Vaginoplasty

Vaginoplasty: the pre-operative aspect (left), and the post-operative aspect (right) of a labial reduction.

Vaginoplasty is a reconstructive plastic surgery procedure for correcting the defects and deformities of the vaginal canal and its mucous membrane, and of vulvo-vaginal structures that might be absent or damaged because of congenital disease (e.g. vaginal atresia) or because of an acquired cause (e.g. physical trauma, cancer). As such, the term vaginoplasty generally describes any such reconstructive and corrective vaginal surgery, whilst the term neovaginoplasty specifically describes the procedures of either partial or total construction or reconstruction of the vulvo-vaginal complex.

The post-operative outcome of vaginoplasty is variable; it usually allows coitus (sexual intercourse), although sensation might not always be present. In biological women, menstruation and fertilization are assured when the uterus and the ovaries have preserved their normal functions; in a few cases, vaginal childbirth is possible. In male-to-female sex reassignment surgery, some trans women patients undergo vaginoplasty as part of their physical (sex) transition. The physical factors that limit vaginal dimensions are the rectoprostatic Denonvilliers’ Fascia (depth) and the Levator ani muscle (diameter); thus, in trans women patients, the narrowness of the male pelvis can reduce the available area to use for vaginoplasty.

Terminology

The term "vaginoplasty" also is applied to hymenotomy, the creation of an opening in an imperforate hymen, and hymenorrhaphy, the recreation of a ruptured hymen.

Vaginoplastic procedures

Vaginoplasty utilizes autologous (patient-derived) tissue from the patient’s person, to construct areas of vagina and areas of the vulvovaginal complex. The tissues available for surgical correction include the oral mucosa, skin flaps, skin grafts, the vaginal labia, penile skin, penile tissue, scrotal skin, and intestinal mucosa. In surgical praxis, it is important to electrolytically remove the follicles from a hair-bearing skin graft, unless the surgeon directs otherwise; usually, the skin graft is depilated intra-operatively, either manually (scraped) or by electrocauterization. Besides the vaginoplastic surgery techniques herein discussed, earlier plastic surgery procedures do exist, but have been superseded by the more effective results (outcome) of contemporary vaginoplasty.

Balloon vaginoplasty

In the balloon vaginoplasty technique, a foley catheter is laparoscopically inserted to the recto-vesical space (recto-pubic space), whereupon gradual traction and distension are applied to create a neovagina.^{[1] [2]} Moreover, balloon vaginoplasty also is a new technique for treating vaginal aplasia, which also is applied as a technically simple, physically safe, and medically effective alternative vaginoplasty for creating a neovagina, especially when conventional laparoscopic surgery is either infeasible or unsafe.^[1]

Buccal (oral) mucosa

A relatively novel surgical approach to treating vaginal agenesis is utilizing the buccal mucosa as the tissue for lining the vagina (ca. 8.0 cm. deep). The medical advantages of this vaginoplasty technique include the biological and healing qualities of the buccal mucosa tissue, minimal scarring, and a short, post-operative recovery for the patient. The disadvantages include limited vaginal dimensions (depth and width), and the possibility of either intraoral damage, when tissue-harvesting, or of complications.^[3]

In surgery, the tissue donor site in the cheek (ca. 2.5 x 8.0 cm.) is marked to avoid damage to the Stensen’s duct (parotid duct) and to the parotid gland. To create the vaginal lining, the buccal mucosa tissue graft is micro-perforated to allow shaping it to a larger size of greater area (surface); it then is formed upon a stent, and afterwards affixed to the vaginal space (created earlier in the operation), with its edge sutured to the minor labia and to the perineal skin. The vaginal mold of buccal mucosa is then (temporarily) secured to the perineal skin, to allow the patient’s recovery.

Colovaginoplasty

The colovaginoplasty (colon section) technique creates a vagina by cutting away a section of the sigmoid colon and using it to form a vaginal lining. This surgery is performed on women with androgen insensitivity syndrome, congenital adrenal hyperplasia, vaginal agenesis, müllerian agenesis, and other intersexual conditions wherein non-invasive forms of deepening the vagina cannot be performed (mostly on trans women patients) as an alternative to penile inversion, with or without an accompanying skin graft (usually from the thigh or the abdomen). Because of the potential complications (e.g. diversion colitis) most surgeons will recommend a colovaginoplasty procedure only when there is no alternative procedure.

