 8.3% vs. 57.1% for recurrent fistulas.[13]

Application 2 — Urethral Diverticulum Excision​

The most commonly used adjunct to urethral diverticulectomy:[3][14]

  • Malde 2017 (largest dedicated series, 70 patients) — diverticulectomy with Martius interposition: 100% complete excision, 1.4% recurrence, 12% persistent de novo SUI at mean 19-month follow-up.[14]
  • Osman 2021 (121 patients) — Martius flap used in 30% of cases (36/121), typically for larger / more complex diverticula; overall recurrence 4%, de novo SUI 13%.[15]
  • Ko 2017 — recurrent diverticula: 7 of 8 successfully treated with Martius interposition.[16]
  • Dykes 2020 — a previously placed Martius flap can be mobilized and repositioned for recurrent diverticulum repair without harvesting a new flap.[17]

Application 3 — Rectovaginal Fistula Repair​

The 2022 ASCRS Clinical Practice Guidelines provide a strong recommendation (Grade 1C) that gracilis or bulbocavernosus (Martius) flap is recommended for recurrent or otherwise complex RVF.[18]

StudySettingSuccessNotes
Swindon 2024 SR/meta (12 studies, 137 Martius flaps)[19]Pooled91.4% primary RVF; 77.5% recurrent RVF; 94.6% radiation-induced RVFOverall complication 29%, recurrence 12%
Pastier 2024 (62 patients)[20]Martius (55) vs gracilis (24)Equivalent 69% vs 69% at 23 moMartius shorter LOS (–2 days, p = 0.01); 27% Martius without diverting stoma without increased morbidity. Authors propose gracilis as salvage after Martius failure
Trompetto 2019 (24 complex low RVF)[21]Martius advancement91.3% at 42 moSignificant improvement in SF-12 and FSFI

Smoking was the only negative predictive factor for Martius flap success in RVF repair (p = 0.02).[20]

Application 4 — Mid-Urethral Sling Erosion Repair​

Martius interposition covers exposed or eroded mid-urethral tape while preserving sling function:[3][22][23]

  • The 2025 ACOG guidelines on mesh / graft complications list Martius graft transposition as an option for preserving a functioning but exposed midurethral sling when conservative management and primary reclosure have failed.[22]
  • Mortimer 2016 — 5 TOT extrusions treated with Martius graft: 100% successful coverage with no ipsilateral recurrence of tape extrusion.[23]
  • Malde (largest series of 159 patients) — 24 patients underwent Martius interposition for MUT erosion repair, 2 had it used as a prophylactic MUT wrap for fragile urethras.[3]

Application 5 — Female Urethroplasty for Urethral Stricture​

The Martius flap provides a vascularized tissue layer over urethral repairs, particularly when combined with buccal mucosal grafts or vaginal flap urethroplasty (e.g., the Blandy ventral vaginal flap). 12 patients in the Malde series underwent Martius interposition as part of female urethroplasty.[3]

Application 6 — Bladder Neck Closure for End-Stage SUI​

In rare cases of complex end-stage stress urinary incontinence requiring vaginal closure of the bladder neck, the Martius flap reinforces the closure. Four such cases were reported in the Malde series.[3]

Application 7 — Urethrovaginal Fistula Repair​

The Martius flap is particularly effective for urethrovaginal fistulas that may occur after sling procedures, urethral diverticulum excision, anterior colporrhaphy, or radiation. In a series of fistulas secondary to mid-urethral sling surgery, Martius was used in 6 of 9 repairs with a 78% overall success rate.[24][25]

Outcomes and Complications​

Indicationn (largest series)SuccessDe novo SUIRecurrence
VVF (complex / irradiated)86 (Pushkar)80–97%—3–20%
VVF (obstetric, simple)—Graftless > 90%; Martius may be unnecessary——
Urethral diverticulum excision70 (Malde)100% complete excision; 1.4% recurrence12% persistent1.4%
RVF — primary137 (meta)91.4%—12% overall
RVF — recurrent—77.5%——
RVF — radiation-induced—94.6%——
MUT erosion repair24 (Malde)100% coverage—0%
Female urethroplasty12 (Malde)Not separately reported——
Bladder neck closure (end-stage SUI)4 (Malde)Not separately reported——

Donor-site complications are remarkably low (Malde 159-patient series):[3]

  • Labial hematoma 1.25% (2/159)
  • Labial wound infection 0.6% (1/159)
  • Cosmetic dissatisfaction 0.6% (1/159)
  • 79% rated labial appearance as good or excellent
  • No significant long-term complications

Other reported complications include seroma, numbness, pain, and labial distortion, though these are uncommon.[8]

When Is Martius Flap Necessary vs Unnecessary?​

Selective application is supported by the contemporary evidence:[9]

