a recent review on the topic of vaginoplasty. reconstructive and aesthetic types. I t addresses different techniques.

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Vaginoplasty: An
Update and future
concepts
Mahmoud Abdel-Aleem
Professor of Obstetrics and Gynecology, Assiut University
•Reconstructive
Vaginoplasty
Section I
• Sex
Reassignment
surgery
Section II
•Aesthetic
Vaginoplasty
Section III

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Section I
Reconstructive Vaginoplasty
Introduction
A plastic surgical procedure for the ablative disorders
of the vagina & vulvo-vaginal structures.
 Anatomical aim:
 Perfect anatomical measurements:
Vaginal length 8 cm.
Vaginal width allowing the easy introduction of two
fingers.
 Cosmetically acceptable.
 Minimal morbidity.
 Low maintenance is required.
 Functional aim:
 Excellent long-term function.
 Satisfactory sexual intercourse.
1- vaginal
aplasia. MRHK
syndrome.
2- cloacal
anomalies.
3- after pelvic
excentration
surgery.

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Outline
 A snapshot at the past
 Current status
 Updates
 Future
A snapshot at the past

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Duputyren
Baldwin
Wagner
McIndoe William Vecchietti
1817
1904
1927
1938 1964 1979
Creation
of
perineal
pouch
Use of
intestinal
vaginoplasty
Use of split
thickness
skin graft
Use of full
thickness
skin graft
The God
father of
native
vaginoplasty
He didn’t operate on
vaginal aplasia.
His patient died of sepsis
The Current Status

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NON-
SURGICAL
SURGICAL
•DILATION
•Native Vaginoplasty
• Vecchietti
• Balloon
•Replacement Vaginoplasty
• Autologous
• Heterologous

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• Adv: easy, cost-effective
• Disadv: questionable results,
maintenance required, discomfort,
requires motivated patient.
Dilation
• Adv: using the native vagina
• Disadv: pain, trocar wounds.
Native
• Adv: permanent vagina.
• Disadv: keloid, contact bleeding,
discharge, trocar wounds.
Replacement
Frank
Ingram
John C. Thomas and John W. Brock, III. Vaginal Substitution: Attempts to Create the Ideal
Replacement. THE JOURNAL OF UROLOGY. Vol. 178, 1855-1859, November 2007
Vecchietti
Balloon
Autologous
Heterologou
s
Rare
disease
Lack of
experience
Biases
Difficult to assess
Best line
Best results
For whom?
This ? That ?

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Update
1- Basic science “origin of the vagina”
2- Preoperative assessment: ESHRE
classification.
3- Operative procedures.
4- Postoperative assessment: Female
sexual function index.
1- Origin of the vagina
 The embryonic origin of the vagina: debate
(MD versus sinus).
 Both Current molecular studies and
Transgenic studies in mice provides some
evidence that the whole vagina is derived
from the Müllerian duct with bone
morphogenic protein 4 (BMP4) reshaping
the intermediate mesoderm-derived from
Müllerian duct into the vaginal primordium.
Yi Cai Revisiting old vaginal topics: conversion of the Müllerian vagina and origin of the "sinus" vagina. Int. J. Dev. Biol.: 2009, 53(7);925-34
Takeshi Kurita Developmental origin of vaginal epithelium. Differentiation: 2010, 80(2-3);99-105

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2- ESHRE/ ESGE classification
Nomenclature of vaginal anomalies

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AGENESIS
SIX
CLASSES
ATRESIA
CLOACA
3 (A) Laparoscopic Approach for
Vecchietti procedure
Neovagina created by drawing olive into the vaginal dimple by
passing thread-bearing cutting needle from abdominal wall to the
retrohymenal fossa, by applying continuous traction via sutures to
a tensioning device on the anterior abdominal wall using different
instrument sets.
Rejdová et al., 2012

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3 (B) Balloon vaginoplasty
 It is the daughter of the original
Vecchietti operation that has the same
concept of using the “native vagina” as
the future vagina.
 It is more simple, no extra- sophisticated
instrumentation.
 This concept was developed at Assiut
University (Egypt) (Elsaman et al., 2007).
The Main steps of Balloon
vaginoplasty

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Approach to
Balloon Vaginoplasty
Laparoscopic
approach
Retropubic
approach
A simple, fast, safe procedure.
It save time and money.
Suitable for extensive intraperitoneal
adhesions.
Don’t disturb urethral support or
urethrovesical angle
Laparoscopic
B V
Vecchietti
One day8 days
Admission
Not reported in our seriesReported
Slipping of device
OnceTwo times
General anesthesia
SimpleSophisticated
Instrumentation
Not reported yet (short
term follow up)
Reported
Postoperative
Stress Incont.

