Vaginoplasty Techniques

Vaginoplasty is a major surgical procedure used to narrow the vagina. It is performed in a variety of situations such as to provide a vagina for women who have androgen insensitivity syndrome, vaginal agenesis, or similar health conditions. It is also adopted to reverse the normal slight laxity that occurs to a varying extent in women who have given birth vaginally, after childbirth, as well as in older women.

Additionally, it can be used to correct congenital defects of the vagina or acquired deformities due to cancer, tumors or trauma.

Procedures for Vaginal Atresia and Vaginal Agenesis

1. When there is a vaginal dimple, various techniques may be used to create a neovagina.
   1. The vaginal pull-through technique involves an incision in the tissue in the lower vagina until the upper normal vaginal tissue is reached. This mucosa is then pulled downward and attached around the hymeneal ring without tightness, after excising excessive fibrous tissue.
   2. One of the most popular procedures is the Vechietti method, in which continuous traction is applied from the abdominal wall on a silicone bead or ‘olive’ introduced into the vaginal dimple. The traction applied is sufficient to pull the olive inwards and upwards about 1 cm a day. The threads leading from the olive are attached to the anterior abdominal wall via laparoscopy, and are tightened daily. This is quite painful and needs constant analgesia throughout the treatment period, but has a high success rate to create a permanent neovagina within two weeks or less. However, it may result in stress incontinence in later life due to elevation of the pubourethral ligaments.
   3. Another method is the balloon vaginoplasty in which balloon dilation is used to create a space in the rectovesical fascia for the neovagina.
2. When there is no vaginal tissue at all, more radical techniques include:
   1. Intestinal vaginoplasty makes use of a segment of vascularized colon or ileum to replace the vagina, and the intestine serves as a capacious and lubricated vagina. However, this is a highly invasive procedure, with many associated risks. One relatively minor but troublesome complication is excessive mucus discharge, necessitating the constant use of a sanitary pad. The occurrence of carcinoma must be ruled out by regular follow up. This is performed in vaginal agenesis occurring as an isolated phenomenon, or as part of the Rokitansky syndrome
   2. The McIndoe vaginoplasty procedure consists of expanding the rectovesical potential space and inserting a split-thickness skin graft usually taken from the buttocks, to line this space. This creates a tubular organ, held in place by a mold until the skin is firmly attached to the underlying fascia. Regular dilation is necessary during the following years to help it develop to the required size. After this, dilation is still necessary to keep it patent until sexual activity begins.
   3. William’s vaginoplasty is a technique in which the labia minora are sutured together to create a pocket which becomes the neovagina. However, the resulting neovagina is too small to allow sexual activity without injury or pain. Several modifications have been made as a result, one of which also involves using labial tissue to form a deeper pouch that allows for comfortable intercourse.
   4. Buccal mucosa is also used as the lining of the new vagina, because of its superior healing properties, which leads to a short recovery time and hardly any scarring. The risk of damage to the mouth during removal of the mucosa, and of a short and tight vagina due to insufficient buccal tissue, must be kept in mind.
   5. The Don flap uses labia minora tissue to create a vagina, or its modification which uses tissue from the clitoral hood for the same purpose. The former requires cosmetic labial surgery to recreate the labia minora, along with cervical dilation to ensure that the vagina is large enough.

Intersex Conditions

With the need to cater to transgender individuals, several new and complex sex-conversion techniques evolved including the Wilson procedure, which uses a three-stage penile inversion technique to create female-appearing external genitalia.

The intestinal vaginoplasty technique is also used to create a vagina in congenital adrenal hyperplasia with ambiguous genitalia, or in androgen insensitivity syndrome. Any of the vaginoplasty techniques which make use of skin, amnion or other external tissue to line the newly created cavity may also be applied in this situation.

Vaginal Laxity

Many women feel that a lax vagina is an inhibitor of sexual pleasure and ask for vaginal tightening. Besides perineal surgery to approximate the perineal muscles and narrow the introitus and vaginal wall, there are modern techniques available, such as laser tightening. This uses carbon dioxide laser beams to produce controlled injury, which stimulates collagen synthesis and leads to regeneration of new supporting tissue, tightening of the vaginal mucosa.

References

1. http://medind.nic.in/jan/t06/i2/jant06i2p92.pdf
2. https://www.ncbi.nlm.nih.gov/pubmed/6996127
3. http://www.kowsarhospital.com/en/treatment/surgery/gynecologyandobstetrics