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Lotus Petal Flap Urethroplasty

The lotus petal flap uses one or bilateral pedicled fasciocutaneous flaps from the gluteal fold (perineal crease) based on perforators of the internal pudendal artery, in a petal-like configuration that provides vascularized tissue for perineal coverage. Yii and Niranjan described lotus petal flaps in 1996 for vulvovaginal reconstruction,[1] and male-perineal coverage extrapolates regional flap principles. The related pudendal-thigh flap was described by Wee and Joseph for vaginal reconstruction in three patients.[2] One or two flaps are designed according to defect size and donor-site laxity.

For flap anatomy and broader applications, see Lotus Petal Flap (foundations).

Indications​

In male urethral reconstruction, reported lotus-petal use is limited to selected high-risk primary or revision perineal urethrostomy, including a very short proximal urethral stump.[5] Anatomy and the broader vulvoperineal evidence are on the foundations lotus petal flap page.

ScenarioWhy lotus petal helps
Complex perineal urethral reconstruction with skin / soft-tissue lossBrings vascularized gluteal-fold fasciocutaneous tissue into a hostile perineum
Panurethral or staged salvage when local penile / scrotal skin is poorPotential regional soft-tissue coverage without free-tissue transfer; the cited urethral outcomes are limited to three high-risk perineal urethrostomies.[5]
Scrotal tissue loss after necrotizing fasciitisA case report describes lotus petal flaps for neoscrotal coverage.[6]
Need for pliable, hidden-scar coverageGluteal-fold donor site closes primarily and hides in the crease
Perineal urethrostomy as the definitive channel, not just coverageA specialist technique tubularizes an islanded flap to form the neourethral circumference itself when native urethral length is extremely short.[3] Check whether skin entering the urinary lumen bears hair; EAU 2026 recommends against hair-bearing perineal or scrotal flaps unless no other option is feasible .[4]

Technique Overview​

The flap is designed along the gluteal fold or perineal crease over the internal-pudendal-artery perforator territory. It can be advanced, transposed, or used as a propeller-style fasciocutaneous flap depending on defect geometry. In the reported three-patient perineal-urethrostomy series, the flap formed the urethrostomy inset; one islanded flap was tubularized to bridge an extremely short urethral stump.[5]

Key Steps​

  1. Define the urethral repair first: graft, staged plate, perineal urethrostomy, or fistula closure.
  2. Identify internal-pudendal perforators with handheld Doppler, spatulate the viable proximal urethra, and measure the skin-to-urethra distance. Map the deficit and decide whether one or bilateral lotus petals will permit tension-free inset.[5]
  3. Design the flap in the gluteal fold so the donor scar remains hidden and closure is tension-free.
  4. Raise the fasciocutaneous flap with enough perforator-bearing tissue to protect vascularity.
  5. Rotate / advance the flap into the perineal defect without kinking the pedicle.
  6. Inset around the urethral reconstruction without compressing the new lumen.
  7. Drain dead space and protect the repair with urinary diversion appropriate to the urethral operation.

In a described perineal-urethrostomy application, internal-pudendal perforators are mapped with a handheld Doppler, the urethra is debrided to viable tissue and calibrated to passage of a 30-F bougie, and the supra-fascial flap is raised from distal to proximal. A posterior skin bridge may be left, or the flap can be islanded and, in extreme shortage of native urethral length, tubularized to form the neourethral circumference. Inset uses interrupted 4-0 Vicryl from the proximal urethra, progressing laterally from 3 toward 9 o'clock, with the donor site closed over a suction drain; in the authors' own postoperative protocol, the catheter is removed at three weeks.[3]

Operative Risks​

Perforator dissection can be technically challenging, and trauma may injure the vascular pedicle; the three-patient series reported no complications.[5] When flap skin lines the urinary channel, hair-bearing skin is associated with hairballs and chronic infection. The EAU urethral-stricture guideline recommends against hair-bearing perineal or scrotal flaps unless no other option is feasible .[4]

Outcomes & Evidence​

Most outcome data come from vulvar, ELAPE, and perineal reconstruction rather than urethroplasty-specific series.[1] Yii and Niranjan reported 13 lotus petal flaps without flap loss, including eight flaps in four patients after radical vulvectomy.[1] In Reilly and colleagues’ three-patient, high-risk perineal urethrostomy series, all three patients voided continently without instrumentation or revision at 22–29 months; flexible cystoscopy at 6–9 months confirmed patency. One flap was islanded and tubularized.[5] Urethral outcomes still depend on the underlying urethral reconstruction: graft take, fistula closure, stricture recurrence, and urinary diversion strategy.

See Also​

References​

1. Yii NW, Niranjan NS. "Lotus petal flaps in vulvo-vaginal reconstruction." Br J Plast Surg. 1996;49(8):547–54. doi:10.1016/s0007-1226(96)90132-0. PMID: 8976747

2. Wee JTK, Joseph VT. "A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report." Plast Reconstr Surg. 1989;83(4):701–9. doi:10.1097/00006534-198904000-00018. PMID: 2648427

3. Chee J, Chauhan A. Lotus Petal Flap. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:325-329. doi:10.1007/978-981-97-5196-9_32

4. EAU Guidelines Office. "EAU Guidelines on Urethral Strictures: Tissue Transfer." EAU Guidelines. 2026, §9.2. https://uroweb.org/guidelines/urethral-strictures/chapter/tissue-transfer

5. Reilly DJ, Sham EK, Chee JBL, Chauhan A. "A novel application of the lotus petal flap in high-risk perineal urethrostomy: principles and outcomes." Australas J Plast Surg. 2018;1(1):169–175. doi:10.34239/ajops.v1i1.17

6. 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