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Lanza H, Balestrelli J, Pastoni D, Molero JF. Vaginoplasty technique using vulvoperineal flaps. Aesthetic Plast Surg 2014; 38:164-168. [PMID: 24271577 DOI: 10.1007/s00266-013-0220-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED The incidence of vaginal agenesis is 1 in 5,000 live newborn baby girls. The most frequent cause is Mayer-Rokitansky-Küster-Hauser syndrome. This report presents three reconstruction cases managed with vulvoperineal fasciocutaneous flaps in patients experiencing this syndrome. It depicts the stages of the procedure and the anatomic bases for it. This technique allows the creation of a sensitive neovagina with high-quality coverage that provides a physiologic and a natural inclination angle together with a correct anatomic axis to make a sexual relationship possible. The procedure is performed in one surgical stage with minimum morbidity for the patient. Its major inconvenience is hair growth inside the vagina. Nevertheless, this decreases as time passes due to follicle atrophy and cutaneous metaplasia. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Lilford RJ, Batchelor A, Johnson N. Myocutaneous flaps for the treatment of stenosis of the upper vagina following radiotherapy. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619309151776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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3
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Keser A, Bozkurt N, Taner OF, Sensöz O. Treatment of vaginal agenesis with modified Abbé–McIndoe technique: long-term follow-up in 22 patients. Eur J Obstet Gynecol Reprod Biol 2005; 121:110-6. [PMID: 15935544 DOI: 10.1016/j.ejogrb.2004.11.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Revised: 04/15/2004] [Accepted: 11/14/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The inlay skin grafting technique proposed by McIndoe is by far the most popular and the safest technique for treatment of vaginal agenesis. The purpose of the current study is to present clinical experiences and long-term results of modified Abbé-McIndoe technique. STUDY DESIGN We present the long-term results of 22 patients with a follow-up period ranging between 7 and 14 years. RESULTS Mean vaginal depth was recorded to be 8 cm and narrowing of the vagina was not noted. Only in two cases was deficient vaginal depth observed which was due to inadequate use of the mould in the postoperative period. Histologic study of the specimens obtained from the neovagina revealed normal vaginal mucosa in all patients. CONCLUSION Although numerous methods have been described since the first surgical intervention for the correction of vaginal agenesis, a modified Abbé-McIndoe technique is still the effective and preferred one.
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Affiliation(s)
- Abdulmuttalip Keser
- Department of Plastic and Reconstructive Surgery, Dr. Muhittin Ulker First Aid and Traumatology Hospital, Ankara, Turkey
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Abstract
Several surgical techniques have been designed to construct a neovagina that will be satisfying in appearance, function, and feeling when the vagina is congenitally absent. However, no method has yet been approved as a perfect solution. With the aim of solving the problems with conventional methods, the authors describe a new surgical technique that is simple and safe for treating vaginal agenesis. This technique consists of creating a mucosal lining of the neovaginal cavity using multiple full-thickness buccal mucosal patch grafts. Four patients with congenital absence of the vagina treated with this technique are presented. This surgical procedure created a mucus-providing lining inside the neovagina. Selecting the donor site in the oral region resulted in an inconspicuous donor-site scar. Histologically, the neovaginal lining was confirmed as mucosal, and the cream-colored viscous fluid found in the neovaginal cavity was confirmed as mucus. At a mean follow-up period of 15 months, the neovagina remained adequate in depth and width. All of the patients were interviewed to evaluate the function of the neovagina. Each patient reported having regular sexual intercourse and that the neovagina had felt normal to their partners. The encouraging results obtained in four cases suggest that this new technique deserves further application.
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Affiliation(s)
- Güzin Yeşim Ozgenel
- Department of Plastic and Reconstructive Surgery, Uludağ University, Bursa, Turkey.
