Vaginoplasty

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Vaginoplasty is any surgical procedure whose purpose is to treat vaginal structural defects, affect aesthetic considerations, or to partially or totally construct or reconstruct a vagina. The term vaginoplasty is used to describe any such vaginal surgery, while the term neovaginoplasty is more specifically used to refer to procedures of partial or total construction or reconstruction of the vulvovaginal complex.

There are many different vaginoplasty techniques. Some involve the use of autologous biological tissue from other parts of the body of the patient to construct areas of vagina. Areas that may be used include oral mucosa, skin flaps, skin grafts, the vaginal labia, penile skin and/or tissue, scrotal skin, intestinal mucosa, and others.

Neovaginoplasty
Neovaginoplasty is a reconstructive surgery procedure used to construct or reconstruct a vaginal canal and mucous membrane. These may be absent in a woman, due either to congenital disease such as vaginal atresia or to an acquired cause, such as trauma or cancer. Some transwomen opt for vaginoplasty as part of their gender transition.

The outcome of neovaginoplasty is variable. It usually allows sexual intercourse, although sensation is not always present. In genetic women, menstruation and fertilization are assured when the uterus and ovaries have preserved a normal function. In a few cases, vaginal childbirth is possible.

Male-to female transsexual patients
Most neovaginoplasty procedures are performed on transsexual women. The penile inversion technique was perfected by the late Georges Burou during his pioneering work in sex reassignment surgery.

For the creation of the male-to-female neovagina, there is also the possibility of using penile skin flaps (so-called penile inversion), as well as the "Suporn technique" and "Wilson method".

In the 1990s and continuing to the present, neovaginal construction has been further advanced by Toby R. Meltzer, M.D., whose technique involves the use of both penile and scrotal tissue to form the vaginal vault, and has yielded more reliable sexual sensation, maintenance of vaginal depth, and a stronger pelvic floor by maintaining a nearly intact levitor ani muscle complex.

Meltzer creates a neurologically sensate clitoris, constructed from a penile glans pedicle, with its attached blood supply and nerves. During a secondary procedure using Meltzer's technique, he forms a labia hood for the clitoris using the inverted Y plasty suturing method, leaving only a single midline incision scar.

When the transwoman is ready, there are two steps to Sexual Reassignment Surgery. The first procedure is called Vaginoplasty. Vaginoplasty is the procedure that essentially turns the penis into the vagina. It is often followed several months later by the Labiaplasty. The Labiaplasty refines the labia or external female genitalia.

During Vaginoplasty "the right spermatic cord is clamped and ligated. The primary incision is continued up the ventral side of the shaft of the penis. [Then] the anterior flap is developed from the skin of the penis. The urethra is dissected from the shaft. The corpora cavernosa are separated to assure a minimal stump. [After that] the anterior flap [is] perforated to position the urethral meatus. The skin flaps are sutured and placed in position in the vaginal cavity. [When that is completed], the preservation of the vaginal cavity is assured by the use of a suitable vaginal form." Finally the vagina is complete.

When a patient receives Labiaplasty, a frequently used procedure, labia and a clitoral hood are created. This is often performed a few months after the first part of the procedure. In some cases, labiaplasty is an elective procedure to improve appearance after a one-stage Vaginoplasty. Labiaplasty (2000).

Even after SRS there are many complications that range from minor to major. There are the minor complications which include infections, bleeding and loss of grafted skin. "The more serious complications include major infections or bleeding, and damage to the bladder. There is a possibility of damage to the prostate or major nerves during the dissection to form the vagina."

While undergoing this surgery the most severe complication is the formation of a vaginal-rectal fistula. This occurs when the doctor accidentally cuts through the rectal wall during vaginal cavity dissection. As a result, excrement bypasses the anal stricture and exits through the vagina. This prevents proper healing. This process can be remedied through a long process of surgeries and many months of wearing of a colostomy bag. Because of the embarrassment, the complication often goes untreated, leading to serious infections.

The Vecchietti procedure
The Vecchietti procedure is a laparoscopic procedure that has been shown to result in a vagina that is comparable to a normal vagina in patients with Mullerian agenesis.

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.

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 male-to-female transsexuals 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.

Penile inversion
Penile inversion is a surgical technique for genital reassignment (sex change) used to construct a neo-vagina from a penis for transwomen, sometimes also for intersex people. It is one of two main sorts of vaginoplasty, along with colovaginoplasty. The erectile tissue of the penis is removed, and the skin, with its blood and nerve supplies still attached (a flap technique first used by Sir Harold Gillies in 1951), is used to create a vestibule area and labia minora, and inverted into a cavity created in the pelvic tissue. Part of the tip (glans) of the penis, still connected to its blood and nerve supplies, is usually used to construct a clitoris, the urethra is shortened to end at a place that is appropriate for a female anatomy.