Don Flap (labia minora flap)

The Don Flap correction of vaginal agenesis, uses a technique similar to that of penile inversion, that sutures the labia minora together to create a neovagina. A refinement of this vaginoplsatic technique is its utilization of the prepucial skin (hood) of the clitoris as a horse-shoe-shaped, one-piece flap. Yet, although the Don Flap technique is a relatively simple surgical procedure, the most obvious disadvantages of the labia minora flap surgery include the need for restorative labiaplasty and cervical dilation to produce a vagina of adequate dimensions (depth and width).^[4]

McIndoe technique

The McIndoe vaginoplasty technique utilizes split-thickness skin grafts that cover a mold, which then is inserted to a surgically created space, between the bladder and the rectum. The principal, technical difference between the McIndoe vaginoplasty and the Vecchietti vaginoplasty, is which tissue to utilize to line the created neovagina. Each surgical procedure has positive and negative factors, especially regarding upon whom such a plastic surgical technique can be applied, because the post-operative outcome varies with the patient’s indications.

Penile inversion

In genital reassignment, penile inversion is the most common plastic surgical technique for creating a neovagina for trans women patients; it also is used for the genital corrections for people born intersex. Along with the colovaginoplasty procedure, penile inversion is one of the two principal vaginoplasty procedures used for creating a neovagina. Applying a flap technique (first used by Sir Harold Gillies in 1951), the spongiform erectile tissue of the penis is removed, and the skin, with its nerves and vascular system (blood supply) still attached, is used to create a vestibule area and labia minora, which then are inverted into the neovaginal cavity created in the pelvic tissue. Part of the glans penis tip, with its nerve and vascular systems still connected, becomes the clitoris; and the urethra is shortened to end at a place appropriate to the female genital anatomy. Another common technique for creating a neoclitoris utilizes the urethral spongiform tissue. This was the most common penile inversion technique, and was so used by Dr. Burou and Dr. Stanley Biber; however, some surgeons do not create a neoclitoris as part of a penile inversion.

Vecchietti procedure

In treating müllerian agenesis, the Vecchietti procedure is a laparoscopic surgical technique that produces a vagina of dimensions (depth and width) comparable to those of a normal vagina (ca. 8.0 cm. deep).^{[5] [6]} A small, plastic sphere (“olive”) is threaded (sutured) against the vaginal area; the threads are drawn though the vaginal skin, up through the abdomen, and through the navel. There, the threads are attached to a traction device, and then daily are drawn tight so that the “olive” is pulled inwards and stretches the vagina, by approximately 1.0 cm. per day, thereby creating a vagina, approximately 7.0 cm. deep by 7.0 cm. wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time.^[7]

Wilson Method

The penile-inversion technique of the Wilson Method is different from the traditional penile-inversion technique in that it is a three-stage surgery, comprising a two-stage initial vaginoplasty.^[8] The Wilson Method surgery is initially performed like a traditional penile inversion, until the vaginal-vault creation step, in which the vault of the vagina is left unfinished, as a raw surface, and is packed with a sterile stent, which, after 5–7 days, then is lined with a skin graft harvested from the buttocks. The penile skin is used to create the labia minora, clitoral hooding, and the anterior fourchette (frenulum); the glans penis is used to create the clitoris, and the scrotum is used to create the labia majora.

Related procedures

Labiaplasty

Labiaplasty is a vaginoplastic surgery technique for reducing the size the genital labia — either the majora or the minora — which are any of the four folds of tissue of the vulva.^[9] It can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty.^[10]

Vaginal rejuvenation

A “vaginal rejuvenation” is a non-reconstructive vaginoplasty that restores the muscle tone and the æsthetics of the vagina, by removing excess tissues and tightening the supportive structures of the vulvovaginal complex, in effort either to reduce or to reverse the effects of aging and parturition (childbearing). The advantages are a physically comfortable health and an improved self-image (mental health); the potential disadvantages are decreased clitoral and genital sensation, and complications, such as infection, tissue adhesions, and scarring.^[11]

