Vaginoplasty

Vaginoplasty is a reconstructive surgery procedure used to either construct or reconstruct a vaginal canal and its mucous membrane. As such, the term vaginoplasty generally describes any such vaginal surgery, and the term neovaginoplasty specifically describes the procedures of either partial or total construction, or reconstruction, of the vulvovaginal complex.

These bodily structures might be absent from a woman, because of congenital disease (e.g. vaginal atresia) or because of an acquired cause (e.g. physical trauma, cancer). 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 sexual reassignment surgery, some trans women patients opt for vaginoplasty as part of their physical gender transition. The term vaginoplasty is often confused with the multiple procedures present in genital surgery and may be used as a catch-all term.

The post-operative outcome of vaginoplasty is variable; it usually allows sexual intercourse (coitus), although sensation is not always present. The general limiting factors in trans women patients to vaginal dimensions are from the Denonvilliers’ Fascia (depth) and the Levator ani muscle (diameter). In addition, the lower pelvis floor (opening) can reduce the available area to use for vaginoplasty.

Techniques available

There are many vaginoplasty surgical techniques, some involve using autologous (patient-derived) biological tissue, from other parts of the body of the patient, to construct areas of vagina and areas of the vulvovaginal complex.

The tissues that may be used include the oral mucosa, skin flaps or grafts, the vaginal labia, penile skin and/or tissue, scrotal skin, intestinal mucosa, and others. In praxis, it is important that, when using a hair-bearing skin graft, the hair be removed preoperative via electrolysis, unless the surgeon directs otherwise, in which case, the hair follicles are removed intraoperatively, via electrocauterization or by manually scraping them off.

Besides the surgical techniques, herein discussed, for effecting vaginoplasty, earlier plastic surgery procedures do exist, however, they have grown out of technical–surgical style, because of the more effective results afforded by the current vaginoplasty techniques.

Penile inversion

For trans women patients, penile inversion is the most common surgical technique for male-to-female genital reassignment that is used to construct a neovagina from a penis; occasionally, it also is used for people born intersex. Along with colovaginoplasty, penile inversion is one of the two vaginoplasty procedures used in creating a vagina in persons assigned male at birth.

Applying a flap technique, first used by Sir Harold Gillies in 1951, the erectile tissue of the penis is removed, and the skin, with its blood and nerve supplies still attached, is inverted skin side out to create the vestibule and labia minora, and draped down into a cavity created in the pelvic tissue. Clitoroplasty is usually performed concurrently as part of reassignment surgery. Vaginoplasty using only penile tissue is becoming less common since grafting of scrotal tissue saves valuable materials for the vulva. Urethra placement varies by surgeon to surgeon.

Colovaginoplasty

With colovaginoplasty, sometimes called a colon section, a vagina is created by cutting away a section of the sigmoid colon and using it to form a vaginal lining. In cases of stricture (narrowing) of the vagina created with colovaginoplasty, it can be augmented with oral mucosa grafts

This surgery is performed on females with androgen insensitivity syndrome, congenital adrenal hyperplasia, vaginal agenesis, müllerian agenesis, and other intersexed conditions, where non-invasive forms of lengthening the vagina cannot be done and, mostly, on trans women as an alternative to penile inversion with or without an accompanying skin graft (usually from either the thigh or abdomen).

Due to numerous potential complications (such as diversion colitis) most surgeons will recommend a colovaginoplasty only when there is no alternative.

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.

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 as a raw surface, and is packed with a sterile stent, which, after 5–7 days, then is lined with a skin graft from the buttocks. The penile skin is used to create the labia minora, clitoral hooding, and the anterior fourchette; the glans penis is used to create the clitoris, and the scrotum is used to create the labia majora.

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.

Moreover, balloon vaginoplasty also is a new technique for treating vaginal aplasia (failure to develop) that also is applied as a technically simple, physically safe, and medically effective alternative vaginoplasty technique for creating a neo-vagina, especially when conventional laparoscopic surgery is either infeasible or unsafe.

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.

The donor site in the cheek, approximately 2.5 by 8 cm, is marked to avoid damage to the Stensen's duct and the duct of parotid gland. To create the vaginal lining, the buccal mucosa tissue graft is micro-perforated to allow shaping it to a larger size, then it 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 perineal skin. The vaginal mold of buccal mucosa is then (temporarily) secured to the perineal skin, to allow the patient’s recovery.

Don Flap (labia minora flap)

In the Don Flap treatment of vaginal agenesis, the labia minora are sutured together to create a neovagina, using a technique similar to that for penile inversion. A technical refinement of this type of vaginoplasty is its utilization of the prepucial skin of the clitoris as a horse-shoe-shaped, one-piece flap. Yet, although the Don Flap technique is a relatively simple surgery, the most obvious disadvantages of the labia minora flap surgery include the need for restorative labiaplasty and dilation to produce adequate vaginal dimensions.

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). 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 — ca. 7.0 cm. deep by 7.0 cm. wide — in 7 days. Depending upon the patient, such an outcome might require more time. The Vecchietti vaginoplasty procedure surgery is of approximately 45 minutes’ duration.

McIndoe technique

The McIndoe technique utilizes split thickness skin grafts that cover a mold, which is inserted into a surgically created space between the bladder and the rectum.

The main difference between the McIndoe technique vaginoplasty and the Vecchietti procedure vaginoplasty, is which tissue is utilized as the vaginal lining. Each surgery has its own 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, and by the surgeon performing the vaginoplasty.

See also

• Gender reassignment therapy
• Intersexuality
• Labiaplasty
• Gender reassignment surgery (male-to-female)

Internal links

• List of MtF surgeons on Susan's

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