Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

19. Martius Fat Pad Construction

Sunshine Murray1 and Philippe E. Zimmern 

(1)

Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA

Philippe E. Zimmern

Email: philippe.zimmern@utsouthwestern.edu

Abstract

The Martius labial fat pad is a pedicle graft of fatty tissue from the labia majora which can be used as an interposition layer during a variety of vaginal procedures. First described by Martius [1], the procedure is fairly simple and quick, allowing the surgeon to harvest a well-vascularized fat pad of variable length (typically 8–12 cm) and transfer it where needed to enhance the repair of complex or recurrent urethral or vesical pathology. However, as with any surgical technique, complications can occur including hematoma, infection, pain or numbness, sexual dysfunction, and labial distortion. We aim to describe these complications as well as provide what information is available from the literature and our own experience on how to avoid them and manage them when necessary. To this end, we will also briefly cover the indications and technique for this versatile procedure.

Introduction

The Martius labial fat pad is a pedicle graft of fatty tissue from the labia majora which can be used as an interposition layer during a variety of vaginal procedures. First described by Martius [1], the procedure is fairly simple and quick, allowing the surgeon to harvest a well-vascularized fat pad of variable length (typically 8–12 cm) and transfer it where needed to enhance the repair of complex or recurrent urethral or vesical pathology. However, as with any surgical technique, complications can occur including hematoma, infection, pain or numbness, sexual dysfunction, and labial distortion. We aim to describe these complications as well as provide what information is available from the literature and our own experience on how to avoid them and manage them when necessary. To this end, we will also briefly cover the indications and technique for this versatile procedure.

Indications

The Martius fat pad is quite versatile and therefore has been used as an adjunct in many complex vaginal reconstructive surgeries to improve outcomes. It can be used as an additional tissue interposition layer in closure of vesico- or urethrovaginal fistulas and may be most important in those fistulas associated with radiation and/or recurrent fistulas that have failed to close after prior attempt at repair [26]. It has been reported in the closure of ano- and rectovaginal fistulas [68] as well as in the transvaginal repair of bladder injury during vaginal hysterectomy to prevent fistula formation [9]. Martius flap can be used in transvaginal bladder neck closures as well as urethral diverticulectomy and can also be useful in transvaginal artificial urinary sphincter placement although most authors recommend a retropubic approach for placement of cuffs. Another rare indication is in the postcystectomy patient with a peritoneovaginal fistula [10] or neobladder-vaginal fistula [11]. It can also be used in construction of a neovagina after pelvic exenteration or other rare cases requiring vaginal construction or reconstruction [12]. The most common indication in our practice is as an adjunct to urethrolysis to prevent rescarring to the back of the pubic symphysis [1315].

Technique

An 8–10 cm long vertical incision is made over the labia majora from the level of the mons pubis down towards the level of the fourchette. This is a typical incision for a high vault vesico-vaginal fistula because the length of the fat pad must be sufficient to reach the vaginal apex. When the procedure is indicated for urethral or bladder neck pathology, the incision can be shorter and may start midway over the labia majora, still extending down to the level of the posterior fourchette. The side, left or right, depends on the location of the pathology being repaired, and at times should be done from the side opposite to where the fat pad will ultimately be placed because of the need for it to cross over.

The labia majora incision is deepened to the level of the labial fat pad. The fat pad can be gently grasped with a Babcock clamp and mobilized on an inferior pedicle providing a postero-inferior blood supply to the graft based on branches from the internal pudendal artery. To facilitate the dissection of the flap, the skin edges can be held retracted by the hooks of a Lonestar retractor. To avoid medial labial skin distortion or retraction after the fat pad harvest has been completed, we recommend leaving some fat medially beneath the labial skin and carrying the fat pad dissection slightly obliquely and away from the inner labial folds. Once a sufficient length has been dissected laterally and medially, the flap is gradually divided superiorly. Large veins can supply the apex of the flap coming from the mons pubis and they may require careful ligature to avoid retraction and a secondary labial hematoma. Next, the Martius fat pad graft dissection continues by detaching the fat pad posteriorly off the underlying ischiocavernosus and bulbocavernosus muscles, taking care once again to leave a broad base inferiorly to protect the blood supply.

Historically, the Martius labial fat pad included the bulbocavernosus muscle vascularized by the labial artery, a branch of the internal pudendal artery, as well as the fat pad of the labia majora vascularized by the obturator artery and the internal and external pudendal arteries. Currently, most specialists use the labial fat pad without excising the bulbocavernosus muscle. However, in situations involving a vaginal wall defect after extensive mesh removal or large vesico-vaginal fistulae, the labial fat pad graft can be harvested with a segment of skin to close both defects.

