The Martius Flap Made Simple: A Practical Guide for Pelvic Surgeons

INTRODUCTION: The Martius flap, first described in 1928, is a well-established technique involving transposition of fibroadipose tissue from the labium majus to provide healthy, vascularized tissue for fistula repair. Despite its simplicity, safety, and versatility, it remains an underutilized adjunct in pelvic reconstructive surgery. It plays a particularly valuable role in complex rectovaginal fistula cases, where tissue vascularity is often compromised by prior surgery, radiation, or infection. OBJECTIVE: To demonstrate a step-by-step surgical approach to harvesting and insetting a Martius flap during rectovaginal fistula repair and to highlight key technical pearls that optimize outcomes and minimize morbidity. METHODS: We present a narrated, step-by-step surgical video illustrating the identification and dissection of the fistulous tract, multilayered closure of the rectal and vaginal walls, harvest of a vascularized Martius flap, and its interposition between repaired tissue planes. The technique includes discussion of anterior versus posterior pedicle options, flap transfer through a subepithelial tunnel, and meticulous donor site closure. RESULTS: The Martius flap provides robust, well-vascularized tissue that reinforces multilayer closure, reduces tension, and enhances healing in complex or recurrent fistula repairs. In our experience, the technique is associated with minimal morbidity, excellent cosmetic outcomes, and reliable long-term fistula closure, even in scarred or radiated fields. CONCLUSIONS: The Martius flap is a simple, effective, and underutilized tool in pelvic reconstructive surgery. Its technical versatility, favorable safety profile, and reliable outcomes make it an essential technique for surgeons managing complex rectovaginal fistulas. This video provides a practical and reproducible approach to incorporating the Martius flap into clinical practice.