X-Flap Perineal Reconstruction for OASIS Injury

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) are complications that occur during vaginal delivery, with a reported overall risk of 6.3. One of the significant complications of OASIS is postpartum fecal incontinence. This case study presents the management and surgical reconstruction of a 37-year-old woman with chronic OASIS sequelae, including perineal disruption, fecal incontinence, and stress urinary incontinence. OBJECTIVE: To demonstrate the technique of X-flap perineal reconstruction combined with overlapping sphincteroplasty and urethral bulking injections, highlighting the key surgical steps and postoperative care in the management of chronic OASIS. METHODS: A 37-year-old G2P2 patient presented with perineal skin disruption, occasional stool passage through the vagina, and stress urinary incontinence. Her obstetric history included two vaginal deliveries and a third-degree laceration during the first delivery. On examination, the patient had a chronically healed third-degree laceration with a minimal perineal body and anterior disruption of the external anal sphincter. The patient elected for surgical management, consisting of X-flap perineal reconstruction, overlapping sphincteroplasty, and urethral bulking injections. The X-flap technique involved an incision with a total length of 8 cm, hydrodissection, mobilization of the perineal body, and overlapping sphincter repair. Postoperative care included antibiotics, bowel management, and close follow-up. Final Cut Pro (Apple, CA) was used to edit the video. Patient consent was obtained. RESULTS: The surgery resulted in a well-reconstructed 5-cm perineal body with excellent anal sphincter reapproximation confirmed by rectal examination. The patient experienced mild swelling on postoperative day 7, which resolved after extending the course of antibiotics. At 6 weeks postoperatively, the incision had healed completely, and the patient was very satisfied with the outcome. She reported resolution of fecal incontinence and improved perineal function CONCLUSIONS: The X-flap perineal reconstruction technique provides an effective method for restoring the perineal body in patients with chronic OASIS injury sequelae. Key surgical principles include the mobilization of adequate perineal tissue, closure in multiple layers, and use of postoperative antibiotics to mitigate infection risk. Proper bowel management and close postoperative follow-up are essential to optimize healing and prevent complications.