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Simman R, Jackson IT, Andrus L. Prefabricated buccal mucosa-lined flap in an animal model that could be used for vaginal reconstruction. Plast Reconstr Surg 2002; 109:1044-9; discussion 1050-1. [PMID: 11884832 DOI: 10.1097/00006534-200203000-00039] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital vaginal aplasia, gynecological tumor excision, and male-to-female sex surgery are three clinical conditions in which the plastic surgeon is involved in vaginal reconstruction. Skin-lined or skin-grafted local flaps are currently used, but for many reasons, keratinized skin is not the ideal lining for such a moist cavity because it leads to dryness, desiccation, maceration of the skin, and even hair growth in the cavity. The purpose of this study was to create a subcutaneous cavity lined with mucosa in an area with a predictable blood supply. The abdominal area supplied by the deep circumflex iliac vessels was chosen. Six minipigs were used. Strips of tongue buccal mucosa formed the lining; if additional tissue was required, it was taken from the mucosal aspect of the cheek. The mucosa was expanded by using multiple stab incisions. The mucosa was sutured onto the fascia supplied by the deep circumflex iliac vessels, and the skin incision was closed over a silicone sheet to prevent adhesion to the underlying mucosa. This was left for 1 week to allow the mucosa to take. The prefabricated fascial flap was rolled over a silicone stent and was closed longitudinally to form a cylindrical shape. The flap was placed in a subcutaneous pocket in the right inguinal area. The caudal end was left open and was sutured to the surrounding skin. The silicone stent was used to keep the cavity patent and to prevent adhesions in the early stage of the healing process. Regular digital examination was performed to assess patency and contour; endoscopy allowed assessment of mucosa viability. This method of producing a mucosa-lined flap may provide a solution to the difficult problem of vaginal reconstruction.
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Affiliation(s)
- Richard Simman
- Institute for Craniofacial and Reconstructive Surgery, 16061 West Nine Mile Road, Third Floor Fisher Center, Southfield, MI 48075, USA
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Rangaswamy M, Machado NO, Kaur S, Machado L. Laparoscopic vaginoplasty: using a sliding peritoneal flap for correction of complete vaginal agenesis. Eur J Obstet Gynecol Reprod Biol 2001; 98:244-8. [PMID: 11574140 DOI: 10.1016/s0301-2115(01)00313-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this technique of peritoneal neo-vaginoplasty, the recto-vesical space is dissected through the vulva under synchronous laparoscopic monitoring. Then the cranial limit of the pelvic peritoneum is incised circumferentially by laparoscopic approach and the two circular edges sutured sequentially. The isolated pelvic peritoneal sleeve is opened inferiorly and sutured to introital mucosal flaps.
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Affiliation(s)
- M Rangaswamy
- Department of Surgery, Sultan Qaboos University Hospital, P.O. Box 38, Postal code 123, Muscat, Sultanate of Oman.
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Monstrey S, Blondeel P, Van Landuyt K, Verpaele A, Tonnard P, Matton G. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap. Plast Reconstr Surg 2001; 107:719-25. [PMID: 11304597 DOI: 10.1097/00006534-200103000-00011] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar. The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum. All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps. This article discusses the expanding indications of this versatile flap and the refinements in operative technique.
