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Transanal advancement flap repair has been considered as a treatment modality for transsphincteric perianal fistulas for over a century. Several systematic reviews have shown that this technique is effective in 80 percent of cases with a minimal and predictable effect on continence. The use of thicker flaps has been shown to increase the rate of recovery, but also to increase the rate of continence impairment. Unfortunately, there are few modifiable factors that seem to affect recovery. These include smoking cessation and weight loss. There is no evidence to support the use of diverting stomas. The placement of setons as part of a standardized treatment regimen is not supported by the literature. It is unadvisable to combine flap repair with other techniques.