ISSN: 2754-8880
Published 00 11 0000
OPEN ACCESS
Edited by
A.Hussain
Submitted 25 May. 2025
Accepted 5 June. 2025
Citation
Khairul Farhan Khairuddin,
Nur Afdzillah, Diana Melissa,
Nabil Azmi, Soma
Balaganapati. Cutaneous
Flap Reconstruction In Anal
Stenosis.Editorial
article:BJOSS::2026:(6);193-
195
Cutaneous Flap Reconstruction In Anal Stenosis
K Farhan1*, N Afdzillah1, D Melissa1, N Azmi1, and S Balaganapati1
1Department Of General Surgery, Universiti Kebangsaan Malaysia, KualaLumpur, Malaysia
*Correspondence author : Khairul Farhan Khairuddin; aan89charlie@gmail.com
ORIGINAL
Abstract
Anal stenosis is a rare but impactful condition that can arise from various aetiologies, including
surgical trauma, inflammatory bowel disease, radiation therapy, and congenital malformations.
Treatment approaches vary based on severity, with surgical intervention often required for
moderate to severe cases ( 1). This case report presents a 52-year-old Chinese male who developed
severe anal stenosis following multiple perineal debridement procedures for a perineal abscess. A
House advancement flap and a Bipedicle flap were used to reconstruct the anal canal, leading to
significant symptomatic relief and functional improvement. This report highlights the importance
of flap-based reconstruction in managing complex anal stenosis cases (2).
Introduction
Anal stenosis is a pathological narrowing of the anal canal that significantly impairs defecatory
function and reduces a patient’s quality of life. It commonly results from surgical procedures such
as haemorrhoidectomy, but may also stem from inflammatory bowel disease, radiation therapy, or
congenital anomalies [1]. While mild cases may be managed conservatively, moderate to severe
stenosis often necessitates surgical correction ( 3 ). Various surgical techniques have been employed
to restore anal canal function, including mucosal and cutaneous advancement flaps ( 4). Studies
comparing diamond versus V-Y advancement flaps for post-haemorrhoidectomy anal stenosis have
demonstrated favourable outcomes, reinforcing the role of flap-based reconstruction ( 1). However,
the absence of a universally accepted gold standard underscores the need for personalized
treatment approaches. This case report presents the successful application of House advancement
and Bipedicle flaps in a patient with severe anal stenosis following perineal debridement. By
detailing the surgical technique and postoperative outcomes, we aim to contribute to the growing
body of evidence supporting flap-based reconstruction (2).
Case Presentation
A 52-year-old Chinese male underwent multiple perineal debridement procedures due to a
perineal abscess, resulting in injuries to both the internal and external anorectal sphincters and
substantial bleeding. Over the course of a year, he developed severe anal stenosis, requiring
forceful dilatation with a 6mm Hegar dilator during physical examination ( 3). Laboratory tests
were normal, and surgical intervention was planned. The patient underwent anal repair with
House advancement and Bipedicle flap reconstruction. Scar tissue at the 3 o’clock and 6 o’clock
positions were excised, and two flaps were carefully designed to ensure vascular preservation
( 2). The grafts were securely fixed into the anal canal without tension, restoring the anal canal
length to 2 cm. Postoperatively, the patient was discharged three days after surgery without
complications. Follow-up assessments confirmed the excellent condition of the flap, with no signs
of infection or necrosis. One-month post-surgery, the patient reported significant improvement
in anal function, with no complaints.
Figure 1. Pre-operative Clinical Picture
(a) (b)
Figure 2. House Advancement and Bipedicle Flap Created, and Sutured.
Figure 3. Post Procedure Outcome.
Discussion
Anal stenosis can lead to severe complications if left untreated, significantly impacting a patient’s
quality of life. Various surgical techniques have been employed to restore the anal canal, with flap-
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(a) (b)
Figure 2. House Advancement and Bipedicle Flap Created, and Sutured.
Figure 3. Post Procedure Outcome.
Discussion
Anal stenosis can lead to severe complications if left untreated, significantly impacting a patient’s
quality of life. Various surgical techniques have been employed to restore the anal canal, with flap-
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based reconstruction proving effective in cases of severe stenosis (2). In this case, dense scarring
was observed at the 3 and 6 o’clock positions, necessitating the use of House and Bipedicle
flaps ( 3). The success of flap-based reconstruction relies on several critical factors, including
optimal vascularization, minimal tension, absence of infection or hematoma, appropriate flap
thickness, and diligent postoperative care ( 5). The perianal region offers distinct advantages for
flap creation due to its abundant vascularity, pliable connective tissue, and thick skin layer, which
is accompanied by a substantial layer of adipose tissue (4). During the procedure, fixation within
the anal canal was achieved using extended absorbable sutures, while non-absorbable sutures
were used for skin fixation (2). Canal calibre and diameter were carefully evaluated to ensure
postoperative patency. The combination of different flap techniques in the same setting enhances
tissue mobility, improves vascularity, and allows for better wound closure with reduced tension
( 4 ). The successful outcome in this case reinforces the efficacy of flap-based reconstruction in
managing severe anal stenosis. Postoperatively, the patient was discharged without complications,
and follow-up assessments confirmed excellent flap condition with no signs of infection or necrosis
(2 ). One month after surgery, the patient reported significant improvement in anal function, with
no complaints. The anatomical and functional improvements observed in this case highlight the
effectiveness of combining multiple flap techniques to achieve optimal surgical outcomes.
