Reprinted from the Chicago Medical Recorder, August, 1893. 
TAIT'S PERINEAL FLAP OPERATION. 
F. BYRON ROBINSON, B. S., M. D. 
PROFESSOR OF GYNECOLOGY IN THE CHICAGO POST GRADUATE SCHOOL; GYNECOLOGIST TO THE 
WOMAN'S HOSPITAL, THE POST GRADUATE HOSPITAL, THE CHARITY HOSPITAL AND THE 
COLUMBIA DISPENSARY. 
Perineorrhaphy is an operation to restore the integrity of the 
perineal body. The object in restoring the perineal body is to 
prevent prolapse of the public segment of the pelvic floor and the 
uterus. The pelvic floor is the levator ani muscle with the recto- 
vesicle fascia above it and the anal fascia below it. The pelvic 
floor is composed of two segments divided by the vaginal lumen. 
To the anterior or pubic segment belong the retro-pubic fat, the 
bladder and the anterior vaginal wall. The anterior pubic seg- 
ment of the pelvic floor is called the (a) anterior, (b) the pubic, 
(c) the visceral, (e) the movable and (d) the obstetrical pelvic 
segment. 
To the posterior segment of the pelvic floor belong the poste- 
rior vaginal wall the perineum and the rectum. The posterior 
segment of the pelvic floor is named (a) the posterior, (b) the ver- 
trebral, (c) the sacral, (d) the fixed pelvic segment. Now these 
two segments of the pelvic floor, viz: sacral and pelvic segments 
act like two valves which close an opening by overlapping each 
other. The chief valve of support is the sacral segment. The 
anterior edge of the sacral valve or pelvic segment is tipped or 
bound by dense fibro-elastic tissue known as the perineal body. 
The uterus lies immediately above the valve, while the perineum 
lies immediately below the valve. 
The only way we can have uterine prolapse or sacro-pubic 
hernia is by the opening up of this valve. In the virgin the seg- 
ments or valves of the pelvic floor are closed. The valves are 
opened up naturally by labor. They are opened up artificially by 
the admittance of air into the vagina. The valves are opened up 
pathologically by uterine prolapse, which should be termed sacro- 
pubic hernia. If a woman suffering from descensus uteri is 
placed on the table and told to strain one sees coming out first the 
anterior vaginal wall, second the cervix uteri, and third the poste- 
rior vaginal wall. So that the anterior pubic segmen, retro- 
pubic fat, bladder and anterior vaginal wall, are all involved in the 
prolapse. But besides we find that a part of the sacral segment, 
the posterior vaginal wall, is included in the prolapse. 
Now the three great factors in uterine prolapse are: 1. Intra- 
abdominal pressure. 2. Deficiency of the sacral segment. 3. 
Loss of tone in the pubic segment. The sacral segment is a 2 
curved segment and the tip is the perineal body. Now if the 
sacral segment is straightened out and its tip, the perineal body, is 
torn, then the uterus simply slides or glides out of the pelvis 
between the pelvic valves. Then the perineal body is an indirect 
support in preventing uterine prolapse or sacro-pubic hernia. 
Difference of opinion still prevails as to the utility of the 
perineal body in the economy of the female genitals, but from 
considerable clinical and operative work and many dissections I 
will claim for the perineal body the following: 1. It sustains the 
lower Qnd of the anterior rectal wall and the posterior vaginal 
wall. 2. It supports and directs the discharging end of the rec- 
tum backward and the discharging end of the vagina forward. 3. 
It not only keeps the discharging ends of the rectum and vagina 
widely apart but it gives both a substantial support in a curved 
direction at their termination, thus affording mechanical advantages 
for maintaining closure of both apertures and preventing the easy 
escape of the contents of either canal, the wide separation of the 
two ends of the canals avoids mingling of the secretions and con- 
sequent infection and irritation from decomposition. The back- 
ward curve of the rectum and the forward curve of the vagina is 
an important factor in support and prevents gaping and eversion. 
4. The perineal body is the point of union of four muscles: the 
levator ani, the sphincter ani, the bulbo-cavernosus and the trans- 
versus perinei, besides the collections of dense connective tissue 
and elastic tissue. The perineum is the skin covering the perineal 
body and extending from rectum to vagina. The perineal body 
extends up between the rectum and vagina, but dissections show 
that it has been exaggerated in its length by many gynecological 
text-books. 5. The perineal body acts as a support to the pelvic 
floor. 6. It strengthens a tried point in labor. 7. Laceration of 
the perineal body to any considerable extent destroys the nice 
balance between anatomical structure and physiological function. 
