Subcutaneous Pedicle Advancement Flap Anoplasty with Pivot Point Medialization for Anal Stenosis: A Single-center Retrospective Study.

Abstract

Objectives: Severe anal stenosis, particularly Whitehead deformity, presents a significant reconstructive challenge. This study reports the clinical outcomes of a modified subcutaneous pedicle advancement flap anoplasty emphasizing pivot point medialization, developed in collaboration with plastic surgeons.

Methods: We retrospectively analyzed data from 52 consecutive patients (aged 32-97 years; median, 67) treated between April 2021 and June 2025. The etiologies included postsurgical cicatricial stenosis (65.4%) and chronic anal fissure (34.6%). The technique involves establishing the pivot point-defined in this study as the biomechanical anchoring point at the deep subcutaneous fat layer-allowing tension-free advancement of the flap medially without rotation while preserving blood flow through the subcutaneous pedicle. Forty-nine patients completed the 6-month follow-up. Bougie examination at 6 months was performed without anesthesia during outpatient visits.

Results: Surgical success, defined as bougie passage of ≥22 mm (#9), was achieved in 48 of 49 patients (98.0%), with a median operative time of 24 min (range, 14-35 min). No flap necrosis occurred (0%). Complications included wound dehiscence in nine patients (17.3%), which healed conservatively within a median of 4 weeks, and rectal prolapse in one patient (1.9%). One patient (2.0%) showed insufficient dilation at 6 months and required reoperation at 12 months. No fecal incontinence was observed. Patient satisfaction at 3 months was high (very satisfied 63.5%, satisfied 21.2%, unchanged 15.4%, dissatisfied 0%).

Conclusion: This technique, utilizing pivot point medialization and straight advancement without rotation, may offer a safe and effective option for severe anal stenosis.