Vaginoplasty

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

Vaginoplasty is a reconstructive plastic surgery and cosmetic procedure for 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 hypoplasia) or because of an acquired cause (e.g., childbirth physical trauma, cancer).^[1] As such, the term vaginoplasty generally describes any such cosmetic reconstructive and corrective vaginal surgery, and the term neovaginoplasty specifically describes the procedures of either partial or total construction or reconstruction of the vulvo-vaginal complex.

Purposes and related procedures

Sex reassignment surgery

In male-to-female sex reassignment surgery, some trans women patients undergo vaginoplasty as part of their physical (sex) transition. In Berlin in 1931, Dora R, born as Rudolph R, became the first known transgender woman to undergo vaginoplasty.^[2] Post-operative sexual intercourse is possible after such surgery, although with a much longer delay (usually around six weeks). Sensation is usually very good. One important difference regarding vaginoplasty on trans women is the need to dilate the vagina. A few days after surgery, the vaginal stent is removed and a long regimen of vaginal dilation begins. A set of dilators is used during each dilation, each one with an increasingly large width. For roughly the first week or two, and sometimes up to a month, dilation is performed several times a day using the smaller dilators. It can then be tapered off gradually, becoming once per day, then every other day, and then once per week, all while working up to the larger dilators. Eventually, it can be slowed down to once per month, and use of only one dilator (of the larger widths from the set) is the goal. Some trans women find they require dilation even less, even once every couple of months, depending on experience and individual physiology. However, it is important to note that waiting too long between dilations (the exact time depending on post-operative time and individual physiology) leads to increased difficulty restarting dilation. Vaginal dilation is also required for life, and sexual activity (including intercourse) in place of dilation may not be sufficient. 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.

Vaginal rejuvenation

A “vaginal rejuvenation” is a non-reconstructive vaginoplasty that restores the muscle tone and desired aesthetic of the vagina, by removing external tissues and tightening the supportive structures of the vulvovaginal complex, in an effort either to reduce or to reverse the effects of aging and parturition (childbearing). The advantages may be increased comfort 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.^[3]

Sometimes referred to as "vaginal rejuvenation”, “aesthetic vaginal surgery”, or “cosmetic vaginal surgery”, various results aim to strengthen the function of the vulvo-vaginal area, firm up and reshape tissue for youthful appearances. In regular terms, the procedure is essentially a “face lift” for the vulva and vagina.^[4] Vaginal rejuvenation is often two combined distinct surgeries of labiaplasty and vaginoplasty, to restore or enhance the vagina's cosmetic appearance or function. Labiaplasty is a labia reduction and cosmetic enhancement genital surgical procedure to reduce or change the shape of the labia minora (small lips) on the outside of the vagina. Some surgeries are needed for discomfort occurring from chronic labial irritation that develops from tight clothing, sex, sports, or other physical activities. Vaginoplasty surgery is done by removing excess vaginal lining and tightening the surrounding soft tissues and muscles.^[5] The post-operative outcome of vaginoplasty is variable; it usually allows coitus (sexual intercourse) after a week, although sensation might not always be present. In fertile 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.

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.^[6] It can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty.^[7]

Hymen procedures

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 rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina.^[8][9] 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.^[8] Balloon vaginoplasty was introduced by professor Ali El Saman from Egypt as the fastest method^[10] for creation of a naturally covered neovagina. Balloon vaginoplasty is both effective and unique in the ability to manage and control both the depth and the length of the reconstructed neovagina.^[11] Interestingly, the balloon vaginoplasty procedure is so simple that it could be conducted under local anesthesia^[12] Furthermore, balloon vaginoplasty is associated with cosmetically appealing vaginae especially when it was conducted via single port.^[13]

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.^[14]

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 labia minora 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 a segment of the sigmoid colon along with its vascular pedicle and using it to form vaginal lining. This surgery is performed on women with androgen insensitivity syndrome, congenital adrenal hyperplasia, vaginal agenesis, müllerian agenesis, and other intersex 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. The benefit of this procedure is that it gives good space and length to neo-vagina.

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 vaginoplastic technique is its utilization of the prepucial skin (hood) of the clitoris as a horseshoe-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).^[15]

Laparoscopic peritoneal pull through vaginoplasty

A simple new laparoscopic peritoneal vaginoplasty was described in a series of 36 patients with long term replicable excellent results culminating in normal vaginal development.^[16] A total of 36 patients with congenital absence of vagina (MRKH syndrome) were treated with laparoscopic peritoneal pull through technique of Dr. Mhatre (modification of Davidov’s procedure) between 2003 and 2012. The new technique of laparoscopic peritoneal vaginoplasty described by the author has not only produced excellent results due to peritoneal metaplasia, but it has also resulted in the formation of normal vagina. This new surgical technique is comparatively simple with no morbidity. The neovagina has an acidic pH and normal cytology. Average operative time was 1-1.5 hrs. Average hospital stay was three days; there were no intra-operative and post-operative complications. All the patients had adequate vaginal length of about 7 to 8 cm, admitting a full-size Sims’ speculum. The neovagina offers patients good coital function with natural lubrication and pleasure, a function which is otherwise denied by nature in the context of their earlier quandary.

McIndoe technique

The McIndoe vaginoplasty technique utilizes split-thickness skin grafts that cover a mold, which is then inserted into 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 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).^[17][18] 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.^[19] The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy.^[20] In vaginal hypoplasia, traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments.^[21]

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.^[22] 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.

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.^[23]

Vaginoplastic procedures (and other female genital cosmetic surgery procedures) embody physical norms with which bodies must discipline themselves. According to Sara Rodrigues, female genital cosmetic surgery procedures creates a "genital normality". Within this framework, women are defined first by vulval and vaginal "normality" and subsequently by the psychological and emotional certainty, sexual confidence, and, ultimately, sexual satisfaction that genital "normality" provides.^[24] Not only does this create a normal/abnormal dichotomy (within which those who fall under "abnormal" are likely to be condemned), this also inhibits general body acceptance and body/self-positivity. Vaginoplasty and labiaplasty are indicative of a deployment of biopolitics in service of the creation of the ‘optimal’ vagina.^[25]

See also

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

References

Further reading

• Miller, PB; Forstein, DA (Apr–Jun 2009). "Creation of a neovagina by the Vecchietti procedure in a patient with corrected high imperforate anus.". JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13 (2): 221–3. PMC 3015920. PMID 19660220. 

Further reading

• Karim RB, Hage JJ, Dekker JJ, Schoot CM (January 1995). "Evolution of the methods of neovaginoplasty for vaginal aplasia". Eur. J. Obstet. Gynecol. Reprod. Biol. 58 (1): 19–27. PMID 7758640. 
• Karim RB, Hage JJ, Mulder JW (December 1996). "Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility". Ann Plast Surg 37 (6): 669–75. doi:10.1097/00000637-199612000-00018. PMID 8988784.