Perineoplasty and Vaginoplasty

Marco A. Pelosi III, Marco A. Pelosi II

Key Points

• Perineoplasty procedures tighten the skin and muscles of the vaginal introitus and create a convergence of the labia majora posteriorly.

• Colpoperineoplasty procedures tighten the skin and muscles of the lower vaginal canal and the vaginal introitus.

• In both procedures—perineoplasty and colpoperineoplasty—the perineal flap is carried into the subcutaneous fat layer, whereas the vaginal flap is a skin-only, superficial dissection.

• Transrectal digital palpation facilitates visualization and suturing of the levator muscles.

Vaginoplasty is a general term for any procedure that reshapes the vagina. These include cosmetic and therapeutic operations of both the introitus and the canal. A few common examples are perineoplasty, vestibulectomy, cystocele repairs, rectocele repairs, colpocleisis, and colpoperineoplasty. In cosmetic gynecology, the word vaginoplasty has taken on a more specific connotation to refer to procedures that reduce the caliber of the vaginal introitus and the vaginal canal with simultaneous plication of the levator ani muscles.

Surgical reduction of the width of the perineum is called perineoplasty. Technically, it involves the excision of midline tissues spanning the perineum and lower posterior vagina and the approximation of tissues immediately lateral to the excision zone. In therapeutic gynecologic operations, perineoplasty is performed to enhance support of the pelvic floor at the time of pelvic reconstructive surgery.1–6 In cosmetic gynecology, perineoplasty is performed to create an external muscular cuff of reduced vaginal circumference to complement a deeper zone of caliber reduction, typically executed through conservative plication of the levator ani musculature and the resection of loosened skin from the posterior vaginal wall. A secondary, purely aesthetic effect of perineoplasty is a convergence of the labia majora posteriorly (Fig. 11-1), an anatomic realignment that tightens laxity along the length of the labia majora. We take advantage of this effect when planning aesthetic procedures of the labia majora. The word perineorrhaphy is frequently used as a synonym for perineoplasty. Most practitioners use these words interchangeably, although it is linguistically incorrect to do so. The suffix -rrhaphy simply means “to suture,” whereas -plasty means “to shape.”

Fig. 11-1 A, The medial edges of the bulbocavernosus and perineal muscles are widely separated before surgery (arrow). B, Perineoplasty causes them to converge centrally (arrows) to tighten the introitus and improve muscle tone beneath the labia majora.

In most instances, perineoplasty is performed as a component of colpoperineoplasty—the tightening of the vaginal canal and levator ani musculature, previously described. The most common scenario for an isolated perineoplasty is the revision of a colpoperineoplasty for a complaint of persistent laxity where only the external portion of the vaginal canal displays residual laxity. The most common misapplication of the procedure is its use in the presence of vaginal canal laxity, and the surgeon fails to recognize the diagnosis. In therapeutic gynecology, perineoplasty is sometimes used in the process of wide local excision of localized neoplasms. Many plastic surgeons use the term external vaginoplasty when discussing perineoplasty or even labial surgery. This is an incorrect use of the term that is common, particularly on the Internet.

Perineoplasty defines any change in the shape of the perineum, including efforts to widen the perineum and create a wider vaginal introitus. In practice, however, widening procedures are not referred to as perineoplasty. In these situations, we see more descriptive names such as perineal expansion, perineal release, or vestibulectomy, frequently referencing the underlying reason for the intervention.

Vaginal rejuvenation is a loose synonym for vaginoplasty. The popular use of the term vaginal rejuvenation in cosmetic gynecology originated in the late 1990s, when Dr. David Matlock of Beverly Hills, California, a gynecologist in private practice, coined and trademarked the term Laser Vaginal Rejuvenation (LVR) to market a version of colpoperineoplasty conducted with the use of a laser as a cutting instrument. A 980-diode fiber laser was used for cutting and not for shrinking tissue, as many had thought. Vaginoplasty is a traditional gynecologic term encompassing anterior and posterior colporrhaphies, but the lay public uses it widely to define procedures that narrow the vaginal introitus and canal.