The object of the flap perineorrhaphy is : 1st. To restore 
partial ruptures. 2d. To restore rectal function from complete 
ruptures. 3d. To prevent prolapse of the pubic segment. 4th. 
To prevent uterine prolapse. The etiological factors of lacerations 
are: 1. Labor. 2. Coitus. 3. Trauma. Partial perineal lacera- 
tions may be accompanied by: 1. Increased vaginal secretions. 
2. Vulvar patency. 3. Instability from pathological conditions of 
nerve endings. 4. Neurosis from continued reflexes. 5. Endo- 
metritis from infection. 6. Descent of anterior rectal wall, pos- 
terior vaginal wall and uterus. 7. Prolapse of bladder. 
Complete laceration may be accompanied by : 1. Anal and 
vulvar patency. 2. Increased vaginal and rectal secretions. 3. 
Hemorrhoids. 4. Incontinence of vaginal and bowel contents. 
5. The mingling of secretions induces disease by decomposition, 3 
e. g., eczema. G. Neurosis from reflex irritation due to disease at 
the nerve ends. 7. Hypertrophy as well as atrophy of lacerated 
parts will induce reflexes. 8. The malnutrition of the parts will 
cause relaxed tissues and prolapse will ensue. 
Perineorrhaphy began with Par6. It passed on and was culti- 
vated by Guillemeau, Noel, Sancerette, Mursina, Mensel, Osiander, 
Zary, Diffenbach, Simon, Sims, Horner, Brown, Voss, Stein, San- 
ger, Duneau, Simpson, Colles and others. At present the most 
useful and simple method of reforming the perineum is by Tait's 
flap-splitting method. 
If a woman with a lacerated perineum is placed on the table 
on her back and the labia are well separated, one can see the 
old white cicatricial line which represents the healed scar. Now 
it may be observed that this linear cicatrix is transverse in 
direction, while the fresh tear in the perineal body was perpendicu- 
lar. The perineum tears in a direction from the vagina toward the 
Fig. 1.-The dark line running from the vaginal orifice toward the rectum 
represents the old perineal laceration. The dark line running from 7 to 1 and 
then up on the labium to 2 shows the exposed tissue made by the scissors clip on 
the left side. From 1 to 6 shows another scissors clip and is known as the "back 
cut." From 3 to 5 shows another "back cut." From 3 to 4 represents the blade 
of the scissors beneath the labial tissue ready to be clipped. 
rectum, but the peculiarity is that it heals in a perpendicular 
direction to the original rent, so that if the perineum tears in the 
direction from the vagina toward the rectum, it will heal exactly 
at right angles to the original wound, and we will have a cica- 
trical line running toward the tuberosities of the ischia. 
Now the flap splitting is based on the very peculiar method 
of healing in the perineal laceration. Sharp pointed elbow scis- 4 
sors are required. A curved needle with a handle and an eye at 
its pointed end is also necessary. 
To do Tait's flap operation the point of the scissors is en- 
tered at the middle of the recto-vaginal septum for about one- 
half inch, say at 7 in Fig. 1; the scissors' point is then carried 
beneath the tissue, as deep as desired, to the side of the vagina, 
and up to the labium as high as desired, say at 2 in Fig. 1. A 
clip is then made by the scissors, exposing the tissue, from 7 to 
2, Fig. 1; the point of the scissors is again entered at 7, and 
the point is carried under the tissue to 3 and up the labia to 4, 
Fig. 2.-The vaginal flap is seized at 7 by forceps and drawn up toward the 
vagina, and the rectal flap seized at 7 and drawn toward the rectum. The raw 
surface is now drawn into an oval shape by tension on the two forceps. The 
needle shows itself entirely inside of skin and mucous membrane; It penetrates 
neither. The needle is best managed by introducing a finger into the rectum so 
as to avoid penetrating the gut wall. 
when it emerges. A clip is then made with the scissors, exposing 
the tissue from 7 to 3 and to 4. The "back cuts" are then made 
by entering the point of the scissors at 3, and making it emerge at 
5, when the scissors are clipped, exposing the tissue from 3 to 
5. The point of the scissors is again entered at 1 and carried to 6 
and the scissors clipped, exposing the tissue from 1 to 6. We now 
have a U-shaped incision around the vaginal orifice, and a 
U-shaped incision around the anal orifice. Now the anterior 
vaginal flap is seized at 7 by a forceps and drawn up toward the 5 
vaginal orifice, see Fig. 2. The posterior flap is also seized by a 
forceps at 7, and drawn back toward the rectum, see Fig. 2. The 
points 7 and 7 will represent the apices of a long, narrow oval, as 
seen in Fig. 2. The second step is the introduction of three to 
six silkworm gut sutures. The silkworm gut should be put into 
hot water a few minutes before using, so as to make it flexible. A 
handled needle with an eye in the point is used. Its point is 
entered just inside the margin of the wound, not in the skin or 
mucous membrame, and is carried under the exposed tissue to 
the bottom of the wound, and then, still under the tissues up to 
the opposite margin of the wound, where it emerges. A thread of 
silkworm gut is put through its eye and the needle is withdrawn. 