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Affiliation(s)
- S Monstrey
- Department of Plastic Surgery, University Hospital, Gent, Belgium
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Abstract
BACKGROUND Vaginal, perineal, and pelvic floor reconstruction is being performed with increasing frequency in conjunction with radical pelvic surgery. Although the vertical rectus abdominis myocutaneous flap is ideally suited to such procedures, little information exists regarding risks or complications associated with it. METHODS A chart review of all patients who underwent this procedure at two institutions was performed, and the results were compared with existing series. Surviving patients were asked to describe their satisfaction with the procedure and their sexual function. RESULTS Between 1990 and 1997, 22 patients underwent placement of a rectus abdominis myocutaneous flap for vaginal/pelvic floor reconstruction, 21 (95.5%) at the time of pelvic exenteration. Attachment of the graft was complete in 20 patients (90.9%) and partial in 1 (4.5%), and 1 patient experienced complete loss that resulted in total vaginal stenosis. Four patients (18.2%) developed mild vaginal stenosis that was corrected with dilators. Donor site complications included wound separation (above the fascia) in three patients and one delayed abdominal closure. There were no cases of bowel obstruction, dehiscence, hernia, or death. The only statistically significant identifiable risk factors for graft necrosis included prior abdominal surgery and operative time. Thirteen of 22 (59.1%) of the patients are cancer free (median progression free interval, 42.2 months), 11 (84.6%) of whom reported having had vaginal intercourse since surgery. CONCLUSIONS The rectus abdominis myocutaneous flap can be safely used with excellent results and acceptable morbidity, and in this series it restored sexual function in the majority of cancer survivors. Because previous abdominal surgery (transverse incisions or colostomy) may compromise blood supply to the flap, alternative sites should be considered in such cases.
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Affiliation(s)
- H O Smith
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque 87131-5286, USA
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Velidedeoğlu HV, Coşkunfirat OK, Bozdoğan MN, Sahin U, Türkgüven Y. The surgical management of incomplete testicular feminization syndrome in three sisters. BRITISH JOURNAL OF PLASTIC SURGERY 1997; 50:212-6. [PMID: 9176010 DOI: 10.1016/s0007-1226(97)91372-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Three sisters with incomplete testicular feminization syndrome are presented. Most of the patients with this syndrome are females and surgery is an important part of their multidisciplinary treatment. Two of the sisters had gonadectomies, herniorrhaphies, vaginoplasty with neurovascular pudendal thigh flaps, reduction clitoroplasty and labia minora reconstruction. The third sister had sufficient vaginal depth and had release of an introitus skin web, clitoroplasty and labia minora reconstruction. All patients had a good result. The reconstructed vaginas are stable and sensate.
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Affiliation(s)
- H V Velidedeoğlu
- Department of Plastic and Reconstructive Surgery, Social Insurance Association Hospital of Ankara, Turkey
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Giraldo F, Solano A, Mora MJ, Abehsera M, González C, Rus JA. The Málaga flap for vaginoplasty in the Mayer-Rokitansky-Kuster-Hauser syndrome: experience and early-term results. Plast Reconstr Surg 1996; 98:305-12. [PMID: 8764719 DOI: 10.1097/00006534-199608000-00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report our experience in vaginoplasty for the treatment of six cases of the Mayer-Rokitansky syndrome using bilateral vulvoperineal fasciocutaneous flaps measuring 8 to 9 X 3 cm. We consider a detailed description of the operative technique, noting the modifications that we have introduced as our experience increased, in addition to the cosmetic and functional results. On the other hand, the indications for using this vaginoplasty are presented. On the basis of our clinical results, the actual anatomy of the blood vessels leading to the pedicle of the flap, and the geometric design of the vulvoperineal flap, the following technical points can be made: (1) It is a secure and reliable technique because of well-established vascularization beneath the lateral border of the labia majora. (2) It is a straightforward method because the transposition and rotation of a vertical flap is easier than the use of more distant flaps. (3) There is a minor risk of injury to the superficial perineal neurovascular pedicle and Bartholin's gland. (4) Innervation extends into the external two-thirds of the artificial vagina. And (5) an acceptable cosmetic and functional result is achieved without the need to use dilators, obturators, or molds.