History

The concept of tightening the vaginal dimensions altered by childbirth is not new. Vaginal rejuvenation or tightening is more than 1000 years old, and it was introduced by women.7 The work of female physician Trotula de Ruggiero of Salerno was published in 1050 ad under the title Treatments for Women. The author described suturing of vaginal lacerations at childbirth, which forms the basis for all modern vaginoplasty techniques.

Also in this volume are five nonsurgical recipes for “restoring” virginity. The section opens as follows: “A constrictive for the vagina, so that women may be found to be as though they were virgins, is made in this manner.”⁸ Renowned Medieval historian Monica Green, who spent decades researching all extant versions of the Trotula ensemble and Salernan culture before her definitive translation, opined: “It may be that some of these constrictives were meant only to tighten the vagina to enhance the friction of vaginal intercourse, not necessarily to produce a fake bloodflow of ‘defloration’; in other words, they may have been intended as aids to sexual pleasure within marriage.”⁸

The Renaissance brought major advances in anatomic knowledge through cadaveric dissections. Vesalius (1514 to 1564), at the University of Padua, best represented these dissections in De Humana Corporis Fabrica.⁹ The printing press, which was invented a century earlier, was instrumental in widely disseminating this information.

However, gynecologic surgical technique and instrumentation underwent little if any change from that of the Greco-Roman era. Nonetheless, celebrated French surgeon Ambroise Paré (1510 to 1590), in Gynaeciorium Physicus et Chirurgicus, and subsequently his pupil Jacques Guillemeau (1550 to 1612), in his 1609 text De la Grossesse et Accouchement des Femmes, were the first to describe repairs of rectovaginal lacerations at childbirth, marking the beginning of complex perineoplasty.⁷

Indications and Contraindications

Perineoplasty is indicated for tightening of the vaginal introitus only. Colpoperineoplasty is indicated for tightening of the vaginal introitus and lower vaginal canal. Rectocele, cystocele, and urinary incontinence are not treated by a perineoplasty or a colpoperineoplasty and require specific repairs, which can be performed concomitantly. Perineoplasty and colpoperineoplasty procedures should be deferred for patients who plan to have children through vaginal childbirth in the future. Patients with active infections or undiagnosed skin lesions or other pathology of the vulvar region should be treated by a gynecologist before surgery.

Patient Evaluation

Unlike medical patients who seek relief from disease, deformity, or dysfunction, cosmetic patients seeking personal or social benefits such as confidence and acceptance must be completely healthy.10 The American Society of Anesthesiologists has developed a Physical Status Classification System for surgical patients that describes six categories: ASA I through ASA VI. Well-chosen patients are identified as ASA I or ASA II patients. These patients have no medical illness or a chronic, well-controlled medical condition. (Detailed information on the ASA system is available at www.asahq.org.) Hospitalization costs associated with cosmetic procedures, planned or unplanned, are not covered by conventional health care insurance.

After the initial conversation regarding the cosmetic request and the requisite psychosocial analysis, a thorough gynecologic and sexual history is obtained. This information is useful to determine whether patients have symptoms of bladder, bowel, or pelvic floor dysfunction or sexual issues that may affect treatment.

A physical examination is conducted with the patient in both a standard gynecologic dorsal lithotomy position and a standing position to fully assess for pelvic organ prolapse. A speculum examination is performed to identify any infection, which may interfere with the surgical procedure. The clitoral and bulbocavernosus sacral reflexes are assessed at the perineum. Tapping the clitoris or stroking the labia majora should produce a reflex contraction of the external anal sphincter. The patient is asked to cough to assess for bladder hypermobility. The width of the levator hiatus and the quality of the puborectalis muscle tone are assessed digitally. A common practice is to measure the hiatus in fingerbreadths with the muscles at rest and with the muscles contracted. These data are converted to centimeters. If the levator muscles are either lax or widely separated, perineoplasty alone will be insufficient to satisfy the patient’s request for vaginal tightening, and colpoperineoplasty is indicated. The thickness and dimensions of the perineal body are noted. An attenuated perineal body in need of repair frequently has a thin web of skin with little to no muscular tissue. A digital rectal examination is conducted to assess for a rectocele or a perineocele, which, if present, warrants repair at the time of surgery. Rectal fullness, pressure, and constipation are very common symptoms of these conditions.