Fig. 3.-The results after tying the four sutures. Notice the wound gapes a 
little from 7 to 7 and that the vaginal flap peeps over the upper 7. The needle 
may be introduced from the margin of the wound to the bottom and then emerged, 
threaded, and drawn out on one side. Then the other side may be done likewise. 
I note this, as in a thick, fat perineum it may be impossible to pass the needle 
from one margin of the wound to the other without threading it twice. The 
sutures are all introduced before any are tied. The newly built perineum from 7 
to 7 will look amazingly large, but it will soon sink to a natural appearance. 
Three to five of such sutures are employed. The sutures 
be left in for six to eight weeks. The operation is easily done 
in ten minutes. I have frequently seen Mr. Tait do it in five 
minutes. On tying the sutures one will note, to his delightful 
surprise, that the original perineum is rebuilt. I would urge that 
the clips with the scissors be made deep, so as to expose wide 
areas of tissue. The labial incisions should be carried high up 
on their wall ; I sometimes carry them as high as the urethra. 
I have so far not seen tension disturb the operation. A little 
practice is required so that a man will not make a pocket above 
the perineum in the vagina. Be sure that the sutures grasp 6 
plenty of tissue, so that firm and uniform coaptation will exist 
after tying. The operation is alike applicable to partial and com- 
plete perineal lacerations. During my six months' course with 
Mr. Tait he would frequently remark that the worse the laceration 
the better the operation showed itself. Mr. Tait has performed 
many hundred perineal operations by the flap method. He has 
twenty-six recorded cases of labor after the operation, and he told 
me that he had never known the peritoneum to be retorn. 
The after-treatment of the operation is simply rest. I prefer 
to keep the bowels loose, and just before movement give an 
enema. The chances of union by first intention are superior to 
the denudation operation, as the rectal and vaginal flaps divert 
secretions from the wound. 
The advantages of the flap operation are: 1. The ease and 
simplicity of its performance. 2. It wastes no tissue; if it fails the 
patient is no worse off than before the operation. 3. It is the only 
operation that restores in a natural method the perineal body. 4. 
It withstands subsequent labors. 5. The sutures are not passed 
through skin or mucous membrane, and therefore are not so liable 
to suppurate.- 6. Its certainty of healing, 7. The flap operation 
secures in the easiest and most convenient manner the widest pos- 
sible surface for coaptation and healing. 8. The pain after the 
operation, in my experience, is less than after the denudation 
operation. 9. Tait's flap operation can be practiced successfully 
where the repeated denudation operation cannot be performed 
because of loss of tissue and excess of tension. 10. The short 
time required to do Tait's flap operation minimizes shock. 11. 
The resulting cicatrix is in its natural location and linear, and 
will thus cause less peripheral nervous disturbance. 12. The 
stitches leave no cicatrices, and therefore will cause no irritation. 
They act like Dr. Bayard Holmes' buried sutures. 
I will say that I have seen men doing what was called Tait's 
flap operation with a small bistoury, but in my opinion it was so 
much inferior to Tait's operation performed with scissors that it 
appeared like a totally different operation. 
When one ties the sutures the newly formed perineum will 
look enormously large, but it will soon shrink to a natural appear- 
ance. By a little experience one can do Tait's operation so that, 
on healing, the linear cicatrix will so resemble the old raph6 that 
one can scarcely tell that an operation has been done. I have done 
the operation and in some eight weeks after the healing, the result 
was so perfect that some practitioners almost doubted that any 
operation had been done. 
In performing the operation one must not penetrate the rec- 
tum or vagina with either the point of the scissors or the point of 
the needle. In either case a vaginal or rectal fistula might result; 7 
or, if fistula did not occur, healing of the wound might be retarded 
or interfered with. One should, of course, avoid entering the 
point of the scissors into the vaginal bulb and so creating profuse 
hemorrhage. The operator should be careful not so sever the 
ducts of the vulvo-vaginal glands. Again, there is some danger 
that the flap may not heal high up in the recto-vaginal septum. 