Criticism

The American College of Obstetricians and Gynecologists (ACOG) published Committee Opinion No. 378: Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures (2007), the college’s formal policy statement of opposition to the commercial misrepresentations of labiaplasty, and associated vaginoplastic procedures, as medically “accepted and routine surgical practices”. The ACOG doubted the medical safety and the therapeutic efficacy of the surgical techniques and procedures for performing labiaplasty, vaginal rejuvenation, the designer vagina, revirgination, and Gräfenberg Spot amplification, and recommended that women seeking such genitoplastic surgeries must be fully informed, with the available surgical-safety statistics, of the potential health risks of surgical-wound infection, of pudendal nerve damage (resulting in either an insensitive or an over-sensitive vulva), of dyspareunia (painful coitus), of tissue adhesions (epidermoid cysts), and of painful scars.^[12]

See also

	Medicine portal
	Transgender portal

• Clitoroplasty
• Gender reassignment therapy
• Genital modification and mutilation
• Hymenorrhaphy
• Hymenotomy
• Intersex surgery
• Intersexuality
• Labiaplasty
• Sex reassignment surgery male-to-female
• Sex reassignment surgery female-to-male
• Vulvovaginal health
• List of transgender-related topics

References

1. ^ ^{a b} El Saman AM, Fathalla MM, Nasr AM, Youssef MA (August 2007). "Laparoscopically Assisted Balloon Vaginoplasty for Management of Vaginal Aplasia". International Journal of Gynaecology and Obstetrics 98 (2): 134–137. doi:10.1016/j.ijgo.2007.04.013. PMID 17572428. 
2. ^ El Saman AM (April 2010). "Retropubic Balloon Vaginoplasty for Management of Mayer-Rokitansky-Küster-Hauser Syndrome". Fertil. Steril. 93 (6): 2016–2019. doi:10.1016/j.fertnstert.2008.12.046. PMID 19200986. 
3. ^ Use of Autologous Buccal Mucosa for Vaginoplasty: a Study of Eight Cases by Lin WC, Chang CYY, Shen YY, Tsai HD. Human Reproduction, Vol. 18, No. 3, pp. 604–607, March 2003
4. ^ Horse shoe flap Vaginoplasty — a New Technique of Vagina Reconstruction with Labia minora flaps for Primary Vaginal Agenesis. Purushothaman V. Journal of Plastic, Reconstructive & Aesthetic Surgery. Volume 58, Issue 7, pp. 934–939 October 2005
5. ^ Vecchietti G. Creation of an Artificial Vagina in Rokitansky–Kster–Hauser Syndrome. Attual Ostet Ginecol 1965;11:131–147
6. ^ Fedele L, Bianchi S, Tozzi L, Borruto F, Vignali M. A New Laparoscopic Procedure for Creation of a Neovagina in Rokitansky–Küster–Hauser Syndrome. Fertility and Sterility 1996;66:854–857
7. ^ University College University Hospitals > Vecchietti Procedure Retrieved 3 April 2010
8. ^ The Aesthetic Vulva: Perineal Cosmesis in the Male-to-Female Transsexual Wilson N. IJT Volume 6, Number 4, 2002
9. ^ The Perfect Vagina Documentary Retrieved 13 February 2011.
10. ^ Mirzabeigi MN, Moore JH Jr, Mericli AF, Bucciarelli P, Jandali S, Valerio IL, Stofman GM. (2011): Current Trends in Vaginal Labioplasty: A Survey of Plastic Surgeons. Ann Plast Surg. PMID 21346521
11. ^ http://womenshealthnews.wordpress.com/2007/08/31/vaginal-rejuvenation-not-proven-safe-or-necessary/
12. ^ American College of Obstetricians and Gynecologists (2007) (PDF). Vaginal "Rejuvenation" and Cosmetic Vaginal Procedures. p. 2. http://www.newviewcampaign.org/userfiles/file/ACOG%20gen.cosm.surg.pdf. 

Further reading

• Karim RB, Hage JJ, Dekker JJ, Schoot CM. Evolution of the Methods of Neovaginoplasty for Vaginal Aplasia. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 1995 January;58(1):19–27. Review. PMID 7758640
• Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in Male Transsexuals: Review of Surgical Techniques and Recommendations regarding Eligibility. Annals of Plastic Surgery. 1996 Dec;37(6):669–675. Review. PMID 8988784