Introduction
Being a woman means you are complete physically and able to consummate marital relations together with child bearing. Unfortunately, women’s organs are kept relatively mysterious and are even considered a taboo to speak about. Not only are they vital love organs, but they are also an essential part of their body that a woman loves and enjoys just because she can. Why is that? It is because she feels that her femininity is ensured by them and fulfills her being a woman! She always wishes that they must be functioning well. If it is so, that makes her have confidence in herself. But she feels deeply disturbed and incomplete if she does not find a functioning vagina.
Some women are born with Rokitansky kustner Hauser Syndrome in which they have normal secondary sexual characteristics (normal female physical features like fully developed breasts, female pattern of hair on body) functioning ovaries, small or absent uterus and Absent vagina. Absence of vagina deeply disturbs a female mentally and physically as she would not be able to have marital relations or carry a child. She start doubting her femininity and the mental agony is undescribable.
Characteristics of an ideal Neovagina
Creating a Neo vagina in such patients has always been a challenge for surgeons and a fear for the patient.
In general, it is considered that an ideal vagina must be –
- located at the proper place,
- postero-superior in position,
- hairless
- of adequate dimensions,
- lined by elastile tissue either by full-thickness skin or mucosa,
- sensate, and
- neither permanently moist, nor malodorous.
Imperfect development of the vagina is by no means rare and is a cause of primary amenorrhoea. One out of 1500, or sometimes one out of 80000 females can have such problems. There can be many indications like Congenital absence though the patients may have normal female karyotype, a normal vulva with an absent vagina or a vagina represented by a shallow dimple only. The cervix and uterus are usually hypoplastic. The ovaries, their functions and secondary sexual characters are found normal. But these patients may have cyclical abdominal pain and increasing abdominal mass due to the accumulation of menstrual products.
The female organs bring life into this world and also give a woman love and pleasure. Vagina is considered to be gateway of reproductive, mental and physical health of a woman.
Why is vaginal reconstruction required?
Vaginal reconstruction or restoration of the vagina is known as vaginoplasty. By creating a neo vagina, a female is able to consummate marital relations and if she has normal size uterus, even menses can be regained and can give birth to child as well.
A vaginoplasty is a form of reconstructive plastic surgery. It aims to recreate a vagina which is non-functioning or absent since birth.
What are the techniques available for vaginal reconstruction?
There are several techniques of vaginal reconstruction being practised the world over, but the best method could not be identified so far. Some of them use intestine transfer, muscle & skin graft from thigh, buccal mucosa graft, scalp graft, abdominal muscle and skin graft, groin, gluteal or thigh skin graft to create neo vagina. But none of them met the requirements of an ideal vagina and were associated with so much morbidity.
Cons of old techniques of Vaginoplasty were very high:
- Donor area morbidity
- Require major surgery at donor area like cutting, re-anastomising intestine, taking graft from abdomen, thigh, causing ugly scarring etc
- Associated with large amount of mucosa discharge which makes vagina have offensive discharge
- Create vagina which is malodorous, asensate, hairy and cosmetically unacceptable
- Above all, there were chances of contracture of new vagina were very high.
Fascio-Cutaneous Flap Procedures have been found to distort the external appearance of the genitalia in addition to an obvious scar in the groin, gluteal fold or medial to it.
Labia minora provides an excellent alternative. The epithelium of labia minora is exactly similar to the vaginal epithelium. It is sensate, hairless, no sweat glands are there, so no offensive discharge. Instead, sebum secretion from labia minora epithelium keeps the vagina well-lubricated. It offers a medium-sized vagina to be dilated over 2-3 months by gradual dilatation. In the literature only one technique with labia minora flap i.e, Horseshoe flap vaginoplasty is described.
What is HorseShoe Flap Vaginoplasty
Space is created postero- superiorly between the bladder and rectum at the proposed place of the vagina, where the vagina is usually present as a dimple. A single horse-shoe flap is marked involving labia minora and preputial skin(skin over clitoris) and a neo vagina tube is created which is inserted with skin turned inwards in the space.
What are limitation of Horse shoe flap Vaginoplasty?
Since labia minora was entirely used for the neovaginal tube creation, so many patients complained of abnormal genitalia anatomy due to lack of labia minora.
Hence, we at PCOSMETIC GYNE CLINIC devised a novel technique of lateral labial flap vaginoplasty to overcome this limitation.
What is Lateral Labial Flap Vaginoplasty?
A Breakthrough Technique of Vaginal Reconstruction in Vaginal agenesis
Dr.Sourabh Rawat, renowned Plastic and Reconstructive surgeon at PCOSMETIC Gyne Clinic have devised a novel technique in which we have used only the lateral fold of labia minora along with prepucial skin to create a tube that resurfaces the neovaginal space. This newly reconstructed neo-vagina is progressively dilated by increasing the diameter of dilators over a period of three months. Since a thin vascularised cover lines the vaginal space, there is a lesser need for dilatation and almost nil chances of neo-vaginal atrophy & contracture.
The final result we achieve is:
- adequate-sized, elastic, stable vagina
- hairless, sensate, cosmetically acceptable neo-vagina
- with minimal donor site morbidity
- No offensive discharge, well lubricated due to sebaceous secretions of labia minora.
- Normal anatomy of genitalia maintained, even labia minora is preserved.
We have successfully done almost 12 cases of vaginal agenesis in Mayer Rokitansky -Kuster -Hauser Syndrome and found this technique to be simple, reliable, single-staged, and easily reproducible with a high patient satisfaction rate.
Post operative Care
A sponge stent is inserted to ensure that both the labia majora are sutured together loosely. The patient is put on a liquid diet postoperatively and absolute bed rest.
The dressing is done on the 5th post-operative day under anaesthesia. All sutures are cut and the stent is removed. The patient is taught about self-irrigation and self-use of the dilator from the next day. They are advised to use it 3–5 times daily and once the wounds have healed, they start enlarging it by using pressure and start using the next bigger-sized dilator. After 3 months, the patient feels to have a good-sized functioning vagina.
Conclusion
Lateral Labial Flap Vaginoplasty can give a woman back the trust that she may have lost due to vaginal agenesis and boost her faith for a better life. This is a simple, easily reproducible, single staged procedure with the almost nil donor site morbidity, adequate sized vagina and totally normal external genitalia anatomy maintained.