I saw such a case in a colleague's practice. I make the incis- 
ions from one-half to one inch deep. One of the difficulties to 
understand in Tait's flap operation is how such incisions can be 
made to produce an oval raw surface. I think the illustrations 
which accompany this article will show it clearly. The incisions 
made are, say, one-half to three-fourths of an inch deep between 
the rectal and vaginal wall. The raw surface on the rectal flap, 
then, is one-half inch, and the raw surface on the vaginal flap is 
one-half inch, making one inch of raw surface. I nearly always 
have one and one-half inches, so that when the middle of the 
vaginal flap is drawn up toward the vagina, and the middle of the 
rectal flap is drawn toward the rectum, as seen in Fig. 2, there will 
be an irregular oval raw surface, whose closure will represent the 
new perineum. The cicatrix in the new perineum will be linear, 
as shown in Fig. 3. If the index finger is now introduced into the 
rectum, and the thumb, or other index finger, is intraduced into 
the vagina, the thick, newly formed perineum is plainly felt. Its 
healing is quite certain, as the rectal and vaginal flaps act as sheds 
to direct all secretions away from the wound. The advantage of 
avoiding the skin or mucous membrane in passing the sutures is 
clearly shown by the subsequent absence of stitch-hole marks. 
The suffering after the operation, so far as I have noted, is far less 
than after the denudation. 
Tait's flap operation can be reversed and performed for pro- 
lapse of the bladder, but as I have had no experience with the 
performance of the reversed flap, I will leave that for experienced 
surgeons to report on. In the case of the reversed flap the newly 
acquired strong tissue would necessarily be formed in the vesti- 
bule. It seems to me that there is a future for Tait's reversed- 
flap operation, for the principle of the operation is just the same 
whether the scissors makes the incision clips between the rectum 
and vagina or between the urethra and clitoris. The amount of 
episiorrhaphy in either perineal flap or vestibule flap will depend 
on the operator's individual judgment. Tait's flap extension will 
be discussed under operations for prolapse. It is simply the addi- 
tion of episiorrhaphy, in the form of the flap method, to the 
perineal flap. It may be called perineo-episiorrhaphy. 
The two types of perineorrhaphy by denudation differ in the 
method of suturing. The old method was to pass the sutures 
through skin across the denuded surface under the exposed tissue. A later method is to use what is called the " £tage " stitch. It is 
the buried catgut suture of Werth, of Kiel. In English it would 
be called the buried spiral catgut. It is an excellent method of 
doing perineorrhaphy. I found by experience that when the 
laceration extends up into the rectum the best way is to use no 
rectal sutures at all, but use the spiral catgut right down to the 
mucous membrane of the rectum. Also, use no vaginal sutures, 
simply carrying the catgut spiral suture up to the vaginal mucous 
membrane and no further. The same may be said about using no 
perineal sutures unless tension is dangerous. Hence I can close 
a laceration of the perineum into the rectum by simply using a 
continuous catgut suture which never goes through skin or mucous 
membrane. So far as the rectum is concerned, I found it much 
better not to introduce sutures into its mucous membrane. So 
that Dieffenbach's vaginal, perineal, and rectal sutures are all left 
out, while the denuded surface is held in fixed coaptation by a 
wholly buried spiral catgut suture. But even this, I think, is 
inferior to the flap method. 
The flap splitting operation is very useful for a partially pro- 
lapsed uterus. I have now practiced the flap splitting in perin- 
orrhaphy for two years and I have never had one failure. I have 
one case in which a fistula exists between the vagina and rectum 
about the size of a knitting needle, three months after the opera- 
tion, but I think that will heal as soon as the portion of suture, 
which no doubt exists there, shall slough out. That case had had 
several of the denuding operations performed unsuccessfully 
and was of thirty-four years standing. As time goes on and I 
become more experienced in the operation I split the rectum and 
vagina higher than I did formerly and I extend the "clips" higher 
up against the urethra. At the Charity Hospital many of the 
cases have complete laceration extending from one to three 
inches up into the rectum, and I have had so far no failure even in 
such cases. Dr. Lucy Waite has also performed the flap opera- 
tion in my service at this hospital and so far she has had no failure 
with it. I also note that other gynecologists of the city are em- 
ploying it with reported success. It may be noted that when 
several denuding operations have been practiced on a patient with 
complete laceration and tissue loss and atrophy have made neces- 
sary tissue scant that side cuts to relieve tension may be made. 
Venetian Building.