Martius flap: historical and anatomical considerations
Shahram Ghotb Sajjadi
Örs Péter Hortváth
Received: 24 April 2012 /Accepted: 21 June 2012 /Published online: 17 July 2012
Abstract Martius flap is used infrequently by urologists and
coloproctologists for repair of fistulae in the perineal region,
and is usually missing from the reconstructive palette of
plastic surgeons. There is a considerable confusion regarding
what the Martius flap contains. It may contain skin, fat, or
muscle from the labium major region. In the original descrip-
tion, Heinrich Martius applied the bulbocavernous/bulbo-
spongious muscle for repair of urethra-vaginal fistula.
Nowadays, what is known as Martius flap contains the more
voluminous labium major fat pad mostly independent of the
above muscle. In cadaveric dissections, the labium major fat
flap and the bulbocavernous muscle flap is demonstrated as
two distinct entities. This way, Martius flap mentioned in the
literature is a group of flaps. The history of Martius flap is
reviewed, the anatomy is demonstrated on cadaveric dissec-
tions, and its clinical application is presented in a case of
rectovaginal fistula repair.
Keywords Martius flap
Martius flap, as referred to in the literature, is a pedicled flap
containing the labium major fat pad as an anatomical unit
alone or together with the overlying skin and/or the underlying
bulbocavernous muscle in female. Originally, it has been
described by Heinrich Martius, professor of gynecology in
Gottingen, for repair of urethro-vaginal fistula in 1928 .
Martius flap, or its modifications, has been used for
urogynaecological fistulae [2–4] and less frequently for
rectovaginal fistulae [5–8].
Rectovaginal fistulae are rare but devastating conditions.
They can be traumatic in origin, among which obstetric trau-
ma is by far the most frequent, followed by inflammatory,
neoplastic, and radiation induced. They can be classified to
simple and complex depending on size and multiplicity, can
be recto- or ano-vaginal, and low middle or high depending on
its location on the posterior vaginal wall .
Surgical approach, depending on the complexity, the cause,
and the location of the fistula ranges from simple rectal mucosal
or vaginal advancement flaps, perineal repair to abdominal
operations. These procedures are performed with or without
additional local tissue transfer in form of gracilis muscle, gluteus
muscle, omental flap, or Martius flap. Healthy tissue transfer is
important for complex fistulae, for redo repairs because of more
extensive scarring and for radiation induced injuries because of
the ongoing unpredictable radiation damage.
For low fistulae, when rectal, perineal, or vaginal ap-
proach is planned, Martius flap is an excellent choice of
tissue transfer being in close proximity of the operation
field. It comes with no functional and minimal cosmetic
deficit of the donor site.
There is a considerable confusion in the literature regarding
what Martius flap contains. When references are made on
Martius’ original operation, most articles state that Martius
incorporated the bulbocavernous muscle/sphincter vaginae
(English nomenclature ; bulbospongious muscle according
to 6th edition of Nomina Anatomica, Latin nomenclature )
in the flap.
S. Ghotb Sajjadi (*)
Ö. P. Hortváth
Department of Plastic Surgery, University of Pécs,
Eur J Plast Surg (2012) 35:711–716