Posterior Vaginoplasty with Perineoplasty: a Canadian

applyparastyle "fig//caption/p[1]" parastyle "FigCapt" applyparastyle "fig" parastyle "Figure" My Way Aesthetic Surgery Journal Open Forum Posterior Vaginoplasty With Perineoplasty: 2019, Vol 1 (4) 1–9 © 2019 The American Society for Aesthetic Plastic Surgery, Inc. A Canadian Experience With Vaginal This is an Open Access article dis- tributed under the terms of the Tightening Surgery Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0/), which permits unrestricted reuse, distri- bution, and reproduction in any medium, provided the original Ryan E. Austin, MD, FRCS(C) ; Frank Lista, MD, FRCS(C); work is properly cited. Peter-George Vastis; and Jamil Ahmad, MD, FRCS(C) DOI: 10.1093/asjof/ojz030 www.asjopenforum.com Abstract Following vaginal trauma, most commonly vaginal delivery, women may experience vaginal laxity as a result of local tissue stretching and separation of the pelvic floor musculature. In addition to this generalized sensation of laxity, women may complain of decreased sexual satisfaction, gaping of the perineum, and excessive vaginal secretions. Since 2014, the authors have used a posterior vaginoplasty with perineoplasty technique for the surgical management of vaginal laxity. To date, the authors have performed surgical vaginal tightening in 30 consecutive patients and found that the posterior vaginoplasty with perineoplasty technique has allowed us to achieve reproducible outcomes with no postoperative complications. This article will review the authors’ approach to patients presenting for surgical vaginal tightening and the authors’ experience to date, including our preoperative screening, perioperative management, and detailed steps of the procedure. Editorial Decision date: August 9, 2019; online publish-ahead-of-print October 15, 2019. Female genital cosmetic surgery (FGCS) is one of the As public awareness regarding treatment options for fastest growing areas in aesthetic plastic surgery.1 When vaginal laxity has increased, vaginal tightening procedures performed in the appropriate patients, FGCS procedures have increased in popularity. Although these procedures have high satisfaction and low complication rates.2–5 have been associated with high patient and partner sat- Although many plastic surgeons offer FGCS treatment op- isfaction,4-6,10-13 descriptions of vaginoplasty techniques tions for the external female genitalia, few provide vagino- for this indication are limited as are data regarding patient plasty and perineoplasty. safety and outcomes.2,11,13-16 Following vaginal trauma, most commonly vaginal delivery, women may experience vaginal laxity due to local tissue stretching and separation of the pelvic floor muscu- Dr Austin is a plastic surgeon in private practice, Mississauga, lature. Women may complain of altered sexual satisfaction, Ontario, Canada. Drs Ahmad and Lista are Assistant Professors, decreased friction during intercourse, altered vaginal sen- Division of Plastic and Reconstructive Surgery, Department of sation, and a generalized feeling of laxity.4,6,7 Furthermore, Surgery, University of Toronto, Toronto, Ontario, Canada. Dr Ahmad is My Way Section Editor and Dr Lista is Breast Surgery Section women commonly complain of gaping of the vaginal ves- Co-Editor for Aesthetic Surgery Journal Open Forum. Mr Vastis is tibule, which creates an aesthetic deformity allowing vis- a Medical Student, Medical School, Royal College of Surgeons in ibility of the vaginal mucosa.8 This gaping also creates Ireland, Dublin, Ireland. several functional concerns including increased/excessive Corresponding Author: vaginal secretions due to mucosa exposure, altered ability Dr Jamil Ahmad, The Plastic Surgery Clinic, 1421 Hurontario Street, to achieve orgasm, and vaginal air entrapment resulting in Mississauga, ON, Canada, L5G 3H5 embarrassing sounds during sexual intercourse.9 E-mail: [email protected]; Twitter: @DrJAhmad 2 Aesthetic Surgery Journal Open Forum Since 2014 we have exclusively used a posterior vagi- for further evaluation.14 If concern exists regarding the de- noplasty with perineoplasty technique to address concerns gree of scarring between the posterior vagina and ante- related to vaginal laxity. This article reviews our approach rior rectum, digital rectal examination may be performed to patients presenting for vaginal tightening and our expe- with patient consent. If a gliding tissue plane exists (ie, the rience with the procedure to date. ability independently mobilize the two surfaces over one another), posterior vaginoplasty is a suitable technique. Contraindications to posterior vaginoplasty with PREOPERATIVE CONSIDERATIONS perineoplasty include active or untreated pelvic infection or inflammatory process, current pregnancy, pelvic ma- Vaginal