Published online: 2019-08-26

Letters to Editor

2. Li GD, Chen K, Fu D, Ma XJ, Sun MX, Sun W, et al. Surgical the flaps X and X’ overlap whereas flaps Y and Y’ overlap strategy for presacral tumors: Analysis of 33 cases. Chin Med J leaving no raw areas (Figure 1 redrawn from Saraiya). (Engl) 2011;124:4086-91. 3. Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M, Audolfsson T, How does this cruciate flap heal (XX’ with YY’) as there is Acosta R. Perineal and posterior vaginal wall reconstruction with no raw area between them? superior and inferior gluteal artery perforator flaps. Microsurgery 2009;29:626-9. As the author uses the flaps from the vaginal mucosa for 4. Unal C, Yirmibesoglu A, Ozdemir J, Hasdemir M. Superior and inferior gluteal artery perforator flaps in gluteal and perianal/perineal reconstruction and primarily closes the donor hydradenitis suppurativa lesions. Microsurgery 2011;31:539-44. site, there is a chance of iatrogenic vaginal stenosis and subsequent risk of dyspareunia; the use of tough vaginal This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 mucosa is akin to creating a transverse vaginal septum License, which allows others to remix, tweak, and build upon the with the consequent risk of infertility. work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. The final appearance following this reconstruction Access this article online is “network-like” as the author describes it, whereas Quick Response Code: the appearance after hymenoplasty following repair Website: described by Prakash[2] and Ou[3] is annular. There being www.ijps.org so many normal anatomical variations of normal hymen

DOI: such as annular, crescentic, cribriform, eccentric, septate 10.4103/0970-0358.173141 and microperforated, which one of these forms should one aim to reconstruct and what will be the advantage of one hymeneal type over the other that the author How to cite this article: Jain L, Kumta SM, Purohit SK, Menezes recommends this method to be better? M, Bhansali M. The pivotal role of pedicled perforator flaps amidst irradiation. Indian J Plast Surg 2015;48:322-4. There are many unanswered issues about this controversial, but still curious procedure. The author describes the

reconstruction to be strong enough to sustain daily activities, but how strong should these reconstructions be? How long these repairs should last? When should Surgical revirgination: Four hymenoplasty be planned in relation to the proposed first vaginal mucosal flaps for intercourse? Moreover what reconstruction would be reconstruction of a hymen considered good as there are so many anatomic variations? How do we assess the success of these ? Is it Sir, based on immediate appearance after repair? Or is it its We read with interest, the original article “Surgical revirgination: Four vaginal mucosal flaps for reconstruction of a hymen”[1] published in your reputed journal. We must congratulate the author for a commendable and innovative approach based on the principles of plastic .

Hymenoplasty or hymenorrhaphy is in increasing demand due to the traditional sociocultural belief associated with ; being still illegal in some countries, it creates a multitude of moral, ethical, social and religious controversies; one finds a lot more information on the internet than in scientific journals.

Any reconstruction should “replace like with like tissues” with the aim of matching colour, texture and thickness, Figure 1: Diagrammatic representation of four flap hymenoplasty (redrawn and also the final appearance to be normal. As described, from Saraiya)

Indian Journal of Plastic Surgery September-December 2015 Vol 48 Issue 3 324 Letters to Editor ability to last long? Is it the size of the introitus at the How to cite this article: Shirol SS, Prabhu M, Ratkal J. Surgical end of repair or first intercourse? Or is it the ability of the revirgination: Four vaginal mucosal flaps for reconstruction of a hymen. Indian J Plast Surg 2015;48:324-5. repair to bleed at first intercourse?

The author prefers the surgery under spinal anaesthesia for better muscle relaxation, but in our experience, many a time these patients attend the clinics looking for a Authors’ Reply quick fix without admission, these being super-secretive procedures and follow-up is difficult. Another question that needs to be answered is who is qualified to perform Sir, this procedure, it not being part of the medical curriculum. We are pleased to learn that this article has evoked a good response. I congratulate Dr. Shirol and his team for We conclude by saying that it is time to answer these excellent questions. I would like to answer all their queries unanswered questions with evidence-based approach and clarify certain technical issues. and to make the procedure more scientific. The sole purpose of hymenoplasty is to cause bleeding Financial support and sponsorship from torn vaginal tissue at the time of the first intercourse. Nil. There being so many anatomical variations of a normal hymen, it is never possible to recreate the shape and Conflicts of interest texture of the original hymen. In our view, the hymen There are no conflicts of interest. that serves the purpose regardless of its shape shall be considered good. S. S. Shirol, Mahesh Prabhu1, 2 Jaideep Ratkal The surgeon and the patient’s comfort decide the type of 1 Departments of Plastic Surgery, Sampige Superspecialty anaesthesia. Scheduling the surgery early in the morning Clinic Hubli and KIMS, KLE University, Belgaum, and the usage of Xylocaine Heavy injection for spinal 2Department of Urology, KIMS, Hubli, Karnataka, India anaesthesia allows the patient to be discharged by the Address for correspondence: evening. Dr. S. S. Shirol, Sampige Super Speciality Clinic, Club Road, Hubli - 580 028, Karnataka, India. E-mail: [email protected] The vaginal tissue flaps are not planned in one circular line; instead they are staggered so that there are no REFERENCES chances of vaginal stenosis or septum creation. None of

1. Saraiya HA. Surgical revirgination: Four vaginal mucosal flaps for our patients have ever complained of dyspareunia. reconstruction of a hymen. Indian J Plast Surg 2015;48:192-5. 2. Prakash V. Hymenoplasty — How to do. Indian J Surg Vaginal tissue flaps are random-patterned flaps and there 2009;71:221-3. is always a risk of flap necrosis if narrow flaps are designed 3. Ou MC, Lin CC, Pang CC, Ou D. A cerclage method for hymenoplasty. Taiwan J Obstet Gynecol 2008;47:355-6. and at the same time there is a risk of non-rupture at the time of the first if wider flaps are This is an open access article distributed under the terms of the planned. In our experience, 1 cm width has worked out Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the to be the optimum. work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Just like superiorly-based pharyngoplasty, the flaps are

Access this article online designed and lined in such a way that the donor area gets Quick Response Code: closed and none of the flap area remains raw. Non-lined Website: flaps may shrink considerably, resulting in large ports that www.ijps.org may allow penile penetration without the hymen getting

DOI: ruptured. In our experience none of the four ports after 10.4103/0970-0358.173142 crisscross should allow more than one finger. Immediate appearance of hymen after the repair or the size of the

325 Indian Journal of Plastic Surgery September-December 2015 Vol 48 Issue 3