  • Probably unnecessary — most simple, non-irradiated obstetric fistulae within healthy tissues (graftless repair achieves > 90% closure)
  • Recommended — complex fistulae with any of:
    • Recurrent or failed prior repair
    • Significant tissue loss or scarring
    • Urethral involvement
    • Radiation-induced fistula
    • Difficulty achieving tension-free, layered closure
    • Multiple fistulae

Comparison with Other Interposition Flaps​

FeatureMartiusGracilisPeritonealOmental
Harvest siteLabium majusMedial thighPeritoneum (vaginal approach)Abdomen
Blood supplyExternal / internal pudendalMedial circumflex femoralPeritoneal vesselsGastroepiploic
Best forDistal VVF, RVF, urethral pathologyComplex / recurrent RVFProximal VVFTransabdominal VVF
Operative complexityLowModerateLowModerate–high
Hospital stayShorterLonger (+2 days)ShortLonger
Diverting stoma needed (RVF)Not mandatory (27% without)Usually recommendedN/AN/A
Success rate (VVF)97%—96%> 90%
Success rate (RVF)69% (long-term)69% (long-term)N/AN/A
Donor-site morbidityVery low (~2%)Moderate (thigh numbness, hematoma)MinimalIleus, abdominal pain
Cosmetic impactMinimal (concealed)Thigh scarNoneAbdominal incision

Key Takeaways​

  1. The Martius labial fat pad flap remains the workhorse interposition flap in female pelvic reconstructive surgery nearly a century after its original description.
  2. Principal advantages: robust dual blood supply, low donor-site morbidity (< 5%), short LOS, and broad applicability to VVF, RVF, urethral diverticulum, MUT erosion, and female urethroplasty.
  3. Recurrent or radiation-induced RVF — Martius 77.5% / 94.6% success; the equivalence to gracilis (Pastier 69% vs 69%) supports Martius-first with gracilis as salvage.
  4. Most simple non-irradiated obstetric VVF do not require Martius interposition (> 90% graftless success); reserve for complex / recurrent / irradiated / urethrally-involved cases.
  5. Right-sided harvest (Rothenberger 2025) shows greater vascular density and is reasonable as the default unless lateralized contraindication exists.
  6. Smoking is the only consistent negative predictor of Martius flap success in RVF repair.

See Also​

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. Kniery K, Johnson EK, Steele SR. "How I Do It: Martius Flap for Rectovaginal Fistulas." J Gastrointest Surg. 2015;19(3):570–574. doi:10.1007/s11605-014-2719-6

3. 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

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. 2025. doi:10.1007/s00192-025-06383-9

5. Wang D, Chen J, Zhu L, et al. "Surgical Repair of Rectovaginal Fistula Using the Modified Martius Procedure: A Step-by-Step Guide." J Minim Invasive Gynecol. 2018;25(4):573–575. doi:10.1016/j.jmig.2017.08.657

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. 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

8. 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

9. 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

10. 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

11. 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

12. Safan A, Shaker H, Abdelaal A, Mourad MS, Albaz M. "Fibrin Glue Versus Martius Flap Interpositioning in the Repair of Complicated Obstetric Vesicovaginal Fistula. A Prospective Multi-Institution Randomized Trial." Neurourol Urodyn. 2009;28(5):438–441. doi:10.1002/nau.20754

13. 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

14. 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

15. Osman NI, Mangir N, Reeves FA, et al. "The Modified Prone Jack-Knife Position for the Excision of Female Urethral Diverticula." Eur Urol. 2021;79(2):290–297. doi:10.1016/j.eururo.2020.11.016

16. Ko KJ, Suh YS, Kim TH, et al. "Surgical Outcomes of Primary and Recurrent Female Urethral Diverticula." Urology. 2017;105:181–185. doi:10.1016/j.urology.2017.02.040

17. Dykes N, Dwyer P, Rosamilia A, Zilberlicht A. "Video and Review of the Surgical Management of Recurrent Urethral Diverticulum." Int Urogynecol J. 2020;31(12):2679–2681. doi:10.1007/s00192-020-04357-7

18. 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

19. 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

20. 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

21. Trompetto M, Realis Luc A, Novelli E, et al. "Use of the Martius Advancement Flap for Low Rectovaginal Fistulas." Colorectal Dis. 2019;21(12):1421–1428. doi:10.1111/codi.14748

22. American College of Obstetricians and Gynecologists. "Management of Mesh and Graft Complications in Gynecologic Surgery." 2025.

23. Mortimer A, Khunda A, Ballard P. "Martius Graft for TOT Extrusion: A Case Series." Int Urogynecol J. 2016;27(1):113–116. doi:10.1007/s00192-015-2799-1

24. Zilberlicht A, Lavy Y, Auslender R, Abramov Y. "Transvaginal Repair of a Urethrovaginal Fistula Using the Latzko Technique With a Bulbocavernosus (Martius) Flap." Int Urogynecol J. 2016;27(12):1925–1927. doi:10.1007/s00192-016-3085-6

25. 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