Step 1: A vertical incision (average 8 cm) is made over the labia majora from the level of the mons pubis down towards the level of the fourchette (Image 18.2). The length of the incision depends on the length of fat pad required. It can always be extended upwards towards the mons pubis to gain more length. Although some authors recommend the use of local anesthetic agents to diminish post-operative pain and potentially long-term chronic labial pain, this has not been our practice to do so.

After placement of the LoneStar retractor to hold the skin edges open (Image 18.3), the dissection is started on each side to separate the labial fat pad in the center of the incision from the skin edges. It is important to leave enough fat underneath the skin on each side to avoid labial distortion, especially medially (Image 18.4).

Step 2. The labial fat pad can be gently grasped with a Babcock clamp (Image 18.5) and mobilized on an inferior pedicle supplied by a postero-inferior branch from the external pudendal artery. Although not our preference, a superior blood supply can also be considered. The dissection is continued medially first, with attention to keep sufficient fat attached underneath the medial labial edge (Image 18.6 and 18.7); then it proceeds superiorly aided by a small retractor which exposes the tip of the fat pad at the mons pubis. When a sufficient length has been freed, the fat pad is divided superiorly (Image 18.8). This can be done by using the bovie cautery or suture ligating the pedicle when larger blood vessels are present.

Step 3. Once divided at its extremity, the fat pad needs to be freely mobilized. To achieve this goal, the dissection then extends in depth until reaching the white shiny fascia covering the underlying ischiocavernosus and bulbocavernosus muscles (Image 18.9). There is no need to go deeper into the muscle. Next the dissection of the back side of the fat pad allows its gradual freeing and elongation (Images 18.10 and 18.11). While progressing, one must keep in mind to preserve a broad base inferiorly and avoid damaging the lateral branch of the obturator artery to preserve the fat pad vascularity.

Step 4. After completing the fat pad mobilization, the extremity of the flap is secured with a figure of eight absorbable suture (Image 18.12) which will allow its transfer alongside the vaginal wall and then anteriorly around the urethra. The MFLP can be measured (Image 18.13). Then, a vaginal tunnel is created with long Metzenbaum scissors (Images 18.14 and 18.15) and/or a ring forceps beneath the ipsilateral vaginal wall. This tract is widened to accept at least two fingers to avoid compressing the fat pad and compromising its blood supply. Once tunnelled (Image 18.16), the suture at the end of the fat pad graft is grasped and the MFLP is delivered in the vagina (Image 18.17a, b). Next, with a curved short Satinsky clamp (Image 18.18), the suture at the end of the MFLP is grasped (Image 18.19) and the MFLP is pulled from right to left in front of the urethra and bladder neck area (Image 18.20) to serve as an interposition layer so that the urethra does not get attracted back by scar tissue to the back of the pubic bone.