laxity is a sensitive and highly personal issue. lignancy, bleeding disorders, and unrealistic expectations Consultation should take place in a private, comfortable of surgical results. History of vulvodynia, dyspareunia, or setting and should not be rushed. To ensure patient com- chronic pelvic pain are considered relative contraindica- fort, we prefer all discussion take place with the patient tions to surgery.17 fully clothed. Patients change into a gown only for physical Potential surgical risks of vaginoplasty are reviewed examination; they are invited to re-dress prior to further with all patients preoperatively, including bleeding, he- discussion taking place. matoma, infection, wound dehiscence, urinary retention, A complete history should be obtained from the patient injury to bowel/bladder, development of a rectovaginal fis- including past medical and surgical history (including any tula, scarring, vaginal stenosis, dyspareunia, altered sensa- prior nonsurgical treatments for vaginal tightening), medi- tion, and an inadequate surgical result.3,4,14 cations, allergies, and smoking status. A focused gyneco- logical history must also be obtained including: obstetrical history and method of delivery, menstrual history, current SURGICAL TECHNIQUE contraceptive use, history of urinary incontinence, history of abnormal cervical cytology (including date of last Pap Vaginoplasty with perineoplasty is performed as a day test), history of hemorrhoids, and any history of prior vag- surgery procedure under general anesthesia. Following inal trauma, sexual dysfunction, sexually transmitted in- administration of prophylactic antibiotics, the patient is fection, pelvic malignancy, or pelvic pain disorder. placed in the lithotomy position in stirrups. Care is taken It is also important to develop an understanding of the during positioning to pad all pressure points to prevent patients’ concerns and motivations for seeking vaginal iatrogenic injury. All patients wear compression stockings tightening surgery. We specifically review these common during the perioperative period and intermittent pneu- complaints with patients preoperatively and document any matic compression devices are placed intraoperatively to additional concerns that are reported. In some instances, provide mechanical VTE prophylaxis. Preoperative photo- a patient’s primary motivation for surgery is decreased graphs are taken for documentation at this time. The va- sexual satisfaction of their partner. In these cases, it is im- ginal canal, perineum, and proximal thighs are prepared portant to remind the patient there is no guarantee that with 10% povidone-iodine solution and draped in a sterile vaginoplasty will affect their partners sexual satisfaction. fashion. The decision to undergo vaginoplasty must always be a The surgical markings for posterior vaginoplasty with personal choice made of the patients own volition. If con- perineoplasty are designed as two triangular-shaped resec- cern exists that a patient is being pressured into surgery, is tion patterns, one internal triangle along the posterior wall using surgery to remedy relationship issues, or if a patient of the vaginal canal and one external triangle of the peri- has unrealistic expectations, this must be identified and neum (Figure 1A-D and Video 1, available as Supplementary addressed during the preoperative consultation. Material online at www.asjopenforum.com). These two tri- A physical examination of the external genitalia should angles meet at the level of the hymenal ring, corresponding be performed, including a bimanual pelvic examination. to the widest point of planned excision (Figure 2). This We advise all surgeons to bring a chaperone into the room gives the overall excision pattern a diamond-shape. The tip for the duration of the physical examination, both for pa- of the internal triangle is placed 4–6 cm inferior to the pos- tient comfort and for medicolegal protection. The degree terior fornix of the vagina. Hymenal remnants are usually of vaginal laxity, the presence of posterior gaping or web- identifiable and the medial edge of the two most midline bing of the vaginal vestibule, perineal body length (ie, dis- remnants serve as a guide for the width of the planned re- tance between the anus and posterior fourchette), and the section at the level of the hymenal ring. The width of the presence of hemorrhoids are documented. It is important resection can be confirmed by approximating the planned to assess for any pelvic masses or pelvic organ prolapse. margins with tissue forceps to ensure they can be approxi- Patients with a history of untreated pelvic organ prolapse, mated with minimal tension. If there is any doubt as to cystocele, or rectocele should

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