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3 (C) Laparoscopic Peritoneal
vaginoplasty
 Soong technique: The peritoneum is dissected
from the bladder and rectum, making it nearly a
free graft.
 Luohu technique: a special peritoneal propeller
is used to push the peritoneum down toward the
orifice of the new canal by applying continuous,
gradually increasing force.
Vaginal
aplasia
No previous
surgery
vaginal
dimple
Dilatation
Successful Failed
Native
Vaginoplasty
No Vaginal
dimple
Peritoneal
vaginoplasty
Successful Failed
Previous
surgery
With No
Adhesions
With
Adhesions
Intestinal
Vaginoplasty

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4- Postoperative assessment
Future

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1- Vaginoplasty with oxidized cellulose
 It is an absorbable plant-based
product that provides a matrix
for platelet aggregation by
melting into bleeding tissue.
 No separate operative
procedure
 Available.
 Inexpensive.
 Bactericidal properties against a
wide range of microorganisms
J. Dornelas et al. Vaginoplasty with oxidized cellulose: anatomical, functional and histological evaluation
European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 204–209
2- Role of Fibroblast growth
factor
 There is a well-documented role for FGF on
epithelization of neovagina.
 Assay of receptors proved expression of FGF receptors
on the cells of neovagina.
 The epithelium of the neovagina was morphologically
similar to that of normal vagina.
Nagata T et al. Efficacy of fibroblast growth factor (FGF) on epithelialization of the neovagina
in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who underwent
vaginoplasty, Journal of Pediatric and Adolescent Gynecology (2016).

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3- Tissue-Engineered Biomaterial Graft
 ADM biological graft:
It is a new type of natural tissue scaffold
composed of animal-derived dermal tissue.
It has vascular channels, and an intact
basement membrane complex.
It contains extracellular matrix components, such
as collagen, elastin, hyaluronic acid, chondroitin
sulfate, and proteoglycans.
It is clean and clear of all cellular components
A flowchart for vaginal tissue
engineering
Cells: from vulva or vagina
Signals: fibroblast growth factor
Incubation: 7 days.
Scaffold: animal-derived dermal tissue
“ADM” shaped like vagina.
Prosthesis: neovagina

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Anatomical success: MRI image of neovagina
8 yearsOne yearBefore surgery

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Anatomical success: histopathology of
neovagina
Advantages
1- Well tolerated vulvar biopsy , vaginoplasty & dilation.
2. Biopsy showed a similar phenotypic and histological
make-up to native tissue.
3- Anatomical success: Serial MRI and Vaginoscopy
confirmed organ patency.
4. Functional success: All patients are sexually active
and have functional variables within normal range (follow
up 8 years).

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4- Will I be a Mom ?
 IVF and ICSI trials were tried with:
Special attention to the abnormal
sites of the ovaries.
Lower results…..
Of course a gestational carrier is a
must.
The value of uterine transplantation!!!

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Section II
Sex Reassignment surgery
3 (D). Male to female surgery
“Not just a Guy in Dress !!”
 Aesthetic and
Functional Male to
Female Genital and
Perineal Surgery:
Feminizing
Vaginoplasty. Male
to female aesthetic
vaginoplasty.
SEMINARS IN
PLASTIC
SURGERY/VOLUME
25, NUMBER 2 2011

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Section III
Aesthetic Vaginal Surgery

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Reconstructive
Surgery
Improving the
function of a
body part
Cosmetic Surgery
Changes the
aesthetics of
essentially normal
anatomy
Vaginal
rejuvenation" and
"designer vagina
WHO defines FGCS as “All procedures involving partial or total
removal of the external female genitalia or any injury to them for
socio-cultural and non-therapeutic reasons”.