After having completed the mobilization of the fat pad, a figure of eight absorbable suture can be placed at the extremity of the flap to help with its tunnelling alongside the vaginal wall later on. The fat pad graft can be harvested ahead of any upcoming steps in the repair which can involve significant bleeding. By doing so, the fat pad is ready for use and can help decreasing the overall blood loss, thus reducing the likelihood for blood transfusion. The fat pad can be wrapped in a moist gauze until its use later on. Once the fistula repair or other procedure for which the fat pad graft was selected is completed, a tunnel should be created alongside the lateral vaginal wall toward the destination of the flap. This tunnel is created with long Metzenbaum scissors and/or a ring forceps. The tunnel should be widened to accept at least two fingers in order to prevent compression of the blood supply of the fat pad which could compromise its survival. The suture at the extremity of the fat pad can then be grasped at the end of a right angle clamp or long Kelly clamp, which can be slid through the pre-established tunnel alongside the vagina. The suture can be retrieved easily on the vaginal side and pulled out to direct the fat pad into its tunnel and ultimately into position over the intended area of coverage. The pedicle graft once passed through the tunnel can be secured in place with a few absorbable sutures over the suture line which it is intended to protect.

Although the dissection of the tunnel can sometime provoke bleeding, once the fat pad is in place the bleeding will typically decrease or stop. However, to avoid a secondary labial hematoma, it is recommended to place a labial drain (small Penrose or #7 Jackson-Pratt). The incision is closed in two layers, a running subcutaneous deep absorbable suture over the drain, and then interrupted absorbable sutures on the skin. In case of a secondary infection or hematoma, some of these interrupted sutures at the lower extremity of the skin incision closure can be easily removed to facilitate a drain placement. In the absence of bleeding, swelling, or infection, the labial drain can be removed within 24–48 h postoperatively.

Complications

Hematoma or Seroma

As is the case with most surgical procedures, there is a risk of bleeding and hematoma formation. The fat pad is mobilized on an inferior pedicle based on branches of the internal pudendal vessels as discussed earlier. One of the benefits of this graft as a tissue interposition is its vascularity, but this also contributes to the risk of bleeding and hematoma formation. Thus, maintaining and ensuring achievement of hemostasis at the site of harvest as well as on the pedicle graft itself is of utmost importance in preventing hematoma formation. In addition to meticulous hemostasis at the time of surgery, the use of a drain (penrose or Jackson-pratt) postoperatively may also decrease the likelihood of hematoma formation. Although incidence of hematoma is not reported in the literature, Songne et al. [8] described a seroma formation in 3 of 14 patients (21%) undergoing repair of anovaginal or rectovaginal fistulas with Martius interposition. Seroma formation may also be prevented or decreased by the use of a drain postoperatively. Typically, seromas and hematomas when they occur will resolve on their own over time without any intervention. However, if either becomes infected as would be indicated by erythema surrounding and/or purulent drainage from the incision, then prompt drainage is indicated.

Infection

Although the incidence of wound infection for a Martius fat pad graft is not well studied or reported, the risk of such a complication appears to be relatively small. McNevin et al. [7] reported one (6%) superficial labial wound breakdown among 16 patients undergoing repair of complex rectovaginal fistulas with the use of Martius as tissue interposition whereas Songne et al. [8] reported no wound infections in their retrospective series of 14 patients. Just as with hematoma and seroma, the use of a drain postoperatively may decrease the risk of infection as may appropriate perioperative antibiotic usage. This has been a very rare occurrence in our practice over the past 25 years. Yeast infection can also easily develop in the groin or over the incision, and should be treated by the use of antifungal ointment or oral medications. This can sometimes be prevented by the preoperative treatment of infections present prior to surgery and by keeping the groin and perineum clean and dry postoperatively. When they occur, postoperative wound infections can be treated with antibiotics and when necessary, incision and debridement.

Pain and/or Numbness

Pain in the immediate postoperative period is expected and typically lasts a few days until the drain is removed and the swelling decreases. Ice packs are recommended initially. Loose underwear or garments allow for avoidance of direct skin contact and irritation. Likewise, a urethral Foley catheter when necessary is taped to the leg opposite the involved labia, or, when not critically needed, it is removed early on, trusting a suprapubic tube for bladder drainage. Following showering or bathing, direct contact with a towel can be avoided by using a blow dryer.