Conclusion
This case report demonstrates the effectiveness of House advancement and Bipedicle flaps in
treating severe anal stenosis. The procedure ensured vascular preservation, minimal tension, and
improved function, with no postoperative complications. The successful outcome underscores
the importance of tailored surgical approaches, reinforcing flap-based reconstruction as a viable
treatment option.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
References
[1] Lefta MJ, Baqir QK. Diamond flap anoplasty for severe anal stenosis. Basrah J Surg. 2013:23-6.
[2] Darwish AA, Kame KA, Eskandaros MS. Diamond versus VY advancement flaps for man-
agement of anal stenosis: efficacy and outcomes. Surgery, Gastroenterology and Oncology.
2022;27(1):37.
[3] Najafi M, Kazemeini A, Meshkati Yazd S, Dashtkuhi M, Ahmadi Tafti S, Behboudi B, et al.
Mucosal vs. cutaneous advancement flaps for the treatment of chronic anal fissures: a
randomized clinical trial. Techniques in Coloproctology. 2023;27(10):891-6.
[4] Bejiga G. Bilateral house advancement flap anoplasty for severe anal stenosis secondary to
traditional medicine application with excellent outcome:“Case report”. International journal
of surgery case reports. 2022;90:106725.
[5] Ibañez N, Abrisqueta J, Luján J, Hernández Q, Parrilla P. VY advancement flaps for extensive
perianal defect repair. Cirugía Española (English Edition). 2016;94(9):525-30.
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was observed at the 3 and 6 o’clock positions, necessitating the use of House and Bipedicle
flaps ( 3). The success of flap-based reconstruction relies on several critical factors, including
optimal vascularization, minimal tension, absence of infection or hematoma, appropriate flap
thickness, and diligent postoperative care ( 5). The perianal region offers distinct advantages for
flap creation due to its abundant vascularity, pliable connective tissue, and thick skin layer, which
is accompanied by a substantial layer of adipose tissue (4). During the procedure, fixation within
the anal canal was achieved using extended absorbable sutures, while non-absorbable sutures
were used for skin fixation (2). Canal calibre and diameter were carefully evaluated to ensure
postoperative patency. The combination of different flap techniques in the same setting enhances
tissue mobility, improves vascularity, and allows for better wound closure with reduced tension
( 4 ). The successful outcome in this case reinforces the efficacy of flap-based reconstruction in
managing severe anal stenosis. Postoperatively, the patient was discharged without complications,
and follow-up assessments confirmed excellent flap condition with no signs of infection or necrosis
(2 ). One month after surgery, the patient reported significant improvement in anal function, with
no complaints. The anatomical and functional improvements observed in this case highlight the
effectiveness of combining multiple flap techniques to achieve optimal surgical outcomes.
Conclusion
This case report demonstrates the effectiveness of House advancement and Bipedicle flaps in
treating severe anal stenosis. The procedure ensured vascular preservation, minimal tension, and
improved function, with no postoperative complications. The successful outcome underscores
the importance of tailored surgical approaches, reinforcing flap-based reconstruction as a viable
treatment option.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
References
[1] Lefta MJ, Baqir QK. Diamond flap anoplasty for severe anal stenosis. Basrah J Surg. 2013:23-6.
[2] Darwish AA, Kame KA, Eskandaros MS. Diamond versus VY advancement flaps for man-
agement of anal stenosis: efficacy and outcomes. Surgery, Gastroenterology and Oncology.
2022;27(1):37.
[3] Najafi M, Kazemeini A, Meshkati Yazd S, Dashtkuhi M, Ahmadi Tafti S, Behboudi B, et al.
Mucosal vs. cutaneous advancement flaps for the treatment of chronic anal fissures: a
randomized clinical trial. Techniques in Coloproctology. 2023;27(10):891-6.
[4] Bejiga G. Bilateral house advancement flap anoplasty for severe anal stenosis secondary to
traditional medicine application with excellent outcome:“Case report”. International journal
of surgery case reports. 2022;90:106725.
[5] Ibañez N, Abrisqueta J, Luján J, Hernández Q, Parrilla P. VY advancement flaps for extensive
perianal defect repair. Cirugía Española (English Edition). 2016;94(9):525-30.
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