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Indications
 Loose vagina 64%
 Change in sexual pleasure 30%
 Unattractive gaping introitus 48%
 To improve self-image 33%
Goodman MP, Placik OJ, Benson RH, et al. A large multicentre outcome
study of female genital plastic surgery. J Sex Med 2010; 7: 1565e77

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Vaginal Rejuvenation techniques
 Classic:
 Non-surgical.
 Surgical.
 Update:
 Laser technique
 Radiofrequency
 Collagen injection
 “G-Spot augmentation”
Surgical vaginoplasty
 Restore Youthful healthy vagina (Appearance, Function
& Sexual gratification)
 Techniques:
 Full depth & length repair.
 Muscles & torn Fascia are re-sutured.
 Relaxed Ligaments are shortened.
 Excess Vaginal skin removed.
 Disadvantages: Bleeding, Injury, Infection, Adhesions,
Scarring, Narrowing, Recurrence, Altered Genital
Sensation.

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Laser Rejuvenation
 Laser Vaginal Tightening by using a vaginal probe; laser energy is
delivered safely to full circumference of vagina to promote
collagen production, vaginal mucosa shrinkage, remodeling &
strengthens the supporting ligaments.
 Advantages:
 Non-invasive & Safe.
 Increased Sexual Gratification to both.
 Reduction in Stress urinary incontinence .
 No Surgery, Anesthesia, Pain, Downtime.
Disadvantages:
 A series of 3 settings, 4-5 weeks apart.
 More Cost & Experience.
Radiofrequency Rejuvenation
 This is in-Office Vaginal Rejuvenation surgery under mild
Sedation and local Anesthesia.
 Ellman Surgitron Radiofrequency device to make precise
and minimally traumatic incisions.
 Less destructive than lasers. It takes about 60 minutes.
 Enhance Sexual Gratification” as well as a Cosmetic
procedure
Sekiguchi et al., 2013

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Collagen injection “G-Spot
augmentation”
 A simple, non surgical collagen injection that can
augment the Grafenburg spot (G-Spot) in sexually
active women to amplify sexual sensation.
 80% effectiveness.
 Must be repeated every 4-6 months.
Labiaplasty= labioplasty
The best established female genital
cosmetic procedure is reduction
labioplasty.
Indications:
Aesthetic dissatisfaction or discomfort.
During exercise or sexual intercourse.

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10. It’s not medically indicated.
9. It’s not been proven to be safe & effective;
potential long-term complications may occur.
8. Women are not educated about the wide range of
“normal.”
7. Women requesting these procedures often really
need psychological counseling.
6. Doctors are promoting an unrealistic ideal.
“Top 10 Arguments Against Performing
Cosmetic Gynecology.”

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5. Doctors are doing it just for the money.
4. It’s unethical.
3. Women are being forced by social
pressures.
2. Seminars offer industry secrets for a
high price.
1. ACOG doesn’t support it.
Do women know what is
normal ?
 A wide variability in the appearance of normal
female external genitalia is a fact.
 Sexual function does not appear to be associated
with genital dimensions.
 This information is important for women and
surgeons alike when considering cosmetic vulvar
surgery.
H. Krissi et al. /Anatomical diversity of the female external genitalia and its
association to sexual function. European Journal of Obstetrics & Gynecology
and Reproductive Biology 196 (2016) 44–47

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Do women know “genital
aging”?
Preadolescent Adulthood Aging vagina
Mons
pubis
Adherent to
periosteum.
More fat Atrophy
Labia
majora
Adherent to
periosteum.
More fat
(perineal
ptosis)
Atrophy
Clitoris
and
prepuce
Small Wrinkled Dryness
Labia
minora
Pink and
hidden
Darker
Exposed
Wrinkled
On the other hand !
Pros clearly agree that there is a wide range of normality in
the external and internal female genitalia, both parous and
nulliparous, many women chose to modify their vulvas and
vaginas.
Data from a diverse group of experienced genital plastic
surgeons, outcome in both general and sexual satisfaction
appear excellent.
Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, Jason RA, Matlock
DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, and Gonzalez F. A large
multicenter outcome study of female genital plastic surgery. J Sex Med
2010;7:1565–1577.

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Precautions !!
 Fine line between female genital mutilation
and female genital cosmetic surgery.
 Both plastic surgeons and gynecologists
performing this type of surgery should be
aware of potential damage being caused
and which in the future may be classified as
‘mutilation’.
Acknowledgments
Thanks to all who helped me during preparation of
the review

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