Chronic pain at the harvest site appears to be a rare complication of the procedure and might be a result of nerve injury during the harvesting. Intermittent discomfort and labial sensitivity was found in a retrospective review by Petrou et al. [13], in 3 of 8 women undergoing a Martius flap at the time of suprameatal urethrolysis for bladder outlet obstruction up to 1 year postoperatively. However, 5 (62%) reported self-perceived decreased sensation or numbness at the harvest site. A few other reports had similar findings, including Webster et al. [15], where 2/12 (17%) women undergoing Martius in combination with urethrolysis reported decreased sensation at the site of harvest, and Carey et al. [14], where 2/23 (9%) reported transient labial numbness. However, Carr and Webster reported on four women who underwent full-thickness cutaneous Martius flap for vaginal reconstruction [16] and all patients reported reduced sensation at the harvest site suggesting that when a skin island of the labia majora is harvested with the fatty pedicle flap the incidence of decreased sensation may be increased.

Sexual Dysfunction

Sexual dysfunction secondary to a Martius fat pad graft appears related to the labial pain and/or numbness, as well as sometimes to skin retraction medially. Sexual function typically resumes within 2–3 months after the original procedure once the labial and vaginal incisions are completely healed. Sexual dysfunction is uncommon even in series reporting initial pain and/or numbness. For example, Petrou et al. [13] noted 38% of pain at the harvest site and 62% with decreased sensation or numbness at 1 year, yet only 1 of 8 patients (12.5%) reported sexual dysfunction due to pain. Elkins et al. [6] in a ­retrospective review of patients undergoing Martius flap along with vesico- and rectovaginal fistula repairs reported a 25% incidence of dyspareunia.

Since the Martius is used in complex vaginal surgery where scarring can be expected and this scarring could potentially lead to a high rate of secondary dyspareunia, it has been suggested that its use will lead to lesser scarring and therefore possibly less vaginal discomfort or dyspareunia. In fact, in one series by Rangnekar et al. [5], 38 patients underwent successful urinary-vaginal fistula repair (20 with Martius and 18 without). No patients undergoing repair with Martius reported dyspareunia postoperatively whereas 6 (33%) of those repaired without Martius did. The authors proposed that the increased blood supply and lymphatic drainage afforded by the flap interposition might have lessened vaginal scarring thereby leading to the lower rates of dyspareunia.

Labial Distortion

Due to the removal of underlying fatty tissue from the labia majora on one side, labial distortion can raise cosmetic concerns. A few reports comment on the incidence of this complication, but all are retrospective reviews and the numbers reported are quite variable. McNevin et al. [7] reported no complaints related to cosmesis among 16 patients undergoing Martius in combination with low rectovaginal fistula repair. However, in eight women who underwent Martius in combination with suprameatal urethrolysis, Petrou et al. [13] reported 2 (25%) felt the harvest site appeared no different from preoperative appearance, 2 (25%) that it was almost normal and 1 (12%) noted it was markedly different. The remaining three patients (38%) had never examined the harvest site. In an attempt to prevent or limit this secondary distortion due to labial skin healing and outward retraction at the superior medial edge of the labia majora, we have changed our practice to a more lateral incision over the bulge of the labia majora. In addition, we purposely leave fat medially over the inner portion of the labia majora. The surgical outcome of this technique is shown with intraoperative and postoperative images in Fig. 19.1. In addition, an in situ technique for Martius harvesting has been described by Rutman et al. [17] which avoids a labial incision entirely by dissecting a tunnel under the vaginal wall and harvesting the pedicle graft through the vaginal incision. Although potentially useful, no reports on these technical variants regarding cosmetic outcomes can be found in the literature thus far.

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Fig. 19.1

Martius fat pad harvested through an incision on the lateral side of the labial bulge. Fat was left medially to avoid any postoperative distortion or retraction (a). Same patient seen 1 year later. The incision is barely visible and there is no asymmetry (b)

In case of symptomatic labial distortion, a labial fat injection to remodel the labia can be considered. In a single patient (pre- and postoperative views seen in Fig. 19.2), autologous fat was harvested and injected with good cosmetic and functional outcomes.

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Fig. 19.2

Pre- (a) and postoperative (b) images of a patient with labial distortion after a Martius who underwent autologous fat injection into the right labia majora for cosmetic repair

Conclusions

The Martius labial fat pad is a pedicle graft which can be used as an additional layer of tissue interposition when needed in complex vaginal reconstructive cases. It is relatively simple to harvest and use, but does have a few known associated complications, including hematoma or seroma formation, wound infection, pain or numbness at the site of harvest, sexual dysfunction, and labial distortion. The true incidence of these complications is not well documented, but believed to be overall low based on the limited evidence found in the literature as well as the opinion and experience of these authors. Solutions to avoid these complications or treat them after the fact are predominantly based on the authors’ experience with very little discussion of such techniques in the literature. Overall the Martius labial fat pad graft is a relatively safe adjunct to complex vaginal reconstruction which can improve rates of successful outcome in some difficult situations.

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