Reconstructive Proctology: A Narrative Review of Flap-Based Anoplasty for Aesthetic and Functional Optimization in Grade Iv Hemorrhoidal Disease

Hemorrhoidal disease is one of the most ubiquitous benign anorectal conditions. While early disease is largely able to be controlled and treated in the office, Grade IV hemorrhoidal disease (i.e., permanently prolapsed and irreducible hemorrhoidal cushions) requires radical surgery. The gold standard for advanced disease is excisional hemorrhoidectomy. These extremely aggressive excisional procedures are very painful and can sacrifice much of the normal anoderm. The resultant healing by secondary intention often causes an iatrogenic anatomical anal stenosis. As a result, the field of contemporary reconstructive proctology has moved towards flap-based anoplasty. Pliable and well-vascularized perianal skin is brought into the anal canal by a set of techniques such as V-Y advancement, Diamond, and House flaps to restore the reconstructive principle of like with like. These techniques are used prophylactically during primary excisional hemorrhoidectomy and reactively to reconstruct the anal canal. The pathophysiology of Grade IV hemorrhoidal disease and postoperative anal stenosis, as well as geometric issues of modern flap anoplasty, are discussed in this review. The clinical outcome is compared with the more effective one by keeping the functional continence intact and the aesthetic satisfaction.