Surgeons should explain the limits of the contemplated vaginal tightening by palpating the targeted structures and by displaying the anatomy with the use of a hand mirror. Markings are useful to define the boundaries of proposed treatments and to show untargeted structures at consultation and at surgery. Dilators and fingers are used as aids to help patients visualize the degree of planned tightening. A discussion of the degree of tightness after surgery is essential.

A complete, documented medical evaluation should precede surgery in patients who have not had a recent examination. Any anatomic distortion that may increase the risk of injury should be assessed and managed by appropriate means preoperatively. Blood analyses include testing for signs of infection, anemia, and coagulopathy. Pregnancy testing is performed or repeated on the day of surgery regardless of the history.

Medications, supplements, herbs, and other substances that could impair coagulation (for example, vitamin E, gingko biloba, ibuprofen, and statins) should be discontinued 1 week in advance of surgery. Substances that interact negatively with anesthetic agents, healing, and perioperative medications should also be withheld. If they cannot be discontinued or substituted, the surgical plan will need to be modified, delayed, or withheld. Cigarette smoking is not a contraindication to perineoplasty.

Expectations and motivations need to be explored in depth in cosmetic patients. Unrealistic expectations will never be fulfilled by surgery even if procedures are performed to perfection by any medical or aesthetic standard. Cosmetic surgery “addicts,” “perfectionists,” and patients expecting cosmetic surgery to remedy interpersonal conflicts are examples of misguided personality types to be screened at the initial consultation.

The degree of planned tightening should be emphasized, the risks of overtightening should be explained thoroughly, and revision policies should be clearly explained.

Preoperative Planning and Preparation

Preparation for cosmetic vaginal surgery is straightforward. Acceptable results of blood analyses are confirmed. Patients should present for surgery rested and well hydrated. If sedation or general anesthesia is planned, patients are advised to not take anything by mouth for 8 hours before surgery. Informed consent is obtained, postoperative medications and wound care instructions are reviewed, and contact information is updated as necessary.

Surgical Technique

Anesthesia

Perineoplasty may be performed with local anesthesia with or without sedation, with epidural anesthesia, or with general anesthesia. Each modality has advantages, disadvantages, inherent risks, and suitability for the unique demands of each operation and patient. In our practice, perineoplasty patients are given a local anesthetic unless other procedures that warrant a different type of anesthesia are performed at the same time. Regardless of the technique, the surgical team should be knowledgeable and prepared, and the facility should be equipped to manage all potential adverse drug effects.

Tumescent local anesthesia (TLA), commonly used for liposuction, is an excellent, long-acting anesthetic for aesthetic vaginal surgery and has hemostatic properties.10 TLA consists of lidocaine hydrochloride (800 mg/L), sodium bicarbonate (10 mEq/L), and epinephrine (1 mg/L) diluted in normal saline solution. It is injected directly into the surgical site sufficiently to cause local vasoconstriction. Typically 30 to 60 ml of TLA is sufficient and produces an anesthetic effect that lasts 8 to 12 hours. Other popular local anesthetics include bupivacaine (Marcaine and Exparel) with epinephrine and ropivacaine (Naropin) with epinephrine.

Perioperative Care

Prophylactic broad-spectrum antibiotics are routinely given immediately before surgery. Patients are placed in a dorsal lithotomy position with the legs supported in boot-type stirrups and the knees mildly flexed. Intermittent pneumatic compression stockings are routinely employed. Indwelling bladder catheterization and vaginal packing are not typically used during perineoplasty. When a colpoperineoplasty is performed, a transurethral bladder catheter and vaginal packing are maintained postoperatively for 24 hours.

Perineoplasty Technique

Markings

The procedure begins with marking of the desired diameter of the vaginal introitus. The surgeon inserts two fingers of the nondominant hand into the vagina while using the dominant hand to compress the labia majora together in the midline underneath the fingers. The uppermost contact point between the two sides is marked, and oblique lines are extended outward from the contact point for reference (Fig. 11-2).