Neoclitoris
There are two ways to create a clitoris for a transsexual woman. The most common method is to remove the head or glans of the penis, and use some of that tissue to function in the position of a biological woman's clitoris. Some transsexual women have the entire penis head used as their clitoris. Some transsexual women have spongiform from their urethras to function as the neoclitoris. The success rate for the creation of a clitoris for transsexual women varies greatly. If the relocation of the glans penis is successful then the transsexual woman may have a sensate neoclitoris capable of orgasm. The glans penis tissue does not resemble a biological woman's clitoris. Most transsexual women's bodies readily accept the relocation of glans penile tissue in the area of a biological woman's clitoris. However, as with all surgeries nothing is perfect and there have been cases of the glans penis neoclitoris bleeding and even falling off entirely. There are many SRS surgeons who do not attempt any creation of a neoclitoris for their transsexual patients. Instead they allow the transwoman to orgasm with the penile lined vagina. Some SRS surgeons do not agree with using the head of the penis to create a neoclitoris. They prefer to either use urethral spongiform or make no attempt at the creation of a clitoris at all. Some SRS surgeons take the head of the penis and surgically place it inside the body in the position of a cervix. The late Stanley Biber preferred this method. Many transsexual women like the glans penis being inside their bodies because it can be greatly stimulated during vaginal penetration. The transsexual activist and playwright Kate Bornstein has indicated in her book 'Gender Outlaw: On Men, Women and The Rest Of Us' that her glans penis was placed inside her body in the position of a cervix. She reports enjoying vaginal penetration and that the use of dildos greatly stimulates her now internalized penis head.

Labioplasty
Labiaplasty is a plastic surgery procedure involving the labia, any of four folds of tissue of the vulva. Labiaplasty may be performed alone or as part of vaginoplasty.

Labiaplasty - Cosmetic Vaginal Surgery (sometimes spelled labioplasty ) is plastic surgery of the Labia majora and/or the Labia minora, the external folds of the female genital organs (Vulva). The procedure involves reshaping or reduction of the labia. Labiaplasty is a plastic surgery procedure involving the labia, any of four folds of tissue of the vulva. Labiaplasty may be performed alone or as part of vaginoplasty.

Labiaplasty may be undertaken for functional reasons, aesthetic reasons, or a combination of the two, although the cosmetic surgery's definition of "functional reasons" has yet to be explained to the rest of society: having large labia does not prevent the "function" of the vagina, and in fact because labiaplasty can make sex painful and prevent orgasm, labiaplasty can actually decrease the functionality of the vagina for sexual pleasure. The procedure is frequently performed to reduce the size of one or both sets of labia. It may also be used to repair the labia following disease or injury, or to reshape after childbirth. Labiaplasty does not improve the "function" of the vagina, but can in fact decrease or eliminate sensory perception of the genitals. Complications from the surgery, outside of those complications from any surgery (scarring, infection), include a loss of sensation of the clitoris, an inability to achieve orgasm, and pain from intercourse.

Labia Majora (outer lips) Reduction - This common anatomical variation may be worsened by childbirth or by weight gain or loss. The Labia Majora may become stretched out, most commonly in the shape of flaps or "wings".

Labia Minora (inner lips) Reduction - Cosmetic surgeons say that overly large labia minora can also result in constant irritation in tight pants, though this has largely been descried as myth by medical professionals.

Women are often pressured into having labiaplasty by partners who are confused about the realistic proportions of unique women; because the side effects can be so devastating (including loss of sensation or pain during sex), most medical professionals who do not have a financial stake in cosmetic surgery advise against the procedure at all costs.

"Vaginal rejuvenation"
Non-reconstructive vaginoplasty or "vaginal rejuvenation" is used to restore vaginal tone and appearance, largely by removing excess tissue and tightening supportive structures. The popularity of surgery to improve the cosmetic appearance of a female's genitalia has increased in North America over the last few years. The term "designer vagina" refers to an idealized image of female sex organs attained through vaginoplasty. In recent years laser has been introduced to assist in the procedure. The rejuvenation procedure is intended to reduce or undo effects of age and childbearing. The American College of Obstetricians and Gynecologists, however, warns that this procedure lacks supporting data regarding safety and efficacy. Indeed, vaginal rejuvenation surgery can lead to decreased sensory perception of the clitoris and the rest of the genital area, potentially to such an extent as to prevent the possibility of orgasm, and can lead to complications such as infection, adhesions, and scarring.

Terminology
The term vaginoplasty has also been applied to:


 * Hymenotomy, a surgical procedure to create an opening in an imperforate hymen
 * Hymenorrhaphy, a surgical procedure to recreate a ruptured hymen.