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Affiliation(s)
- F Giraldo
- Plastic and Reconstructive Unit, Regional Hospital 'Carlos Haya' Málaga, Spain
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van den Berg MP, Hage JJ. Graft versus flap: reaction of a plastic surgeon. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1995; 102:429-30. [PMID: 7612545 DOI: 10.1111/j.1471-0528.1995.tb11308.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Karacaoglan N, Velidedeoglu H, Şahin U, Ercan U, Bozdogan N, Çiçekçi B, Türkgüven Y. Reconstruction of vaginal agenesis by Singapore flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 1994. [DOI: 10.1007/bf00181092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lilford RJ, Johnson N, Batchelor A. Repair of prolapse by means of a living ligament. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1993; 100:859-60. [PMID: 8218009 DOI: 10.1111/j.1471-0528.1993.tb14315.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- R J Lilford
- Institute of Epidemiology and Health Services Research, Leeds
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Coney P. Effect of vaginal agenesis on the adolescent: Prognosis for normal sexual and psychological adjustment. ACTA ACUST UNITED AC 1992. [DOI: 10.1016/s0932-8610(12)80100-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Johnson N, Batchelor A, Lilford RJ. Experience with tissue expansion vaginoplasty. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1991; 98:564-8. [PMID: 1873246 DOI: 10.1111/j.1471-0528.1991.tb10371.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In vaginal agenesis, a vagina can be treated by tissue expansion vaginoplasty. We have performed 17 such procedures. One procedure was abandoned because of infection of the temporary implant. In four women the first stage had to be repeated: in one the implant was placed too superficially, in another it did not provide adequate expansion, in a further instance the implant became infected and the fourth woman received a surgical wound to her labia. The second stage was successful in all 16 women who now have a vagina lined with viable epithelium. The vaginal length was satisfactory in all but one. Two women complained of a vaginal discharge due to hair at the vaginal vault, two women developed postoperative haematomas and one experienced introital stenosis. The disadvantage of the procedure is that it requires two operative stages and involves a prolonged hospital stay but it is not technically complex and results in a full length vagina that does not require dilatation.
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Affiliation(s)
- N Johnson
- Department of Gynaecology, St. James's University Hospital, Leeds, UK
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Johnson N, Lilford RJ, Batchelor A. The free-flap vaginoplasty; a new surgical procedure for the treatment of vaginal agenesis. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1991; 98:184-8. [PMID: 2004056 DOI: 10.1111/j.1471-0528.1991.tb13366.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The ideal operation for a young woman born without a vagina would be a one stage procedure, creating a functionally normal vagina without cosmetically unattractive scars, without the need for subsequent dilatation, stents or obturators. This goal was achieved with a free flap vaginoplasty using a full thickness skin graft taken from the scapula region. The blood supply of the graft was maintained by microvascular anastomosis of the graft pedicles to vessels in the groin. The operation has been performed in three young women who were born with uterine hypoplasia and vaginal agenesis. We experienced no unexpected complications, the procedure was well tolerated and left our patients with a good length, fully functional vagina. However, the operation is a major undertaking and needs to be performed by those with expertise in plastic surgery as well as in gynaecology.
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Affiliation(s)
- N Johnson
- Department of Obstetrics & Gynaecology, St James's University Hospital, Leeds
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Shepherd JH, Van Dam PA, Jobling TW, Breach N. The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1990; 97:1020-5. [PMID: 2252868 DOI: 10.1111/j.1471-0528.1990.tb02475.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Rectus abdominis myocutaneous flaps have been used in 16 women following radical excision of extensive vulvar cancer. In two women the procedure was part of the primary surgery, in 11 for recurrence of vulvar cancer and in three for symptomatic palliation. Fifteen (94%) of the grafts took with primary healing. Thirteen of the 16 patients are alive 6-60 months (median 29 months) after surgery and the three who died benefited from symptomatic palliation. Simultaneous vulvar reconstruction allows good cosmetic rehabilitation and is an important part of the armamentarium for the management of patients with advanced primary or recurrent vulvar carcinoma. This technique offers excellent surgical clearance of massive offensive and painful vulvar tumors.
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Affiliation(s)
- J H Shepherd
- Department of Gynaecological Oncology, St. Bartholomew's, Royal Marsden Hospital, London, United Kingdom
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